How to Spot Charting Red Flags in Nursing Home Fall Injuries
Falls are one of the most common—and most preventable—injuries in nursing homes. When an elderly resident falls, the consequences can be devastating: broken hips, traumatic brain injuries, permanent loss of mobility, or death.
But for attorneys, proving negligence or failure to prevent the fall often comes down to what’s written (or not written) in the chart.
At Lexcura Summit Medical-Legal Consulting, our legal nurse consultants (LNCs) are trained to identify charting red flags that may reveal substandard care, missed interventions, or even cover-ups. Here's how we help attorneys evaluate nursing home fall injury cases through careful medical record analysis.
🧾 Why Nursing Home Falls Require Close Documentation Review
Falls in long-term care facilities are rarely isolated events. They are often the result of:
Inadequate fall risk assessments
Poor supervision
Medication side effects
Staff shortages
Failure to implement safety measures
📌 Medical records should clearly show how risks were identified, what steps were taken to prevent falls, and how staff responded when a fall occurred. If these elements are missing, vague, or inconsistent, that’s a red flag.
⚠️ Top 6 Charting Red Flags in Fall Injury Cases
✅ 1. Incomplete or Outdated Fall Risk Assessments
Facilities are required to assess fall risk on admission and update assessments after any change in condition or medication.
Red Flag:
The most recent fall risk score is weeks or months old
No update after a previous fall, hospitalization, or new medication
Risk labeled as “low” despite multiple known fall factors
📌 Impact: May suggest neglect in monitoring or failure to update the care plan.
✅ 2. Missing or Vague Incident Reports
After a fall, there should be a clearly documented incident report detailing:
Date, time, and location of the fall
What the resident was doing
Whether the fall was witnessed or unwitnessed
Any injuries noted
Red Flag:
The report is vague, contradictory, or missing entirely
Different versions of the incident across the nurse and CNA notes
No body map or injury assessment included
📌 Impact: May indicate inconsistent care—or possible concealment of facts.
✅ 3. Lack of Timely Provider Notification
Regulations require that providers be notified of any fall, especially when an injury or change in condition occurs.
Red Flag:
No documentation shows that the physician was called
Delays of several hours between fall and provider contact
No follow-up orders or assessment after notification
📌 Impact: May support allegations of failure to monitor, delayed treatment, or poor communication.
✅ 4. Post-Fall Monitoring Gaps
Residents should be monitored after a fall for neurological changes, pain, and any signs of deterioration.
Red Flag:
No neuro checks documented for head injuries
No pain assessments following a fracture
Long gaps in monitoring (especially overnight)
📌 Impact: May demonstrate failure to follow post-fall protocols, contributing to injury progression.
✅ 5. Inconsistent Witness Statements or CNA Notes
Nursing home fall cases often rely on documentation from CNAs and nurses. Conflicting accounts can weaken the defense—or support your claim.
Red Flag:
CNA says resident was found on the floor; nurse notes “was getting out of bed”
Progress notes copied/pasted with no update
Statements contradict video footage or family accounts
📌 Impact: Undermines facility credibility and suggests charting inconsistencies or falsification.
✅ 6. Lack of Preventive Interventions in the Care Plan
If the resident was a known fall risk, the chart should include:
Bed or chair alarms
Floor mats
Scheduled toileting
Assistive devices
Low beds or increased supervision
Red Flag:
No fall prevention interventions documented
Interventions listed, but no evidence that they were used
No care plan update after a prior fall
📌 Impact: Strong indicator of systemic neglect or failure to individualize care.
👩⚕️ How Lexcura Summit Helps Attorneys Evaluate Fall Injury Cases
Our legal nurse consultants:
Review admission, nursing, CNA, therapy, and incident documentation
Reconstruct care timelines from days or weeks before the fall
Identify red flags that support claims of neglect, understaffing, or documentation errors
Compare interventions to standard fall prevention protocols
Create chronologies, expert-ready summaries, and annotated exhibits
✅ We help attorneys connect documentation gaps to causation, liability, and damages.
📁 Real-World Case Example
Case: Unwitnessed Fall Leads to Subdural Hematoma
A 76-year-old woman fell in her room overnight. No bed alarm or toileting schedule was in place, despite three prior falls. Post-fall notes lacked neuro checks, and the provider was not notified for 6 hours. Lexcura Summit’s LNC team reconstructed a timeline, identified multiple red flags, and supported a $625,000 settlement for the family.
🛡️ Why Attorneys Trust Lexcura Summit
Over 200 licensed medical professionals with long-term care experience
HIPAA-compliant portals and secure record review
7-day turnaround on most case files
Trusted by plaintiff and defense firms nationwide
Specializing in falls, pressure ulcers, medication errors, and elder neglect cases
Final Thoughts
Falls in nursing homes are not just accidents—they are often foreseeable and preventable. With Lexcura Summit’s expert review, attorneys gain the insight needed to uncover documentation failures and prove how neglect led to injury.
📞 Contact Lexcura Summit Medical-Legal Consulting today to strengthen your next nursing home fall case with clinical clarity and legal strategy. www.lexcura-summit.com or Tel: 352-703-0703
