Reduction of Inpatient Fall Rate in an Adult Acute Care Setting

Practice Problem: Falls are among the most reported hospital-acquired conditions and can lead to severe injuries, increased length of hospital stays, pain, distress, and emotional trauma in the elderly. The Centers for Medicare and Medicaid Services (CMS) identifies falls as preventable and no longer authorizes reimbursement to healthcare systems for treating inpatient fall-related injuries. PICOT: The PICOT question that guided this project was: In adult acute care patients admitted to the telemetry unit (P), how does implementing evidence-based multimodal fall prevention strategies (I) compared to routine fall prevention strategies (C) affect inpatient fall rate (O) over a period of 6-8 weeks (T)? Evidence: The literature review revealed that using multimodal risk prevention strategies effectively reduces fall risk and fall-related injuries and thus improves patient safety and outcomes. Intervention: A multimodal fall prevention strategy was developed, according to the Morse Fall Risk Assessment score, utilizing tools such as bed alarm on, lights on, a urinal within reach, purposeful hourly rounding, and bedside reporting during shift change. The oncoming shift nurse checked with the off-going shift nurse at the patient’s bedside to ensure that the fall risk patients’ fall precaution strategies had been initiated and maintained throughout the shift. Outcome: The EBP project did not result in an overall reduction in the fall rates; however, the fall rate with injury was low in the telemetry unit. The project resulted in an increase in the staff’s knowledge and awareness of multimodal fall prevention strategies. Conclusion: The reduction in the incidence of falls after the implementation of the EBP project in the telemetry unit was not statistically significant. However, the result indicated a clinically REDUCTION OF INPATIENT FALL RATE 3 meaningful improvement in fall-related injury outcomes and increased staff knowledge and awareness of the fall prevention strategies. REDUCTION OF INPATIENT FALL RATE 4 Reduction of Inpatient Fall Rate in an Adult Acute Care

physiological, psychological, and financial impact on patients, and some will experience posttraumatic stress disorder, depression, and decreased quality of life (Zhao, 2016).
The national average of adults 65 years and older falling each year was about 28% (CDC, 2020). In the state of Texas, the rate is 33.9%. Falling was the leading cause of injury-related deaths in adults 65 years and older (CDC, 2020). According to the CDC (2020), "Each year about $50 billion is spent on medical costs related to non-fatal fall injuries, and $754 million is spent related to fatal falls" (para.1).
Inpatient falls negatively affect the healthcare organization. The Centers for Medicare and Medicaid Services (CMS) no longer reimbursed healthcare systems for treating preventable injuries, such as inpatient fall-related injuries (AHRQ, 2013). This initiative imposed a substantial financial burden on the healthcare system.
The project site experienced an increase in patient falls and identified the need for fall prevention strategies related to assessment and intervention to prevent patient falls. Even with a fall prevention protocol in place, falls and related injuries continued to increase in acute care settings. Nursing practice and knowledge gaps had been identified in the project site with fall prevention strategies. In the calendar year 2020, the inpatient fall rate at the project site steadily increased. (From the fall committee meeting on 09/18/2020, by M. Zubiate -RN) From January to October 2020, the hospital experienced 118 falls. From July through September of 2020, they reported 65 falls. Occurrences in the telemetry unit accounted for 30 falls. The fall rate for the previous quarter was 4.06%, and the institution endeavors to reach the national average of 2.18%.
Inpatient falls affected not only the patients and families but also healthcare providers.
Several national policies and initiatives are in place to prevent falls and related injuries. The CMS considers falls a never event and will not reimburse for the additional treatment resulting from falls. According to Chaudhry (2020), "fall prevention is one of the national patient safety goals, and the Joint Commission had included prevention of falls in the 2009 sentinel event alerts, a reportable event to the Joint Commission" (p. 2).

