Uncovering Patterns of Falls in Elderly Care Facilities: Linking Intentions, Actions, and Caregiver Involvement

Background/Objectives: Falls among elderly people pose a serious threat to their quality of life (QOL). However, overly restrictive preventive measures can inadvertently reduce activity levels and accelerate both cognitive and physical decline. Then, for effective fall prevention that respects residents’ autonomy, it is essential to understand the behavioral intentions and environmental circumstances leading to falls. However, in elderly care facilities, such information is often recorded only as free text in accident reports and remains insufficiently analyzed. This study aims to propose a method for visualizing patterns of behavioral intentions and accident contexts frequently observed in elderly care facilities. Methods: Fall-related accident reports collected from three Japanese care facilities were analyzed using an after-coding approach. Each report was labeled with three elements: (1) failed actions, (2) underlying behavioral intentions, and (3) staff involvement. A Sankey diagram was used to visualize the flow from residents’ intentions to actions and staff responses, enabling the identification of common accident pathways. Additionally, time-series graphs and interview insights were integrated to explore the characteristics of falls and potential intervention strategies. Results: Analysis identified 18 codes for failed actions, 20 for behavioral intentions, and 8 for staff involvement. The Sankey diagram revealed frequent cases where residents with cognitive and physical decline attempted to walk to the toilet without staff assistance, resulting in falls later discovered by staff. Facility-specific accident trends and situational differences were also visualized. Conclusions: This study identified hazardous daily behavior patterns unique to each facility. By focusing on behavioral intentions during accidents, the proposed approach may contribute to fall prevention strategies that respect residents’ voluntary actions and promote safer behavior without limiting independence.