At my last facility we had a rising fall rate: 9.5 falls per 1,000 resident-days and three falls with injury in two months. I convened a 12-person interdisciplinary team (RNs, CNAs, PT, pharmacist, activities) and led a focused review of incident data over two weeks. We implemented hourly purposeful rounding, medication risk reviews for 100% of residents, environmental fixes, and short focused training sessions. I ran weekly huddles and monthly PDSA cycles so staff owned small tests of change. Within six months falls dropped to 5.5 per 1,000 resident-days (a 42% reduction), falls with injury fell 60%, staff compliance with rounding hit 90%, and we estimated $45,000 saved by avoiding three hospital transfers.
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