Nursing Home Fall Litigation: What Attorneys Need From Medical Experts

Falls are the most ordinary event in long term care and one of the hardest claims to try. Every attorney who handles nursing home cases has seen the pattern: a resident with a documented fall risk, a care plan that lists interventions, a night shift with too few aides, and a hip fracture or a brain bleed that starts a decline ending in death. There is no MDL and no bellwether calendar for these claims. They are tried one resident at a time in state court. And 2026 has made one point very clear: a fall case that cannot explain how the resident fell, and why a specific missing intervention would more likely than not have prevented it, can be lost on a directed verdict no matter how sympathetic the facts. That is a medical question, and it is why both sides need long term care nursing, geriatric medicine, consultant pharmacy, rehabilitation, orthopaedic and neurosurgical, and forensic experts.

This is the fourth post in our long term care series, after pressure injuries, sepsis and infection, and elopement. Med Legal Pro has written about falls before, including our look at hip fracture liability in hospitals and nursing homes. This post focuses on what has changed in 2026 and on what each expert has to prove.

The Litigation Landscape

Falls are cited under F689, the federal tag for accidents and supervision. The regulation, 42 C.F.R. Section 483.25(d), requires that the resident environment remain as free of accident hazards as possible and that each resident receive adequate supervision and assistance devices to prevent accidents.³ In the CMS health deficiency file with a processing date of September 1, 2026, which covers the three most recent inspection cycles for every certified nursing home, F689 was cited 21,343 times out of 418,947 health citations.¹ The severity grid is what matters for litigation. F689 accounts for 4,293 of the 13,316 citations at the actual harm level (scope and severity G, H, or I), about 32 percent, and 2,634 of the 9,248 immediate jeopardy citations (J, K, or L), about 28 percent. Of the F689 citations, 11,828, more than half, came from complaint surveys rather than routine inspections.¹ F689 also covers elopement and other accident hazards, so these figures are not falls alone, but falls are the core of the tag.

On the outcome side, the CMS national average file with the same September 1, 2026 processing date reports that 3.23 percent of long stay residents experienced one or more falls with major injury.² That number should be read with caution, and an expert who uses it should say why. In September 2025 the HHS Office of Inspector General reported that nursing homes failed to report 43 percent of falls with major injury that resulted in a Medicare paid hospitalization in the required Minimum Data Set assessments, looking at assessments from July 2022 through June 2023.⁴ OIG found under reporting was most common at for profit, chain, and larger facilities, and that the facilities with the lowest fall rates on Care Compare were the least likely to report the falls OIG examined. In other words, a low published fall rate may reflect missing paperwork rather than safe care. For plaintiffs, that finding supports discovery into incident reports, hospital records, and EMS run sheets, not just the MDS. For defendants, it is a reminder that the facility’s own records will be tested against outside documents.

Verdicts in 2025 and 2026 show what is at stake when a jury believes the records do not match what happened. In Estate of Combs v. Chesterwood Village, a Butler County, Ohio jury returned a $12.5 million verdict on May 14, 2026, including $1.5 million in punitive damages, according to plaintiff’s counsel and local reporting.⁵ The plaintiff alleged that an 83 year old blind resident was dropped on the back of her head during a wheelchair to bed transfer, that the facility documented only a minor face first fall from a wheelchair, and that the EMS run report described a head injury and blood in her room. She suffered an intracranial bleed and died about ten months later. The facility has said it strongly disagrees with the verdict. We did not find a post-trial ruling. In Minnesota, a Dakota County jury awarded more than $5.47 million on February 28, 2025 in the death of an 87 year old rehabilitation patient who, according to plaintiff’s counsel, was assigned an agency aide on her third day who had not been told about her fall precautions.⁶ And in April 2026, plaintiff’s counsel at Spangenberg Shibley & Liber reported a $5 million verdict where a mechanical lift with a missing safety clip allegedly let its strap slip off the spreader bar, causing a fall and a subdural hematoma.⁷ These are case specific jury findings, subject to post-trial motions and appeal, and none establishes liability in any other case.

Two appellate decisions and one trial court ruling from 2026 shape how these cases are pleaded and proved.

