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Assisted Living Case – Analysis

The organization is an Assisted Living facility. Its mission is to be the preferred senior living provider focused on choices and independence while promoting health and exceeding the expectations of those it serves and employs. The vision is to promote health care, transform the industry innovatively and promote lifestyle enhancement. The services provided include offering meals, social and recreational activities, housekeeping, personal care, some medical services, and monitoring medication. The organization is state-funded and serves a client population of approximately 1,000 people at the moment.

The major problem is high cases of falls and injuries among the clients in the facility. The organization differs from an ordinary hospital in many aspects, such as function, client, and staff groups. As a result, there is a need to redesign the health care principles on quality improvement to be effective in this scenario. Falls are common in older people, and they pose a significant problem because of associated injuries and the psychological impact on patients. Older adults restrict their movements in response to a fall (Pereira et al., 2008). This problem compromises the organization’s objective of creating independence and enabling patients to carry out their life routine tasks.

The rates of falls and injuries in the organization have impacted several systems essential in achieving the organization’s objectives. For instance, this problem has reduced the overall quality of care. Whenever a client falls and suffers an injury, they are likely to feel that the organization is liable in some form. The blame game between health care providers and clients is a barrier to the effective delivery of health care services (Brborović et al., 2019). Secondly, the organization’s mission is affected adversely by legal issues. In most instances, clients might file lawsuits against the organization because they feel it is liable for such occurrences. Lawsuits impede its commitment towards care improvement programs because of the expenses and legal obligations that must be followed (Mello et al., 2010; Stevenson et al., 2013). Finally, it impacts the facility’s financial capacity because of the expenses of caring for the injured and the opportunity cost involving staff’s time and resources.

For improved quality of care, it is essential to assess patients with a significant fall history and address fall risk factors identified by clients and the staff. Using the model proposed by Ganz et al. (2009), the first step should be to hold an initial meeting with the providers to ascertain whether they all agree on the importance of preventing falls, strategies to prevent falls, and accomplish those strategies. The second step is to develop a group of staff responsible for creating a concrete plan to prevent falls by discussing specific options for the fall prevention program. The final step is to present the suggested action plan and receive feedback on its effectiveness regularly. Further training may be necessary for compliance with OSHA’s obligations about falls and injuries (OSHA, n.d.). Doing so must involve collaboration among all departments in the organization while paying attention to the organization’s mission.


Brborović, O., Brborović, H., Nola, I. A., & Milošević, M. (2019). Culture of blame—An ongoing burden for doctors and patient safety. International Journal of Environmental Research and Public Health16(23), 4826. https://doi.org/10.3390/ijerph16234826

Ganz, D. A., Yano, E. M., Saliba, D., & Shekelle, P. G. (2009). Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system. BMC Health Services Research9(1). https://doi.org/10.1186/1472-6963-9-206

Mello, M. M., Chandra, A., Gawande, A. A., & Studdert, D. M. (2010). National costs of the medical liability system. Health Affairs29(9), 1569-1577. https://doi.org/10.1377/hlthaff.2009.0807

OSHA. (n.d.). OSHA’s fall prevention campaign. Occupational Safety and Health Administration. https://www.osha.gov/stop-falls

Pereira, C. L., Vogelaere, P., & Baptista, F. (2008). Role of physical activity in the prevention of falls and their consequences in the elderly. European Review of Aging and Physical Activity5(1), 51-58. https://doi.org/10.1007/s11556-008-0031-8

Stevenson, D. G., Spittal, M. J., & Studdert, D. M. (2013). Does litigation increase or decrease health care quality? Medical Care51(5), 430-436. https://doi.org/10.1097/mlr.0b013e3182881ccc

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