Date of Conferral



Doctor of Nursing Practice (DNP)






Residents who fall in SNF either sustain significant decline to quality of life or die from their injuries. The average fall costs about $34,000 per incident. On average, 19.8% of residents fall at least once per month. The purpose of this project was to assess, identify, and advance nursing practice to decrease falls by evaluating current facility standard of practice, fall policy, procedures, and protocol. The objective was to create actions that would close the communication gap between clinicians and residents. This project encourages clinicians to intertwine resident feedback and strategies into the plan of care to help reduce fall risk. A focus group was conducted with 11 residents with previous fall experience. Through structured discussion, several important gaps in communication related to residents' plan of care were identified. Examples identified include, 10 of 11 residents indicated they were never asked to participate in their plan of care, 10 of 11 residents indicated staff did not listen to them, and 11 of 11 stated they did not know they could change the plan of care that staff had put in place. Further feedback from the focus group demonstrated residents desire to be involved in their care however, they were largely excluded from this process in the past. This project contributes to positive social change by identifying ways to close the communication gaps and reduce risk for falls by intertwining clinician and resident fall practices. A highly recommended fall committee was established at the project facility to encourage staff buy in, advancement of nursing practice and resident involvement in reducing falls.