Root-Cause Analysis and Safety Improvement Plan

Clarion Court Skilled Nursing Facility in Shakopee, MN, is facing several issues associated with the quality of the provided services. One of the most urgent problems to be addressed is an unacceptable rate of falls in the facility, which may lead to significant reputational and financial losses. The administration of the health center is determined to address the issue due to its commitment to the highest value, which is the safety and positive outcomes of patients. This paper includes a root-cause analysis of the mentioned problem and a plan to resolve it effectively using the available resources.

Analysis of the Root Cause

The increasing number of falls is seen as a serious issue to be solved within a short period of time since the majority of patients are older people whose health may deteriorate considerably. The administrator identified major challenges after an implemented study aimed at exploring the quality of the provided care. The interviews that were conducted after this research unveiled particular characteristics of the issue and its causes. Employees reported that safety measures were not always followed due to work overload and ineffective communication patterns.

It is noteworthy that ineffective communication is one of the most influential factors leading to safety issues such as patient falls (Vlaeyen et al., 2017). The staff fails to respond to possible hazards as they do not use the available resources properly. ColĂłn-Emeric et al. (2017) found that healthcare professionals did not utilize available communication channels to the fullest, which caused numerous problems. In the facility in question, employees do not check emails regularly. Nursing practitioners and other members of the personnel may forget to notify the corresponding staff about filthy floors or other potentially hazardous factors due to the focus on other tasks.

Communication at Clarion Court Skilled Nursing Facility is characterized by the reliance on computers. All employees have access to computers and corporate electronic mail that is the central communicational channel. The members of the staff also communicate in a clinical setting when they have time. However, many members of the personnel report that they have no time to check emails or try to communicate with their peers, even when there is a situation that implies knowledge or information sharing. Vlaeyen et al. (2017) found that such cases contribute considerably to the deterioration of care quality.

Nursing professionals at the facility under consideration try to respond to the challenges and avoid various negative consequences including patient falls. However, these practitioners tend to have limited time to solve or even notice problems that emerge due to various reasons. Therefore, it is critical to concentrate on the improvement of communication in the health center and reduce nurses’ workload, which will be instrumental in addressing the most urgent problem, which is a high rate of falls.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The improvement plan developed for the health center in question will include such components as workload, falls response, and communication. The use of fall assessment tools has proved to be effective as these instruments enable nurses to identify the most vulnerable groups and pay more attention to such patients (Duckworth et al., 2019; Vlaeyen et al., 2017). Duckworth et al. (2019) offered a three-phase fall prevention intervention that can be utilized at Clarion Court Skilled Nursing Facility.

The intervention includes fall assessment, the creation of a prevention plan for patients, and strict adherence to this plan. This approach is associated with nurses’ reduced workload due to a more effective distribution of their time and attention. Nurses are able to pay more attention to certain patients while having more time to complete other tasks and avoid patient falls.

At the same time, it is essential to ensure the effective implementation of this intervention. It has been found that fall assessment toolkits are often ineffective because they are employed in an inappropriate way (Hiyama, 2019). Nurses tend to ignore the results of the evaluation, which leads to increased fall rates. One of the central factors contributing to these situations is nursing professionals’ working experience and their trust in such tools. Hiyama (2019) noted that the number of years spent in the profession positively correlated with the misuse of assessment instruments. In simple terms, the more nurses had worked, the less confident in the effectiveness of the toolkit they were.

Hence, in order to ensure the effectiveness of the suggested intervention, nursing practitioners should receive training involving the discussion of the benefits of the assessment and diverse methods of its utilization. This training will also aim at improving the personnel’s communication skills that are necessary for the effective implementation of the three-stage intervention. This project implies close interaction between nursing professionals and patients, as well as their caregivers and families. Communication skills will also be instrumental in developing proper relationships with other healthcare practitioners and the creation of a favorable working environment.

The improvement plan should not be confined to training and the focus on the assessment tool. Colón-Emeric et al. (2017) emphasized that training aimed at improving employees’ communication skills may be ineffective if the corresponding resources are unavailable. As mentioned above, access to computers and corporate email has an impact on employees’ performance and their participation in solving problems. Therefore, it is important to ensure the availability of effective communication channels and devices.

Existing Organizational Resources

Clarion Court Skilled Nursing Facility can be characterized by the appropriate use of technology. Nurses and other employees have an opportunity to use computers when needed. Nevertheless, some members of the staff report that they have limited time to check emails although this is the central communication channel administration utilizes to distribute tasks or notify the personnel about some issues to be addressed. Apparently, this approach is not beneficial for the facility, so more devices should be available to the employees.

The use of screens where a set of tasks is visible for the personnel and some devices that enable the staff to report and react will help in solving the problem. Instead of noticing a problem and keeping focused on certain tasks, a nurse or other authorized employees will be able to report the issue by including it in the list of problems to address. Due to the scarcity of resources, in some places, internal telephones can be installed. This communication channel will be employed to inform the responsible employee (a coordinator) about a problem, and this information will be added to the list of tasks to be performed during a day.


In conclusion, it is necessary to state that the major issue at Clarion Court Skilled Nursing Facility is a considerable rate of falls that is closely related to ineffective communication. The suggested improvement plan will include the utilization of a three-stage intervention, the provision of training to the personnel, and the use of additional devices facilitating communication. It is expected that employees will be less overloaded with tasks, and will have more time to be responsible and address emerging problems in a timely manner.


Colón-Emeric, C. S., Corazzini, K., McConnell, E. S., Pan, W., Toles, M., Hall, R., … Anderson, R. A. (2017). Effect of promoting high-quality staff interactions on fall prevention in nursing homes. JAMA Internal Medicine, 177(11), 1634-1641. Web.

Duckworth, M., Adelman, J., Belategui, K., Feliciano, Z., Jackson, E., Khasnabish, S., … Dykes, P. C. (2019). Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: An implementation science study. Journal of Medical Internet Research, 21(1). Web.

Hiyama, A. (2019). The relationship between the usability of fall prevention tools and characteristics of nurses. International Journal of Nursing, 6(1), 99-106. Web.

Vlaeyen, E., Stas, J., Leysens, G., Van der Elst, E., Janssens, E., Dejaeger, E., … Milsen, K. (2017). Implementation of fall prevention in residential care facilities: A systematic review of barriers and facilitators. International Journal of Nursing Studies, 70, 110-121. Web.

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NursingBird. "Root-Cause Analysis and Safety Improvement Plan." November 13, 2023.