Falls can be custodial neglect, not professional negligence. In Aud v. RRT Enterprises, LP, 121 Cal.App.5th 1231 (Cal. Ct. App. July 22, 2026), a jury awarded $2,342,800 to a resident who fell repeatedly at a skilled nursing facility, with the worst fall fracturing her humerus, pubic ramus, and ischium. The trial court cut noneconomic damages to the $250,000 MICRA limit. The Court of Appeal reversed that ruling, holding under Holland v. Silverscreen Healthcare, Inc., 18 Cal.5th 364 (2025), that the claims arose from the facility’s role as custodian and caregiver, not as a health care provider, so the MICRA cap did not apply.^8,9 The court quoted the Supreme Court’s line: a fall claim may sound in professional negligence when it is based on prescribing or executing a plan for a resident’s medical needs, but a claim based on failure to supervise and assist residents with daily activities generally does not. The resident’s evidence included call lights out of reach or not working and 30 to 45 minute response times. How an expert frames the breach, as clinical judgment or as basic supervision and assistance, can decide which damages rules apply in California.

Without evidence of how the fall happened, the causation opinion can fail. In Dozier v. Indian Hills Healthcare Group, Inc., 2026-Ohio-3116 (8th Dist. Aug. 13, 2026), a resident fractured his hip in an unwitnessed fall in his room and died about ten days later. The plaintiff’s physician expert listed interventions he said were missing: a bedside table, positioning pillows, a concave mattress, a toileting schedule, a floor mat, and a low bed. On cross examination he agreed that if the resident fell while simply walking in his room, none of those interventions would have helped. The court of appeals affirmed a directed verdict for the facility, holding that because there was no evidence of how the resident fell, the opinion that more precautions would have prevented the fall was speculative.¹⁰ The same opinion upheld exclusion of federal and state regulations as evidence of the standard of care under Ohio R.C. 2317.45(B). By contrast, the Combs jury found a violation of Ohio’s statutory Nursing Home Residents’ Bill of Rights, R.C. 3721.13.⁵ In Ohio, the statute and a well supported expert carry the case, not the CMS tag.

Arbitration still turns on capacity and medical records. Admission arbitration agreements remain a first battleground. In Blackshear v. Providence Operator, LLC, as summarized by defense counsel in October 2026, the Philadelphia Court of Common Pleas declined to enforce an admission ADR agreement after finding, by clear and convincing evidence, that the resident lacked capacity when he signed it. The court relied on contemporaneous records, including a low BIMS score, a cognitive communication deficit, and inability to answer basic orientation questions.²¹ That puts a clinician’s reading of the chart at the center of a procedural fight that often decides the forum.

The Injuries at Issue

The typical serious outcomes are hip and other proximal femur fractures, pelvic and humerus fractures, vertebral compression fractures, and head injuries ranging from scalp lacerations to subdural and other intracranial hemorrhage, especially in residents on anticoagulants or antiplatelet drugs. Death cases usually follow one of two paths: a head bleed with a rapid neurologic decline, or a fracture followed by surgery or nonoperative care, immobility, delirium, pneumonia, pressure injury, and failure to thrive. The death certificate in Dozier listed “failure to thrive with recent hip fracture,” a phrasing that both sides will fight over in a wrongful death case.¹⁰

Delayed recognition is its own injury. In Dozier the resident reported hip pain two days after the fall.¹⁰ Claims often allege that staff failed to perform a post-fall assessment, failed to notify the practitioner and family, failed to obtain imaging, or kept a resident on a blood thinner without a neurologic check. Each of those is a separate standard of care question with a separate causation answer.

The Science Behind the Claims

Hip fracture outcomes in nursing home residents are poor. In a cohort of 60,111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fracture, Neuman and colleagues found that 36.2 percent died within 180 days. Among residents who were not already totally dependent in locomotion, 53.5 percent died or became totally dependent within 180 days. Nonoperative management was associated with roughly double the hazard of death compared with internal fixation (HR 2.08, 95% CI 2.01 to 2.15).¹¹ Those numbers support damages and causation in death cases. They also give the defense a baseline: a frail resident with a hip fracture carries a high mortality risk even with good care, and the expert has to address what share of the outcome the fall, rather than the underlying condition, caused.

