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Course Name
Clinical Improvement Project II CAPSTONE
Graduation Year
12-2026
Faculty Advisor
Michelle Williams
Abstract
Abstract
Background: Patient falls remain a significant safety concern in inpatient rehabilitation settings, where patients with neurological and mobility impairments work toward regaining functional independence. Despite established fall-prevention protocols at Stockton Regional Rehabilitation Hospital (SRRH), falls continue to occur, highlighting the need to evaluate existing prevention practices and identify potential implementation gaps.
Purpose: This quality improvement project aimed to evaluate the implementation fidelity of existing fall-prevention practices at SRRH, identify recurring factors associated with patient falls, and develop evidence-based recommendations to strengthen patient safety.
Methods: Guided by the Plan-Do-Study-Act (PDSA) framework, a retrospective review of facility fall reports and patient records from January through August 2026 was conducted. Descriptive statistics and qualitative review of fall-event documentation were used to examine fall frequency, patient characteristics, mobility-related circumstances, and documented prevention measures.
Results: A total of 55 fall events were reviewed. Neurological diagnoses or impairments were documented in 81.8% of events (n = 45), while 78.2% (n = 43) involved mobility or transfer-related circumstances and 34.5% (n = 19) involved bathroom or toileting activities. Recurring findings included unassisted transfers, independent toileting, alarm-related concerns, missing safety precautions, and patients not requesting or waiting for assistance. These findings identified potential opportunities to strengthen the consistent application of existing fall-prevention practices.
Conclusion: The findings highlight the importance of reinforcing individualized safety precautions, proactive toileting assistance, alarm functionality, and interdisciplinary communication regarding patient mobility and assistance needs. Recommendations focused on strengthening existing practices rather than introducing a new fall-prevention program. Future PDSA cycles may evaluate the implementation and effectiveness of these recommendations to support sustainable improvements in patient safety.
Keywords
Fall prevention, implementation fidelity, inpatient rehabilitation, quality improvement, patient safety.
Recommended Citation
Igweka, Bouncy; Baltazar, Justin; Navas, Ashley; and Baligad, Clarisse, "Evaluating Falls Prevention Processes and Implementation Fidelity in Acute Rehabilitation: A Quality Improvement Project" (2026). ELMSN E-Portfolio. A collection of Scholarly and Creative Works. 53.
https://scholarlycommons.pacific.edu/nursing-portfolios/53
