Falls are the most common adverse event in aged care, and they're one of the first things HealthCERT inspectors look at. Every rest home operating under a contract with the Ministry of Health must have a falls management programme — but what that actually means in practice is often buried in dense regulation.

This guide breaks down what's required, what good documentation looks like, and the exact steps staff need to take when a resident falls.

What the regulation requires

New Zealand rest homes are certified under the Health and Disability Services Standards (NZS 8134:2021), which set the minimum requirements for aged care providers. Falls management sits primarily under:

  • Standard 2.2 (Safe environment) — requiring identification and management of fall risks
  • Standard 2.5 (Restraint minimisation and safe practice) — relevant where falls have led to restraint considerations
  • Standard 3.1 (Continuum of service delivery) — requiring documented care plans that address individual falls risk

On top of the NZS standards, providers must also comply with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights, particularly the right to services of an appropriate standard (Right 4) and the right to be fully informed (Right 6).

Audit focus area HealthCERT auditors consistently flag falls management as a high-risk area. In 2024–2025, inadequate post-fall assessment and incomplete incident documentation were among the most common corrective action requirements issued to NZ rest homes.

The four elements of a compliant falls programme

1. Risk assessment on admission (and ongoing)

Every resident must have a falls risk assessment completed within 24 hours of admission. Most facilities use a validated tool — the STRATIFY or Morse Fall Scale are both widely accepted. The assessment must be documented in the resident's care plan and reviewed:

  • After any fall
  • After any significant change in condition
  • At each formal care plan review (minimum every six months)

2. Individualised care plan

A falls risk assessment alone is not enough. The risk must translate into a written, individualised prevention plan. This plan should specify:

  • The resident's specific risk factors (e.g. nocturia, medication effects, cognitive impairment)
  • Agreed interventions (call bell access, bed height, non-slip footwear, sensor mats)
  • Who is responsible for each intervention
  • The resident's and family's involvement in the plan
Is your falls protocol buried in a PDF? Upload your SOPs to ShiftScript. Staff get the exact answer with the exact clause — on any device, any time.
Try free with your own docs →

3. Post-fall response protocol

When a fall occurs, staff must follow a defined post-fall protocol. A compliant response includes:

  1. Immediate assessment — assess for injury before moving the resident. Check for pain, deformity, and cognitive state.
  2. Call for clinical support — if injury is suspected or the resident cannot weight-bear, call the RN or on-call clinician immediately.
  3. Medical review — any resident who loses consciousness, sustains a visible injury, or is in pain must be seen by a medical professional within a timeframe specified in your facility's protocol (typically 4 hours for falls with injury).
  4. Family notification — family/next of kin must be notified as soon as practicable. Under the HDC Code, this means the same shift in most circumstances.
  5. Incident report — a full incident report must be completed before the end of the shift. It must include: date, time, location, witnesses, circumstances, resident's physical and cognitive state at time of fall, injuries sustained, and actions taken.
  6. Post-fall monitoring — neurological observations (if head injury is possible) and regular checks per clinical protocol.
  7. Care plan review — the care plan must be reviewed and updated following the fall, with any new prevention measures documented.
HDC liability risk Failure to notify family promptly after a fall is one of the most frequently cited HDC complaints in aged care. The standard is notification "as soon as practicable" — in practice, this means the same shift unless the resident has explicitly opted out of family notification. Document the notification time and who was contacted.

4. Incident review and learning

HealthCERT expects providers to have a systematic process for reviewing falls data — not just individual incidents. This means:

  • Monthly falls data tracking (numbers, locations, times, outcomes)
  • Regular (at least quarterly) team review of trends
  • Evidence that findings lead to changes in care or environment
  • Minutes or notes documenting these reviews

What HealthCERT inspectors look for

During a certification audit, inspectors will typically:

  • Pull a sample of resident files and check that falls risk assessments exist, are current, and link to the care plan
  • Review the incident register and cross-check with care plans to see if falls prompted care plan updates
  • Interview staff — including HCAs — about what they would do if a resident fell. The answer needs to match the documented protocol
  • Check that family notification is documented, not just assumed
  • Look for evidence of organisational learning — meeting minutes, quality reports
Staff interview tip Inspectors routinely ask HCAs: "What would you do if a resident fell?" If your staff can't answer this fluently — referencing your specific protocol — it's flagged as a training gap. Staff should be able to describe the steps without looking anything up.

Common non-compliance issues

Based on HealthCERT corrective action notices and HDC decisions, the most frequent falls-related failures are:

  • Delayed or missing incident reports — reports completed days later, or not at all
  • Generic care plans — the same falls prevention paragraph copy-pasted across multiple residents
  • No post-fall care plan update — fall happens, incident logged, but care plan unchanged
  • Missing family notification record — staff say they called, but there's no timestamp or note
  • Inconsistent risk assessment tool — different staff using different scoring methods

How ShiftScript helps

The challenge with falls protocols isn't that staff don't care — it's that the information is spread across multiple documents (the falls policy, the incident reporting SOP, the HDC Code, your internal care plan template) and staff, especially new HCAs, can't access them quickly when they need them.

With ShiftScript, you upload your falls management policy, your post-fall SOP, and any relevant standards. Staff can then ask questions in plain English — "what do I do if Mrs Johnson falls at 2am?" — and get the exact answer from your documents, with the source clause cited, in seconds. Every query is logged with timestamp and staff handle for your audit trail.