Date of Graduation

Fall 12-11-2020

Document Type

Restricted Project - USF access only

Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions




Population Health Leadership

First Advisor

Dr. Serafin-Dickson, Francine

Second Advisor

Dr. Capella Elena


Problem: A 120-bed capacity skilled nursing facility (SNF), located in the San Francisco Bay area, showed increased patient falls (two to four in a day, with minor to major injuries). The Spring 2019 Centers for Medicare and Medicaid Services (CMS) state survey required the facility to develop an action plan to reduce patient falls and improve patient safety concerns.

Context: For better patient safety and to increase the CMS 5-star facility rating, the affordable fall prevention project plan began in June 2019. The multidisciplinary team of management leaders, doctors, nurses, quality and safety teams, DNP student, and administrators decided to address patient safety concerns and the unacceptable number of falls/day.

Interventions: The Lippit change theory model was used to apply evidence-based practice interventions, such as the fall-risk screening assessment tool, ongoing patient safety education classes, and bedside nursing communication. The fall-risk screening tool conducted upon admission helped the nurses identify patients with high, moderate, and low risk for falls.

Measures: The plan was concise and straightforward, intending to decrease the number of falls by 50%, increase patient safety knowledge among nursing staff by 50%, and increase bedside nursing communication among nurses by 50% by July 2020. Outcome data were collected and measured daily, weekly, monthly, quarterly, and annually via staff and patient surveys, interviews, and the facility’s incidents website.

Results: The results were remarkable and achieved the goals, until the COVID-19 pandemic hit in March 2020, when management attention shifted their attention to the pandemic.

Conclusions: The SNF facility will continue to address patient safety concerns and diminish patient falls. The improvement project can be replicated to like SNFs.

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