In the hours after a fall, your priorities are medical care and accurate documentation. But what you do next can affect how well the facts are preserved.
Take these steps as early as possible:
- Make sure the resident is evaluated—especially after head impacts, fractures, suspected internal injuries, or sudden behavior changes.
- Write down the timeline while it’s fresh: approximate time of fall, where it occurred, what staff said, and what symptoms appeared afterward.
- Request incident information through the facility’s process (and keep what you receive). Ask for the incident report and any related nursing notes.
- Preserve communications: texts, call logs, discharge instructions, and follow-up appointment details.
If the facility contacts you with paperwork, questions, or requests for statements, it’s wise to pause and get legal guidance first. Early statements can be misunderstood later—particularly when a facility’s written narrative conflicts with medical documentation.