The evidence for individual interventions in care facilities is weaker than many care plans assume. The 2018 Cochrane review of falls prevention in care facilities and hospitals included 71 trials and 40,374 participants in care facilities. For care facilities, the authors were uncertain of the effect of exercise on the rate of falls, found general medication review may make little or no difference, and were uncertain of the effect of multifactorial interventions on the rate of falls. Vitamin D probably reduced the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95) but not the number of residents who fell, in populations with low vitamin D levels.¹² This cuts both ways. A plaintiff’s expert should not claim that a generic list of interventions is proven to prevent falls. A defense expert should not claim that because single interventions have modest effects, nothing the facility did or failed to do mattered. The real question is whether the facility assessed this resident’s specific risk factors and responded to them, which is what the 2022 World Guidelines for Falls Prevention recommend: a multifactorial assessment and individualized interventions for residents at high risk, with medication review and attention to the circumstances of prior falls.¹³

Medications are a central causation issue. A 2018 meta-analysis of psychotropics and falls in older adults found pooled adjusted odds ratios of 1.54 for antipsychotics (95% CI 1.28 to 1.85), 1.57 for antidepressants (1.43 to 1.74), and 1.42 for benzodiazepines (1.22 to 1.65).¹⁴ The CMS September 1, 2026 national averages report that 15.38 percent of long stay residents received an antipsychotic and 19.52 percent received an antianxiety or hypnotic medication.² A fall after a dose increase, a new sedative, or a missed gradual dose reduction is a pharmacology question as much as a nursing question.

Alarms and rails are not the answer many families expect. A cluster randomized trial of bed alarm use in hospital units increased alarm use but showed no difference in falls, injurious falls, or restraint use.¹⁵ CMS surveyor guidance states there is no evidence that physical restraints, including bed rails and position change alarms, prevent or reduce falls, and that restraints can contribute to serious injury.¹⁹ Bed rails carry their own hazard: the CPSC identified 284 entrapment deaths involving adult portable bed rails from 2003 through 2021 and adopted a mandatory safety standard for rails manufactured after August 21, 2023.¹⁷ In March 2026, CPSC announced a recall of about 122,000 Vive Health adult bed rails after two reported entrapment deaths, one at an assisted living facility.¹⁸

Hip protectors and post-fall imaging have real evidence. A Cochrane review found moderate quality evidence that providing hip protectors in nursing or residential care probably reduces hip fracture risk slightly (RR 0.82, 95% CI 0.67 to 1.00), about 11 fewer fractures per 1,000 residents, with adherence as the main barrier.¹⁶ On head injury, the Falls Decision Rule derived in 4,308 emergency department patients age 65 and older found 3.2 percent had clinically important intracranial bleeding; 26 percent were on anticoagulants. The rule, which still required external validation, would forgo head CT only when there was no head injury on falling, no amnesia, no new neurologic abnormality, and a Clinical Frailty Scale score below 5.²⁰ Most nursing home residents will not meet that last criterion, which matters in a case alleging a facility failed to send a resident out after an unwitnessed fall.

Why Expert Witnesses Are Critical, by Specialty

Long term care nursing and Directors of Nursing. The nurse expert reads the admission fall risk assessment, the care plan, the CNA care card, the incident report, and the post-fall huddle, and explains whether interventions were individualized, communicated to the aide on the floor, and revised after each fall. The Englin allegations, an agency aide not told about fall precautions, are a nursing communication case.⁶ Nurse experts are also the ones who catch documentation that does not match the EMS run report, as alleged in Combs.⁵

Nursing administration and staffing. Most fall cases allege short staffing. The September 1, 2026 national averages show 3.86 total nurse staffing hours per resident day, 3.42 on weekends, and 45.8 percent total nursing staff turnover.² An administration expert compares the facility’s payroll based journal data and assignment sheets with the acuity of its residents and with the care plan the facility wrote. In California, under Aud and Holland, this supervision and assistance evidence is also what keeps a case on the custodial side of the line.^8,9

Geriatric medicine and physician oversight. A geriatrician addresses frailty, orthostatic hypotension, delirium, dementia, vision, and continence as fall risk factors, the attending physician’s and medical director’s role, and whether the post-fall medical evaluation was adequate. In death cases, the geriatrician is often the expert who has to separate the fall from the resident’s underlying trajectory, using data like the Neuman cohort.¹¹

Consultant pharmacy and clinical pharmacology. Pharmacists review the medication regimen, sedating drug changes in the days before the fall, gradual dose reduction history, anticoagulation, and whether monthly drug regimen reviews flagged fall risk. Psychotropic exposure is one of the best documented fall risk factors in the literature.¹⁴

Physical therapy and rehabilitation. Therapists address gait, transfer status, assistive devices, and whether therapy recommendations reached the care plan. In Dozier, the resident had just been discharged from therapy as “independent,” a fact the court relied on.¹⁰ A rehabilitation expert can explain what that label meant and did not mean.

