Date of Graduation

Winter 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

Abstract

Objective: Falls in skilled nursing facilities increase the risk of injury, readmissions, and higher healthcare costs. This facility’s rates remained high due to inconsistent post-fall protocols, no standardized review process, and insufficient communication. Seventy-five falls were documented in the first eight months of 2025, exceeding the national benchmark of 3–5 per 1,000 patient-days (AHRQ, 2024). Aim: This quality improvement project will occur over a 5-week period from October 1, 2025, to November 5, 2025, and aims to decrease the fall rate by 25%, from 4.3 falls per 1,000 patient-days to 3.3 falls per 1,000 patient-days, through improved team communication and standardized post-fall huddles. Methods: The pre-survey assessed nursing staff knowledge about falls, their communication methods, and self-identified obstacles. The Post-Fall Huddle Binder contained an educational sheet, a standardized huddle form, and visual aids. Staff received educational materials and short training sessions during daytime and evening shifts. The post-survey used identical questions to measure changes in staff knowledge, communication, and engagement. Outcome measures included huddle completion rates, staff evaluations of communication and situational awareness, and care-plan modifications. Results: Post fall huddles were completed for 58% of recorded falls. Staff reported improved communication, better reflection, and stronger teamwork, though time constraints and inconsistent staff attendance remained challenges. Over the five week period, fall numbers did not show major changes. Conclusions: This project showed that scheduled post-fall meetings improved staff communication and understanding of fall events, but did not reduce accidents in the short term. Leaders must establish accessible documentation systems and provide regular staff training to achieve long-term fall rate reductions.

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