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Healthcare risk assessment

Geriatric Medicine and Long-Term Care Risk Assessment: Falls, Medication, Infection and Escalation Controls

A worked example of how a geriatric and long-term care team finds, scores and controls the risks that threaten older residents, from falls and medication errors to infection, delayed escalation, staffing gaps and record failures.

Updated November 2026 8 hazards assessed Review every 3 months Highest risk: Critical to Medium
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Executive summary

This assessment shows how a geriatric and long-term care team can find, rate and control the risks that matter most to older residents. Eight risks were chosen because they are plausible in daily work, from medicine errors and falls to infection, delayed escalation, staffing gaps and record or equipment failure. Medicine errors and delayed recognition of deterioration are the most serious before controls. Each risk is scored before controls and again after existing and added controls. Most fall to Medium or Low once controls are in place, but deterioration and infection stay High while frailty and shared living remain. The first actions are a two person check for high risk medicines, a structured handover format, a rehearsed downtime plan and a minimum staffing level. The service is a teaching example, so every score illustrates method, not a real resident or home.

Focus area
Geriatric medicine and long-term care
Setting
Geriatric inpatient unit and residential long-term care home with community support services
Method
Five by five likelihood and impact risk register with inherent and residual scoring

Scope

This assessment covers older adults receiving assessment, treatment and daily care in a geriatric unit and a residential long-term care home, including handovers, medicines, equipment, records and escalation to specialist services. It does not cover individual diagnosis, treatment decisions or the care plan of any real person. Jurisdiction, funding model, staffing levels and electronic record system are assumptions made for teaching only.

Context

The service has physicians, nurses, care assistants, a pharmacist, physiotherapists, a social worker and a family liaison. Residents often have several long-term conditions, cognitive impairment and reduced mobility. Medicines are dispensed from a pharmacy, records are kept in an electronic system, and specialist review is requested by phone or referral. Each risk is scored before controls to show its natural level, then again after existing and additional controls.

Objectives, assets and stakeholders

The objective is to keep older residents safe from avoidable harm, deliver timely and dignified care, protect their privacy and consent, and keep the trust of families, staff and regulators. The assets in scope are residents and their wellbeing, medicine supplies, clinical equipment, the electronic record, staff competence and the reputation of the service. Stakeholders include residents, families, nurses, care assistants, physicians, pharmacists, allied health staff, the infection prevention team, specialist services and regulators. Every risk has one owner role, and the clinical director reviews the register with the governance group each quarter.

Risk matrix: before and after controls

Each cell shows hazard numbers placed by likelihood and impact. Compare the two grids to see how controls move each hazard.

Before controls

Inherent risk

Risk before controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely Likelihood 4, impact 3, score 12, high: H06 Likelihood 4, impact 4, score 16, high: H02 H04 Likelihood 4, impact 5, score 20, critical: H01
3 Possible Likelihood 3, impact 3, score 9, medium: H07 Likelihood 3, impact 4, score 12, high: H03 Likelihood 3, impact 5, score 15, high: H05
2 Unlikely Likelihood 2, impact 4, score 8, medium: H08
1 Rare

After controls

Residual risk

Risk after controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely
3 Possible Likelihood 3, impact 3, score 9, medium: H02
2 Unlikely Likelihood 2, impact 2, score 4, low: H07 Likelihood 2, impact 3, score 6, medium: H03 H04 H06 H08 Likelihood 2, impact 4, score 8, medium: H01 H05
1 Rare
  • Low 1 to 4
  • Medium 5 to 9
  • High 10 to 16
  • Critical 17 to 25

Hazard register

A summary first, then the detail for each hazard.

Summary of hazards with scores before and after controls
No.HazardBeforeAfterOwner
H01 Medication administration and reconciliation errors 20 Critical 8 Medium Lead pharmacist
H02 Falls and fall-related injury 16 High 9 Medium Nurse unit manager
H03 Pressure injury and skin deterioration 12 High 6 Medium Tissue viability nurse
H04 Infection outbreak and exposure in shared living 16 High 6 Medium Infection prevention and control lead
H05 Delayed recognition of deterioration and poor handover 15 High 8 Medium Clinical director
H06 Staffing shortfall and competence gaps 12 High 6 Medium Director of nursing
H07 Privacy, consent and documentation failures 9 Medium 4 Low Information governance lead
H08 Equipment and information system failure 8 Medium 6 Medium Biomedical engineering lead
H01

Medication administration and reconciliation errors

Safety Before 20 After 8

Doses are missed, duplicated or given to the wrong resident, and medicines are not reconciled at transfer, so harm such as bleeding, sedation or low blood pressure occurs.

