Celebrating Scholarship and Creativity Day (2018-)
Document Type
Presentation
Publication Date
4-30-2026
Disciplines
Nursing
Advisor
Nicole Lang
Abstract
Falls remain a significant safety concern in skilled nursing facilities and are associated with increased morbidity, hospitalization, and loss of independence among older adults. While fall prevention strategies are widely implemented, inconsistent post-fall follow up and incomplete documentation can negatively impact residents and the facility. At a moderate-sized skilled nursing facility in central Minnesota, a review of recent fall reports identified inconsistencies in post-fall follow-up documentation, as well as gaps in staff education and the absence of a clearly defined post-fall documentation policy. The facility experienced 44 resident falls in the month of January alone, highlighting the urgency of addressing this issue. Inconsistent documentation practices and limited education regarding expected post-fall assessments increase the risk of incomplete clinical evaluation, delayed identification of injuries, compromised continuity of care, and potential regulatory noncompliance. These gaps also limit the facility’s ability to accurately analyze fall trends and implement effective prevention strategies. Therefore, improving the standardization and clarity of post-fall documentation processes is essential to enhancing resident safety, strengthening quality of care, and reducing organizational risk. Current literature supported the importance of standardized post-fall protocols, structured assessment tools, and targeted staff education to improve documentation accuracy, ensure timely reassessments, and enhance overall resident safety. For example, studies show that structured documentation templates can increase completeness by up to 30%, while educational interventions improve adherence to post-fall procedures and reporting accuracy. This quality improvement project focused on developing and reinforcing a standardized post-fall follow up protocol, a structured assessment tool, clear timelines for reassessment, and staff education. Education was provided to nursing staff regarding accurate and timely charting, proper completion of incident reports, and the importance of completing post reassessments. The goal of this project was to improve consistency in post-fall assessment and documentation, increase communication, and strengthen overall resident safety and practices at this facility.
Recommended Citation
Beier, Brooke, "Inconsistent Post-Fall Follow-Up and Documentation in a Skilled Nursing Facility" (2026). Celebrating Scholarship and Creativity Day (2018-). 358.
https://digitalcommons.csbsju.edu/ur_cscday/358