PICOT Question
In adult acute care patients admitted to the telemetry unit (P), how does implementing evidence-based multimodal fall prevention strategies (I) compared to routine fall prevention strategies (C) affect inpatient fall rate (O) over a period of 8 weeks (T)?
Even with a fall prevention protocol in place, falls and related injuries continued to increase in acute care settings. This project was proposed to pilot at the acute care unit of a 320bed hospital located in the South Texas area. The project site experienced an increase in patient falls and identified the need for fall prevention strategies related to assessment and an intervention to prevent patient falls. The question answered in this evidence-based project was how to reduce the inpatient fall rate.
The current practice included fall risk assessment using the Morse Fall Risk Scale and standard fall prevention protocol such as hourly rounds, using fall signs, non-skid socks, fall risk armbands, and bed alarms. The proposed intervention was to implement a consistent use of the Morse Fall Scale and the fall prevention strategy. This project included fall prevention strategies such as fall signs, purposeful hourly rounding, activating bed exit alarms, yellow fall risk patient armbands, two nurses verifying the prevention strategies, use of non-skid socks, and staff education on fall risk assessment. Two staff members ensured a safe environment once every shift. The oncoming shift nurse checked with the off-going shift nurse at the patient's bedside to ensure that the fall risk patients' fall precaution strategies were initiated and maintained throughout the shift. An existing gap in compliance with the protocol was identified after meeting with the quality council and fall committee. These strategies were not followed consistently. The proposed outcome was to reduce the fall rate after the implementation and to improve staff knowledge and compliance with the fall prevention strategy.

Evidence-Based Practice Framework and Change Theory
An evidence-based practice (EBP) framework was instrumental for this change project to guide the research process, explain the research findings, and translate the research findings into practice. The theoretical framework helped to translate the research findings into clinical practices. Selecting the suitable models that are appropriate to the organization and the practice problem was vital to ensure the effectiveness of the EBP model and avoid poor outcomes or failure (Schaffer et al.,2013). The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model focuses on translating the best evidence for bedside nurses to use in clinical decisionmaking (John Hopkins Medicine, n.d.).
The JHNEBP model uses a three-step process called PET: practice question, evidence, and translation. The steps are: • Identification of practice question, • Collection of evidence including evidence search, critiquing, summarizing, evaluating the strength of recommendation, and making recommendations • Translation of evidence into practice; including assessing the practicability of adopting change and creating an action plan for implementation This model offers the following tools for the users: a question development tool, an evidence rating scale, and appraisal criteria for research and non-research evidence (Schaffer et al.,2013).

Change Theory
Kurt Lewin(1951) developed one of the most influential organizational change models (as cited in Connelly, 2020). According to Connelly (2020), the three-stages of the theory of change are Unfreeze, Change, Freeze (or Refreeze). Lewin's theory of change fit this project well because it aligned with the project objective of promoting positive clinical practice change and promoting a culture of safety. Unfreezing made it possible for the staff to let go of what was done in the past and create positive change motivation. It was essential to develop an awareness for the nurses to understand a problem that existed and unfreeze the current practice.
The second stage of Lewin's change theory is moving or changing (as cited in Connelly, 2020). This change stage occurred when there was a transition of behavior and involvement of employees. The organization and the employees needed to comply with the new EBP to promote patient safety and reduce harm. To ensure a change in behavior and acceptance of the new process, support from the stakeholders, leaders, and staff is essential during the implementation of fall prevention strategies (Ramasamy, 2019).
The final refreezing stage occurred by establishing a new habit. This new habit became the new standard of practice. The success of this stage was greatly affected by the commitment and motivation of stakeholders, leaders, and staff nurses (Ramasamy, 2019). The new habit became a culture of practice to assess the patients every shift and, as needed, to ensure that fall prevention strategies were implemented. Through continuous support, education, and a reward system, the organization sustained the practice change. The quality of the article was rated as A for high-quality, B for good-quality, or C for low-quality. Quality A was used for material officially sponsored by a government organization or by a professional, private, or public organization, developed or revised within the last 5 years, that stated clear aims and objectives and produced consistent results across multiple settings.

Evidence Search Strategy
Quality A materials also showed evident expertise and definitive conclusions and provided a scientific rationale (John Hopkins Medicine, n.d.).
Good-quality or B-rated articles were officially sponsored by a government agency or a professional, public, or private organization, that stated reasonably clear aims and objectives and produced consistent results in a single setting. B articles were written or revised within the last 5 years. Quality B materials show credible expertise and relatively definitive conclusions and provide logical arguments (John Hopkins Medicine, n.d.) Low-quality or C articles contains materials not sponsored by an official organization or agency, that are poorly defined and offered insufficient evidence, and where poor results with a limited literature search strategy and conclusions could not be drawn. C articles had not been revised within the last 5 years. The results were inconsistent, the aims and objectives were either missing or unclear, recommendations could not be made, and expertise is dubious or not discernable (John Hopkins Medicine, n.d.).
Most of the studies used for this EBP change proposal were pre-post interventional studies and systematic reviews. Out of the ten articles reviewed, one article was Level I, seven articles were level II, one article was level III, one article was level IV, and one article was level V. Eight of the articles were graded B, and one article graded A, and one article graded C. A summary of the article review can be found in Appendix A, Table A1, and Table A2.

