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
Katie Hooven, PhD, RN, MBA, CNE
Second Advisor
Lydia Forsythe, PhD, MA, MSN, RN, CNOR
Third Advisor
Melanie Brewer, DNSc, RN, FNP-BC, NEA-BC, FAANP
Abstract
Problem: Falls are a persistent patient-safety concern in skilled nursing facilities (SNFs), contributing to injury, functional decline, reduced quality of life, healthcare utilization, and costs. At the project site, a short-term rehabilitation unit in an urban SNF, 13 resident falls occurred during the baseline period, with 23% resulting in injury, and prevention relied on routine risk assessments, environmental checks, and post-fall reporting rather than proactive strategies.
Aim: To decrease the overall fall rate by 20%, reduce fall-associated injuries from 23% to 15% or less, and raise staff adherence to evidence-based fall-prevention interventions to 90% or higher within 12 weeks.
Evidence: A review of 11 studies supported multifactorial strategies that integrate fall-risk assessment, purposeful rounding, staff and resident education, interdisciplinary communication, and post-fall learning into a standardized bundle.
Design and Intervention: A quality improvement design used Plan-Do-Study-Act cycles with the OhioHealth Change Management Model guiding readiness assessment, stakeholder engagement, education, and adoption. The 12-week bundle included standardized fall-risk assessment, purposeful hourly rounding using the 5 Ps, staff education, resident and family education, and interdisciplinary post-fall huddles within 24 hours, supported by weekly audits and feedback.
Outcomes: The fall rate decreased from 4.70 to 3.11 falls per 1,000 patient-days, a 33.8% reduction. The injury proportion decreased from 23.0% to 12.5% with no major injuries. Average bundle compliance reached 92.5%, and post-fall huddle completion was 100%.
Implications: A comprehensive fall-prevention bundle supported a proactive, system-based approach to resident safety; sustaining these outcomes requires continued nursing leadership, education, audit and feedback, and interdisciplinary collaboration.
Recommended Citation
Lubin, Ginette, "Implementing a Fall-Prevention Bundle to Reduce Falls in a Skilled Nursing Facility" (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 78.
https://fuse.franklin.edu/dnp-project/78
Rights
Copyright, all rights reserved
Included in
Geriatric Nursing Commons, Public Health and Community Nursing Commons, Quality Improvement Commons
