Date of Completion
Fall 2026
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Sandra Cleveland
Second Advisor
Kelly Manda
Third Advisor
Kristie Lowry
Abstract
Problem: High resident fall rates and repeat falls caused by an unreliable nurse-only post-fall huddle (PFH) process that lacked structure, interdisciplinary participation, and timely root-cause analysis.
Aim of the Project: To reduce falls and fall-related injuries in long-term care units by implementing a standardized, evidence-based PFH workflow that strengthens root-cause analysis, improves interdisciplinary communication, and increases PFH reliability.
Review of the Evidence: Evidence from fourteen high-quality, peer-reviewed studies demonstrates that structured, interdisciplinary post-fall huddles are more effective than informal, nurse-only approaches in improving fall analysis and reducing repeat falls in long-term care settings. Structured PFHs strengthen root-cause analysis; interdisciplinary participation enhances communication, situational awareness, and psychological safety; and standardized workflows improve reliability, documentation completeness, and PFH completion. These findings show that PFHs grounded in evidence-based practice improve the dependability of fall evaluation by clarifying expectations, increasing team engagement, and ensuring complete documentation. Collectively, the evidence supports adopting the University of Nebraska Medical Center PFH model as a reliable, interdisciplinary strategy to strengthen fall-prevention performance and reduce repeat fall events in long-term care.
Project Design: The design was quality-improvement-centered on the implementation of the University of Nebraska Medical Center (UNMC) standardized PFH workflow across two LTC units. The design used Plan-Do-Study-Act (PDSA) cycles to iteratively test and refine the workflow. The OhioHealth Change Management Model guided stakeholder engagement and communication, implementation, and sustainment.
Intervention: Implementation of the University of Nebraska Medical Center’s standardized post-fall huddle workflow across two LTC units. The intervention required clinicians to initiate the PFH immediately after fall recovery, identify root causes, document contributing factors, engage residents or caregivers, and record interdisciplinary attendance.
Significant Findings/Outcomes: 1. The fall rate decreased from a June fall rate of .92 to a July rate of 6.62 per 1,000 BDOC, and the repeated faller rate declined from 74% to 60%. 2. PFH reliability increased to 70%, an increase from 20.8%. 3. Workflow efficiency was maintained as the PFH duration averaged 17 minutes.
Implications for Nursing: PFH intervention has significant implications for nursing by strengthening clinical decision-making, improving interdisciplinary communication, increasing workflow reliability, enhancing patient safety outcomes, and supporting regulatory compliance.
Recommended Citation
Perry, Janette, "Strengthening Post-fall Huddle Practices in Long-Term Care" (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 75.
https://fuse.franklin.edu/dnp-project/75
Rights
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