Implementing Evidence-based Fall Prevention Bundle in a Long-term Memory Care Unit: A Quality Improvement Project

Nature and scope of the project

Falls in older adults are prevalent and can result in an injury affecting their quality of life. Whether a fall is fatal or not, it has a high financial impact. Older adults with dementia are more likely to fall than their cognitively healthy counterparts, increasing their risk of serious injury or even death. This quality improvement project developed, implemented, and evaluated an evidence-based fall prevention bundle to reduce preventable falls in a long-term memory care unit.

Synthesis and analysis of supporting literature

Databases such as PubMed, Scopus, Joanna Briggs, and CINAHL were used to search for evidence. The keywords were accidental falls, dementia or cognitive impairment, and nursing home. The John Hopkins Nursing Evidence-based Practice Research Evidence Appraisal Tool was used to rate the level and quality of articles. Based on the evidence reviewed, the interventions implemented were fall risk screening, physical exercise, vitamin D supplementation, purposeful hourly rounds, and post-fall huddles.

Project implementation

Kurt Lewin’s force field analysis guided the project’s implementation. Nurses, healthcare providers, certified nursing assistants, restorative aides, and life enrichment staff from all shifts at a long-term memory care unit participated in the project. The participants implemented the evidence-based fall prevention bundle based on their scope of practice. They participated for 12 weeks.

Evaluation criteria

The frequency of falls was compared three months before, during, and after implementation. Paired t-test and independent samples t-test were used to analyze statistically significant differences between variables.


Thirty staff members attended educational sessions, and 22 residents received interventions. Fall rates dropped 50% during the project's implementation but increased subsequently. The difference in the number of falls before, during, and after implementation was not statistically significant.


Staff working in a long-term care facility may help reduce fall rates using evidence-based interventions, but measures should be taken to sustain the initiative's implementation.



Implementing Evidence-based Fall Prevention Bundle in a Long-term Memory Care Unit: A Quality Improvement Project