What is the recommended management of a fall in an elderly assisted‑living resident, including acute assessment, imaging, medication review (anticoagulants, osteoporosis treatment), pain control, and fall‑prevention strategies?

Management of Falls in Assisted Living Facilities

Conduct a comprehensive post-fall assessment within 7 days, develop an individualized treatment plan with staff education, and refer to the primary physician for medical optimization—this combined approach reduces subsequent falls and hospital admissions. 1

Immediate Post-Fall Assessment

Critical History Elements

Obtain detailed fall circumstances immediately after the event:

• Exact location and time spent on the floor/ground (prolonged downtime indicates severity) 1, 2
• Loss of consciousness or altered mental status during or after the fall 1, 2
• Symptoms of near-syncope, dizziness, or orthostatic hypotension that may have precipitated the fall 1, 2
• Presence of witnesses and exact mechanism of fall 1

Complete Physical Examination

Perform a head-to-toe examination on every resident regardless of apparent injury severity, as failure to do so commonly results in missed occult fractures and subdural hematomas 1, 2:

• Head trauma assessment (scalp lacerations, skull tenderness, neurological changes) 1
• Palpation of all extremities for tenderness, deformity, or occult fractures 1, 2
• Orthostatic vital signs (supine, sitting, and standing blood pressure/heart rate) to identify postural hypotension—a priority target for intervention 1, 2
• Neurological examination focusing on peripheral neuropathies, proximal muscle strength, gait abnormalities, and balance deficits 1, 2

Diagnostic Testing Thresholds

Maintain a low threshold for ordering 1, 2:

• EKG if cardiac symptoms, syncope, or unexplained fall occurred 1
• Complete blood count and electrolyte panel to identify metabolic derangements 1
• Medication levels (digoxin, anticonvulsants) when applicable 1
• Head CT for altered mental status or suspected intracranial injury 1
• Radiographs for any suspected fractures 1
• DEXA scan with vitamin D, calcium, and PTH levels to evaluate fracture risk and osteoporosis 1, 3

Comprehensive Medication Review (Mandatory)

Review and modify medications within 7 days of the fall, as education without physician referral does not reduce falls 4, 1:

High-Risk Medications Requiring Immediate Attention

• Vasodilators and diuretics (consistent association with falls) 1, 2
• Antipsychotics and sedative/hypnotics (equal fall risk for both long- and short-acting agents) 1, 2
• Benzodiazepines (both long- and short-acting carry equal fall risk) 1
• Antidepressants 2, 3

Polypharmacy Assessment

Flag residents taking ≥4 medications, as polypharmacy significantly increases fall risk regardless of drug class 1, 2. This threshold is critical—the number of medications matters independent of specific drug classes.

Mandatory Physician Referral

Refer to the primary physician for medication adjustment—this step is non-negotiable, as medication review without physician involvement and subsequent modification fails to reduce falls 4, 1.

Development of Individualized Treatment Plan (Within 7 Days)

The British Medical Journal guidelines emphasize that assessment combined with individualized treatment plans and staff education reduces falls, whereas assessment alone does not 4, 1:

Exercise Prescription (Evidence-Based Targets)

• Balance training ≥3 days per week for at-risk residents 4, 1, 3
• Strength training twice weekly targeting lower extremity strength, range of motion, and transfer ability 4, 1, 3
• Gait assessment and training with focus on safe ambulation techniques 4, 1, 3

Critical caveat: Non-selective exercise programs for all residents do not reduce falls—only targeted programs for high-risk residents are effective 4.

Priority Medical Interventions

• Treat postural hypotension aggressively—this is a priority target with strong evidence for fall reduction 4, 1, 3
• Prescribe vitamin D 800 IU daily for residents at increased fall risk 4, 1, 3
• Manage cardiovascular disorders including arrhythmias 4, 3

Environmental Modifications

Implement specific home safety measures 2, 3:

• Remove loose rugs and floor clutter (reduces tripping hazards)
• Ensure adequate lighting throughout the facility (improves visual cues)
• Install handrails in hallways and grab bars in bathrooms (provides support during transfers)
• Address slippery surfaces with non-slip mats

Important distinction: Home assessment with disability evaluation, education, and referral to the physician reduces falls, whereas assessment and education without referral does not 4.

Mandatory Staff Education (Within 7 Days)

Educate nursing staff on the specific treatment plan within 7 days of the fall—this combined approach (assessment + individualized plan + staff education) is what decreases subsequent falls 4, 1. The American Geriatrics Society and British Geriatrics Society emphasize that staff education alone without individualized assessment is ineffective 4.

Key education components:

• Specific fall risk factors for the individual resident 1
• Implementation of the individualized treatment plan 1
• Recognition of high-risk situations and appropriate monitoring 4, 1

Hip Protectors

Offer hip protectors to all residents—they prevent femoral neck fractures when worn during falls, though compliance remains challenging 4, 5. The British Medical Journal guidelines give this a strong recommendation despite compliance issues 4.

Follow-Up and Monitoring

• Schedule reassessment to evaluate intervention effectiveness and adjust the plan as needed 1
• Monitor for recurrent falls closely—residents with one fall have significantly increased risk for subsequent falls 1, 2
• Arrange expedited outpatient follow-up within 1-2 weeks if the resident was transferred to acute care 2

Common Pitfalls to Avoid

1. Conducting assessment without physician referral for medication modification—this approach fails to reduce falls 4, 1
2. Implementing non-selective exercise programs for all residents—only targeted programs for high-risk residents are effective 4
3. Failing to complete head-to-toe examination—this commonly results in missed occult injuries 1, 2
4. Discharging residents who cannot pass the "Get Up and Go" test without reassessment or admission 2, 3
5. Providing staff education without individualized resident assessment and treatment plans—the combination is essential 4, 1

Quality Assurance

The most successful fall prevention strategies in assisted living are multifactorial interventions that include assessment within 7 days of a fall, development of individual treatment plans, staff education, and physician referral 4, 1, 5. Single interventions consistently fail to reduce falls 4.