Degree Name
Nursing Practice, DNP
Publication Date
9-29-2025
First Advisor
Lisa Drake
Second Advisor
Beverly Clark
Abstract
Falls remain a persistent patient-safety threat in skilled nursing facilities (SNFs). At a Dallas–Fort Worth SNF, a needs assessment identified rising unassisted falls and inconsistent protocol adherence. This quality improvement (QI) project examined whether a structured, evidence-based bundle could improve staff knowledge and fall-prevention processes and reduce falls over four weeks. Guided by Lewin’s Change Theory and implemented with Plan–Do–Study–Act (PDSA) cycles, the pre–post design engaged direct-care staff (registered nurses, licensed vocational nurses, certified nursing assistants; n = 20). The intervention included standardized risk screening with the Morse Fall Scale (MFS), targeted staff education, high-risk visual identifiers, and post-fall huddles. Outcomes were staff knowledge (pre/posttest), process compliance (MFS completion, visual alerts, huddles), and fall counts and rates per 1,000 patient days. During the intervention, MFS completion increased from 59% to 72%, visual alerts from 50% to 72%, and post-fall huddles from 41% to 83%. Falls decreased from 22 to 18 (18%), with the rate declining from 13.32 to 11.07 per 1,000 patient-days (17%), although the difference was not statistically significant, χ² (1, N = 20) = 0.18, p = .67. Staff knowledge improved significantly from pretest (M = 79.35, SD = 5.00) to posttest (M = 90.30, SD = 5.78), W = 0.00, p < .001. Findings indicated that the bundle was feasible within 12-hour shifts, improved process reliability, and showed an early favorable trend in outcomes; continued monitoring was warranted to assess durability over longer periods.
Rights Management
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License
Recommended Citation
Jenkins, LaKeesha, "Quality Improvement Project Improving Fall Risk Protocol Compliance Through a Structured Fall Prevention Program in a Skilled Nursing Facility" (2025). Doctor of Nursing Practice Projects. 220.
https://arch.astate.edu/dnp-projects/220