Who or what is affected: Residents, nurses, pharmacists and prescribers

Causes

Many medicines per resident, frequent changes, and handovers that rely on memory or paper lists.

Consequences

Preventable harm, hospital readmission, loss of trust and possible regulatory review.

Existing controls

  • Medicines are given from a labelled chart checked against the prescription.
  • A pharmacist reviews the medication list at admission.

Control gaps

Reconciliation at weekend transfers is often incomplete and changes are not always passed on.

Additional controls

  • Prevent: Use barcode or two person checks for high risk medicines such as anticoagulants and insulin.
  • Detect: Run a weekly audit of missed and late doses and reconcile every transfer against the current list.
Likelihood 4 x impact 5 before; 2 x 4 after Owner: Lead pharmacist Target: Within 30 days Early warning: Two or more missed or late doses of a high risk medicine in one week.
H02

Falls and fall-related injury

Safety Before 16 After 9

Residents with weak legs, poor balance, sedating medicines or night time confusion fall while moving, toileting or reaching for items, causing fractures, head injury or long lie.

Who or what is affected: Residents, care assistants and visiting families

Causes

Frailty, polypharmacy, low blood pressure on standing, poor lighting and rushed toileting help.

Consequences

Fractures, head injury, loss of independence, fear of falling and bed rest that causes further decline.

Existing controls

  • Falls risk is assessed at admission and after any fall.
  • Call bells are placed within reach and beds are set at a low height.

Control gaps

Post fall reviews do not always lead to a medicine review or a change in the care plan.

Additional controls

  • Prevent: Review sedating medicines and orthostatic blood pressure each month with the prescriber.
  • Respond: Set a rapid check and post fall review protocol, including a neurological check after any head strike.
Likelihood 4 x impact 4 before; 3 x 3 after Owner: Nurse unit manager Target: Within 45 days Early warning: Three or more falls for one resident in 30 days, or any fall with a head strike.
H03

Pressure injury and skin deterioration

Safety Before 12 After 6

Residents who cannot move or who have poor nutrition sit or lie in one position too long, and friction, moisture or shear damages the skin, causing pressure injuries that can become infected.

Who or what is affected: Residents, nursing staff and wound specialists

Causes

Immobility, incontinence, poor nutrition, dehydration and staff shortages at night.

Consequences

Pain, infection, longer stays, surgical repair and loss of dignity.

Existing controls

  • Skin is checked at admission and on a set schedule.
  • Pressure relieving mattresses are used for residents at high risk.

Control gaps

Repositioning charts are sometimes completed without checking the skin.

Additional controls

  • Prevent: Turn or reposition high risk residents on a written schedule that is matched to their skin assessment.
  • Detect: Record weight loss and intake each week and refer to dietetics when they fall below a set level.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Tissue viability nurse Target: Within 60 days Early warning: Any new redness that does not fade within 30 minutes of pressure release.
H04

Infection outbreak and exposure in shared living

Safety Before 16 After 6

Respiratory, urinary or gastrointestinal infections spread between residents and staff through shared rooms, poor hand hygiene or visitors, and frail residents become unwell quickly.

Who or what is affected: Residents, staff, visitors and families

Causes

Shared rooms, close physical care, visitors who are unwell and staff working across several units.

Consequences

Outbreak, hospital transfer, deaths in vulnerable residents and temporary admission bans.

Existing controls

  • Hand hygiene stations are placed at each room entrance.
  • Staff with symptoms are asked to stay away from work.

Control gaps

Symptom checks at shift start are not recorded consistently.

Additional controls

  • Prevent: Audit hand hygiene and personal protective equipment use each week and give direct feedback.
  • Respond: Isolate symptomatic residents, notify the infection lead and start a written outbreak plan at the first case cluster.
Likelihood 4 x impact 4 before; 2 x 3 after Owner: Infection prevention and control lead Target: Within 30 days Early warning: Two or more residents with similar symptoms within 72 hours on one unit.
H05

Delayed recognition of deterioration and poor handover

Operational Before 15 After 8

Changes in confusion, breathing, intake or temperature are missed or reported late, and handovers between shifts or to specialists omit key facts, so urgent treatment starts too late.

