Background <p>Falls are a major cause of injury and death among older adults, yet recent data from Iran are limited. This study examines the demographic and clinical characteristics of fall-related hospitalizations in Tehran and identifies predictors of adverse in-hospital outcomes.</p> Methods <p>This retrospective cohort study included all adults aged ≥ 65 years initially presenting to the Emergency Department of a major trauma center in Tehran and subsequently admitted for fall-related injuries from September 2024 to September 2025. Electronic records provided demographic, clinical, and fall data. Logistic regression analyses were performed to identify factors associated with intensive care unit (ICU) admission and prolonged (≥ 7 days) hospitalization, while Firth penalized logistic regression was used for in-hospital mortality.</p> Results <p>Among 192 older adults (mean age 78.70 years; 53.1% female), same-level falls were most frequent (81.3%), with lower-extremity injuries predominating (52.1%), notably intertrochanteric fractures (26.0%) and femoral neck fractures (14.6%). Overall, 21.9% required ICU admission, 7.3% died in hospital, and the mean length of stay was 6.8 days. In the multivariable analysis, injury severity was the only predictor of in-hospital mortality and the main predictor of other adverse outcomes. Besides injury severity, having cardiac disease was associated with ICU admission (OR 2.667, 95% CI 1.083–6.566; <i>p</i> = 0.033), and neurological disease was associated with both ICU admission (OR 2.494, 95% CI 1.070–5.814; <i>p</i> = 0.034) and prolonged hospitalization (≥ 7 days) (OR 2.118, 95% CI 1.008–4.449; <i>p</i> = 0.048).</p> Conclusion <p>Characterizing older adults hospitalized for falls can help clinicians and health-service planners identify high-risk patients, optimize care pathways, and inform targeted interventions.</p>