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Calculate fall risk using the Morse Fall Scale. This validated assessment tool helps identify patients at risk for falling and guides prevention strategies.
Morse Fall Score
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Risk Level
Fall Prevention Interventions:
The Morse Fall Scale is a widely used, rapid, and simple method of assessing a patient's likelihood of falling. Developed by Janice Morse, PhD, RN, this scale has been validated across multiple healthcare settings and is considered one of the gold standards for fall risk assessment.
Each factor in the Morse Fall Scale contributes differently to overall fall risk. History of falling is the strongest predictor, followed by ambulatory aids and gait disturbances. The scale emphasizes both intrinsic patient factors (mental status, physical ability) and extrinsic factors (equipment, medications).
The Morse Fall Scale should be completed within 24 hours of admission and repeated whenever there is a significant change in the patient's condition. Regular reassessment helps identify emerging risks and allows for timely intervention adjustments.
The Morse Fall Scale has demonstrated high sensitivity (72-83%) and specificity (51-82%) across multiple studies. It has been validated in acute care, rehabilitation, and long-term care settings, making it a reliable tool for fall risk assessment.
A positive history includes any fall within the past 3 months, or a fall during the current hospitalization. Even if the patient denies falling but has a documented fall in their medical record, this should be scored as positive.
Weak gait is characterized by stooped posture, small steps, and seeking support from furniture or walls. Impaired gait involves difficulty rising from a chair, requiring assistance with transfers, or an unsteady, staggering walking pattern.
IV lines and heparin locks increase fall risk because they tether patients to equipment, limit mobility, and can cause patients to become tangled in tubing when attempting to ambulate independently. This is especially problematic during nighttime bathroom trips.
Perform initial assessment within 24 hours of admission, then reassess with any change in condition (new medication, procedure, change in mental status), after a fall, and at minimum every shift or daily depending on facility protocol.
Evidence supports multi-factorial interventions including bed/chair alarms, non-slip footwear, frequent toileting, adequate lighting, minimizing sedating medications, physical therapy consultation, and keeping frequently used items within reach. No single intervention prevents all falls.
While validated primarily in acute care hospitals, the Morse Fall Scale has been successfully adapted for use in rehabilitation facilities, long-term care, and home health settings. Some organizations modify scoring thresholds based on their patient population and fall rates.
Document the total score, risk level, specific interventions implemented, patient/family education provided, and any environmental modifications made. Also note patient response to interventions and any barriers to fall prevention compliance.
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