Why It’s Important to Perform an Effective Post-Fall Investigation

September 12, 2022

On her way out of a senior living center following her shift, a care team member helped a 79-year-old resident to the bathroom without using an ordered gait belt. The woman fell, hit her head and subsequently died from a head injury.

An 85-year-old woman who was admitted to the hospital with complaints of vertigo and double vision died from complications of a fall after being left alone in the bathroom by the nursing team despite being assessed as an elevated risk for a fall.

A 76-year-old man who resided in a senior living community died after falling out of a lift sling when a care team member transferred him from his wheelchair to his bed inappropriately and without assistance.


A quick and thorough investigation of fall events like these allows for earlier insight into the contributory causes of the fall.

“Investigating the circumstances of a fall and implementing appropriate and timely interventions is crucial, as a history of falls is the single best predictor of future falls.”

Monica Chadwick, Constellation Sr. Risk Consultant
What to do immediately following a fall event

Following a fall, the main priority is the stabilization and ongoing care of the patient or senior living resident. Care teams must immediately provide the person with necessary medical attention and stabilization and offer emotional support for the person as well as any family members.

Established notification practices will ensure that any treating clinicians, other care team members, administration and family members are made aware of the fall event and provided with the critical details as they are known.

Fall event investigation

A fall event investigation process should define the method and timeliness for notification of the individual responsible for performing the investigation. See Constellation’s resource, HEAL Tools Quick Reference Guide: Event Response.

  • Fall circumstances: One of the initial steps in the fall event response process is documenting a full written description of all the circumstances surrounding the fall. In some instances, the person may be found on the floor and the exact time of the fall is not known. In this situation, it is a best practice to document the exact time the person was found and not speculate when the fall may have occurred. Through care team interviews and a review of the medical record, it may be possible to determine the last time the patient or senior living resident was visualized by the care team.
  • Location: Documentation should include as many details about the location of the fall as possible. This should include information regarding the proximity to any furniture, assistive devices found nearby and blood or other indicators of how the fall occurred. Drawing a diagram of the room in which the fall occurred along with reference to the location of the fallen person in relation to other objects in the room is also helpful. Photographs of the location of the fall may also be helpful in determining causes and contributing factors.
  • Safety devices: If safety devices such as bed/chair alarms, bed bolsters or floor mats were in use, note that as well. If a safety device was in place but failed to operate as intended, note any significant findings that might explain the reason. For example, “The resident had a chair alarm attached to her sweater; however, the resident removed her sweater and was able to stand up from the wheelchair without causing the alarm to sound.”
  • Transfer devices: If a transfer device was involved in the fall, secure it immediately, remove it from service and prohibit any alterations or repairs to the device. Secure any other relevant information such as security camera footage, alarm system data, equipment maintenance records, and staffing schedules and assignments.
  • Witnesses: It is also important to document if the fall was witnessed by any care team members. In the event of an unwitnessed fall, do not speculate as to how the person fell (e.g., slid out of wheelchair during self-transfer). Simply stick to the facts of what is known. For example, “The resident was found supine on the floor in front of her wheelchair.”
  • Statements: The investigator should take statements from all involved parties and witnesses, including the family, and inform them they may be contacted later for additional follow-up. It is good practice to obtain full names and contact information for all parties and include this information with the witness statement.
  • Broader investigation: Next, determine if a broader investigation is needed and, if so, which type (apparent, common, root cause analysis). Then create a timeline of the facts from the interviews, room inspection, and accounts from witnesses and the medical record.
  • Record-keeping: Maintain investigative notes in a confidential risk management file with restricted access. Secure the medical record, including any records from other departments such as laboratory, imaging or clinicians independent from the facility.

Establishing an effective process for investigating a fall will ensure readiness to respond quickly in the critical first hours and days following an event. It will also ensure processes are focused on investigating facts, preserving evidence and analyzing for improvement.

Report unanticipated outcomes early so we can offer our early intervention program: HEAL

At Constellation, we’re creating a better way forward after harm events—a way that can preserve relationships, promote communication and improve everyone’s experience. Our early intervention program, HEAL, champions this better way forward.

We’re prepared and ready to support our customer care teams, clinicians and health care organizations immediately following a harm event. We encourage customers to contact us as soon as possible when things don’t go as planned, so we know to offer our HEAL services.

Our HEAL Prepare Toolkit will help assess your team’s readiness to respond to a fall harm event and then help you get to best practices. The Toolkit includes assessments, sample tools and coaching. Start your journey by taking the HEAL Assessment and then the Action Plan will guide you through the Toolkit’s four units: (1) culture, (2) event response, (3) communicating after harm events, and (4) moving forward.

Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.

To learn more about Constellation’s early intervention program, HEAL, and to assess your ability to respond effectively to a harm event like this one, sign in to ConstellationMutual.com to access the HEAL Prepare Toolkit and take the HEAL assessment.


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