PA005 Healthcare Program/Policy Evaluation
Student Name
Walden University
NURS 6050 – Policy and Advocacy for Improving Population Health
Prof. Name
Date
Healthcare Program/Policy Evaluation: Falls and Incident/Accident Reporting at Crestpark Nursing Home, LLC, Spring of 2021
Description
Falls and unexpected incidents remain among the most pressing safety concerns in long-term care facilities. Within settings such as Crestpark Nursing Home, LLC, these events can significantly affect residents’ quality of life, often resulting in injuries, loss of independence, hospital transfers, and psychological distress. During the spring of 2021, Crestpark implemented a structured fall-prevention program combined with a standardized incident/accident reporting policy aimed at strengthening resident safety practices.
This evaluation explores how effectively those measures were executed, the quality of the reporting process, and how well the program aligned with broader patient-safety goals. Emphasis was placed not only on identifying trends in fall occurrences but also on understanding how the interdisciplinary team collaborated to mitigate risks and enhance preventive strategies.
What Are the Healthcare Program/Policy Outcomes?
The intended outcomes of Crestpark’s fall-prevention and reporting policies centered on two major goals: (1) lowering the frequency of resident falls and (2) minimizing the severity of injuries when falls occurred. Given that long-term care residents often experience gait instability, cognitive decline, and chronic health conditions, falls are a common clinical concern.
To achieve these desired outcomes, each fall event underwent a structured evaluation by an interdisciplinary team—including nurses, rehabilitation specialists, and administrative personnel. The team assessed environmental, medical, and functional factors contributing to each incident. From these assessments, individualized, evidence-based care plans were developed to better protect residents and prevent recurrence. The policy aimed not only to reduce immediate harm but also to create long-term safety cultures within the facility.
How Is the Success of the Healthcare Program/Policy Measured?
Success was measured through continuous performance-monitoring methods embedded in Crestpark’s Quality Improvement (QI) structure. Quarterly QI meetings served as dedicated forums where trends, case reviews, and staff concerns were examined. In these meetings, the interdisciplinary team reviewed:
- Changes in the number and type of falls
- Severity levels of injuries
- Timeliness and completeness of incident reports
- Staff compliance with prevention protocols
- Environmental hazards and corrective actions
Additionally, qualitative feedback from families, residents, and staff members offered insight into perceived safety improvements and operational shortcomings. A successful evaluation was indicated by a clear reduction in fall rates, improved documentation practices, and enhanced staff responsiveness to safety issues.
Who Are the People Reached by This Evaluation?
This evaluation directly and indirectly influenced approximately 300 individuals, including residents, nursing and support staff, administrative leadership, and family members. Residents benefited from safer environments and more proactive monitoring. Staff benefited from updated training expectations and clearer reporting guidelines, which in turn supported more coordinated care. Family members were also included, recognizing that they contribute important perspectives about residents’ functional changes, preferences, and safety needs.
When Was the Evaluation Conducted?
At Crestpark Nursing Home, LLC, evaluations occur routinely on a quarterly basis. However, the March 2021 evaluation carried unique significance because it marked the first comprehensive QI review following a nearly seven-month gap created by COVID-19 disruptions. The pandemic had altered staffing patterns, visitation procedures, and care workflows, making this evaluation critical in reassessing resident safety post-disruption. Additional assessments were conducted as needed when adverse events occurred or when staff identified emerging safety concerns.
What Data Sources Were Used?
A wide range of data sources informed the evaluation to ensure rigor and accuracy. These included:
- Internal incident/accident reports
- Resident medical charts
- Hospital transfer documentation
- Diagnostic imaging reports
- Rehabilitation assessments
- Medication review summaries
- Staff written statements and witness reports
By triangulating clinical and administrative data, the evaluation provided a comprehensive understanding of the factors contributing to falls and allowed the team to identify recurring patterns, such as medication interactions, environmental hazards, or mobility impairments.
What Are the Potential Benefits and Unintended Consequences of the Evaluation?
Benefits:
One of the major benefits identified was the requirement for immediate fall notification, which facilitated quick response times and ensured that residents received prompt assessments. Newly licensed nurses especially benefited from structured protocols, enabling them to gain confidence while ensuring patient safety. The evaluation also increased transparency and accountability among team members by encouraging consistent reporting practices.
