NZ Aged Care Standards — HealthCERT / Health and Disability Commissioner

Falls management in NZ aged care: what staff must do when a resident falls

Falls are the most common serious incident in aged care. When a resident falls, staff must follow a specific protocol — both for the resident's safety and to meet HealthCERT and Health and Disability Commissioner obligations.

📋 Health and Disability Services Standards (NZS 8134) — HealthCERT compliance requirement

Immediate response — do this first

The 6-step immediate protocol

  1. Do not move the resident — assess for injury in place. Moving a resident who has a spinal injury can cause serious harm.
  2. Call for the on-duty RN immediately using the call system or by calling out.
  3. Stay with the resident — keep them calm, reassured, and still until the RN arrives.
  4. RN assesses — the RN conducts a falls assessment including vital signs, orientation, and visual inspection for injury.
  5. Complete a Falls Assessment Form — within 15 minutes of the fall, document exactly what was found.
  6. Complete an incident report — before end of shift, in your incident management system.

Family and next of kin notification

Within 4 hours — unless assessed as minor

Under the Health and Disability Commissioner's Code of Rights, residents have the right to have their family or next of kin informed of significant events. Your facility's policy will specify the timeframe — most require family notification within 4 hours of a fall, unless the RN assesses it as entirely minor with no injury.

Document when you notified, who you spoke to, and what you told them.

Documentation requirements

What must be recorded

  • Date, time, and exact location of the fall
  • What the resident was doing at the time
  • Whether there were witnesses
  • Environmental factors (wet floor, poor lighting, clutter)
  • Resident's condition at the time (medication, fatigue, confusion)
  • Injuries found on assessment
  • Actions taken — who was called, treatment given
  • Notification to family and doctor

HealthCERT obligations

Audit Standard 1.8 — Incident reporting

NZ Health and Disability Services Standard 1.8 requires that all incidents, including falls, are documented, investigated, and used to improve care. Your facility must demonstrate at audit that:

  • All falls are documented in the incident management system
  • Each fall is reviewed by the clinical team
  • Falls risk assessments are updated after each fall
  • Patterns are analysed and care plans adjusted
  • Families are informed and involved

When to call emergency services (111)

Call 111 immediately if the resident shows signs of:

  • Loss of consciousness (even briefly)
  • Suspected fracture (especially hip, wrist, or vertebral)
  • Head injury with confusion, vomiting, or unequal pupils
  • Chest pain or difficulty breathing after a fall
  • Severe pain that limits movement

Do not wait for the RN before calling 111 if there are obvious signs of serious injury.

Source: NZ Health and Disability Services Standards (NZS 8134), Health and Disability Commissioner Code of Rights, and HealthCERT inspection requirements. This is general guidance — your facility's own falls management policy takes precedence and should be consulted for specific procedures.

Frequently asked questions

Do I need to call a doctor after every fall?
Your facility's policy and the clinical assessment will determine this. At minimum, the on-duty RN must be notified and must assess the resident. The RN will determine whether a doctor needs to be called. For any suspected fracture, loss of consciousness, or head injury, a doctor must be contacted urgently.
What if the resident refuses assessment after a fall?
A resident has the right to refuse assessment under the Code of Rights. Document the refusal in detail, explain the risks to the resident, and notify the RN and if possible the family. Continue to monitor the resident closely.
What is a falls risk assessment?
A standardised tool used to assess a resident's risk of falling, including factors like mobility, medications, cognitive status, vision, and history of falls. Common tools used in NZ include the Morse Fall Scale and the STRATIFY tool. The assessment should be updated after every fall.
How long should incident reports be kept?
Health records including incident reports must be retained for at least 10 years for adult patients in NZ, or until the patient is 26 years old if they were a minor when the incident occurred.

Give your aged care staff instant access to your protocols

Workstep lets your HCAs and support workers ask compliance questions at 11pm and get the right answer from your facility's procedures and NZ standards — with exact citations.

Try Workstep free → Book a 20-minute demo for your team