Who or what is affected: Residents, nurses, junior doctors and families

Causes

Busy shifts, atypical signs of illness in older people and unclear thresholds for calling for help.

Consequences

Sepsis, aspiration, delayed transfer, avoidable death and moral distress among staff.

Existing controls

  • Observations are recorded at set times using an early warning score.
  • Shift handover is given at the bedside for high risk residents.

Control gaps

Escalation thresholds are not reviewed against actual outcomes and atypical signs are not taught.

Additional controls

  • Prevent: Use a structured handover format and a shared list of residents who need extra checks.
  • Detect: Review every score that reached the escalation threshold and check the response time.
Likelihood 3 x impact 5 before; 2 x 4 after Owner: Clinical director Target: Within 30 days Early warning: An early warning score at the escalation level with no documented response within 30 minutes.
H06

Staffing shortfall and competence gaps

People Before 12 After 6

Shifts are covered by agency or newly qualified staff who are not trained in dementia care, moving and handling or medicines, so care is rushed and unsafe practice is missed.

Who or what is affected: Residents, permanent staff and agency workers

Causes

Vacancies, sickness, high turnover and reliance on temporary staff.

Consequences

Missed care, more falls and errors, staff burnout and higher turnover.

Existing controls

  • Rotas are set four weeks in advance and reviewed daily.
  • New staff complete a induction checklist before working alone.

Control gaps

Competence records for agency staff are not checked before the shift starts.

Additional controls

  • Prevent: Set a minimum safe staffing level for each unit and stop admissions when it cannot be met.
  • Respond: Hold a short competence check for agency and new staff on high risk tasks before first shift.
Likelihood 4 x impact 3 before; 2 x 3 after Owner: Director of nursing Target: Within 60 days Early warning: Shifts filled below minimum staffing or with more than one new worker alone.
H07

Privacy, consent and documentation failures

Legal and compliance Before 9 After 4

Records are incomplete, consent for care or sharing is not recorded, or confidential information is seen by people without a need to know, which breaks trust and legal duties.

Who or what is affected: Residents, families, staff and regulators

Causes

Time pressure, paper and electronic records side by side, and unclear rules on who may view a record.

Consequences

Unsafe care decisions, complaints, regulatory action and loss of trust.

Existing controls

  • Staff sign confidentiality agreements when they join.
  • Consent forms are kept in each resident file.

Control gaps

Capacity decisions are not always revisited when a resident's condition changes.

Additional controls

  • Prevent: Check consent and capacity decisions at each review and record who was involved.
  • Detect: Audit a sample of records each month for gaps, late entries and unauthorized access.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Information governance lead Target: Within 90 days Early warning: A record audit that finds consent or capacity entries missing for more than 10 percent of files.
H08

Equipment and information system failure

Technology and data Before 8 After 6

Hoists, oxygen supplies, pumps, alarms or the electronic record fail or lose data, so residents are moved, treated or monitored late or with wrong information.

Who or what is affected: Residents, nurses, technicians and pharmacy staff

Causes

Ageing devices, software updates, power cuts and reliance on a single system.

Consequences

Delayed care, medicine errors, lost records and possible harm to residents.

Existing controls

  • Equipment is serviced on a fixed schedule and logged.
  • Records are backed up each night.

Control gaps

Downtime procedures are not rehearsed and spare devices are not checked.

Additional controls

  • Prevent: Test emergency oxygen and backup power each month and keep a spare for each critical device.
  • Recover: Keep paper downtime forms and test restoring the record system from backup each quarter.
Likelihood 2 x impact 4 before; 2 x 3 after Owner: Biomedical engineering lead Target: Within 60 days Early warning: Any critical device that fails a monthly test or a backup restore that does not complete.

Rating method and evaluation

Each risk is rated on two five-point scales. Likelihood runs from Rare to Almost certain, and impact runs from Minor to Catastrophic for the resident. Multiplying the two gives a score from 1 to 25, which falls into one of four bands: Low from 1 to 4, Medium from 5 to 9, High from 10 to 16 and Critical from 17 to 25. The score guides the order of work and is not a measurement. Inherent risk is the score before any controls. Residual risk is the score after existing and additional controls. Impact is judged on physical harm, distress, time to recover, effect on the resident's independence and harm to trust, and a risk is never rated down only because it has not yet happened. Critical and High risks need senior attention and a dated plan, Medium risks need routine controls with a named owner, and Low risks are accepted and watched. Frontline staff, residents' families where appropriate and the governance group should challenge the ratings, and every rating is reviewed when an indicator reaches its threshold or after a serious event.

