Document Type


Publication Date

Spring 2022

Date of Final Presentation


Committee Chair

Cara Gallegos, PhD, RN

Committee Member

Lucy Zhao, PhD, SMN, MPAff, RN

Coordinator/ Chair of DNP Program

Pamela Gehrke, EdD, RN

Abstract/ Executive Summary

Background: Falls among the elderly population, aged 65 years and older, are a significantly growing public health problem. For elderly people residing in residential care facilities and facility administrators, falls are of great concern due to the post-fall associated consequences. Preventing resident falls in long-term care is a priority to reduce injuries and associated costs.

Project Design: This evidence-based quality improvement (EBQI) pilot project focused on fall prevention and was conducted on 1 unit (3 long-term care hallways) at a facility that provides both long-term care (LTC) and short-term rehabilitation services in Utah County, Utah. Interventions chosen for the Falls Management Program Bundle (FMPB) included (a) providing staff educational and training sessions, (b) providing resident educational and training sessions, (c) instituting a Falling Star program, and (d) creating a Fall TIPS poster program.

Results: The post-test results following the education sessions on fall risk factors and fall prevention strategies showed an overall increase in knowledge in a minimum of 47% of resident and nurse participants. After the trainings, 94.4% (n = 17) of the nurses were able to determine the correct level of risk for a resident case-study scenario, and 55.5% (n = 10) were able to identify 3 out of 4 tailored interventions. Due to contextual factors, findings were inconclusive of whether the three-month evidence-based Falls Management Program Bundle resulted in a reduction of resident falls in the target hallways.

Recommendations: Implementation of a standardized, evidence-based Fall Management Program (FMP) that includes multiple fall-prevention strategies has the potential to prevent and/or reduce falls. Continuation of interventions included in the Falls Management Program Bundle would assist in keeping staff and residents educated on fall prevention measures, as well as communicating risk level and needed interventions in fall prevention. More accurate data 8 collection on the number of falls for the specific unit is needed to confirm effectiveness of the standardized fall prevention program. Continuation and monitoring of the Fall Management Program Bundle would be beneficial to assist the facility in its decision to add this project to other units.

Conclusion: The implementation of a standardized, evidence-based Fall Management Program to reduce falls at this facility increased nurses’ and residents’ knowledge regarding fall risk factors and fall prevention strategies. Training regarding risk assessment was beneficial in identifying risk levels and tailored interventions. Nursing staff was able to utilize the Fall TIPS poster program to communicate a fall intervention plan to residents and other staff members.