between personal, staff-related and environment-related interventions. Examples for each of these categories can be: hip protectors, training of staff or call systems to summon nursing staff that can be easily reached. The reports of all six commissions during the past three years show that fall prevention does not meet the requirements of an effective prevention process in some of the facilities that were visited. The visits made during 2015 substantiated this assessment by the NPM. In one facility in Salzburg and in one in Upper Austria, fall management was set up for the first time upon recommendation by the NPM. In other cases, the commissions objected to the fact that the existing system was not adequately implemented and/or there was no regular evaluation of measures taken after falls had occurred. If existing risks are being ignored completely and over a lengthy period of time, this can have fatal consequences for residents. This was adequately confirmed by way of visits by commissions. Deficiencies in new construction, remodelled buildings and older buildings In a facility in Tyrol, for example, Commission 1 found that based on the documentation within two weeks, a total of 62 falls had been recorded. Residents indicated that since then they were extremely uncertain, they hardly trusted themselves to do anything, even after less serious injuries. Observing painful falls by others made persons needing care fearful. Commission 1 recommended directly on site that a well-founded reassessment of fall prevention for the entire retirement and nursing home be tackled. In the meantime this has been done and was supported by staff training. 62 falls in two weeks Expert assessment of each individual fall and the analysis of falls throughout the entire facility (recording of frequency, circumstances and consequences of all falls in the facility) are always required in order to be able to analyse the effects of measures taken to prevent falls over the long term. One of these assessments in a facility showed that falls occur increasingly when there are team meetings, in other words during a period in which fewer staff are available for the residents. By making organisational changes, this hazard could be corrected relatively easily. Analysis of how falls occur In the fall prevention process, documentation is an important factor. However, it is often viewed as a burden in daily nursing care when staff resources are scarce. Careful and comprehensive documentation ensures an adequate sharing of information. This is the basis for the evaluation of care planning. The documentation and central recording of fall incidents is necessary in order to identify weak points and to be able to react to them accordingly. Central documentation is absolutely necessary  Only effective fall prevention ensures the right of residents of retirement homes to the best level of health possible.  Training in fall prevention, dealing with behavioural abnormalities and care concepts for 37