Fall QAPI: Quality Assurance Performance Improvement

“Fall” refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall.

Evaluation includes:

  • Re-assessment for effectiveness of the interventions
  • Data gathering to confirm the problem has been resolved
  • Fall Committee meeting to review each patient’s fall trend by location, diagnosis, behaviors and functional status; the more detailed your information is, the more effective your root cause analysis will be
  • Changing to a new approach if needed
  • Monitoring for effectiveness and modifying interventions when necessary

With Nursing Intervention, we evaluate whether:

  • The Plan of Care was promptly updated
  • Individualized interventions are put into place based on investigation
  • Hazards and risks were identified
  • Staff consistently implement new care plan interventions
  • We’re communicating interventions and rationales to everyone to reinforce safety as soon as possible

Planning involves:

  • Putting together and educating a team, promoting an interdisciplinary approach
  • Identifying team responsibilities
  • Establishing desired and achievable outcomes
  • Validating expected outcomes with the resident/family
  • Selecting interventions to achieve the outcomes such as assistive devices, staff/resident/family education
  • Signs placed on the resident’s door next to their name
  • Signs placed on the resident’s W/C


  • Pre-admission considerations for history of falls/accidents, fall assessment upon admission
  • Investigate circumstances
  • Physical mobility/functional status, cognitive, mood, behavior, underlying illness and disease process, sensory status, visual deficits

Nursing Diagnosis – root cause analysis:

  • External factors:
    • Poor lighting
    • Loose rugs
    • Poorly fitting shoes
    • Beds/Toileting without handrails
    • Clutter
    • Call light not within reach
  • Internal factors:
    • Unsteady gait
    • Balance problems
    • Vision/hearing loss
    • Memory
    • Confusion
    • Medications
    • Behavior/cognitive impairment

View poster: Fall Q.A.P.I. (PDF format)

Dawee Pho, RN, DON – The Orchard Post Acute Care