Themes with Practice Recommendations
The literature synthesis revealed evidence that multidisciplinary fall prevention strategies could reduce the inpatient fall rate and improve staff knowledge and compliance with fall prevention. The literature showed that falls could result in significant injury, extended hospital stays, increased health care costs, loss of independence, and even death. Most of the studies showed how an appropriate tool could help identify and address the fall risk appropriately. Since national initiatives aimed to prevent patient harm from falls, prevention programs were necessary for healthcare organizations. Implementing an appropriate evidence-based fall reduction program could significantly improve patient outcomes and decrease the costs associated with fall complications. Fall risk assessments could identify patients at greater risk of injury to implement individualized prevention strategies as needed.

Fall Risk Assessment and Screening Tool
According to the American Nurses Association (ANA, 2020), hospitals should complete fall risk assessments for every patient at admission and with each status change. In acute-care settings, screening every day or even every shift may be required. After completing the fall risk screening, each patient should receive a personalized plan to address each identified risk factor (ANA, 2020). Consistency in implementing the fall prevention plan and discussing it with the patient and family was essential. Re-designing the current practice with an optimized, consistent, and transformational multidimensional approach was required to manage inpatient falls effectively. Davies (2019) revealed that appropriate screening tools could predict those at high risk for falls and reduce fall incidence in acute care settings. Campbell (2016) reported that evidence-based fall safety bundles and staff education could reduce the number of falls and improve staff knowledge and understanding.

Staff Education
According to Thierry (2018), educational training in Hourly Rounding and Morse Fall Risk Score procedural tools are essential in improving fall outcomes. Education and training to address the fall prevention initiative were optimal in acute care settings. Belcher (2020) reported that educating nursing staff on fall prevention policies decreased falls in the acute care setting and kept the patient safe. Ramasamy (2019) revealed that an educational program on evidencebased fall prevention strategies using the American Medical Directors Association clinical guidelines improved staff members' knowledge in recognizing, assessing, and managing falls.
The educational project resulted in positive social change for the patients, staff, and organization.
Staff education improved the nurse's knowledge and understanding of fall risk and injuries and reduced the number of falls in acute care settings.

Multimodal Fall Prevention Program
Ward (2015) suggested that hospitals implement multifactorial fall prevention programs using evidence-based interventions to reduce falls and injuries. The result from a quasiexperimental study suggested that implementing multimedia programs contributed to changes in fall risk awareness among hospitalized adults. A systematic literature review by Hudson (2020) recommended that identifying fall risk factors and implementing multifactorial fall prevention interventions could reduce the number of inpatient falls. Examples included a unit-based fall prevention team, fall champions, and a risk assessment tool to reduce the number of inpatient falls. An interprofessional team with evidence-based interventions significantly reduced the number of falls in acute care settings. Mendoza (2018) reported that multidimensional fall prevention strategies such as bed alarm on, lights on, a urinal within reach, and purposeful hourly rounding provided significant measures to prevent fall occurrence.

Evaluation of Fall Prevention Strategy
McCracken (2019) revealed that evaluating the current fall prevention strategies and educating the staff on using the process were essential in reducing the inpatient fall rate. Staff involvement in assessing and improving the current fall prevention strategy created a positive outcome for the patients and enhanced staff morale. Staff education created awareness of fall prevention.
A synthesis derived from the literature review identified evidence-based interventions to assess fall risk and prevention. Most of the studies were conducted in hospital settings and included patients from acute care settings. The main themes emerging from the synthesis were multidimensional fall prevention strategies, use of fall risk assessment tools, and developing protocols for using the tool. Fall self-efficacy was an essential factor in helping older adults become more engaged in fall prevention efforts (Cerilo, 2016).

Practice Recommendation
Based on a thorough literature review, the PICOT question was answered, recommending using a multidimensional fall prevention strategy to reduce the number of falls in acute care settings. Spano-Szekely et al. (2019) reported that staff education created an awareness that fall prevention was a shared responsibility and that through teamwork, patient safety could be improved. Involving the staff in an action plan built a sense of ownership and responsibility.
According to the Morse Fall Risk Assessment score, a multimodal fall prevention strategy should be developed. France et al. (2017) revealed that multifaceted risk prevention strategies effectively reduce fall risk and fall-related injuries more than single-intervention strategies.
The current strategy was evaluated and revised to provide a multifactorial fall prevention strategy utilizing tools such as bed alarm on, lights on, a urinal within reach, purposeful hourly rounding, and bedside report during shift change. A protocol was established to use the Morse Fall Risk Assessment tool. The oncoming shift nurse checked with the off-going shift nurse at the patient's bedside to ensure that the fall risk patients' fall precaution strategies were initiated and maintained throughout the shift. Two staff members ensured the safe environment once every shift. Educational programs were selected for the staff, and they received education on the use of the assessment tool and the protocol. A charge nurse or designee conducted a chart review every shift to identify errors in fall risk assessment scores. A process was created for remediating the nurses who did not follow the strategy or incorrectly used the assessment tool.

