# 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. Source: https://incidentkit.ai/templates/fall-incident-report ยท Updated Oct 5, 2026 ## 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. ## The template ### 1. Person and event - Patient or resident name and ID - Date of fall - Time of fall - Time found (May be all you know for an unwitnessed fall.) - Exact location (Be specific: 'beside bed, window side' says more than 'room 14'.) - Shift: Day / Evening / Night - Witnessed or unwitnessed: Witnessed by staff / Witnessed by visitor or another patient / Unwitnessed: found on floor / Near-fall: prevented by staff or the person ### 2. Before the fall - Pre-fall activity (Ask what they were trying to do. Reaching and toileting are common.): Walking / Transferring (bed, chair or commode) / Toileting / Getting out of bed / Standing from a chair / Reaching for an object / Being assisted by staff / Showering or bathing / Sitting or lying in bed or chair / Unknown / Other - Footwear: Non-skid shoes or socks / Regular shoes / Slippers / Socks without grips / Barefoot / Other - Assistive device (Say if a device was ordered but out of reach.): None needed / Walker / Cane / Wheelchair / Gait belt with staff / Mechanical lift / Ordered but not in use or not within reach / Other - Most recent fall risk score, tool and date (Use 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 use (Alarms do not replace enough supervision.) - Medications in the last 24 hours that may raise fall risk (Note sedatives, opioids, blood pressure drugs, diuretics, blood thinners and dose changes.) - Environment at the time (Lighting, floor, spills, clutter, bed height, brakes, cords. Look before tidying.) ### 3. What happened - Narrative (What you saw and did. Facts only.) - The person's own account of the fall (Use their words. If they cannot say, write why: confusion, sedation, aphasia.) - Mechanism (Choose what the person or a witness described. 'Unknown' is a valid answer.): Slip / Trip / Loss of balance / Legs gave way / Dizzy or fainted / Slid from bed or chair / Assisted to the floor by staff / Unknown - Witnesses (name and role) ### 4. Injury and assessment - Injury level: None / Minor: scrape, bruise or skin tear / Moderate: needs sutures, splint or treatment / Major: fracture, dislocation, head injury or bleed / Death - Injuries found (body location, size, description) - Head strike or possible head strike (Many policies assume a head strike if the fall was unwitnessed.) - Neuro checks started per policy (Record 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 safe (Orthostatic 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 found / Yes: helped up after assessment / Yes: 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 harm (The 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 today (Examples: 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 yes / Maybe / No: it happened despite safeguards / Not 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 ## 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. ## 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](https://incidentkit.ai/templates/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. ## Frequently asked questions ### 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. ## Sources - [CMS State Operations Manual, Appendix PP: F689, Accidents (definitions and guidance)](https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf) - [eCFR: 42 CFR 483.25, Quality of care (paragraph (d), accidents)](https://www.ecfr.gov/current/title-42/section-483.25) - [CDC: STEADI clinical resources for fall prevention](https://www.cdc.gov/steadi/hcp/clinical-resources/index.html) - [The Joint Commission: Sentinel Event Policy (Comprehensive Accreditation Manual, SE chapter)](https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/camncc_20_se_all_current.pdf) - [AHRQ PSNet: Preventing Falls in Hospitals toolkit](https://psnet.ahrq.gov/issue/preventing-falls-hospitals-toolkit-improving-quality-care) ## Related - [Fall Reporting: What to Record and Review After a Fall](https://incidentkit.ai/use-cases/fall-reporting) - [F689 accidents and supervision: falls, hazards, devices](https://incidentkit.ai/compliance/f-tags/f689) - [Incident reporting software for skilled nursing facilities](https://incidentkit.ai/solutions/skilled-nursing-facilities) - [Patient safety event reporting software for hospitals](https://incidentkit.ai/solutions/hospitals) - [Root Cause Analysis Worksheet (5 Whys Template)](https://incidentkit.ai/templates/root-cause-analysis-worksheet) - [Root cause analysis: definition and meaning](https://incidentkit.ai/glossary/root-cause-analysis)