What you do early can affect what evidence exists later.
1) Get medical care and make sure injuries are documented. Even if the resident “seems okay,” ask the clinician to document symptoms, exam findings, and fall-related concerns (head injury signs, pain, mobility changes, dizziness, etc.).
2) Request the incident packet immediately. Ask for the incident report, fall risk assessment, the resident’s current care plan, shift notes, and any post-fall monitoring documentation.
3) Preserve surveillance—don’t assume it will be kept. Many facilities rely on cameras in hallways and common areas. Ask the facility to preserve any relevant footage right away.
4) Write down the timeline while it’s fresh. Note the approximate time of the fall, who was present, where the resident was located (room, hallway, bathroom area, common room), and what staff said happened.
5) Be cautious about statements. Family members are often asked to sign forms or agree with explanations quickly. Don’t guess about fault. Let the medical records and the documentation drive the facts.