Project Setting
The proposed DNP project setting was a 320 -bed acute care hospital located in the South Texas area. This facility houses a general medical and surgical facility operated by the Tenet Healthcare Corporation. Specialties at this hospital include; cardiovascular, cancer, obstetrics and gynecology, urology, orthopedics, joint replacement, and stroke care.
This hospital's mission is to help people achieve health for life through compassionate service inspired by faith. This organization's vision is to provide quality compassionate care based on the values of compassion, safety, excellence, accountability, innovation, and faith. This healthcare system offers outstanding, compassionate care to the patients when and where they need it. The hospital is part of the largest healthcare system network in the South Texas area, with five campuses offering five types of care. This healthcare system is well known for its dedication to positively impacting the lives of patients, their families, and the community.

Organizational Structure and Culture
Each medical center is individually accountable and focuses on the geographical area they serve with a wide variety of services. The leadership team consists of the chief executive officer (CEO), president of the site, CEO for the medical center, chief medical officer for the area, and chief operating officer. These leaders are dedicated to bringing expert health care to the communities through world-class innovation and service.
Members of this organization are culturally diverse and competent to serve their community. By maintaining close relationships with the people in the community, leaders have access to consistent, reliable feedback that helps the organization to strengthen the care processes and improves the health of everyone they serve. Every employee of the organization is accountable and expected to follow the rules, regulations, policies, procedures, and standards.
Employees are encouraged to be responsible for providing safe, quality patient care.

Organizational Need
An organizational need assessment and a gap analysis were conducted to identify the current practices and areas for improvement. The organization's fall prevention strategy was identified, but a lack of compliance with this protocol exists. The current practice included fall risk assessment using the Morse Fall Risk Scale and standard fall prevention protocol such as hourly rounds, using fall signs, non-skid socks, fall risk armbands, and bed alarms. Since CMS no longer reimburses the healthcare system for the treatment of fall-related injury, and the hospital had to pay for the treatment expenses, this project enabled the healthcare system to reduce falls and fall-related injury and reduced overall cost. After receiving the facts, the leaders decided to implement this project.
The organization had wanted to implement this project for some time, so the leadership was entirely supportive of this project. The assistant chief nursing officer (ACNO) expressed the need to evaluate the current process and implement evidence-based practice changes to reduce inpatient falls. The different stakeholders in this project were the ACNO, various department leaders, the director of quality and safety committee, fall committee champions, inpatient nurses, physicians, patient care assistants (PCAs), physical therapists, pharmacists, informaticists, support staff (housekeeping, dietary), and patients. The ACNO confirmed organizational support.
Sustainability for this project involved continuous monitoring of the use of the fall risk assessment tool. Since this assessment was part of the nursing assessment in the EHR for every shift, it was easy to monitor score accuracy and compliance. The fall committee champion continued to monitor the fall prevention strategies weekly to determine the nurses' use of risk assessment tools and the effective use of multidimensional prevention plans and compliance. The charge nurses monitored the assessment score for completeness and relevance every shift and reported non-compliance to the fall committee. Education was provided to the nurses and PCAs before implementing the project and for new hires.
Interprofessional collaboration and teamwork were essential for the success of this project. Fall prevention strategies and team collaboration were integral in keeping the patient safe from falls and fall-related injuries. The different team members included the project manager, department leaders, the director of the quality and safety committee, fall committee champions, inpatient nurses, physicians, PCAs, physical therapists, pharmacists, informaticists, and support staff. Everyone who saw and interacted with the patient was part of the fall prevention team. All the team members worked towards the common goal of reducing inpatient falls and fall-related injuries.

