Date of Graduation
Fall 12-12-2025
Document Access
Project/Capstone - Global access
Degree Name
Master of Science in Nursing (MSN)
College/School
School of Nursing and Health Professions
Program
MSN project
First Advisor
Markus Tungol
Abstract
Objective To implement a post-fall huddle guide at a San Francisco Bay Area skilled nursing facility to address the 75 resident falls that occurred over an eight-month period. The literature emphasized the positive impact of huddles on staff communication, awareness, and collaboration which ultimately created a safe environment. Aim By November 4, 2025, the overall fall rates among patients in a San Francisco Bay Area SNF will decrease by 25%, from 4.8 falls per 1,000 patient days to 3.6 falls per 1,000 patient days. Methods Pre-implementation and post-implementation surveys were completed by LVNs and CNAs to assess knowledge of post-fall huddles and obtain feedback about barriers to its implementation. In-service sessions were conducted to introduce post-fall huddles to the LVNs and leadership staff. The electronic health record (EHR) was used to obtain and analyze fall data including overall falls, recurrent falls, injuries, and to identify trends. Results The data obtained from the EHR revealed 12 falls post-intervention and six falls pre-intervention indicating the intervention was not successful. Staff understanding of post-fall huddles was enhanced post-implementation. Conclusion Introducing post-fall huddles to the unit did not reduce the number of falls on the unit however with oversight from a change agent the QI team believes this intervention can create a safe environment for the residents.
Recommended Citation
Dominguez Dominguez, Evelin Yajaira, "Enhancing Patient Safety in a Skilled Nursing Facility with a Post-Fall Huddle Protocol: A Quality Improvement Initiative" (2025). Master's Projects and Capstones. 1954.
https://repository.usfca.edu/capstone/1954
