“Resident had a fall. MD aware.”

No injury survey, no neuro checks, no notification detail, no root cause or plan change.

The unwitnessed-fall model note in §4: injury survey, protocol neuro checks, provider and representative notification with times, orders, new interventions, coding, and a root-cause review.

“Fall-risk precautions in place.”

Generic; does not show which individualized interventions or that they were verified.

“Bed/chair alarm functioning, non-skid footwear on, call light in reach, scheduled toileting followed, bed low/locked — verified this shift.”

“Neuro checks WNL.”

No values, no schedule, no comparison — a covering nurse can’t continue them.

“Neuro checks q15min ×4 then q1h per protocol: PERRL, A&O×3, strength 5/5 symmetric, no new deficit; next check 04:20.”