Falls Protocol in Aged Care NZ — What Staff Must Do

Falls are the most common adverse event in aged residential care. How staff respond in the first minutes determines both the outcome for the resident and your facility's compliance obligations. This guide covers the immediate response, documentation requirements, and what HealthCERT auditors look for.

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Immediate priority: do not move the resident

Unless the resident is in immediate danger (fire, flood), do not attempt to help them up until you have assessed for injury. Moving a resident with a fracture or spinal injury can cause serious additional harm.

Immediate response — step by step

Stay calm and approach safely. Call out to the resident. Assess their level of consciousness.
Do not move them. Assess for visible injury — check head, limbs, and pelvis. Ask the resident where they feel pain.
Call for the on-duty RN immediately — do not attempt to assess injuries beyond your scope of practice.
If unresponsive, not breathing normally, or showing signs of serious injury: call 111 before calling the RN.
Stay with the resident until the RN arrives. Keep them comfortable and calm. If cold, cover with a blanket.
Do not give food, drink, or medication until the RN has assessed.
Document your observations: time found, position, environment, what you saw.

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Documentation requirements

Under Ngā Paerewa, falls must be documented. Most facilities use a combination of:

Incident report — completed by the staff member who found or witnessed the fall, within the timeframe set by your policy (typically 24 hours, sooner for serious events)
Clinical notes — the RN records their assessment, any injury found, actions taken, and notifications made
Care plan update — if the fall indicates a change in the resident's condition or mobility, the care plan must be updated
Family notification record — document when family or next of kin were notified, who spoke to them, and what was communicated

HealthCERT auditors review falls documentation as a core part of every audit. Common findings include: incomplete incident reports, failure to update care plans after falls, and no evidence of family notification.

Section 31 notification to HealthCERT

Under Section 31 of the Health and Disability Services (Safety) Act 2001, you must notify HealthCERT in writing when a serious incident occurs that has put or may put resident health or safety at risk. Falls resulting in:

Fractured hip or other serious fracture
Head injury requiring hospital admission
Death where the fall may have been a contributing factor

...should be assessed for Section 31 notification. When in doubt, notify — HealthCERT prefers over-notification to missed notifications.

Falls prevention obligations

Ngā Paerewa requires facilities to have systems to identify residents at risk of falling and to implement individualised prevention plans. Auditors check:

Falls risk assessments are completed on admission and after any fall
Risk assessments link to the resident's care plan
Prevention measures are documented and reviewed
Environmental risks (lighting, floor surfaces, bed height) are addressed

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Falls data is scrutinised in audits

Auditors look at falls trends across your facility — frequency, location, time of day, and recurrence. If a resident has fallen three times and their care plan hasn't changed, that's a finding. Falls data should drive care plan reviews, not just fill an incident register.

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This article is for general information only. Your facility's specific falls protocol — as documented in your policy manual — takes precedence. Always follow your facility's procedures and consult your RN for clinical decisions.