Strengths, Weaknesses, Opportunities, and Threats Analysis
The Strengths, Weaknesses, Opportunities, and Threats (SWOT) Analysis is a technique for assessing the organization's current position before implementing any new strategies (Mind Tools, n.d). The SWOT analysis determines an organization's internal capacity, such as strengths and weaknesses, to deal with external opportunities and threats. The assessment's strength and weakness components reveal an organization's current situation, and opportunities and threats focus on its future state (McDonald et al., 2011). The SWOT analysis of the organization revealed various strengths, weaknesses, opportunities, and threats.
The existing fall committee and champions were a strength for this project, especially in terms of sustainability. Interdisciplinary team support and organizational support were other areas of strength. Inaccurate or false assessment scores and non-compliance were weaknesses.
This project provided an excellent opportunity to reduce the number of falls and fall-related injuries. The increased workload for nurses and false assessment scores were threats. A summary of the analysis can be found in Appendix F.

Systems Change
This project brought positive system change in terms of improving the quality and safety of patient care. This project closed the gap between research and current practice and improved patient safety, which was later applied in everyday operations. The practice change improved the reimbursement of care by reducing the incidence of falls and fall-related injuries. Educating nursing staff on fall prevention measures enhanced their knowledge and skills regarding fall prevention and helped them provide safe and effective care. This project positively affected patient safety reduced the length of hospital stays, and reduced health care expenses to patients and health care organizations.

Project Overview
The project's vision was to reduce the number of inpatient falls in acute care settings by using the Morse Fall Risk assessment tool and prevention strategy. The project's mission was to use a multidimensional fall prevention program to reduce the number of falls and improve nurses' knowledge and compliance. This project's vision and mission aligned with the organization's vision and mission to help people achieve and maintain health by providing compassionate care based on quality, safety, compassion, innovation, and faith.

Objectives
The short-term objectives were to use an evidence-based fall risk assessment tool to identify patients at risk for falls. Davies (2019) revealed that appropriate screening tools could predict those at high risk for falls and reduce fall incidence in acute care settings. A protocol was developed for the use of the tool. In acute-care settings, screening every day or even every shift was required. Re-screening was necessary when there is a change in status. After completing the fall risk screening, each patient received a multidimensional intervention to address each identified risk factor (ANA, 2020).
Another short-term goal was educating the nurses on how to use the tool effectively before implementing the project. Staff education improved nurses' knowledge and understanding of fall risk and injuries and reduced falls in acute care settings. According to Thierry (2018), educational training in hourly Rounding and Morse Fall Risk Score procedural tools was an essential step in improving fall outcomes.
Continued evaluation by the fall committee on the use of tools for accuracy and completeness was needed. Charge nurses were auditing the charts every shift to assess errors in assessment. An appropriate teaching method was used to re-train the staff. Upon successful implementation of this project, information was disseminated to the other units. Using a pilot unit to evaluate the efficiency of the program helped to identify potential barriers and risks and address them before using the protocol in the other units.
The long-term objectives were to reduce the rate of falls by < 2.8% during the period of the project. This brought positive outcomes to the organization and improved the quality and safety of patient care. The hospital costs were lowered by improving the reimbursement and reducing the cost of treating the injuries caused by falls. It decreased the substantial financial burden on the healthcare system.

Risks and Unintended Consequences of the Project
One risk of this project was inaccurate or false fall risk assessment leading to the wrong risk score. It was essential to teach the nurses and train them on how to use the assessment tool correctly. Since the prevention strategies depended on the assessment score, incorrect assessment scores led to nurses' poor judgment. Other risks were lack of compliance from nurses to adhere to the protocol and proper documentation. Proper education and having a fall champion overlook the assessment process and documentation eliminated this risk.
Chart audit of the patients admitted to the telemetry unit occurred to see if the fall risk assessment tool was used consistently and correctly and the documentation of fall prevention strategy every shift. If the assessment tool was not used correctly, the nurse was reeducated. If the nurses were not compliant with the assessment and documentation of prevention strategy, corrective actions were initiated by the fall champion.