Orthopaedic surgery, neurosurgery, and neurology. These experts address the injury mechanism, fracture pattern, the effect of delayed diagnosis, surgical versus nonoperative decisions, and, for head injuries, the timing of a subdural hematoma and whether earlier imaging or reversal of anticoagulation would have changed the outcome.

Emergency medicine and radiology. Emergency physicians speak to transfer decisions and post-fall imaging standards.²⁰ Radiologists can date fractures and hemorrhage, which is often the key to proving or disproving an undocumented fall.

Equipment, environment, and human factors. Mechanical lift, bed rail, and wheelchair cases need an expert on device inspection, maintenance, manufacturer instructions, and entrapment zones.^7,17,18

Forensic pathology. In death cases, the forensic pathologist addresses cause and manner of death, how a fracture or head bleed connects to death weeks later, and whether certificate language like “failure to thrive” reflects the medical evidence.

Life care planning and economics. For survivors, a life care planner documents the cost of the new level of care, which is usually permanent after a hip fracture or brain injury in an older adult.

What Attorneys Should Look For

• Mechanism evidence. After Dozier, identify how the fall happened before retaining causation experts: roommate and staff statements, EMS run sheets, hospital history, room layout, call light logs, and alarm data.¹⁰
• Intervention to mechanism fit. The expert should tie a small number of specific interventions to the actual mechanism, not list every possible precaution.
• Documentation gaps. Compare the incident report, MDS, nursing notes, and outside records. OIG’s 43 percent under reporting finding makes this comparison routine, not accusatory.⁴
• Medication timeline. Map every sedating drug and anticoagulant against the fall date.¹⁴
• State law framing. Know whether regulations are admissible (they were excluded in Dozier), whether a residents’ rights statute applies, and, in California, whether the claim is custodial or professional.^8,9,10
• Defense side. Look for a documented, individualized, revised care plan, the baseline mortality risk of the resident’s conditions, and evidence that the fall would have occurred despite reasonable precautions.^11,12

Key Dates and Authorities

Date	Authority or event	Why it matters
August 21, 2023	CPSC adult portable bed rail standard, 16 C.F.R. Part 1270, applies to rails made after this date	Product standard for entrapment cases17
February 28, 2025	Englin verdict, Dakota County, Minn., over $5.47 million	Agency aide not told of fall precautions, as alleged6
April 28, 2025	CMS Appendix PP Rev. 229 implemented	Current surveyor guidance on restraints, rails, and alarms19
August 14, 2025	Holland v. Silverscreen Healthcare, 18 Cal.5th 364	Custodial versus medical line for fall claims in California9
September 11, 2025	HHS OIG report OEI-05-24-00180	43 percent of serious falls not reported in the MDS4
March 26, 2026	CPSC recall of about 122,000 Vive Health bed rails	Two reported entrapment deaths18
April 2026	Mechanical lift fall verdict, $5 million, as reported by plaintiff’s counsel	Equipment maintenance theory7
May 14, 2026	Combs v. Chesterwood Village verdict, Butler County, Ohio, $12.5 million	Undocumented fall alleged; punitive damages awarded5
July 22, 2026	Aud v. RRT Enterprises, 121 Cal.App.5th 1231	MICRA cap does not apply to custodial fall neglect8
August 13, 2026	Dozier v. Indian Hills Healthcare Group, 2026-Ohio-3116	Directed verdict affirmed: no evidence of fall mechanism10
September 1, 2026	CMS processing date for current deficiency and national average files	F689 cited 21,343 times; 3.23 percent long stay major injury fall rate1,2

How Med Legal Pro Helps

Med Legal Pro connects plaintiff and defense attorneys with credentialed experts who review long term care records every day: LTC nurses and Directors of Nursing, nursing administration and staffing experts, geriatric physicians, consultant pharmacists, rehabilitation therapists, orthopaedic, neurosurgical, emergency and radiology specialists, forensic pathologists, and life care planners. We start with the chart, the incident reports, and the outside records, so the causation opinion is built on how the fall actually happened. Browse our expert witness directory or learn more about our nursing home expert witness services.

