Mm week 4 gap
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Gap Analysis – Fall Risk Prevention and Assessment Nurse-Led.
Michelle Murray
Herzing University
NU801
Dr. Stephanie Turner
Jan 30, 2026
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Gap Analysis – Fall Risk Prevention and Assessment Nurse-Led.
Background:
Older adults in adult day care settings experience falls, which is a severe patient safety
problem. Such accidents usually lead to trauma, increased medical consumption, and impaired
quality of life. Studies indicate that fall risks evaluation and fall prevention measures that are
well-organized and individually tailored especially when organized under the supervision of
nursing practitioners can greatly decrease the number of falls (Mathew, 2025). In spite of this,
most of the adult day care centers are run with no standardized process, uniform screening, or
coordinated interdisciplinary prevention programs.
Current State:
The facility currently informally measures the risk of falls by the observation of the staff
and by documentation that is occasionally done. They do not routinely use a validated screening
tool and preventive actions are usually taken only after a fall occurred and not before. The
training of the staff on prevention of falls is not uniform in the shifts and lacks evidence-based
practice. There is also a lack of an official framework that could be used to monitor fall
incidence or assess the success of any strategies.
Best Practice / Desired State:
The validated fall risk assessment tools that can be a part of evidence-based practice
include the Morse Fall Scale or the CDC-based (Stopping Elderly Accidents, Deaths and
Injuries) framework, STEADI. Personalized care plans, frequent staff training, and physical
environment safety alterations are also considered the best practice. The STEADI program
proves that the annual screening and specific interventions are effective to lower the risk of falls
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in older adults (CDC, 2025). The nurse-led programs have been specifically successful in the
community and long-term care facilities with the control of the identification of risks, education,
and follow-up care.
Gap Identification
• There are a number of critical differences between the practice and the standards of best
practice:
• Lack of standardized screening: There is no evidence-based tool utilized during
admission or by the regular intervals.
• Lack of consistency in prevention programs: Prevention is not provided in a systematic
way according to the fall risk of a person.
• Poor education of the staff: There is no continuous, evidence-based training on fall
prevention.
• No monitoring system: Fall incidents and outcomes are not regularly monitored and
analyzed.
Root Causes:
Such lapses are most probably because of the lack of training of the personnel in
evidence-based fall prevention, the lack of formal organizational policies that presuppose
identification of standardized assessment, and a shortage of resources that has postponed the
implementation of structured protocols.
Recommendations:
• Use a tested tool like STEADI, which is used by nursing personnel at the time of
admission and every month (CDC, 2025).
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• Develop personalized prevention interventions that could involve such activities as
strength and balance training, medication counseling, and safety assessments of the
environment (Giovanni et al., 2022).
• Offer continuous nurse-based staff training based on evidence-based prevention of falls.
• Construct a data tracking tool to keep track of the occurrence of falls, the risks, and the
results in order to facilitate continuous quality improvement.
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References
Centers for Disease Control and Prevention. (2025). STEADI: Older adult fall prevention.
Giovannini, S., Brau, F., Galluzzo, V., Santagada, D. A., Loreti, C., Biscotti, L., … & Bernabei,
R. (2022). Falls among older adults: screening, identification, rehabilitation, and
management. Applied Sciences, 12(15), 7934.
3417/12/15/7934
Mathew, R. (2025). Quality Improvement Project Fall Prevention Among Skilled Nursing
Facility Residents Through Staff Education.
