Every fall requires immediate assessment, safety intervention, notification, documentation, and follow-up. Nurses must determine whether the fall was witnessed or unwitnessed, whether injury occurred, whether the resident hit the head, whether anticoagulants are used, and whether neuro checks are required by policy.
Immediate Nursing Actions
- Stay with resident and assess before moving.
- Check airway, breathing, circulation, pain, deformity, bleeding, head injury, range of motion, and mental status.
- Obtain vital signs.
- Notify provider and supervisor.
- Notify family/responsible party.
- Initiate neuro checks when required.
- Document circumstances and resident statement.
- Update fall risk interventions.
Neuro Check Documentation
- Level of consciousness.
- Pupils.
- Grips/strength.
- Speech.
- Facial symmetry.
- Vital signs.
- Headache, vomiting, dizziness, confusion.
- Pain and behavior changes.