Are you a clinician with long term care, geriatric, pharmacy, rehabilitation, or orthopaedic experience who wants to do expert work? We are adding experts in these specialties now. Med Legal Pro: The Expert for Experts.

Sources

1. CMS Provider Data Catalog, Health Deficiencies dataset (r5ix-sfxw), processing date September 1, 2026. data.cms.gov
2. CMS Provider Data Catalog, State and US Averages dataset (xcdc-v8bm), processing date September 1, 2026. data.cms.gov
3. 42 C.F.R. Section 483.25(d), Accidents. ecfr.gov
4. HHS Office of Inspector General, Nursing Homes Failed To Report 43 Percent of Falls With Major Injury and Hospitalization Among Their Medicare-Enrolled Residents, OEI-05-24-00180 (September 11, 2025). oig.hhs.gov
5. Eadie Law press release, June 8, 2026 (Butler County C.P., verdict May 14, 2026) nursinghomeinjurylawyers.com; WCPO, June 9, 2026 wcpo.com
6. Ciresi Conlin LLP, $5.4M Verdict Obtained for the Wrongful Death of 87-year-old Nursing Home Patient (Dakota County, Minn., February 28, 2025). ciresiconlin.com
7. Spangenberg Shibley & Liber, Spangenberg Wins $5 Million Verdict for Woman Who Died as a Result of Nursing Home Neglect (April 2026). spanglaw.com
8. Aud v. RRT Enterprises, LP, 121 Cal.App.5th 1231, No. B341254 (Cal. Ct. App., 2d Dist., Div. 7, July 22, 2026) (partially published). courts.ca.gov
9. Holland v. Silverscreen Healthcare, Inc., 18 Cal.5th 364, No. S285429 (Cal. August 14, 2025). justia.com
10. Dozier v. Indian Hills Healthcare Group, Inc., 2026-Ohio-3116, No. 115923 (Ohio Ct. App., 8th Dist., August 13, 2026). supremecourt.ohio.gov
11. Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Internal Medicine. 2014;174(8):1273-1280. doi:10.1001/jamainternmed.2014.2362
12. Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews. 2018;9:CD005465. doi:10.1002/14651858.CD005465.pub4
13. Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing. 2022;51(9):afac205. doi:10.1093/ageing/afac205
14. Seppala LJ, Wermelink AMAT, de Vries M, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: II. Psychotropics. Journal of the American Medical Directors Association. 2018;19(4):371.e11-371.e17. doi:10.1016/j.jamda.2017.12.098
15. Shorr RI, Chandler AM, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Annals of Internal Medicine. 2012;157(10):692-699. doi:10.7326/0003-4819-157-10-201211200-00005
16. Santesso N, Carrasco-Labra A, Brignardello-Petersen R. Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews. 2014;3:CD001255. doi:10.1002/14651858.CD001255.pub5
17. U.S. Consumer Product Safety Commission, Safety Standard for Adult Portable Bed Rails, 16 C.F.R. Part 1270, 88 FR 46979 (July 21, 2023) ecfr.gov; CPSC news release, July 6, 2023 cpsc.gov
18. CPSC, Vive Health Recalls Adult Portable Bed Rails Due to Risk of Serious Injury or Death from Entrapment and Asphyxiation; Two Deaths Reported (March 26, 2026). cpsc.gov
19. CMS, State Operations Manual Appendix PP (Rev. 229, issued April 25, 2025, implementation April 28, 2025), guidance on physical restraints, bed rails, and position change alarms. cms.gov
20. de Wit K, Mercuri M, Clayton N, et al. Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen. CMAJ. 2023;195(47):E1614-E1621. doi:10.1503/cmaj.230634
21. Weber Gallagher Simpson Stapleton Fires & Newby LLP, Philadelphia Trial Court Finds Nursing Home Arbitration Agreement Unenforceable Due to Resident’s Lack of Capacity, JD Supra (October 2026), discussing Blackshear v. Providence Operator, LLC (Phila. C.P.). jdsupra.com

Tracy L. Liberatore Esq, PA-Emeritus, Med Legal Pro. This article is general information for attorneys and is not legal or medical advice. All claims described in pending or recently tried cases are allegations unless and until finally adjudicated.