Using root-cause analysis for the reduction of falls in a long-term care facility

Long-term care facilities have encountered increased pressure from the federal government to ensure that the facility is providing quality care, which includes preventing falls that can cause major injury to the patient. As an assistant administrator for a 200-bed long-term care facility, the author of this study used of root-cause analysis to investigate falls at an interdisciplinary level in order to determine how to reduce major injuries. Falls among the elderly in long-term care facilities such as skilled nursing homes are common and very dangerous; however, often these falls with injuries to the residents are preventable. Performing a root-cause analysis allows for a more in-depth examination of why an individual may experience a fall and how to develop an action plan to minimize future falls with injury. An analysis of the critical factors of the fall, such as medications, location, time, and environment, assisted facility administrators in determining root causes and led to the development of action plans to minimize falls that cause a major injury. By forming a Falls Committee composed of members from all the facility's disciplines, every fall was examined from multiple viewpoints. The successful improvement of one aspect of the Centers for Medicare and Medicaid Quality Measures by performing a root-cause analysis shows that the same method can be applied toward improving other aspects of quality care. The information discovered and the research conducted for this study helped the author to prepare for a successful future as a leader in the healthcare administration field. Key words: Health Care Administration, Dr. Dana Hart, Professor Maria DeGiglio, root-cause analysis, long-term care facility, elderly, safety, injury prevention, falls, Medicare, medication.