Project Implementation Plan
Lewin`s theory of change model was used for the implementation of this project. Because healthcare grew increasingly complex every day; it was essential to improve and sustain the best outcomes for high quality and safe patient care. The interprofessional collaboration provided a crucial component for achieving it. Lewin's change model consists of three steps: unfreezing or awareness creation of the problem, changing or creating the needed change, and refreezing, so the change becomes a habit (as cited in Connelly, 2020). Unfreezing involved making it possible for people to let go of something counterproductive. This was crucial to overcoming individual resistance.
The unfreezing phase started with recognizing the need for change and motivating for the change (as cited in Connelly, 2020). The organization identified an increased need for reducing the inpatient fall rate. Evidence-based guidelines created a changing environment for quality improvement and reducing healthcare costs. Regular meetings occurred with the fall committee, quality and safety committee, and ACNO to update the project's planning. An interdisciplinary team was developed, including front-line nurses, charge nurses, department leaders, fall champions, physicians, and informaticists.
Increased workload created staff resistance but educating the staff on using the fall risk assessment tool and fall prevention was essential to reducing the inpatient fall rates and fallrelated injuries. Unfreezing made it possible for the team to let go of what was done in the past and create positive change motivation. It was essential to develop an awareness for the nurses to understand that a problem existed and unfreeze the current practice.
The change phase included the planning and implementing stage of the project (as cited in Connelly, 2020). It was essential to create timelines for implementation and staff education.
Developing a workflow made this process smooth. Strong support from leadership was vital for the success of this stage. Reduction of inpatient fall rate and improving the staff knowledge and compliance on fall prevention was the primary goal of this project. Education needed to be provided to the nurse on the importance of fall risk assessment, fall prevention strategies, and how to use the assessment tool. A summary of staff education PowerPoint can be found in Appendix N.
The nurses started using the Morse Fall Risk assessment tool and fall prevention protocol.
The protocol for fall prevention was as follows: • The assessment was done once every shift, and whenever there was a change in status • After completing the fall risk screening, each patient received a multidimensional intervention to address each identified risk factors • The oncoming shift nurse checked with the off-going shift nurse at the patient's bedside to ensure that the fall precaution strategies for the fall risk patients were initiated and maintained throughout the shift.
• A score > 25 needed intervention • A score between 25-45 was considered a moderate risk • A score above 45 was considered high risk and required full intervention such as multidimensional prevention strategies, safe environment, bed alarm on, lights on, a urinal within reach, and frequent purposeful rounding • Two staff members ensured the safe environment once every shift The final stage for stabilization and evaluation (as cited in Connelly, 2020) occurred when establishing a new habit, and this new habit became the new standard of practice.
Leadership support was the key to success at this stage. The new routine became a culture of practice to assess the patients every shift and, as needed, to ensure fall prevention strategies were implemented. Through continuous support, education, and a reward system, the organization sustained the practice change. An evaluation was done at this stage to ensure goals were achieved in reducing the number of falls in acute care settings, and the change became permanent.
Evaluation of the challenges encountered was done during this stage for future reference.
Challenges encountered were also evaluated for future reference. Data were analyzed, and the result and the dissemination plan were finalized and presented to the leaders and staff. The nurses recognized that the screening tool was part of the daily assessment that was expected from them.

Barriers and Facilitators
Identified the barriers and facilitators that impacted the implementation and created strategies to overcome the obstacles. Some of the barriers were resistance to change, lack of motivation to use the guidelines, lack of compliance in the documentation, and the belief that the policies are not relevant to their settings. An increased workload created a barrier because nurses must complete additional assessments and preventive measures based on the assessment every shift. Facilitators included leadership support, interprofessional collaboration among healthcare providers, willingness to change, and adequate training. Having a fall committee and fall champion in each unit provided added facilitators who supported and troubleshot for the nurses.

Project Timeline
The first step of the project was completing an organizational assessment and a literature review. The total time for the project implementation was eight weeks. EPRC approvals were obtained from The University of St Augustine for Health Sciences and the organization. After the appropriate approvals, data were collected on inpatient fall rate pre-implementation.
Education and training of staff on the proper use of the fall risk assessment tool and protocol began. Collection of pre-implementation data and staff education on how to use the assessment tool and protocol was done in 4 weeks. Once training was completed, the assessment tool and protocol were used by nurses, and data were collected for 6 weeks post-implementation (see Appendix G for a detailed timeline for the project).

Resources and Budget
The

Role of DNP Project Manager
As a project manager, the DNP student was responsible for the successful planning, initiation, coordination of the team members, and the project's supervision. A strong leader was essential to achieving the goals and for the success of the project. The project manager set timelines, scheduled meetings, and delegated the tasks. As a leader, the project manager motivated the team and helped problem-solve. Effective interprofessional communication and support from the management were essential for the success of this project.

