Fall & Injury Analysis Worksheet

Falls are among the most common — and most preventable — sources of injury in healthcare settings. This worksheet helps attorneys analyze the circumstances surrounding a fall, identify deviations from standards of care, and determine whether the event was preventable.

Use this tool during case screening, breach analysis, deposition preparation, and expert review to map risk, intervention adequacy, supervision failures, and post-fall response integrity.

1. Patient Baseline & Risk Factors

Establish Baseline

• Cognitive status
• Functional status
• Mobility level
• Assistive devices
• Medication profile
• Vision/hearing impairments
• History of falls
• Behavioral symptoms
• Safety awareness

Identify Risk Factors

• Sedating medications
• Orthostatic hypotension
• Incontinence
• Weakness or deconditioning
• Confusion or delirium
• Recent illness or hospitalization

2. Safety Interventions & Prevention Measures

Required Interventions

• Bed / chair alarms
• Non-skid footwear
• Toileting schedule
• Frequent rounding
• Mobility assistance
• Environmental safety checks
• Low bed / floor mats
• Call light within reach

Identify Failures

• Interventions not implemented
• Interventions removed or turned off
• No documentation of monitoring
• No reassessment of effectiveness
• Inconsistent implementation across shifts

3. Fall Event Reconstruction

Document Key Details

• Date and time of fall
• Location
• Activity at time of fall
• Staff present or nearby
• Witness statements
• Environmental conditions
• Assistive devices in use
• Alarms active or inactive

Identify Red Flags

• Unwitnessed fall
• Conflicting accounts
• No documentation of circumstances
• Alarms not functioning or not in use

4. Post-Fall Assessment & Response

Required Steps

• Immediate assessment
• Neurological checks
• Vital signs
• Pain assessment
• Provider notification
• Family notification
• Incident report
• Safety plan update

Identify Failures

• No post-fall assessment
• Delayed provider notification
• No neurological checks
• No documentation of family notification
• No update to safety plan

5. Injury Analysis

Document Injuries

• Bruising
• Lacerations
• Fractures
• Head injury
• Internal injury
• Pain or functional decline

Identify Contributing Factors

• Unsafe environment
• Missed interventions
• Delayed response
• Medication effects
• Inadequate supervision

6. Change in Condition After Fall

Track Post-Fall Deterioration

• New symptoms
• Decline in mobility
• Increased confusion
• Pain escalation
• New abnormal vitals
• New abnormal labs

Identify Failures

• No reassessment
• No provider follow-up
• No escalation despite deterioration

Global Fall-Related Breach Indicators

• No fall risk assessment
• No reassessment after change in condition
• Missing or ineffective interventions
• Alarms not used or not functioning
• No supervision despite high risk
• Unsafe environment
• No post-fall assessment
• No neurological checks
• Delayed provider notification
• No update to safety plan
• Contradictory documentation

These are among the strongest breach indicators in fall-related negligence cases.

Fall & Injury Analysis Identifies Risk Factors, Prevention Failures, and Liability Exposure

Falls and related injuries are among the most common sources of healthcare liability and regulatory scrutiny. This worksheet evaluates whether fall risk assessments, prevention measures, supervision, environmental controls, and post-fall responses met applicable standards of care and regulatory requirements. Our clinical-legal team analyzes care plans, monitoring practices, staffing decisions, documentation, and injury response to identify deviations, causation pathways, and defensibility issues.

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