Nursing Home Falls in Pennsylvania: The Ones With No Incident Report

The question is the assessment, not the fall

Residents fall. Many are frail, many are cognitively impaired, and preventing every fall would require restraint, which brings its own harms and is separately regulated.

The claim is about whether the facility identified the risk and responded to it. Falls risk assessment on admission and after any change in condition, a care plan reflecting the risk, and interventions actually delivered: bed and chair alarms where appropriate, lowered beds, floor mats, appropriate footwear, toileting schedules, assistance with transfers, and adequate staffing to provide it.

The pattern worth investigating

• A fall with no witness and no incident report.
• A delay before the family was told, particularly overnight.
• A fracture explained as a fall that nobody saw.
• Repeat falls with no change to the care plan after the first.
• An assessed high falls risk with no interventions recorded.
• A delay between the fall and imaging or transfer to hospital.

Repeat falls without a care plan revision is the single most common finding in these cases. The first fall is arguably bad luck. The third is a decision.

Hip fractures are not a minor injury in this population

A hip fracture in an elderly resident frequently marks a permanent decline in mobility and independence, and carries significant mortality risk in the following year. It should not be treated as a broken bone that heals.

Delay in treatment

Sometimes the negligence is not the fall but what followed. A resident left in pain overnight, imaging deferred until the morning, a fracture unrecognized for days. The timeline between the fall, the assessment, the imaging and the transfer is worth examining as closely as the fall itself.

What to ask for

The falls risk assessments, the care plan and every revision, all incident reports including for earlier falls, nursing notes for the 24 hours either side, the medication administration record, and staffing rosters for that shift. Ask in writing and date the request.