A Clinical Guide: How to Assess a Resident After a Fall

With over one in four older adults falling each year, prompt and accurate assessment is critical. Knowing how to assess a resident after a fall can prevent further injury and guide immediate care decisions, ensuring resident well-being.

Quick Summary

Assessing a resident post-fall involves an immediate safety check, a systematic head-to-toe examination for injuries, neurological and vital signs evaluation, and clear documentation to guide care and prevent future incidents.

Key Points

• Immediate Safety: Do not move the resident immediately; first, assess for obvious signs of severe injury and call for assistance.

• Primary Survey: Use the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) method to identify and address life-threatening conditions first.

• Head-to-Toe Assessment: Conduct a systematic physical examination from head to toe to check for injuries, paying close attention to the head, neck, and hips.

• Neurological Checks: Assess the resident's level of consciousness, pupil response, and motor function to rule out head trauma.

• Vital Signs and Documentation: Always take a full set of vital signs and document every finding and action with clear, objective language in the incident report.

• Post-Fall Follow-up: Monitor the resident for 24-48 hours and conduct a root cause analysis to update the care plan and prevent future falls.

Introduction: The Critical Moments After a Fall

Falls in a senior care setting are both common and potentially severe. For caregivers and clinical staff, the moments immediately following a resident's fall are a critical window for assessment and intervention. A systematic and thorough approach is not just a matter of protocol; it's a vital process that can identify life-threatening injuries, mitigate complications, and inform a long-term fall prevention strategy. This guide provides a comprehensive framework for how to assess a resident after a fall, from the initial response to detailed documentation and follow-up care.

Step 1: Immediate Response and Safety (The First 60 Seconds)

Before any physical assessment begins, the first priority is safety—for both the resident and the caregiver. Rushing to move a resident can exacerbate an undetected injury, such as a spinal fracture or hip fracture.

1. Stay Calm and Reassure the Resident: Approach the resident calmly. Their anxiety and fear will be high, and a calm demeanor can help de-escalate their distress.
2. Do Not Move the Resident Immediately: Instruct the resident to stay still. Ask them simple questions to gauge their level of consciousness and pain. For example, "Can you tell me your name?" and "Where do you feel pain?"
3. Call for Assistance: Never attempt to lift a resident alone. Use the call bell or shout for help from other staff members. This ensures you have support for a safe transfer if needed and a second opinion during the assessment.
4. Assess the Immediate Environment: Look for obvious hazards that may have contributed to the fall, such as spills, cords, or poor lighting. Note these for the incident report.

Step 2: Primary Survey (ABCDE Approach)

Once help has arrived and the scene is safe, conduct a primary survey to rule out immediate life-threatening conditions. The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is a standard tool.

• Airway: Is the resident's airway clear? Are they talking? If they are unconscious, check for obstructions.
• Breathing: Are they breathing normally? Note the rate and effort. Look for signs of respiratory distress, like gasping or cyanosis (bluish skin).
• Circulation: Check for a pulse. Look for signs of severe bleeding. Note skin color and temperature.
• Disability: Assess their neurological status. Are they alert, responding to voice, responding to pain, or unresponsive (AVPU scale)? Check pupil size and reaction. Ask about numbness or tingling in their limbs.
• Exposure: While maintaining dignity, you must check the entire body for injury. This means looking for cuts, bruises, swelling, or deformities that might be hidden by clothing.

If any life-threatening issues are discovered during this primary survey, activate emergency medical services (EMS) immediately and begin first aid.

Step 3: Secondary Survey (Head-to-Toe Examination)

If the resident is stable, proceed with a more detailed head-to-toe physical assessment. This systematic check ensures no injury is missed.

Neurological Assessment

• Level of Consciousness: Beyond the initial AVPU check, can the resident recall the events before, during, and after the fall? Amnesia can indicate a concussion.
• Pupils: Check if pupils are equal, round, and reactive to light (PERRLA). Unequal pupils can signal significant head trauma.
• Motor Function: Ask the resident to wiggle their fingers and toes. Can they squeeze your hands with equal strength? Can they push their feet against your hands?
• Sensation: Lightly touch their arms and legs, asking if they can feel it equally on both sides.

Head and Neck

• Head: Gently palpate the scalp for lumps (hematomas), depressions (fractures), or cuts. Check the ears and nose for any clear fluid or blood, which could indicate a skull fracture.
• Neck: Ask about neck pain. If they report any, or if you suspect a head injury, immobilize the neck and assume a spinal injury until cleared by a physician. Do not move them.

Torso and Limbs

• Chest and Abdomen: Ask about pain with breathing. Gently palpate the abdomen for tenderness or rigidity, which could indicate internal injury.
• Pelvis and Hips: Hip fractures are extremely common. Ask about hip or groin pain. Any rotation or shortening of one leg compared to the other is a classic sign of a hip fracture.
• Upper and Lower Extremities: Inspect each arm and leg for deformities, swelling, bruising, or open wounds. Palpate along the bones and ask the resident to move each joint (if able and not painful).

