Mm week 4 gap analysis

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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.

https://www.cdc.gov/steadi/index.html

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. https://www.mdpi.com/2076-

3417/12/15/7934

Mathew, R. (2025). Quality Improvement Project Fall Prevention Among Skilled Nursing

Facility Residents Through Staff Education.

https://arch.astate.edu/cgi/viewcontent.cgi?article=1134&context=dnp-projects

INSTRUCTIONS

Gap Analysis Tool Adapted from AHRQ

What is this tool? The purpose of the gap analysis is to provide project teams with a format in which to do the following:

• Compare the best practices with the processes currently in place in your organization. • Determine the “gaps” between your organization’s practices and the identified best

practices. • Select the best practices you will implement in your organization.

Who are the target audiences? The project liaison (you will serve as the liaison for this assignment) will be the primary individual to prepare this written gap analysis, but the entire improvement project team should be engaged in performing the gap analysis. How can the tool help you? Upon completion of the gap analysis, project teams will have the following:

• An understanding of the differences between current practices and best practice. • An assessment of the barriers that need to be addressed before successful implementation

of best practices.

How does this tool relate to others? Information from AHRQ’s Self-Assessment (Tool A.3) about the readiness of the hospital/practice setting to perform quality improvement for the Quality Indicators or Best/Evidence-based practices can be considered in the gap analysis as possible strengths or weaknesses (i.e., barriers) to be managed when implementing improvements. The best practice elements defined in the Selected Best Practices and Suggestions for Improvement (Tool D.4) are prefilled in the gap analysis tool. This provides the elements for the Implementation Plan (Tool D.6). Instructions

1. List the identified practice problem in Column 1. 2. In Column 2, provide a description of identified best practices (3 best practices required) to address the problem 4. In Column 3, identify barriers that may hinder successful implementation of each best practice strategy. Consider systems, procedures, policies, people (i.e. stakeholders), equipment, etc. 5. In Column 4, discuss your thoughts on whether your organization will implement that best practice strategy. If not, explain why. 6. Repeat steps 1-4 for each best practice.

Gap Analysis Tool (as adapted from AHRQ’s Tool D-5)

Improvement Project: _____________________ Quality Indicator/Practice Metric: ____________________________

Individual Completing This Form: ______________________________

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #1: [insert description of best practice here]

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #2: [insert description of best practice here]

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #3: [insert description of best practice here]

1. Improvement Project:
2. Quality IndicatorPractice Metric:
3. Individual Completing This Form:
4. Column 1:
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8. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem:
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13. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem_2:
14. Column 1_3:
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16. Column 3_3:
17. Column 4_3:
18. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem_3:
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