Unintended Consequences:
Despite these benefits, the policy produced some unintended emotional and professional tensions. Experienced nurses expressed feelings of being overly scrutinized when falls occurred under their care. This sentiment occasionally led to reduced morale. To address this, leadership used the evaluation period to emphasize collaborative problem-solving rather than individual blame. Team-based discussions helped reframe fall events as system-level issues rather than personal shortcomings.
Who Are the Stakeholders Involved in the Evaluation?
The evaluation process included a broad array of stakeholders:
- Residents, who are the primary recipients of the policy’s safety benefits
- Family members, who contribute knowledge and expectations regarding resident well-being
- Nursing staff, who implement fall-prevention strategies and complete reports
- Rehabilitation therapists, who assess mobility and functional risk factors
- Administrative staff, who oversee compliance and allocate resources
- Social workers, who address psychosocial needs and family communication
Each stakeholder category played a distinct role in shaping policy implementation and providing feedback used to refine safety practices.
How Successful Was the Evaluation?
Based on the results reviewed during the spring 2021 QI meeting, the evaluation demonstrated meaningful improvements, including a reduction in the total number of falls and enhanced resident mobility due to increased therapy engagement and individualized interventions. Additionally, incident reporting rates became more accurate and comprehensive. The evaluation confirmed that the policies in place were contributing positively to long-term safety outcomes and fostering a more proactive patient-safety culture.
What Recommendations Were Made Regarding the Policy?
The evaluation supported the continuation of the existing policies due to their positive impact on safety outcomes. Recommendations included:
- Maintaining current policies while introducing minor revisions as new trends emerge
- Increasing staff education on accurate documentation and environmental hazard identification
- Enhancing family engagement through periodic safety briefings
- Implementing technology-assisted monitoring tools where appropriate
These recommendations aimed to reinforce safety culture while ensuring that policies evolve in response to resident needs and clinical best practices.
PA005 Healthcare Program/Policy Evaluation
How Could Nurses Be Involved in Future Evaluations?
Nurses will continue to play a central role in future evaluations, especially as frontline observers of resident behavior and environmental safety. Expanding nurse involvement can be achieved through:
- Increasing nurse participation in QI committees
- Encouraging nurse advocates to gather structured feedback from families
- Providing opportunities for nurses to lead root-cause analyses after incidents
- Allowing more dedicated time on the floor to observe workflow challenges
These efforts would ensure that nurses’ firsthand knowledge informs ongoing policy refinement, strengthening both safety outcomes and interdisciplinary collaboration.
Summary Table: Evaluation Overview
| Aspect | Details |
|---|---|
| Program/Policy Focus | Fall prevention and incident/accident reporting at Crestpark Nursing Home |
| Evaluation Period | Spring 2021 (major review in March following COVID-19-related gap) |
| Number of People Reached | ~300 residents, staff members, and family participants |
| Data Sources | Incident reports, medical charts, hospital transfer records, imaging, rehabilitation data |
| Stakeholders | Residents, families, nursing staff, administration, therapists, social workers |
| Outcomes | Lower fall rates; improved mobility; enhanced reporting accuracy |
| Success Measurement | Quarterly QI meetings, trend reviews, stakeholder feedback |
| Benefits | Faster fall response, stronger novice nurse support |
| Unintended Consequences | Perceived competency concerns among experienced nurses; resolved through team dialogue |
| Recommendations | Continue policies; revise as needed; enhance education and family involvement |
| Future Nurse Involvement | Family feedback collection, increased floor presence, leadership in root-cause reviews |
References
Agency for Healthcare Research and Quality. (2020). Preventing falls in hospitals: A toolkit for improving quality of care. U.S. Department of Health & Human Services.
Centers for Disease Control and Prevention. (2021). Important facts about falls. https://www.cdc.gov/falls/facts.html
Dykes, P. C., & Carroll, D. L. (2020). Fall prevention in hospitals: An integrative review. Journal of Nursing Care Quality, 35(3), 207–213.
PA005 Healthcare Program/Policy Evaluation
Najafpour, Z., Godarzi, Z., Arab, M., & Yaseri, M. (2019). Risk factors for falls in hospital in-patients: A prospective study. Nursing Open, 6(2), 232–239.
Zhao, Y., & Kim, H. (2021). A systematic review of patient fall prevention strategies in long-term care settings. BMC Geriatrics, 21, 509.