Falls are the most common safety event in nursing homes, with roughly 11% of residents experiencing at least one fall per year and over 5% sustaining an injury from one. Preventing these falls requires a layered approach: screening every resident for risk, managing medications carefully, redesigning the physical environment, and tailoring interventions for residents with cognitive impairment.
Why Falls Are So Common in Nursing Homes
Nursing home residents face a convergence of risk factors that people living independently may not. Muscle weakness, impaired balance, chronic conditions, multiple medications, and unfamiliar surroundings all compound each other. Many residents also have cognitive impairment, which affects judgment, spatial awareness, and the ability to recognize personal limitations. The result is that falls happen not because of one single cause but because several moderate risks stack up in the same person at the same time.
This is why effective prevention isn’t about any single intervention. It’s about systematically identifying each resident’s specific combination of risks and addressing as many as possible.
Screening Every Resident for Risk
Structured risk assessment is the foundation of any fall prevention program. One widely used tool, the Hendrich II Fall Risk Model, scores residents across eight variables: confusion or impulsivity (worth 4 points), depression (2 points), dizziness (1 point), problems with bladder or bowel control (1 point), use of seizure medications (2 points), use of sedatives like benzodiazepines (1 point), male sex (1 point), and a simple mobility test.
That mobility test, called the “Get-Up-and-Go” test, asks the person to rise from a seated position. If they can stand in one smooth movement, they score 0. If they need multiple attempts, they score 3. If they can’t rise without help, they score 4. A total score of 5 or higher flags high risk, though recent research suggests a cutoff of 2 catches significantly more at-risk residents. In one validation study, lowering the threshold from 5 to 2 identified an additional 74 patients who would have been missed.
The CDC’s STEADI initiative provides a broader framework that walks providers through screening, assessment, and intervention in a step-by-step algorithm. It includes resources for inpatient settings, outpatient follow-up, and even pharmacy-specific protocols for reviewing fall-related medications.
Medication Reviews Make a Measurable Difference
Medications are one of the most modifiable fall risk factors, and many nursing home residents take drugs that directly affect balance, alertness, or blood pressure. The CDC identifies six categories of psychoactive medications most strongly linked to falls: anticonvulsants, antidepressants (including both older tricyclics and newer SSRIs), antipsychotics, benzodiazepines, opioids, and sleep medications like zolpidem.
Beyond those, several other drug classes cause dizziness, sedation, blurred vision, or drops in blood pressure when standing. These include antihistamines, anticholinergic drugs (found in many over-the-counter allergy and bladder medications), blood pressure medications, and muscle relaxants. Herbal supplements can interact with these as well.
A practical step for caregivers and family members is to request a comprehensive medication review, ideally by a pharmacist or geriatrician, at least once a year or whenever a resident has a fall. The goal isn’t necessarily to stop all medications but to identify ones that can be reduced in dose, switched to a safer alternative, or eliminated entirely. Even trimming one sedating medication can meaningfully lower risk.
Redesigning the Physical Environment
Environmental hazards are everywhere in institutional settings, and many are easy to fix once someone looks for them. The Agency for Healthcare Research and Quality recommends a room-by-room approach: keep frequently needed items like glasses, water, call lights, and phones within safe reach so residents don’t have to stretch or stand unnecessarily. Rearrange furniture to create clear, wide walking paths without obstacles. Add safety equipment like grab bars and non-slip mats in bathrooms.
Lighting matters more than most people realize. Dim hallways, glare from polished floors, and poorly lit bathrooms all contribute to missteps. Consistent, even lighting throughout resident rooms, hallways, and bathrooms, especially at night, reduces the chance that a resident misjudges a step or misses an obstacle. Nightlights along the path from bed to bathroom are one of the simplest and most effective changes a facility can make.
Flooring is another consideration. Hard surfaces like tile increase injury severity when falls do occur, while overly soft or thick carpeting can catch feet and walkers. Low-pile, non-slip flooring strikes the best balance between traction and impact absorption.
Special Considerations for Residents With Dementia
Residents with dementia present a unique challenge because many standard fall prevention tools don’t work for them, and some can actually cause harm. Bed alarms, for instance, startle confused residents and can trigger the exact agitation that leads to a fall. Physical restraints, once common, are now widely discouraged because they increase injury risk, cause distress, and lead to muscle wasting that makes future falls more likely.
Current best practice for residents with advanced dementia follows a person-centered, sequential approach. Start by establishing care preferences with the resident’s family. Then make environmental changes: lower the bed as close to the floor as possible, place padding on the floor beside the bed, and use supportive arm rests on chairs. Evaluate reversible causes of restlessness like pain, constipation, or urinary discomfort.
Nonpharmacologic strategies are the next line of intervention. Purposeful rounding, where staff check on the resident every hour on a set schedule, catches problems before they escalate. Therapeutic activities, music, massage, rocking chairs, and relaxation techniques all help manage the psychomotor agitation that often drives a confused resident to get up and wander unsafely. Training caregivers and family members in these techniques extends their benefit beyond scheduled activity times. Medication for agitation is reserved as a last resort, used only for severe cases and always aligned with the resident’s overall goals of care.
Hip Protectors: Useful but Hard to Sustain
Hip protectors are padded undergarments designed to absorb impact if a resident falls sideways. In nursing home settings, a Cochrane review of 14 studies covering nearly 12,000 residents found they reduce hip fracture risk by about 18%, translating to roughly 11 fewer hip fractures per 1,000 residents who wear them. That’s a modest but real benefit, especially for residents already identified as high risk.
The catch is adherence. Long-term compliance ranged from just 24% to 80% across studies. Residents find the protectors bulky, uncomfortable, or difficult to manage during toileting. Side effects are minor, with skin irritation affecting 0% to 5% of wearers, but discomfort is enough to make many residents stop using them. Hip protectors also showed no benefit for people living in the community, suggesting their value is specific to the higher-risk nursing home population.
If your facility or loved one’s care team recommends hip protectors, choosing a well-fitting, comfortable design and integrating them into the daily dressing routine improves the odds they’ll actually be worn consistently.
Technology as an Added Layer
Newer technologies are adding a surveillance layer to fall prevention programs. Some facilities now use in-room cameras paired with artificial intelligence that can detect when a resident is attempting to get out of bed or has fallen, sending immediate alerts to staff. Unlike traditional bed alarms that only signal after the resident has already moved, AI-based systems can flag risky movement patterns earlier, potentially allowing staff to intervene before a fall happens.
These systems work best as a supplement to, not a replacement for, the fundamentals: risk screening, medication management, environmental safety, and individualized care planning. No sensor compensates for a cluttered room, an unreviewed medication list, or staff who aren’t trained in safe transfer techniques.
Putting It All Together
The most effective fall prevention programs combine multiple strategies simultaneously. A practical checklist for any nursing home includes screening every resident with a validated risk tool on admission and after any fall, conducting regular medication reviews with a focus on sedating and blood-pressure-lowering drugs, auditing rooms and common areas for environmental hazards, implementing hourly rounding for high-risk residents, using low beds and floor padding for residents with dementia, and considering hip protectors for those at highest fracture risk.
Falls in nursing homes will never be eliminated entirely, but facilities that layer these interventions consistently see meaningful reductions in both falls and the serious injuries that follow. For family members, asking specific questions about each of these areas during care conferences is one of the most productive things you can do to advocate for a loved one’s safety.