In many nursing facilities around Essex County and the Madison area, staffing and workflow can be hardest to maintain during shift changes—especially when residents need assistance with toileting, transfers, or mobility aids. When a resident falls during these “handoff” periods, families often discover gaps in how risk was communicated.
We look closely at questions like:
- Was the resident’s fall risk communicated accurately at shift change?
- Were alarms, supervision levels, or transfer assistance used as required?
- Did the resident’s care plan match their actual mobility and cognition?
- Was post-fall response timely and consistent with facility protocol?


