Compared to their counterparts living in the community, older adults residing in long-term care facilities (LTCFs) have a higher risk for falls (1,2). About half of residents at the LTCFs fall at least once a year (1), resulting in physical injuries as well as psychosocial consequences (e.g., fear of falling, and reduction in social activities)(3,4). Fall prevention interventions can be divided into two groups depending on the target of risk factors: (1) person-focused interventions and (2) system-level interventions. This is the second of two scoping reviews focused on fall prevention within LTCFs and focuses on system-level fall prevention programs.

System-level fall prevention interventions in long-term care facilities refer to comprehensive strategies designed to minimize fall risks by enhancing the entire care environment and organizational practices, rather than focusing on individual residents. These interventions can be applied broadly to all residents in the facility and are implemented through facility-wide modifications, technological integrations, policy enhancements, comprehensive monitoring, and management practices. While person-level programs include interventions delivered directly to individual residents, system-level programs focus on broader strategies such as staff education, environmental alterations and audits, safety maintenance of patient equipment, implementation of multidisciplinary fall prevention teams, and the review of policies or processes regarding fall prevention (2).

Although falls in LTCFs constitute a substantial public health issue, research predominantly focuses on person-level interventions, often overlooking the critical role of system-level strategies. Part 1 of our series detailed these person-level interventions and their impacts. Now, Part 2 shifts focus to these system-level interventions, to synthesize evidence on system-level approaches. Prior reviews by Francis-Coad et al.(2) and Gulka et al.(5) provide synthesis of quantitative evidence demonstrating that multifaceted interventions, including additional staffing and expert resources, have been shown to reduce fall rates in LTCFs. Nevertheless, these analyses generally neglect the qualitative dimensions that are pivotal for comprehending the contextual and experiential factors integral to the efficacy and sustainability of fall prevention initiatives. To address this gap, our scoping review includes both quantitative with qualitative evidence, thereby synthesizing a more comprehensive perspective on system-level fall prevention strategies within LTCFs. This integrative approach aims to deepen our understanding of the aspects that contribute to successful fall prevention, ensuring that proposed strategies are not only statistically effective but also practically feasible and adaptable within the intricate environments of LTCFs.

Thus, the aims of this scoping review were to: (1) synthesize the evidence for the fall prevention interventions focusing on system-level approaches in the LTCFs, and (2) identify clinical and research implications derived from review. The results will assist facility administrators and policy makers to identify effective system-level fall prevention and implementation strategies to decrease adverse outcomes of falls among older adults living in the LTCFs.

We conducted a scoping review using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines (6).

This scoping review underscored the importance of comprehensive interventions that necessitate active participation and collaboration from the full spectrum of nursing staff and residents in LTCFs. Such inclusive strategies may lead to more efficacious outcomes in fall prevention efforts. Broader engagement across all levels of staff not only diminishes staff isolation but also enhances the quality and sustainability of preventive measures (27,28). Inclusive approaches ensure that interventions are tailored to the diverse needs and perspectives within the LTCF community. This review also found that staff educational programs, when specifically targeted, were effective in reducing fall rates. These programs equip staff with crucial knowledge and skills to proactively manage fall risks, thereby reducing fall rates significantly. Additionally, involving residents in the development and execution of fall prevention programs is essential as it brings diverse perspectives that can refine and optimize the effectiveness of these initiatives.

Several multicomponent and multidisciplinary interventions demonstrated positive effects on fall prevention, and key factors contributed to their success. Successful interventions often incorporated a combination of staff education, individualized risk assessments, and environmental modifications. These components worked synergistically to address both immediate fall risks and longer-term prevention strategies. However, in some studies, such as those by Colón-Emeric et al. (13) and Rask et al. (11), challenges related to staff engagement, leadership buy-in, and inconsistent application across facilities hindered the full potential of these interventions. In the included studies, several implementation challenges were identified, including staff engagement (7,11), unclear specific staff roles and responsibilities (7), and integration into daily routines (11). Additionally, staff turnover and limited financial resources made it difficult to maintain consistent application of fall prevention strategies, reducing their effectiveness in the long term (11). Organizational culture hindering implementation and poor interdisciplinary collaboration also posed significant challenges (12). These challenges were consistent with those found in previous review studies (27,29). These studies highlight that successful implementation requires not only comprehensive interventions but also organizational support and leadership commitment to ensure that strategies are consistently applied. Furthermore, interventions that focused primarily on reducing physical restraints (15,16) did not address other critical components, such as staff training on broader fall prevention strategies or environmental modifications. Simply focusing on reducing restraints was not enough to significantly prevent falls, as more comprehensive approaches are needed to address the multifactorial nature of fall risks.

