Falls in the First Weeks After SNF Admission: Why Risk Peaks Early

A resident arrives from the hospital tired, weaker than before, and in a room they have never seen. A day or two later, they try to get to the bathroom alone at night. Many skilled nursing teams know this scenario, and the research supports what they see.

The first days and weeks after admission are a high-risk window for falls. Knowing why helps teams focus attention where it counts.

What the Research Shows About Timing

A national study in the Journal of the American Geriatrics Society followed 230,730 people newly admitted to U.S. nursing homes in 2006. About 21% fell at least once during roughly their first month. Facilities with higher certified nursing assistant staffing had lower fall rates.

A large German study of 93,424 newly admitted nursing home residents found that fracture risk was highest in the first months after admission and declined afterward. The authors concluded that newly admitted residents have the highest fracture risk and recommended that prevention start at admission.

A third study, from geriatric rehabilitation units rather than nursing homes, tracked falls day by day. Fall risk was highest in the first week and dropped by about a third in weeks two and three. The early peak was strongest in patients who were disoriented, cognitively impaired or more dependent in daily activities. That setting is close to, but not the same as, a skilled nursing unit, so treat it as a helpful signal rather than a direct measurement.

Why Early Falls Happen

Several common factors stack up in the first days:

• A new environment. The room layout, bed height, call light and bathroom path are all unfamiliar, especially at night.
• Delirium and confusion. Residents coming from the hospital may be newly confused, and confusion was linked to the sharpest early fall risk in the rehabilitation study.
• Medication changes. Hospital stays often bring new or adjusted medications. Some can affect alertness, balance or blood pressure, which is why a medication review is part of most fall-prevention programs.
• Blood pressure drops on standing. Dizziness when getting up can follow illness, dehydration or bed rest. CDC's STEADI materials include checking for postural hypotension as part of fall-risk assessment.
• Footwear and equipment. Hospital socks, missing shoes, or a walker left out of reach.
• Toileting. Urgency, incontinence and a strong wish not to wait for help lead many residents to get up alone.

Use a Post-Fall Huddle

When a fall happens, a short huddle on the same shift captures details that are lost by the next day. Keep it brief and blame-free:

• What was the resident trying to do?
• Where and when did it happen, and who was nearby?
• What changed recently: medications, mental status, sleep, intake, room or equipment?
• What will we try now, and who will tell the next shift?

Report the fall and the huddle findings to the provider and family according to your facility's policy, and update the care plan.

Free Toolkits Worth Using

• AHRQ's Falls Management Program is an interdisciplinary quality improvement program built for nursing facilities. It includes chapters on fall response, data tracking, long-term management, staff and family training, and environment and equipment safety, plus forms and training materials.
• CDC's STEADI (Stopping Elderly Accidents, Deaths, and Injuries) offers an algorithm for fall-risk screening, assessment and intervention, a Stay Independent checklist, a family caregiver brochure, and STEADI-Rx materials for pharmacists.

Neither toolkit requires new software. Both can be adapted to your existing forms.

When Falls Lead to the Emergency Department

In a study of 17 Indiana nursing facilities, falls were the second most common reason for hospital transfer, behind cognitive, behavioral and psychiatric reasons. About 65% of fall-related transfers were emergency department visits only, without hospital admission. The authors suggested studying whether facilities can assess more fall-related injuries on site, and whether having no provider available at the time of the fall increases transfers.

Some falls clearly need emergency care, and that decision belongs to the provider. The practical point is that clear assessment, fast provider access and good handoff information help the provider make the right call.

What to Do This Week

• Flag every new admission as higher fall risk for the first week, regardless of score.
• On admission day, walk the resident's path to the bathroom and check lighting, bed height, call light and footwear.
• Ask the provider or pharmacist to include fall risk in the admission medication review.
• Start a simple post-fall huddle form using AHRQ's Falls Management Program as a guide.
• Review last quarter's falls: how many happened in the first seven days after admission?

A daily admission screen can bring higher-risk new residents to the team's attention in those first days, which is one way Keystone supports facility staff.

This article is general education for skilled nursing teams. Follow your facility's policies and the direction of your medical director and providers.