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Fall incident report template

A fall incident report that records what surveyors and post-fall reviews ask for. It covers witnessed or not, what the person was doing, footwear and device, injury and head strike, and notifications with times. It ends with a short post-fall huddle that feeds the care plan. Use it for falls, near-falls and found-on-floor events.

Updated Oct 5, 20268 sectionsFree to print
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Before you start

When to use it

  • A patient or resident comes to rest on the floor or a lower surface by accident, with or without injury.
  • A near-fall: the person lost balance and was caught, by staff or by themselves, before falling.
  • A person is found on the floor and no one saw what happened.
  • You need a record for the post-fall huddle and the care plan update.
  • The QAPI committee wants falls tracked by location, shift, time of day and activity.

How to fill it out well

  1. Check for injury before anyone moves the person. Fill in the form once the person is safe.
  2. Record witnessed or unwitnessed honestly. If no one saw it, say what was found and when the person was last seen.
  3. Note footwear, device, call light and the room as they were, before it is tidied.
  4. Record every notice with a time, and every failed try to reach family.
  5. Complete a report even with no injury. A fall without injury is still a fall.
  6. Hold a short huddle with the people there. Agree one or two changes you can make and give each an owner.

Fall incident report template

Organization: ______________________   Site: ______________________

1. Person and event
Patient or resident name and ID
Date of fall
Time of fall
Time foundMay be all you know for an unwitnessed fall.
Exact locationBe specific: 'beside bed, window side' says more than 'room 14'.
ShiftDayEveningNight
Witnessed or unwitnessedWitnessed by staffWitnessed by visitor or another patientUnwitnessed: found on floorNear-fall: prevented by staff or the person
2. Before the fall
Pre-fall activityAsk what they were trying to do. Reaching and toileting are common.WalkingTransferring (bed, chair or commode)ToiletingGetting out of bedStanding from a chairReaching for an objectBeing assisted by staffShowering or bathingSitting or lying in bed or chairUnknownOther
FootwearNon-skid shoes or socksRegular shoesSlippersSocks without gripsBarefootOther
Assistive deviceSay if a device was ordered but out of reach.None neededWalkerCaneWheelchairGait belt with staffMechanical liftOrdered but not in use or not within reachOther
Most recent fall risk score, tool and dateUse your site's tool, such as the Morse Fall Scale or Hendrich II.
Call light was within reach and working
Bed, chair or other position-change alarm was in useAlarms do not replace enough supervision.
Medications in the last 24 hours that may raise fall riskNote sedatives, opioids, blood pressure drugs, diuretics, blood thinners and dose changes.
Environment at the timeLighting, floor, spills, clutter, bed height, brakes, cords. Look before tidying.
3. What happened
NarrativeWhat you saw and did. Facts only.
The person's own account of the fallUse their words. If they cannot say, write why: confusion, sedation, aphasia.
MechanismChoose what the person or a witness described. 'Unknown' is a valid answer.SlipTripLoss of balanceLegs gave wayDizzy or faintedSlid from bed or chairAssisted to the floor by staffUnknown
Witnesses (name and role)
4. Injury and assessment
Injury levelNoneMinor: scrape, bruise or skin tearModerate: needs sutures, splint or treatmentMajor: fracture, dislocation, head injury or bleedDeath
Injuries found (body location, size, description)
Head strike or possible head strikeMany policies assume a head strike if the fall was unwitnessed.
Neuro checks started per policyRecord the start time. Frequency follows your protocol.
Takes a blood thinner (anticoagulant or antiplatelet)Tell the physician. It raises the stakes after a head strike.
Vital signs and pain score, with lying and standing blood pressure if safeOrthostatic hypotension (low blood pressure on standing) is a common, fixable cause. CDC STEADI checks for it.
Was the person moved before assessment?Check for injury before moving. Use a lift if a fracture is suspected.No: assessed where foundYes: helped up after assessmentYes: moved before assessment
5. Notifications
Physician or provider notified (name, time, orders received)
Family or representative notified (name, time)If you cannot reach someone, record each try and its time.
Supervisor or charge nurse notified (name, time)
Risk manager or administrator notified (name, time)Tell leaders at once for a major injury, a death or an unexplained injury.
Hospital or emergency transfer (facility, time, mode)
Possible sentinel event: fracture, surgery or casting, brain, nerve or internal injury needing care, or death or permanent harmThe Joint Commission counts these falls as sentinel events if the injuries come from the fall itself. Start a full analysis.
6. Immediate actions
Care and treatment given
Equipment checked (bed brakes, wheelchair locks, call light, alarms)
Care plan updated
Fall risk reassessed
Interim safety measures put in place todayExamples: toileting schedule, bed in lowest position, non-skid footwear, closer watch, medication review.
7. Post-fall huddle
Huddle date
Participants (roles)
Why did the person fall? Ask why until you reach something you can change.Example: 'reaching for the call light', then 'light out of reach', then 'no bed set-up check'.
Contributing factors (patient, task, environment, equipment, staffing, medication)Write 'not a factor' where none applies.
Was the fall avoidable?Likely yesMaybeNo: it happened despite safeguardsNot sure
Follow-up actions (what, owner, due date)
Date to check the actions are working
8. Sign-off
Completed by (name and title)
Signature of person completing the report
Nurse manager or director of nursing review
Date reviewed
Editable copy

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We send an editable version you can adapt to your policies, plus a short checklist. No patient information, ever.

Tips

  • Use one fall definition on all units. CMS counts coming to rest on the ground, floor or a lower level by accident, plus a stopped lost-balance episode.
  • Ask why twice. 'Reaching for the call light' is where the question starts, not ends.
  • Review falls by time of day and location. CMS surveyor guidance names both.
  • Prefer fixes that change the setup, like bed height, lighting or layout, over reminders. The root cause analysis worksheet ranks actions by strength.
  • Position-change alarms can help, but CMS says they do not remove the need for enough supervision.

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Questions

About this template.

Something we missed? Ask us, and a person answers.

What counts as a fall?

CMS: unintentionally coming to rest on the ground, floor or other lower level, not from an overwhelming outside force. A lost-balance episode that someone or something stopped counts. A resident found on the floor is treated as having fallen unless evidence shows otherwise.

Does a fall without injury need an incident report?

Yes. Falls without injury are the best early warning. They show where and when falls happen before anyone is hurt, and they feed the risk assessment and care plan. QAPI committees track all falls.

What should a fall incident report include?

Date, time and place. Witnessed or not. Activity, footwear and device. Call light and alarms. Risk medications. Injury and head strike. Vital signs. Notifications with times. Immediate actions. Care plan changes. This form covers each.

When is a fall a sentinel event?

For Joint Commission sites staffed around the clock, a fall counts when it causes a fracture. It also counts if it needs surgery, casting or traction, care for a brain, nerve or internal injury, or blood products for a clotting disorder, or if it causes death or permanent harm. Every sentinel event needs a full analysis, reported or not.

What is the difference between an avoidable and an unavoidable accident?

CMS calls an accident avoidable when the facility failed to find hazards or assess risk. It is also avoidable if the facility did not act on them, carry out steps like supervision and devices, or check that the steps worked. It is unavoidable when it happened despite all four. The huddle section records this call.

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