Resident Fall Response SOP Template

1.Purpose

To respond safely and consistently when a resident falls, assess for injury before moving them, notify the right people promptly, and reduce the chance of a repeat fall.

2.Scope

Applies to the immediate response after a witnessed or found fall involving a resident. Routine fall risk prevention measures are covered by a separate SOP.

Definitions

Witnessed fall

A fall observed directly by a staff member as it happens.

Found fall

A fall discovered after the fact, where the resident is found on the floor or shows signs of having fallen.

Post-fall huddle

A short team discussion held after a fall to identify contributing factors and adjust the care plan to reduce repeat risk.

3.Responsibilities

Certified Nursing Assistant (CNA)

Stays with the resident, calls for help and assists the nurse with the response.

Licensed Nurse (LPN/RN)

Assesses the resident for injury, decides on safe handling and notifies the physician and family.

Director of Nursing

Reviews the incident report, leads the post-fall huddle and tracks fall trends.

Family Member / Responsible Party

Is notified of the fall and any resulting care changes.

RACI matrix

R = Responsible, A = Accountable, C = Consulted, I = Informed

4.Materials and PPE

Materials, tools and systems

• →Fall incident report form
• →Vital signs equipment
• →Post-fall assessment checklist
• →Care plan for updating fall risk interventions
• →Physician and family notification log

Personal protective equipment

• →Disposable gloves

5.Procedure

1. 5.1

   Stay with the resident and call for help

   Certified Nursing Assistant (CNA)

   Do not leave the resident alone; call out or use the call system to get another staff member to bring help and equipment.

2. 5.2

   Do not move the resident immediately

   Certified Nursing Assistant (CNA)

   Do not attempt to move or lift the resident until a licensed nurse has assessed them, unless there is an immediate danger such as fire that requires moving them.

   Warning: Never move a resident before a nurse assesses for possible injury, especially head or spine injury, unless there is an immediate danger.

3. 5.3

   Assess the resident for injury

   Licensed Nurse (LPN/RN)

   Check the resident's level of consciousness, look for visible injury, bleeding or deformity, and ask about pain before deciding how to proceed.

   Checkpoint: A licensed nurse assesses for injury before the resident is moved or repositioned.

4. 5.4

   Call emergency services if warranted

   Licensed Nurse (LPN/RN)

   Call emergency services immediately if the resident shows signs of a serious injury, cannot be safely assessed, or per your facility's clinical judgment protocol.

   Warning: When in doubt about a possible head, spine or hip injury, call emergency services rather than attempting to move the resident yourself.

5. 5.5

   Assist the resident up safely if appropriate

   Licensed Nurse (LPN/RN)

   If no signs of serious injury are found and it is safe to do so, use a proper lift technique or mechanical lift and the appropriate number of staff to assist the resident up.

6. 5.6

   Take vital signs

   Licensed Nurse (LPN/RN)

   Take and document vital signs immediately after the fall and again at the intervals required by facility policy over the following hours.

7. 5.7

   Notify the physician

   Licensed Nurse (LPN/RN)

   Notify the resident's physician of the fall, the assessment findings and any injury identified, following facility policy for timing.

   Checkpoint: The physician is notified of every fall, with the assessment findings, before the end of the shift.

8. 5.8

   Notify the family or responsible party

   Licensed Nurse (LPN/RN)

   Notify the resident's family or responsible party of the fall and the resident's current condition promptly.

9. 5.9

   Increase monitoring after the fall

   Certified Nursing Assistant (CNA)

   Increase observation frequency for the resident following the fall, watching for delayed symptoms such as increasing pain, confusion or swelling.

10. 5.10

    Complete the incident report

    Licensed Nurse (LPN/RN)

    Document the circumstances of the fall, the response taken, assessment findings and notifications made on the fall incident report form.

11. 5.11

    Hold the post-fall huddle

    Director of Nursing

    Gather the involved staff shortly after the fall to review what happened, identify contributing factors such as footwear, lighting or timing, and agree on any immediate changes.

12. 5.12

    Update the care plan

    Director of Nursing

    Update the resident's care plan and fall risk interventions based on the huddle findings, and communicate the changes to the full care team.

6.Quality checks

• →Every fall has a licensed nurse assessment documented before the resident is moved.
• →Physician and family notification is documented for every fall.
• →A post-fall huddle is held and documented for every fall.
• →Vital signs are taken and documented at the required intervals following a fall.

7.Records

• →Fall incident report
• →Post-fall vital signs log
• →Physician and family notification log
• →Post-fall huddle notes and care plan updates

8.KPIs

• →Falls per resident days
• →Percentage of falls with a documented nurse assessment before moving the resident
• →Time from fall to physician notification
• →Repeat fall rate for the same resident within 30 days

9.Common mistakes

• →Helping a resident up right away without a nurse assessing for injury first.
• →Delaying physician notification until the next scheduled check-in.
• →Skipping the post-fall huddle when the fall seems minor.
• →Not increasing observation frequency after a fall with no obvious injury.

10.Revision history