Results
The evaluation was an integral component of the EBP project to monitor the project's impact and identify and deal with any issues arising in the project. It is a systematic application to assess the approach, design, implementation, and utility of interventions (CDC, 2013). The primary outcome measure of this study was the reduction of the rate of inpatient falls using a multidimensional fall prevention strategy. The participants of this EBP project included adult acute care patients admitted to the telemetry unit during the 6 weeks of the EBP project. Patients were assessed for their fall risk level using the Morse Fall Scale (MFS), and patients who scored >35 received the fall prevention interventions. The staff participants included the nurses primarily assigned to the telemetry unit.
Training and education were provided to nurses from the telemetry units. Educational training included a review of the MFS criteria, the use of the Fall prevention protocol, and fall prevention documentation. The EBP change project was implemented from May 10 th through June 19 th , 2021, in three telemetry units (5B, 5C, and 5D) at an acute care hospital in South Texas. All data were collected after EPRC approval from the University of Saint Augustine and approval from the facility's IRB committee. The data collected for this project included preintervention and post-intervention data.
The pre-intervention data included the number of patients who suffered a fall while admitted to the hospital. Data collected from the hospital's fall reporting system was used to calculate the rate of inpatient falls before the implementation of the EBP project. Postintervention data included the number of patients who suffered a fall after implementing the project. All data were collected from the electronic fall reporting system.

Staff knowledge assessment occurred using the AHRQ Pre-Fall and Post-Fall
Knowledge Test. The project manager obtained permission from AHRQ to use this tool (see Appendix I). Data were collected using a numbering system to provide participant anonymity for both the pre-test and post-test. Therefore, no identifying information or names were collected while assigning participant numbers. A post-test was performed, and an analysis of the scores was completed to determine the education session's effectiveness, following the education session and one month after implementation (see Appendix C for the scores). Chart audits were conducted to identify if staff completed the Fall Risk Assessment using the Morse Fall Score and utilized the appropriate protocol. In addition, fall prevention documentation was used to determine if the protocols were followed correctly (see Appendix D).

Data Analysis
An Intellectus software was used to compare pre-intervention and post-intervention data.
A two proportions z-test was conducted to determine if a significant difference existed between the proportions of falls from February-April and May-June. The assumption of normality was assessed using the Central Limit Theorem (CLT).
The result of the two proportions z-test was significant based on an alpha value of 0.05, z = -2.57, p = .010, 95% CI = [-0.00096, -0.00208], indicated that the result did not support the intervention. The proportion of falls in February-April was significantly lower than the proportion of falls from May-June. The 95% confidence interval for the difference between the proportions of falls occurring in February-April and in May-June was -0.00096 to -0.00208. Table 1 presents the results of the two sample proportions z-test. A separate analysis was conducted for the telemetry unit's fall data. A two proportions ztest was conducted to determine whether or not a significant difference resulted between the proportions of falls February-April and May -June in the telemetry unit.The result of the two proportions z-test was not significant based on an alpha value of 0.05, z = -1.55, p = .122, 95% CI = [-0.0012, 0.0026],indicating that the results did not support intervention. This showed no significant difference occurred between the proportions of the falls from the February-April telemetry unit and the May-June telemetry unit. This EBP change project was clinically significant because of its impact on clinical practice. The 95% confidence interval for the difference between the proportion of falls in the February-April telemetry unit and May-June telemetry unit was 0.0012 to 0.0026. Table 2 presents the results of the two sample proportions z-test. A two-tailed paired samples t-test was conducted to examine whether the mean difference of knowledge pre-test and knowledge post-test was significantly different from zero. The result of the two-tailed paired samples t-test was significant based on an alpha value of 0.05, t (29) = -3.55, p = .001, and indicated that the results supported the intervention. This finding suggested the difference in the mean of knowledge pre-test and the mean of knowledge post-test was significantly different from zero. Therefore, the mean of the knowledge pre-test was considerably lower than the mean of the knowledge post-test. Table 3 presents the results of the two-tailed paired samples t-test. (see Appendix K for a bar plot of the means in Figure 1 and  Outcome measures included the patient fall rate in the acute care setting before and after implementing the project. Additionally, staff knowledge was assessed using pre-education and post-education scores. During the 6 weeks, only 5 of 2,000 patients experienced a fall in the telemetry unit. A paired proportion z-test results supported the intervention by improving the clinical practice. Improved staff knowledge was calculated using a paired sample t-test, and the results supported the intervention with improved staff knowledge.
Process measures included assessing every patient by the nurse using the assessment tool and score documentation. If the patient's score was >35, the fall prevention protocol was initiated. The percentage of staff using the tool was calculated by chart audit and fall prevention documentation.
Balance measures included calculating the average length of hospital stay for hospitalacquired falls. This was determined by subtracting the actual number of days a patient with a hospital-acquired fall stayed in the hospital from the average length of stay for any patient. The goal was to reach < 4.8 days, and during the implementation period, only two patients sustained an injury that required one additional day in the hospital in the telemetry unit.
Financial measures included the cost of training each RN and the cost associated with hospital-acquired falls. The RN's received 30 minutes of training during their work hours, and chart auditing occurred during work hours. Only two patients sustained an injury, and none transferred to a higher level of care following the falls.
Sustainability measures included monitoring the use of tools each shift and observing the nurses for protocol compliance. Adherence and non-adherence to protocol usage will be monitored by charge nurses and reported to the fall committee chair for re-training and corrective action as needed. The fall committee chair will be responsible for educating and training all new hires and evaluating the continuous use of the screening tool and prevention protocol initiation monthly.

