Date of Paper/Work
5-2022
Type of Paper/Work
Doctor of Nursing Practice Project
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Joyce Brettner
Department/School
Doctor of Nursing Practice
Abstract
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.
Recommended Citation
Lee, Julia J.. (2022). Implementation of a Fall Root Cause Analysis Investigation and Intervention Process: Improving Resident Safety in a Long-Term Care Facility. Retrieved from Sophia, the St. Catherine University repository website: https://sophia.stkate.edu/dnp_projects/162