Research suggests that thoughtfully designed natural spaces and other environmental modifications may contribute to fall prevention in long-term care facilities. These environmental adaptations, as indicated in three studies (8,17,18), address potential physical hazards and promote a therapeutic environment that supports the well-being and mobility, and safety of residents. For example, Grant et al. (18) found that dynamic lighting systems significantly reduced falls by improving visual acuity, cognition, and sleep patterns. Future research should examine a range of environmental adaptations, from simple to extensive, to inform best practices for safer living environments.

Electronic health records and computerized order entry tools showed promise in fall prevention, though their adoption was limited due to challenges like staff turnover, resistance to workflow changes, and inadequate training (19,20). Future efforts should focus on providing ongoing staff training, customizing user-friendly tools that fit seamlessly into clinical workflows, and generating robust evidence to demonstrate the effectiveness of these technologies (30). Leadership commitment to fostering a supportive culture for technology use, alongside mechanisms for interdisciplinary communication and regular feedback, could enhance electronic health record adoption and optimize patient care outcomes in LTCFs (31).

The integration of video footage in LTCFs serves as an invaluable tool for enhancing the accuracy of fall incident reports and identifying environmental risk factors. Studies by Yang et al.(22) and Woolrych et al.(21) have demonstrated that video analysis can reveal discrepancies in fall reports and uncover unique resident behaviors that contribute to falls, such as interactions with furniture or nocturnal activities. By providing objective evidence, video footage has proven critical in refining our understanding of fall dynamics and improving intervention strategies (32). Despite the clear benefits, the implementation of video technology in LTCFs must navigate challenges such as ensuring resident privacy and managing costs, with studies showing that thoughtful placement of cameras in common areas and anonymization techniques can effectively address privacy concerns.

Staff education and training programs are crucial to effective fall prevention strategies in LTCFs. Studies in this review, including Bonner et al. (23), Burland et al. (8), Muñiz et al. (26), and Teresi et al. (25), highlighted the importance of equipping staff with practical tools and knowledge to manage fall risks. These programs typically focused on enhancing awareness of environmental hazards, improving staff skills in the proper use of assistive devices, implementing safe resident handling techniques, and ensuring effective communication and collaboration among staff. While Bonner et al. (23) and Burland et al. (8) emphasized continuous training to maintain long-term effectiveness, Muñiz et al. (26) and Teresi et al. (25) pointed to the need for organizational support and role clarity to ensure consistent application of fall prevention strategies. Although Teresi et al. (25) did not find statistically significant results, the intervention’s reduction in fall rates was considered clinically meaningful, demonstrating the value of improving staff awareness of behavioral and environmental risk factors.

The reviewed studies highlighted several methodological challenges, including inconsistent definitions of falls, varied data collection methods, and a lack of standardized outcome measures (33–35). Many studies relied on quasi-experimental designs and small sample sizes, limiting generalizability, while randomized controlled trials were rare but necessary to establish causality. Short follow-up periods also made it difficult to assess long-term effectiveness.

There is a notable lack of studies focused specifically on system-level fall prevention interventions in LTCFs, with most research reviewing person-level and system-level interventions together. Discriminating between these intervention types is critical, as it highlights the importance of institutional commitment, such as changing organizational culture, addressing staff shortage, and implementing comprehensive technology-based fall prevention strategies. In response to this gap, various innovative technological approaches have emerged to enhance fall prevention strategies. These range from traditional emergency call systems to more advanced technologies like AI-based fall detection sensors (36), radar-based systems (37), and ambient sensor-based technologies such as acoustic sensory floors (38), microphone-based systems (39), and smart carpets (40,41), which have demonstrated high accuracy in controlled settings. Recent studies have shown promising results with novel interventions combining sensors and machine learning algorithms, achieving high sensitivity and specificity in fall prediction and detection (42,43). Future research should focus on evaluating the effectiveness of these technologies, using standardized definitions and rigorous designs to better understand their impact on fall rates.

LTCFs residents are a high fall risk population. This scoping review emphasizes the significance of collaborative, system-level fall prevention strategies in LTCFs, highlighting multicomponent fall programs, targeted educational programs and environmental modifications as effective measures. These interventions are shown to enhance fall prevention outcomes when they involve both staff and residents in their development and implementation. However, the adoption of technologies like electronic health records, despite their potential, faces challenges such as resistance to change and integration difficulties. Moving forward, efforts should concentrate on improving technology adoption through ongoing training, tailored tool customization, and robust leadership support to foster a technology-positive culture. Addressing these challenges and continuing to refine interventions will be crucial for advancing fall prevention practices in LTCFs.