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

Mark Tungol, MS, RN, ACCNS-AG, PHN

Abstract

A skilled nursing facility in the San Francisco Bay Area is experiencing fall rates surpassing the national average throughout the year. Falls among elderly residents lead to multi-level complications, from minor bruising to major injuries such as fractures, head injuries and hospital transfer, and in the most severe cases, higher mortality rates. To address the issue of high fall rates at the nursing facility, the post-fall huddle protocol was developed on the unit. The team intends to reduce the facility's fall rate by 25% over the next five weeks, from October 1 through November 5, 2025, along with improving the current post-fall prevention protocol, to enhance staff communication and increase staff awareness regarding falls. Methods, including a pre-survey, SWOT analysis, and Root Cause Analysis, were conducted to assess the microsystem. Education sessions on post-fall huddles were provided to staff, a guideline binder was created for educational purposes, and tip sheets were posted around the unit to reinforce staff understanding of post-fall huddles. The results showed that post-fall huddles did not reduce fall rates within the short project timeline, though the intervention improved communication, teamwork, and staff engagement around fall prevention protocols.

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