Comparison Table: Minor vs. Major Fall Indicators

Assessment Area	Minor Fall Indicators	Major Fall/Red Flag Indicators
Consciousness	Alert, oriented, no memory loss	Loss of consciousness, confusion, amnesia
Head/Neck	Small bump, minor headache	Severe headache, vomiting, fluid from ears/nose, neck pain
Limbs	Minor scrapes, small bruises	Obvious deformity, inability to bear weight, severe pain
Pain	Localized, mild to moderate pain	Severe, uncontrolled pain, chest or abdominal pain
Mobility	Able to move all limbs, can get up with help	Inability to move a limb, leg rotation/shortening

Step 4: Vitals and Documentation

After the physical exam, a complete set of vital signs is essential. This provides a baseline and can track the resident's condition over time.

• Blood Pressure and Heart Rate: A drop in blood pressure or a rapid heart rate could indicate shock or internal bleeding.
• Respiratory Rate: Note the rate and quality of breathing.
• Oxygen Saturation: A pulse oximeter reading can identify hypoxia.
• Temperature: Check for fever or hypothermia.

Thorough Documentation

Accurate and detailed documentation is a legal and clinical necessity.

1. Time and Location: Record the exact time the resident was found and where the fall occurred.
2. Resident's Account: Quote the resident's description of what happened, if they can provide one.
3. Witness Statements: Include accounts from anyone who saw the fall.
4. Assessment Findings: Document every part of your assessment, from the primary survey to the head-to-toe check and vital signs. Be objective. Instead of "resident's leg looked broken," write "resident's left leg noted with external rotation and shortening, reports 10/10 pain with any movement."
5. Actions Taken: Detail every action, including who was notified (physician, family), interventions performed (first aid, safe transfer), and if EMS was called.

For more information on fall prevention, you can consult the Centers for Disease Control and Prevention (CDC).

Step 5: Post-Fall Management and Prevention

The assessment doesn't end once the resident is back in their bed or chair.

• Monitoring: The resident should be monitored closely for the next 24-48 hours, especially after a suspected head injury. This includes regular neurological checks and vital signs.
• Root Cause Analysis: The interdisciplinary team should investigate the cause of the fall. Was it a medical issue (e.g., hypotension, infection)? An environmental hazard? A medication side effect?
• Care Plan Update: The resident’s care plan must be updated to include new interventions aimed at preventing another fall. This could involve physical therapy, medication review, environmental modifications, or new assistive devices.

Conclusion

A fall is a significant event in the life of an older adult. A prompt, calm, and systematic assessment is the cornerstone of effective post-fall management. By following a structured process—from immediate safety to a detailed head-to-toe check and thorough documentation—caregivers can ensure the resident receives the appropriate care, minimize the risk of complications, and lay the groundwork for preventing future falls. This diligent approach protects the resident's health and reinforces a culture of safety within the facility.

Frequently Asked Questions

What is the very first thing you should do after finding a resident who has fallen?

The very first thing is to assess the situation without moving the resident. Stay calm, reassure them, and call for help immediately. Instruct them to stay still until a basic assessment for severe injury can be completed.

What are the signs of a hip fracture after a fall?

Key signs of a hip fracture include severe pain in the hip or groin, inability to bear weight on the affected leg, and a visible shortening or external rotation of the leg on the injured side.

When should I call emergency services (911) after a resident falls?

You should call 911 immediately if the resident is unconscious, shows signs of a head or spinal injury (e.g., neck pain, fluid from ears), has difficulty breathing, shows signs of a fracture, or has uncontrolled bleeding.

How long should a resident be monitored after a fall?

A resident should be monitored closely for at least 24 to 48 hours. This includes periodic neurological checks (for head injuries), vital signs, and pain assessments, with the frequency determined by facility protocol and the severity of the fall.

What is the AVPU scale used for in a fall assessment?

The AVPU scale is a simplified system to assess a resident's level of consciousness. It stands for Alert, responds to Voice, responds to Pain, or Unresponsive. It provides a quick snapshot of their neurological status.

Why is it important not to lift a resident alone after a fall?

Lifting a resident alone poses a high risk of injury to both the caregiver and the resident. It can worsen an undetected fracture (like a spinal or hip injury) and can easily lead to musculoskeletal injury for the staff member. Always use proper lifting equipment and assistance.

What kind of information should be included in a post-fall incident report?

The report should include the time, date, and location of the fall; a description of the event from the resident and any witnesses; all assessment findings (physical, neurological, vitals); actions taken; notifications made to family and physician; and any contributing environmental factors.