Investigating a nursing home fall means gathering evidence quickly, reviewing the resident’s care plan and medications, and determining whether the facility met its legal obligations to prevent the fall in the first place. Whether you’re a family member who got a phone call about a loved one’s injury or a facility administrator conducting an internal review, the process follows a clear set of steps, and timing matters. Federal rules require facilities to begin investigating immediately upon discovery, with a five-day window to complete the process.
Start With the Incident Report
Every nursing home is required to document falls through an internal incident report. This report should include the date, time, and location of the fall, what the resident was doing, who found them, and what injuries resulted. But a complete investigation file goes well beyond that single form. Facilities should also have witness statements, a statement from the resident (if they’re able to provide one), the resident’s medical record, their current care plan and diagnoses, a cognitive evaluation, and employee training records for staff on duty at the time.
If you’re a family member, ask for a copy of the incident report as soon as possible. You’re also entitled to request the full medical record. Under federal privacy rules, a “personal representative” has the same right to access health information as the resident. You qualify as a personal representative if you hold a health care power of attorney, if your state’s surrogate decision-making law designates you as next of kin, or if a court has appointed you as guardian. Even without one of those formal roles, the resident can sign a simple written authorization directing the facility to share their records with you. That authorization just needs to identify you by name and specify where to send the information.
Review the Care Plan for Prevention Measures
One of the most important questions in any fall investigation is whether the facility had an adequate prevention plan in place before the fall occurred. Federal regulations require nursing homes to assess each resident’s fall risk and develop a care plan with specific, measurable interventions tailored to that risk. A high-risk resident’s plan should include concrete steps: hourly rounding, assistance with toileting and transfers, a bedside commode if needed, visual flagging so all staff recognize the risk level, and ensuring the resident wears glasses or hearing aids if they have sensory deficits.
For residents with physical limitations, the plan should address assistive devices like walkers or canes, supervision during ambulation, and a toileting schedule that accounts for nighttime urgency. Confused residents should be reoriented regularly, and the facility should consider moving them to a room with direct sightlines from the nursing station. If none of these interventions appear in the care plan, or if the plan exists on paper but staff weren’t actually following it, that’s a significant finding.
Compare what the care plan says to what was actually happening at the time of the fall. Was the resident supposed to have assistance getting out of bed? Were they left alone in the bathroom? Was anyone rounding on schedule? Gaps between the written plan and the reality on the ground are where most preventable falls originate.
Check Medications That Raise Fall Risk
A medication review is a critical piece of any fall investigation. Several common drug classes are known to increase fall risk in older adults. Sleeping pills and anti-anxiety medications (particularly benzodiazepines and related drugs) cause drowsiness and impaired balance. Antidepressants, antipsychotics, and seizure medications can all affect coordination and alertness. Muscle relaxants, opioid pain medications, and even common over-the-counter anti-inflammatory drugs contribute to fall risk through dizziness, sedation, or changes in blood pressure.
Pull the medication administration record for the 24 to 48 hours before the fall. Look for any recent changes: a new medication added, a dosage increased, or multiple sedating drugs given in combination. The care plan should include pharmacist consultations and note potential side effects of high-risk medications. If a resident was started on a new sedating drug and no one updated the fall prevention plan to account for it, that’s a systemic failure worth documenting.
Inspect the Physical Environment
Environmental hazards account for roughly 25 percent of root causes identified in fall investigations. Walk the area where the fall happened and look for specific conditions: wet or freshly mopped floors without warning signs, poor lighting (especially in hallways and bathrooms at night), loose or bunched rugs, cluttered walkways, and malfunctioning call lights. Check whether the bed was in its lowest position, whether grab bars are installed and secure in the bathroom, and whether nonskid mats are in place on surfaces that get wet.
Night lights should be present in the bathroom and near the bed. Hallways should have light switches at both ends. If the resident uses a wheelchair or walker, verify it was within reach at the time of the fall. Also check whether the call light was accessible and functioning. A resident who can’t summon help may try to get up unassisted, which is one of the most common fall scenarios in long-term care.
Understand the Root Cause Analysis Process
Facilities are expected to conduct a root cause analysis after a fall, a structured process designed to identify systemic problems rather than blame individual staff members. Research examining fall investigations across healthcare facilities found that root causes break down into four main categories: patient-related factors like cognitive decline or mobility limitations (about 38 percent of cases), environmental factors (25 percent), organizational and process failures such as inadequate staffing or missing protocols (about 20 percent), and staff communication breakdowns (about 18 percent).
A proper root cause analysis should involve an interdisciplinary team, not just the nurse who was on duty. It should result in a written plan to prevent recurrence, with specific changes to the care plan, environment, staffing, or communication protocols. If the facility’s “investigation” consists of a single form filled out by one person with no follow-up plan, it hasn’t met the standard.
Know What the Facility Is Required to Report
Not every fall triggers a mandatory report to state authorities, but falls resulting in serious injury do. Under the Elder Justice Act, incidents causing serious bodily injury must be reported to the state within two hours of the facility forming a reasonable suspicion. All other reportable incidents must be reported within 24 hours. The facility also reports fall data through the Minimum Data Set, a standardized assessment tool that feeds into the public quality ratings on Medicare’s Care Compare website.
A 2025 report from the Office of Inspector General found that nursing homes failed to report 43 percent of falls with major injury and hospitalization among Medicare-enrolled residents. This is a staggering underreporting rate, and it means you cannot rely on official records alone to understand a facility’s fall history. If your loved one suffered a serious injury from a fall, verify that the facility reported it. You can check the facility’s quality measures on Care Compare and compare them against what you know happened.
When to Involve Outside Agencies
If you believe the fall resulted from neglect, inadequate supervision, or a pattern of unsafe conditions, several external resources can help. The Long-Term Care Ombudsman program, established under the Older Americans Act, has the legal authority to investigate complaints made by or on behalf of nursing home residents. Ombudsman representatives can enter the facility, review relevant records, and work to resolve complaints to the resident’s satisfaction. They don’t determine whether a law was violated or take enforcement action themselves, but they can help you contact the appropriate regulatory or protective services agency and coordinate with your loved one’s legal representative.
You can also file a complaint directly with your state’s health department, which conducts inspections and can issue citations. For falls involving suspected abuse or neglect, Adult Protective Services is another avenue. If the injury is severe and circumstances suggest intentional harm or gross negligence, law enforcement may be appropriate, and the ombudsman program can assist you in making that referral with the resident’s consent.
Building a Complete Record
Throughout the investigation, document everything yourself. Take dated photos of the fall location, any injuries, and environmental hazards. Write down the names of staff on duty and anyone you speak with about the incident. Request copies of the incident report, the care plan that was in effect before the fall, the medication administration record, and nursing notes from the shift when the fall occurred. If the facility resists providing records, put your request in writing and cite the resident’s right of access under federal privacy rules.
Keep a timeline of events: when the fall happened, when you were notified, what the facility told you, and what actions they took afterward. If this is not the first fall, request records of previous incidents and compare the care plans. A facility that documents the same type of fall repeatedly without changing its prevention approach is demonstrating a systemic failure, which is exactly the kind of pattern that regulators and attorneys look for.