Serving an aging, vulnerable population means some falls are unavoidable. Depending on how you respond, these incidents can help improve the standard of care at your facility or make you more susceptible to risk and litigation.
A fall incident that occurs today in your skilled nursing facility (SNF) can resurface as a lawsuit five years from now. Best practices for responding to and documenting falls can help reduce them and mitigate your risk of a future lawsuit.
Hindy Katz, RN, owner of Mitig8 and a legal nurse, helps senior care facilities improve their standard of care and create a real-time defense for future lawsuits. “A thorough, accurate and robust investigation after a fall incident allows you to implement better corrective measures and improve your defensibility and protection in case of litigation,” says Katz
Katz recommends a two-pronged risk management approach to reduce damage to your reputation and bottom line:
What you don’t want is a reactive approach to falls, which can make you more vulnerable to defending yourself against legal issues that arise years later. “A lawsuit can surface long after an incident, and at that point, the burden falls on you to prove defensibility,” says Katz.
To prove defensibility in a fall-related lawsuit, a senior care facility must show that it took reasonable and appropriate actions before, during and after the incident. This means providing clear, real-time documentation of the fall, including assessments, interventions and communication. The facility must also demonstrate these actions are aligned with facility policies and standards of care. In addition, conducting a root cause analysis and implementing corrective actions demonstrate due diligence, reinforcing that your facility took reasonable steps to prevent recurrent falls and responded appropriately.
Not all falls are preventable, but many result from systemic issues. “When we’re looking at incidents, we might be hyper-focused on this particular event and resident, but ultimately, you have to ask what led up to this event,” says Katz.
By conducting root cause analyses, facilities can identify patterns of avoidable incidents. For example, if a resident falls due to an untreated infection, the real issue may be a breakdown in reviewing lab results and antibiotic administration. “If we’re seeing repeated incidents of this nature, then we know something in the process is broken,” says Katz.
Related read: Best practice fall documentation and root cause analysis
Communication breakdowns are a common cause of falls, says Katz. “So many key team members care for each resident, and everyone needs to know their specific role.”
When a fall occurs, implementing a corrective measure going forward often requires reviewing an incident to identify the root cause and then informing everyone on the interdisciplinary care team. “The structure of your morning meeting and the inclusion of the right team members in incident discussions often sets the foundation for effective communication and proactive problem-solving,” says Katz.
Instead of only discussing incidents with the clinical team, inform everyone who works with the resident, such as physical therapists and activities staff. They are all part of the care team and can help implement preventative measures. “Accountability breeds responsibility,” says Katz.
For instance, the activities team can help reduce falls related to agitation by engaging residents during high-risk times, such as sundowning around the evening. Physical therapists can assess environmental factors like bed height when a resident falls while getting in or out of bed. “Therapy is often the glue in fall prevention, yet they’re frequently left out of these critical conversations,” Katz adds.
To improve communication and accountability, Katz recommends:
“It doesn't take long to have these discussions if we're asking the core questions and the right people are in the room, “ says Katz.
Including and documenting these interdisciplinary meetings as part of your care plan also help to demonstrate due diligence toward fall prevention in the case of a lawsuit.
Documenting a fall in a resident’s electronic medical record (EMR) is required, but that alone isn’t enough. You must also take appropriate measures to prevent the incident from happening again.
In the case of a lawsuit about a fall, the burden is on you as the SNF owner to prove defensibility. “If the first time you're reviewing an incident is five years later when a lawsuit surfaces, you won't be able to change the outcome,” says Katz. “Your defense will rely almost entirely on the quality and completeness of your documentation.”
Accurate, timely documentation is the foundation of defensibility in the event of a lawsuit or state survey. Traditional paper-based incident reports are unreliable, and basic EMR modules don’t always guide staff through a thorough root cause analysis.
Katz recommends using software to simplify incident documentation. After a fall, incident documentation should capture the following:
The more specific your documentation, the better. For example, Katz and her team frequently see facilities make the critical mistake of failing to document interventions in the correct order. “If a resident falls, and the documentation says they were transferred back to bed before being assessed, that’s a problem. Policies dictate that residents must be assessed first, so that’s a breach of protocol.”
Using a digital risk reporting tool, like Gener8 Risk Reporter, an app from Mitig8, makes completing comprehensive incident reports in real time easier
From frontline staff to leadership, the platform allows teams to track, respond and learn from risk events as they unfold. Facilities can easily differentiate between high-risk and low-severity incidents, monitor time to closure and access powerful tracking and trending tools.
Tools like Gener8 also help teams identify resident-specific trends, such as repeated falls or changes in behavior, allowing for earlier interventions and better-targeted care. With this level of insight, facilities can move from reactive to proactive, reducing risk exposure, improving incident response, and strengthening compliance at every level. “It’s not just about documenting what happened. It’s about recognizing patterns, responding faster and preventing the next incident before it occurs,” says Katz.
Effective risk management in senior care facilities may not eliminate every incident, but the right strategy can prevent avoidable falls, improve documentation and strengthen defensibility in litigation. “Ultimately, it comes down to having a strong process and giving every part of that process a home. When risk management is done right, residents and facilities benefit,” says Katz.
While documentation and communication are critical to defensibility, preventing injuries from falls in the first place is just as important.
That’s where Accora’s FloorBed systems come in. With ultra-low height, smooth transitions, and thoughtful design, FloorBeds help reduce the risk of injurious falls — especially during high-risk moments like transfers and nighttime toileting.
Related read: Better than a high-low bed: The Accora FloorBed range for LTC facilities