Impact
The practice problem was that despite the organization exercising a good fall prevention strategy, falls were not prevented. The practice change was to introduce a multimodal fall prevention strategy over 6 weeks. This study's results were not statistically significant. Despite implementing a multimodal fall prevention strategy, the fall rate did not decrease compared to the previous months. This EBP change project was clinically significant because of its impact on clinical practice. The outcomes led to a better understanding of the possible fall prevention strategy and staff compliance.
The fall rate was calculated as the number of falls divided by the number of occupied bed days for the month multiplied by 1,000. This calculation returned the rate of falls per 1,000 occupied bed days. This calculation used a validated formula established by the National Database of Nursing Quality Indicators (NDNQI), as presented by AHRQ (AHRQ, 2013). The data collection tool used was one developed for fall prevention documentation. The project's limitations included reduced census during the pandemic, lack of staff participation, staff floating to other units, and isolation situations for COVID-19 patients. To assess the effect of the overall fall rate, the project needed to be extended to evaluate the entire 3-month period and use other units in the organization for comparison. Once re-evaluated, this change in practice can be extended to other inpatient acute care units.
It would also be beneficial to conduct the project in other departments and assess the outcomes. There should be an ongoing evaluation of the protocol to maintain sustainability.
Leaders of the units must review EHR to ensure that the nurses are documenting the assessment on the patients.

Dissemination Plan
Once the implementation was completed and results were evaluated, the next step involved sharing the results with the organization's other units. The results were presented to the fall committee first and then shared with stakeholders, including the front-line nurses, in a PowerPoint presentation. After making the nurses aware of the importance of fall risk assessment and fall prevention protocol, the results discussing the rate of inpatient falls pre-implementation and post-implementation of fall prevention protocol were shared using the intranet.
Once this project thrived in the pilot units, it was disseminated to the other units, the organization's regional level, and more medical centers involving all in the implementation of this protocol. The presentation was also posted on the organization's website for peer review and specific recommendations to the project at the peer level.
Archiving the change project at the University of St. Augustine for Health Sciences Scholarship and Open Access Repository (SOAR@USA) allowed students and faculty to access and share the results with the professional community. San Antonio Indian Nurses Association (SAINA) Newsletter, published quarterly and includes articles that educate, entertain, and enhance nursing practice, research, and leadership, was selected for publishing. This Newsletter had a peer-review process for submission. The National Association of Indian Nurses of America (NAINA) Newsletter, a peer-reviewed Newsletter published every 4 months, was selected for publishing at the national level.

Conclusion
The primary goal of this project was to implement a multidimensional fall prevention program to reduce the number of inpatients falls. Studies showed that inpatient falls could lead to injury, increased length of hospital stay, increased healthcare cost, loss of independence, and death (Williams et al., 2014). Since multiple factors caused inpatient falls, fall prevention should focus on addressing those factors. This paper discussed the significance of the problem, the PICOT question, the framework for the evidence-based practice change, change theory, evidence search strategy, evidence search result, and evaluation plan. It also discussed the themes from the evidence, practice recommendations, and the project setting. It also gave an overview of the plan and project evaluation plan with dissemination plans and a conclusion.   a. Fall prevention efforts are solely the nurses' responsibility. b. A patient who is taking four or more oral medications is at risk for falling. c. A patient who is taking psychotropic medication is at higher risk for falling. d. Testing or treatment for osteoporosis should be considered in patients who are at high risk for falls and fractures.
8. In hospital settings, intervention programs should include: a. Staff education on fall precautions b. Provision and maintenance of mobility aids c. Post fall analysis and problem-solving strategy d. Bed alarms for all patients, regardless of risk 9. When assessing patients, which of the following statements is false?
a. All patients should be assessed for fall risk factors at admission, at a change in status, after a fall, and at regular intervals. b. Medication review should be included in the assessment. c. All patients should have their activities of daily living and mobility assessed. d. Environmental assessment is not important in the hospital as it is all standardized. Which of the following statements on education in fall prevention is false?