Speaker
Description
Background/Rationale: Downsview Long-Term Care Centre is a for-profit, 252-bed multicultural home in North York, managed by Gem Health Care Group since 2012 and part of the North West Ontario Health Team. Newly admitted residents have consistently contributed to fall incidents. To ensure accurate measurement despite fluctuations in census and admissions, we monitor the fall rate per 1,000 resident days rather than relying on raw counts.
Aim: Through this quality improvement initiative, we aimed to mitigate fall risk among new admissions and reduce the overall fall rate.
Methods: We designated a staff member to systematically track fall data, which we reviewed quarterly through our Falls Prevention and Professional Advisory Committees. In alignment with RNAO’s three-year programs, BPSO and CP, we launched Admission, Delirium, and Resident-Centred Care in July 2025. We implemented CPs & BPSOs BPGs on Falls Prevention and Pain guidelines in April 2026. Our approach emphasizes shift-specific, real-time behavioural coaching. For example, when we admitted a high-risk resident in July 2025 who subsequently experienced 10 nighttime falls, we deployed a Behavioural Support Ontario PSW to the night shift. She directly observed nocturnal behaviours and provided coaching to frontline staff.
Outcomes: This collaborative intervention, involving the resident’s family, OT, and interdisciplinary team, resulted in zero falls for the resident from February 2026 onward. Over three years, these programs will help transform our organization:
• Culture & Staff: Shift from reactive tracking to proactive frontline coaching.
• Processes & Systems: Continue to adopt current and upcoming BPGs
• Resident Care: Individualized care plans
Lessons Learned: We learned that aggregate data must be translated into individualized clinical action. Sustainable improvements require connecting interdisciplinary planning with practical, shift-specific coaching. Integrating RNAO’s BPSO guidelines with behavioural support proves highly effective in eliminating complex fall patterns and optimizing safety for our evolving, multicultural resident population.
What RNAO BPG or tool/toolkit is your abstract related to?
Preventing Falls and Reducing Injury from Falls
Author(s) Credentials and Title
Mary Buhion, RN (Director of Care)
Lydia Jodoin, RN (Clinical Nurse Manager& Lead of Falls Prevention and Management)
Shawn Smith, RPN (Co-Lead, Falls Prevention and Management)
| Organization Name | Downsview Long Term Care |
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