Date of Paper/Work


Type of Paper/Work

Doctor of Nursing Practice Project

Degree Name

Doctor of Nursing Practice



First Advisor

Joyce Brettner


Doctor of Nursing Practice


Falls continue to be a major safety concern for adults aged 65 years or older living in long-term facilities due to their age, weakened conditions, and chronic diseases. To improve resident safety in a long-term care facility in a skilled nursing facility, the Root Causes Analysis (RCA) method was utilized to establish a standardized process for evaluating and documenting falls in hopes of understanding the contributing factors when a fall occurs and how to prevent it from happening again by developing targeted fall prevention interventions. Empira’s Falls Scene Investigation (FSI) Report (Minnesota Department of Health [MDH], n.d.) was adapted and developed into the Root Cause Analysis Fall Investigation and Intervention (RCA-FII) form. Early results indicate the RCA-FII form did not reduce falls. Fall rates for December 2021, was 17.07%, January 2022, was 5.19% and in February 2022, it was 9.02%. However, the RCA-FII form process was followed 92% of the time and helped nurses to consider resident-centered fall prevention interventions. A significant finding indicates a high frequency of falls related to a resident’s medical status/physical condition/diagnosis and transferring. In addition, the most selected individualized fall prevention intervention on the RCA-FII form was frequent monitoring of a resident’s condition. In conclusion, the RCA-FII form is a useful tool in identifying contributing factors of a fall. Furthermore, it can help improve nurses’ critical thinking skills, but the RCA method is complex and will require a collaborative team approach to improve patient safety.

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