Date of Award


Degree Type

Evidence-Based Project Report

Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Jeffrey A. Coto


The purpose of this paper is to discuss the quality improvement project, implementation of the post fall huddle in a long-term care facility. Falls are the most common problem in adults 65 years and older. Falls in this population can have devastating effects, often leading to significant changes in morbidity or death. Adults in long term care settings have an increased risk of falling and having a subsequent fall due to an acute illness, weakness, or confusion (CDC, 2015). At the skilled facility, there has been a significant increase in hospitalizations due to injuries sustained from falls. To address this problem, the literature recommends and supports the practice of a post-fall huddle to discuss and drill down the root cause of the falls. Most of the literature written today is about utilizing post fall huddles in Hospital settings. There is limited clinical practice data that addresses the implementation of post fall huddles in long term care settings and its effects on reducing falls. Based on the literature review recommendations and the needs of the facility, a quality improvement project was implemented. The results of the project were analyzed to show if the post-fall huddle reduced the number of recurrent patient falls and reduce the number of falls within the facility in the eight-week time frame. The analyzed results showed a significant decrease in falls therefore decreasing the number of hospitalizations due to fall related injuries.

Creative Commons License

Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
This work is licensed under a Creative Commons Attribution-NonCommercial-Share Alike 4.0 International License.

P. Lomax DNP poster.pdf (938 kB)