Date of Degree
Summer 2024
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Dr. Brewer
Second Advisor
Dr. Connor
Third Advisor
Dr. Cochran
Abstract
Falls in skilled nursing facilities (SNFs) pose a significant safety risk, causing injuries, extended stays, and increased morbidity mortality. With a fall rate 6.08 per 1,000 patient bed days, exceeding the national benchmark of 5.3, this project aimed to reduce falls using an evidence-based prevention bundle in a facility lacking a comprehensive fall prevention program. A literature review indicated multifaceted fall prevention bundles reduce falls in SNFs. Key components include risk assessment tools, patient education, post-fall huddles, and purposeful hourly rounding. This quality improvement project used Deming's Model for Improvement and the OhioHealth Change Management Model. An interprofessional team of nurses, physical therapists, and other care staff developed and implemented the fall prevention bundle using Plan-Do-Study-Act cycles over an eight-week pilot period. The intervention included Morse risk assessment within 24 hours of admission, purposeful hourly rounding, patient and family education, and post-fall huddles. Staff education emphasized adherence to fall prevention protocols. Results were significant: the fall rate decreased to 0 falls in eight weeks, with bundle compliance averaging 90%. The potential return on investment exceeded 1000%, with estimated cost savings over $85,000 per 1,000 patient days. This nurse-led, evidence-based fall prevention bundle demonstrates the effectiveness of interdisciplinary collaboration and ongoing staff education in reducing fall rates. The project aligns with the Institute for Healthcare Improvement's Triple Aim and supports the IOM's six domains of healthcare quality, enhancing patient safety and outcomes while reducing costs. The success highlights the importance of standardized processes and continuous quality improvement in long-term care facilities.
Recommended Citation
De Los Santos, Mariah, "Reducing Patient Falls in a Skilled Nursing Facility" (2024). Doctor of Nursing Practice (DNP) Scholarly Project. 7.
https://fuse.franklin.edu/dnp-project/7
Rights
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