In our experience handling injury claims in the Twin Cities metro, many serious falls share common setup factors—especially when residents have mobility limits, balance issues, or cognitive impairment.
You may see issues such as:
- Transfer breakdowns during toileting, bed-to-chair movement, or wheelchair repositioning
- Environmental hazards in high-traffic areas (bathrooms, hallways, or common rooms)
- Delayed or inconsistent response after an attempted stand or near-fall
- Care plan gaps when staffing levels or shift coverage fail to match a resident’s documented needs
- Post-fall monitoring problems, particularly after head impact or suspected fracture
Even when a resident has fall risk, facilities still have a duty to use reasonable safeguards. When those safeguards aren’t implemented—or aren’t followed—injuries can become preventable.


