Harmony Healthcare International (HHI) Blog

ICYMI: QAPI Program for Falls


Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency • Survey

Young woman helping old man to stand upThe objectives of developing a QAPI Program for Falls includes the following: 

  • Review the regulatory interpretive guidelines for accidents and injury investigation.
  • Discover the key components of completing an accident root cause analysis.
  • Apply the quality improvement components to the investigative process. 

What is a Fall?  The regulations define a fall as: 

“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., 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. 

Key Components - QAPI 

  • Identifying hazard(s) and risk(s)
  • Evaluating and analyzing hazard(s) and risk(s)
  • Implementing interventions to reduce hazard(s) and risk(s)
  • Monitoring for effectiveness and modifying interventions when necessary 


Interventions that the facility might incorporate in care planning include: 

  • Providing restorative care to enhance abilities to stand, transfer, and walk safely
  • Providing a device such as a trapeze to increase a resident’s mobility in bed
  • Placing the bed lower to the floor and surrounding the bed with a soft mat
  • Providing frequent monitoring by staff with periodic assisted toileting for residents who attempt to arise to use the bathroom
  • Furnishing visual and verbal reminders to use the call bell for residents who are able to comprehend this information and are able to use the call bell device
  • Providing exercise and therapeutic interventions, based on individual assessment and care planning, that may assist the resident in:
    • achieving proper body position
    • balance and alignment
    • without the potential negative effects associated with restraint use. 

Discovering Root Causes 

Key features of Root Cause Analysis: 

  • Blameless problem-solving
  • Involvement of those most affected by the issue
  • Willingness & means to coach & mentor after training
  • Person-centered care 

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Review Your Programs 

  • How effective is your restorative program?
  • Do residents lose function through reduced mobility?
  • Could you review ambulation status to find out? 

Use Your Data – MDS 

  • Run a report of Current Mobility Status for this quarter and last quarter.
    • Walk in room
    • Walk in corridor 

Compare it to report from last quarter.  Have there been any changes or declines? 

QAPI Definition 

Quality Assessment & Performance Improvement is a data driven & pro-active approach to quality improvement. 

What to Look For - Trending 

Look for trends in conjunction with – wing, diagnosis, falls, behaviors – the more granular, the more effective your root cause analysis will be.  

  • Location - room, hallway, bathroom
  • Devices in use, call lights, alarms, etc. 


  • Reasons for the mobility decline
  • Root Cause Analysis Interview direct care-giving staff, family, resident for their perspectives regarding why the decline happened
  • Document interview results & analyze 

Realizing Goals 

QAPI aims to help nursing home residents realize their own goals for care and how they live their lives, including these areas:  

  • Health and Safety
  • Quality of Life
  • Exercise of Choice
  • Effective Transitions 

Resident/Family Alliances 

  • Establish commitment to Falls and Injury Prevention:
  • Market your commitment
  • Pre-admission considerations to determine risk factors for falls upon admission
  • Admission assessment in-put ALWAYS include them in assessment findings & Education if responsible, or with resident permission 

Risk Assessment Tools 

Risk assessment tools by themselves do not prevent patient falls - they predict them. 

When to Assess 

  • On admission
  • Upon transfer from one unit to another
  • With any status change
  • Following a fall
  • At regular intervals 

Assessment Recommendations 

History & Root Causes Documentation Current Status: 

  • Footwear
  • Seating
  • Standing
  • Transfers
  • Toileting status
  • Resident & family response to commitment
  • Immediate care plan measures 

Seating Challenges 

  • Ideal sitting posture is unnatural
  • People slide into a position of comfort and support.
  • However . . . everyone fatigues out of the ideal sitting posture
  • Body type and disability often prevent ideal sitting posture 


Untreated, pain leads to: 

  • Restlessness
  • Irritability
  • Depression
  • Reduced mobility
  • Atrophy 

What’s Your Response to Alarms 

  • Remain in place, wait for direction
  • Get up to see what’s wrong
  • See what you can do to help 

Why Alarms Don’t Work 

The body registers noise pollution as assaultive. The automatic tightening of muscles to armor (protect) and defend themselves produces sensations that range from mild discomfort to extreme pain. Gentle, appropriate touch can help the body to relax without more intrusive intervention. Caring touch can restore equilibrium and balance. 

Critical Investigation Elements 

  • Environmental review at the time of the event by on-shift staff
  • Make immediate modifications
  • Add to care plan immediately
  • Communicate interventions & rationales immediately 

Use of Devices 

  • Watch them in action to assess correct use
  • Therapies evaluation to identify modifications
  • Do not let the device be a potential cause for falls 

Anticipate Medication Risks 

Do not wait until a fall happens to check for:  

  • Effects
  • Side effects
  • Interactions 


Excessive decrease in ability to form blood clots can cause bleeding, leading to anemia, weakness & dizziness. Watch for bruising easily, unusual bleeding around gums, blood in urine, or rectal bleeding. 

Mandatory Return Demonstration (Patient) 

Practice to reinforce Stand up slowly after sitting or lying down. If lying down, sit up first, remain seated for a few minutes, then stand slowly. 

Match Interventions to Risks 

  • Muscle weakness – Exercise, therapy
  • Gait problems – Exercise, devices, modifications, therapy
  • Balance problems, Exercise, therapy, devices
  • Arthritis, Degenerative Joint Disease – Exercise, therapy
  • Impaired ADLs – Exercise, therapy, devices, modifications 

Investigate Immediately! 

To get the most information out of critical times around an event Staff on the scene must be coached in:  skills of observation critical thinking. 

Don’t Wait! 

Delaying the investigation until morning or Monday, or whenever the DON or Risk Manager gets around to it will not improve your outcomes or statistics. 

More Eyes and Ears 

QAPI More eyes & ears = more thorough perspectives + problem-solving. 

Observations and Questions 

  • Placement of the person’s body at the time of the fall.
  • What was the person trying to do?
  • Was it unusual or typical – has it happened before? 

What Exactly Happened? 

‘Person needed to use bathroom’ Urgently? – Why? Does this follow their usual pattern? Do they usually call for help? – If they do, but didn’t, what happened this time? – If they did, why didn’t they wait? 

And Then What? 

If they don’t, or didn’t wait what makes them unsafe to do it independently - weakness, stiffness, dizziness…? 

Compensation Vs. Restriction 

If they are known not to call for help, what are you doing to make it safer for them? Strengthen, loosen up, address causes of dizziness.

The team at Harmony Healthcare International (HHI) is here to help.  Through our on-site audit process and teaching methodologies via the practical application of case specific studies, we can assist with your organizations goals in: 









You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


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Topics: falls

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