Date of Conferral

8-6-2026

Date of Award

August 2026

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Cara Krulewitch

Abstract

This executive summary presents the final plan for implementation of an evidence-based fall-prevention clinical practice guideline on an open neurological rehabilitation unit. It does not propose a new device, a new electronic platform, or a separate education-only initiative. The practice change is the implementation and evaluation of a structured interdisciplinary clinical practice guideline designed to reduce inpatient falls and improve the reliability of daily prevention practices. The unit reports a baseline fall rate of 6.3 falls per 1,000 patient days. Thirty-five staff members from nursing, therapy, and support roles completed the survey, and 57% reported that patients had experienced falls within the previous 6 months. Staff identified patient impulsivity or poor safety awareness, staffing or competing priorities, toileting urgency, communication gaps during handoff, and training gaps as practical barriers. They make the case that fall prevention cannot depend on memory, good intentions, or one more reminder posted near the time clock. The proposed change aligns with the partner organization’s mission of returning patients to lives of productivity and meaning. In neurological rehabilitation, safe mobility is part of recovery itself. Patients need to move, transfer, toilet, participate in therapy, and regain confidence. That same movement creates risk, especially when cognition, balance, strength, fatigue, and judgment are impaired. The guideline therefore serves two purposes at once. It protects patients from preventable harm, and it protects the rehabilitation process from the interruptions that follow a fall.

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Nursing Commons

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