Falls Management Update Continuous Quality Improvement Project

The falls Management team has been working to improve unwitnessed falls in the

facility. As we get older our mobility and movement can become more difficult.

This can result in more falls among older populations.

The team has been tracking data for two years and observed a significant increase

in the number of unwitnessed falls. An unwitnessed fall means that staff find

residents on the floor however did not observe an actual fall or movement from one

surface to another (for example, chair to floor, bed to floor).

The team has decided, in consultation with the nursing managers, that on Monday

mornings during management and care team communications, falls will be tracked

and discussed on a weekly basis. During these meetings the incidents will be

analyzed in more detail to determine whether the documentation and follow-up

after a fall has been completed thoroughly. This will include education with the

LPN/RN staff on incident report investigations (following up on how the fall

occurred and what was done to prevent future falls).

We hope these more in-depth meetings, discussions and analysis will help to

provide solutions and reduction in the overall number of unwitnessed falls in the

building. We will continue tracking data over the next year to measure whether our

interventions are successful.

Submitted by Carrie Frazier, Programs Manager