Date of Graduation

Fall 12-15-2017

Document Type


Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Mary Lou De Natale

Second Advisor

Robin Jackson

Third Advisor

Francine Serafin-Dickson



Falls are a major preventable problem in healthcare that affects people of all ages but disproportionately affects the frail and elderly. Fall reduction programs play a significant role in reducing falls and fall related injuries and are a critical component in Home Health settings. This project takes place in a home health and hospice services agency. The purpose of the project consisted of aggregating fall data for benchmarking metrics to bring the agency’s Fall Reduction Program closer to compliance with state and national fall prevention guidelines. Two hundred and three fall event reports were analyzed and a problem arose from the collected information. Close to half of the reports were incorrectly or insufficiently documented. Frontline staff was invited to complete an informal questionnaire which delved into the clinician’s familiarity with the fall reduction program and asked questions regarding the reporting tool usage. The discovery of results led to the secondary objective of the project which involved modification of the reporting tool to make it more effective. Application of care environment manager and clinical outcomes manager were the clinical nurse leader themes utilized along with Kotter’s theory of change to conduct this quality improvement project. The expectations are that this project will raise falls awareness via training and education, raise the compliance rate for correct fall event report documentation, and serve to provide continued data aggregation for the Fall Reduction Program’s tracking and trending purposes.