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, MS, RN
Abstract
A quality improvement initiative was implemented in a San Francisco Bay Area, skilled nursing facility serving primarily older residents in need of chronic disease management. The facility displayed a high fall-risk burden, in which an extensive microsystem assessment was conducted to determine possible contributors. Information gathered through observation, as well as staff and stakeholder interviews displayed insufficient education, poor interdisciplinary communication and collaboration, limited staff adherence, and inconsistencies in post-fall protocol completion to be among the most imperative areas for improvement. A thorough analysis of literature was conducted to determine potential evidence-based interventions to address barriers and achieve the project's goal of reducing falls, recurrent falls, and associated injuries within the microsystem. The implementation strategy of integrating structured post-fall huddles was determined to be an effective approach in promoting fall prevention by enhancing education, communication, and collaboration. This project aimed at reducing fall rates by 25% over a five-week period. A comprehensive binder with educational materials and post-fall huddle guide was developed and placed at the nursing station. In-service trainings and informational presentations were conducted to educate staff on the implementation project, and tip sheets were posted within the unit to continuously reinforce these efforts. Although predicted fall metric outcomes were not achieved, survey results regarding knowledge and perceptions displayed a positive increase. Great emphasis was placed on promoting education, collaboration, and structure within the facility, yet adherence to post-fall huddles remained limited. Thus, allowing recommendations to be made regarding continued leadership support, on-going staff education, and strengthened workplace culture to achieve sustainability.
Recommended Citation
Sanroman, Leslie, "Integration of Post-Fall Huddles to Promote Fall Prevention in a Skilled Nursing Facility" (2025). Master's Projects and Capstones. 1958.
https://repository.usfca.edu/capstone/1958
