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Fall Prevention

Best practice fall documentation and root cause analysis

Does your fall documentation support effective fall prevention? Learn the essentials in root cause analysis and documentation from the experts.

At Accora we are passionate about fall prevention. That’s why we do what we do and why we make what we make. Our innovative floor bed design means that falls from beds in senior care settings and the injuries they cause can be dramatically reduced.

We think that makes a significant difference in the world, but we don’t see any reason why we should stop there. Our series of educational webinars cover the current problems facing long-term care, acute care, and skilled nursing facilities including fall prevention.

To help address these common care concerns, we hosted a free webinar on fall documentation and root cause analysis with a view to helping care providers accurately record, understand, and ultimately prevent falls in their care communities.

94 % of senior falls are not witnessed
Safely You state of falls report

According to Safely You, 94% of falls are unwitnessed. So how can senior care professionals prevent falls if they don’t see them happening? That’s where root cause analysis and fall documentation come in.

The Webinar

We asked senior care experts Emilia Bourland OTR, ECHM, and Nicole Watson BSW, RN, to share their top tips on best practices for fall documentation and root cause analysis to help nursing staff:

· Understand the essentials of fall risk reduction documentation

· Learn how to document appropriately after a fall

· Discover how to perform an effective root cause analysis

And they also provided a case example to put all these techniques into play. The webinar was divided into three key categories which were “before the fall”, “after the fall”, and the case study.

Here’s a summary of the key takeaways from each section.

01. Before the fall – Fall prevention is for everyone

How good documentation practices and fall risk assessments can help after a fall and also prevent some falls. According to Emilia, pre-fall documentation “starts from the initial assessment or intake of someone into a community and it’s really an ongoing process.”

Some factors to consider in an initial fall risk assessment are:

· Physical – How much assistance do they need to walk or bathe?

· Cognitive – What is their cognitive state and which factors are likely to influence this?

· Pharmacological – Are they taking medications that could increase the risk of falling?

· Behavioral - What routines prior to their intake might affect their behaviors now?

· Environmental – Think about where they were, versus where they are now. Document all DME or furniture they are bringing into the environment

One of Emilia’s top tips for pre-fall documentation is to include therapy personnel and caregivers in the decision-making process to establish someone’s fall risk. They may have a different insight and always include a thorough fall history report in fall risk assessments.

After you have identified a person’s fall risk, it’s essential to outline the action plan for mitigating that risk. That way you can go back during a root cause analysis and identify where your care action plan needs to be adapted and you have documentation to show your team’s response to risk factors over time.

02. Defensive documentation after the fall

Documenting the fall thoroughly after it occurs is key to getting to the root cause of the fall and preventing recurring falls from happening. There are many elements of post-fall documentation that the first responder and clinical team are responsible for completing. Some of the types of documentation you should complete or alter after a fall takes place are:

· A head-to-toe assessment – Record vital signs, injuries, and obvious abnormalities

· EMR - Document thoroughly in the EMR what you know about the fall

· Incident report – Every organization has its own version of an incident report. Having a great incident report that asks questions is vital for fall prevention through data documentation

· Create a new fall risk assessment – Keeping fall risk assessments up to date allows you to track the impact of care measures and the effectiveness of fall interventions

· Update care plan – Keep visibility of all intervention planning by updating the care plan post-fall

· Notify provider and resident representative – Those that know the resident well may be able to give further insight about that person’s preferences and prior routine to bring new elements to light

· Inform others - Communicate news of the incident and any adjustments to the care plan to the rest of IDT

The key takeaway here is to ensure every observation about the fall and the circumstances around it is clearly recorded for future reference. Also, keeping all members of the team included in post-fall discussions will enable you as a team to offer complete and consistent care. Lack of communication between different groups of care staff is the enemy of fall prevention. It’s up to you to implement a channel of communication in relation to falls so everyone is in the loop. Don’t wait for the next morning meeting or shift-change handover to communicate that a resident fell. Timely and open communication about any care plan changes is the ultimate key to fall prevention.

Nursing staff discussing fall documentation
Nurses discussing fall documentation

Root cause analysis

Tracking your observations as the first responder after a fall is vital to determining what caused the fall and therefore reducing the risk of it happening again. When you carry out a root cause analysis after a fall, Nicole Watson recommends taking stock of the following factors.

Pre-fall documentation

Making use of past fall risk assessments might shed light on the cause of this fall. Past falls should be noted down here and might indicate a trend that would otherwise have gone unnoticed.

Internal/ intrinsic conditions

Noting the patient’s vital signs, existing conditions, current medication, and any recent changes in their care plan, cognition, and sense impairment will help you consider all aspects of the cause of the fall.

Environment/ extrinsic conditions

Considering the noise levels, time of day, lighting situation, bed height, and any equipment involved in the fall will help to build a clear picture of environmental factors which could have contributed to or directly caused the fall.

Operational/ system conditions

What operational factors might have influenced how the fall happened? Did it happen during a shift change for example or during staff break time? Were there a higher number of temporary staff on shift than usual at the time of the fall due to illness or unforeseen circumstances? This is not blame but simply about building a clear picture of what happened with a view to defending proactively against future falls.

Collating data around all of these factors will help you and your team to get to the root cause of the fall and to collect data that could be useful in the future for further fall analysis.

Nicole stressed the importance of these post-fall assessments and analyses, saying “I’d like to stress that these reviews should never be punitive. We always want to have these conversations so that we’re improving our processes for everyone that’s involved.”

That is what care is all about, after all. It’s about offering a safe situation and as full a life as possible to the residents in your care. The definition of what that looks like for your individual care community will certainly shift over time depending on individual needs so it’s vital that standards are constantly monitored and that improving work processes is always a priority.

03. Case study and real-life best practice documentation

Emilia and Nicole go through a real case study of a geriatric fall and how best practice documentation assisted their root cause analysis.

This demonstrated how many factors (both intrinsic and extrinsic) contributed to the fall happening and outlines how staff were able to establish the causes despite it being an unwitnessed fall, which of course, the vast majority of senior falls are.

The takeaway

The essential theory around best practice fall documentation is that implementing a team-wide system that promotes inquiry through questions and encourages data collection will aid with root cause analysis. If we don’t have all the information about past falls and fall risks, then how can we be expected to ascertain the cause and contributing factors of a fall? If care professionals are not able to determine the cause of falls, then how can they prevent them from happening again?

Ensuring that all team members are aware of and trained in the agreed fall documentation procedure will mean that consistent paperwork and an up-to-date EMR are maintained. In turn, this will aid fall prevention by guaranteeing accurate data is recorded.

If you’d like to learn more about fall prevention through documentation and root cause analysis, then you can watch the recording of the live session here for free. Please do share this valuable resource with your colleagues who may also find it useful.


Fall Prevention
Accora Team
FloorBed technology to help skilled nursing, rehabilitation and long term-care facilities prevent falls and fall-related injuries.
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Emilia Bourland
Emilia Bourland
BSW, RN, WCC, VP of Clinical Excellence
Watch the recording
Available on-demand for free
Fall documentation and root cause analysis, getting it right
Watch the recording
Fall documentation and root cause analysis, getting it right
Watch the recording
Fall documentation and root cause analysis, getting it right
Watch the recording
Available on-demand for free
Fall documentation and root cause analysis, getting it right