When Missed Entries Lead to Missed Prevention: A Falls Prevention Care Planning Breakdown

How falls prevention care planning failed to translate into individualised nursing action

In elderly care settings, falls are a major patient safety concern and proper documentation is a cornerstone of their prevention. When a patient is known to be at risk and yet assessments are incomplete or duplicated without critical thinking, the door is opened to avoidable harm.

In this case, a patient admitted to a rehabilitation unit was assessed as being at risk of falling. However, while the care plan ticked the box for “risk of falls,” no rationale was recorded as to why the risk applied, and none of the interventions were personalised. The prescribed falls care plan included Comfe rounding, cohorting, low beds, sensor alerts, and crash mats but there was no indication these were introduced, reviewed, or evaluated in any documented way.

Several days after transfer, the patient suffered a fall. Days later, another. Both incidents occurred against a backdrop of uncoordinated nursing notes and documentation gaps, with care plans failing to adapt to the patient’s ongoing risk factors such as confusion, mobility issues, and a modified Parkinson’s medication regime.

Falls prevention care planning must go beyond generic checklists

The central issue in this case wasn’t that staff failed to recognise the patient’s risk of falling, they did. It was that the care planning remained passive. There was no escalation to medical teams for medication review, no tailored risk mitigation, and no evaluation of interventions. A robust falls prevention care plan should be individualised and updated regularly.

Key issues included:

• Lack of recorded reasoning behind risk assessment

• No documented evaluation of falls interventions

• Missed opportunity for medical and therapy review

• Poor correlation between digital and handwritten records

• No escalation or multidisciplinary input despite repeat falls

As the expert noted, the failure to implement, tailor, and review the prescribed interventions amounted to a breach of duty under the Bolam/Bolitho test. A responsible body of nurses would not have considered this level of care adequate.

“The absence of individualised falls planning and poor documentation mean we don’t know what measures were in place or whether they were ever followed. That is indefensible.”— Apex Nurse Expert Witness

Why individualised falls risk plans must be the default

In high-risk populations, no care plan is meaningful unless it is contextualised to the individual. That means reflecting not just the diagnosis, but the patient's mental state, medication changes, gait, and history of falls. Here, the lack of structured thinking and documented accountability turned a standard risk into a predictable outcome.

Falls cannot always be prevented but poor planning and documentation make even unavoidable events indefensible.

Need an expert witness to comment on a falls case? Get in touch with us at info@apexexperts.co.uk, call us on 0203 633 2113 or visit our contact us page.