Likelihood, impact and rating bands

Likelihood

  • 5 Almost certain: Expected to happen in most circumstances.
  • 4 Likely: Will probably happen in many circumstances.
  • 3 Possible: Could happen at some time.
  • 2 Unlikely: Not expected, but it could happen.
  • 1 Rare: Only in exceptional circumstances.

Impact

  • 1 Insignificant: No lasting effect. Handled within routine work.
  • 2 Minor: Small effect that is quickly corrected.
  • 3 Moderate: Noticeable effect that needs managed effort to correct.
  • 4 Major: Serious effect on people, delivery or reputation.
  • 5 Catastrophic: Severe or lasting effect that threatens the whole activity.

Bands (likelihood x impact)

  • Low (1 to 4): Accept and monitor.
  • Medium (5 to 9): Manage with routine controls.
  • High (10 to 16): Senior attention and a treatment plan.
  • Critical (17 to 25): Act first. Do not proceed until reduced.

Monitoring, escalation and review

Review this assessment every 3 months, and sooner when an indicator below reaches its threshold.

Early-warning indicators and escalation thresholds
Indicator to watchEscalate when
Missed or late doses of high risk medicines recorded in the week.Escalate to the lead pharmacist when two or more occur in one week, and to the clinical director if the pattern continues for a month.
Falls per resident in a rolling 30 day period, including any head strike.Escalate to the nurse unit manager after any fall with a head strike, and to the clinical director when a resident has three or more falls.
Early warning scores at escalation level without a documented response within 30 minutes.Escalate to the clinical director at once, and to the medical lead if the response is still missing after one hour.
Shifts filled below minimum staffing or with a new worker working alone.Escalate to the director of nursing before the shift starts, and stop new admissions to the unit if the level cannot be met.
Failed monthly device tests or backup restores that do not complete.Escalate to the biomedical engineering lead within one day, and to the governance group if a critical device is out of service.

Contingency arrangements

If a serious event occurs, such as a resident death, a confirmed medicine error, an outbreak or a major equipment failure, the nurse in charge takes immediate clinical action, informs the responsible physician and calls for specialist help. The unit manager secures the scene and preserves records. The infection lead or pharmacist is contacted as needed. Families are told promptly and honestly, and the governance group reviews the event. Downtime forms and a spare device are used until services are restored.

Prioritized action plan

  1. Introduce two person checks and reconciliation at every transfer for high risk medicines, owner lead pharmacist, within 30 days.
  2. Adopt a structured handover format and a clear escalation threshold for early warning scores, owner clinical director, within 30 days.
  3. Set a minimum safe staffing level per unit and check competence before agency staff start, owner director of nursing, within 60 days.
  4. Run a hand hygiene and symptom check audit each week with an outbreak plan ready, owner infection prevention and control lead, within 30 days.
  5. Test backup power, emergency oxygen and record restore, and rehearse downtime forms, owner biomedical engineering lead, within 60 days.

Conclusion

Safe geriatric and long-term care depends on steady habits: two person checks for high risk medicines, structured handovers, early recognition of change, safe staffing, clear consent records and tested equipment and downtime plans. The highest scores sit with medicine errors and delayed escalation, and each has actions that bring the residual score down. Treat the register as a living record, review it on the stated cycle, and seek qualified clinical and legal advice for any real resident or service decision.

Assumptions and limitations

Assumptions

  • Residents are adults aged 65 or over, with varied cognitive and physical needs.
  • Staff hold recognized qualifications and work under local supervision rules that are not specified here.
  • Jurisdiction, funding and the electronic record system are not specified, so duties are described in general terms.

Limitations

  • Scores are examples for learning and do not describe any real service or resident.
  • Clinical practice and legal duties vary by setting and change over time, so specialist review is needed.
  • This is educational content and does not replace a formal site-specific assessment or licensed clinical advice.

Related frameworks to study

  • Hierarchy of controls
  • Structured handover tools such as situation, background, assessment and recommendation
  • Medication reconciliation at admission, transfer and discharge

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For Learning Reference Only: This assessment demonstrates how risk assessment principles are applied in a practical setting, providing a useful reference for learning and understanding. Actual assessments may be adapted to suit specific site conditions and circumstances.

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