There are gaps in care given to elderly people in England who have fallen and fractured bones, a Royal College of Physicians report says.
It says figures from 157 of the 173 hospital trusts showed nearly a third of hip fracture patients were not treated within the 48-hour target.
Many of the 8,800 people treated for falls did not get assessments to help them avoid future falls, it says.
The Department of Health is issuing new guidance to improve standards.
About a third of people over 65 will fall each year and for over 75s the figure is even higher.
Hip fractures, which occur in about 60,000 people a year who fall, cost the NHS £1.7bn and are associated with up to 14,000 deaths.
Guidelines developed by the government's National Service Framework for Older People and the NHS advisory body, the National Institute for Health and Clinical Excellence, have set down a range of standards for health professionals to follow.
The RCP received data from 157 of the 173 hospital trusts on 8,800 patients who were either classed as hip fracture patients or non-hip fractures, which includes wrist, pelvis or vertebra.
It found 31% of hip fracture patients were not given surgery within the recommended 48 hours with one in 10 not treated by the four-day mark.
When they first arrived at hospital, four out of five of these patients spent over two hours in A&E before transfer to a suitable ward.
There were also inconsistencies in the risk assessments offered to patients returning home to stop them falling again.
Two thirds of hip patients were given balance assessments, but the figure among non-hip patients was just 28%.
A fifth of non-hip and 16% of hip patients did not have home hazard assessments performed despite requiring one.
And just a minority of patients - a fifth of non-hip and a third of hip - had osteoporosis risk assessments.
The report called on hospitals to review their practices and called on local health bosses to develop better fracture services in the community to help prevent secondary falls.
Lead author Dr Finbarr Martin said: "Despite several years of national policy and clear evidence based guidelines, local health services have much more progress to make in this vital clinical area for older people.
"The wide variation between the sites in this audit does show however what can be done, and it is up to local NHS commissioners, managers and clinicians to work together to provide for their local populations what only a few are currently achieving."
The findings mirror a report by the British Orthopaedic Association and the British Geriatrics Society in September which called for the overhaul of fractures care.
Pamela Holmes, healthy ageing programme manager for Help the Aged, said: "It's a huge worry that most local health services charged with running falls services are still poorly coordinated.
"How many times must we emphasise the importance of prevention when it comes to older people, falls and bone health?"
Nick Rijke, of the National Osteoporosis Society, said many fractures were preventable.
Health Minister Ivan Lewis said preventing and responding effectively to falls was a crucial element in ensuring older people's health and well-being.
He said advances had been made, with a 60% increase in knee replacements, and a 20 increase in hip and cataract operations since 2001.
But he added: "I am issuing guidance today to support best practice in this area and will consider the range of recommendations made within the report."