Falls are an enormous issue in long-term care facilities, and are often at the heart of lawsuits against care providers. The medical record is a crucial tool for the defense as it pieces together a timeline of what happened before, during and after a fall. It is imperative to document all of the steps the provider took to demonstrate its awareness of the resident’s fall risk, attempts to prevent them from falling, and response when a fall does happen.

Solving the Mystery of the Fall

In a lawsuit where the plaintiff is claiming the nursing home could have prevented the fall, the defense will want to demonstrate from the medical record that the care team knew and documented the steps taken to identify a patient as a fall risk, to create and implement a care plan, and to evaluate and address the factors that led to a fall. The response should be immediate and demonstrate that the care team researched the factors that prompted the fall and implemented steps to remove or address that cause.

Determining how and why a resident fell can be similar to solving a mystery. Going directly to the source—the resident—doesn’t always yield a conclusive answer. The resident may not be able to remember what happened, or may not have realized what caused the fall. In such instances, the nursing staff may need to rewind the timeline to determine what the resident was doing immediately before the fall, such as getting out of bed to use the bathroom, or reaching down to pick up an item that dropped to the ground.

Post-Fall Considerations and Changes to the Care Plan

• For a resident who fell on the way to the bathroom, did the care team place the resident on a toileting routine to promote regular bathroom assistance? Did the facility implement appropriate interventions, such as grab bars or elevated toilet seats?
• If a resident fell out of bed while trying to reach something, did staff respond by placing items like tissues, drinking water, or television remotes within easy reach of the patient’s bed?
• Did the care team assess the resident’s medications to determine whether one medication or a combination of them caused the resident to experience dizziness or feel lightheaded when standing up?
• Did the facility place a sign in the resident’s room reminding them to use the call light, and did the facility document the resident’s knowledge of the call system?
  If the resident’s fall was due to slipping or losing balance, did the care team provide the resident with appropriate footwear, including well-fitting shoes and non-skid socks? Or, if necessary, did the facility introduce a cane, walker, or wheelchair?
• For residents who are prone to becoming bored and restless, did staff make an effort to engage him in activities?
• Was an interdisciplinary approach used to determine what caused the fall and then address that cause? This may include communicating with housekeepers about their behavioral observations, or assuring that therapists have alerted other members of the care team to a resident’s tendencies.

A resident’s medical record may provide the best evidence that a care team appropriately and quickly responded to a fall. The defense should look for information that the care team immediately updated the care plan by evaluating and adjusting any existing interventions to address the circumstances surrounding the fall.

Ultimately, defense attorneys rely on medical records to create a narrative surrounding the fall and demonstrate that the provider properly cared for the resident. It requires a familiarity with care standards and a knowledge of what to look for—and when. Contact us for assistance with this aspect of building a strong defense to a medical malpractice lawsuit.