Hospital and nursing home fall case review
Fall cases ask whether the patient's risk was recognized, whether the precautions in the care plan were in place when the fall happened, and whether the injury was assessed and treated properly afterward, which matters most for patients on anticoagulants.
What the nurse reviewer examines
- Fall risk assessments (such as the Morse Fall Scale) on admission and after changes
- Precautions ordered and actually in place: alarms, low bed, assistance, toileting schedule
- Sedating medications and recent changes
- Supervision, rounding and call-light response
- Post-fall assessment, neuro checks and imaging, especially with anticoagulation
- Notification of the provider and family and the post-fall huddle
- For nursing homes: the care plan and federal requirements on accidents and supervision (F689)
Records to request
A starting checklist; the reviewer will flag what's missing once they have the chart.
- Nursing notes and fall risk assessments
- Care plan with revisions
- MAR
- Incident and post-fall reports (subject to privilege rules)
- Bed and chair alarm records
- Call light logs if available
- Imaging and neurologic check records after the fall
Questions attorneys ask
Are falls always preventable?
No. The review looks at whether the precautions matched the documented risk and were actually followed, not just whether a fall occurred.
Why does anticoagulation matter after a fall?
Patients on blood thinners are at higher risk of intracranial bleeding, so post-fall assessment, neurologic checks and imaging decisions carry more weight.
Consultants
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