explanation of morse fall scale elements & post fall

Explanation of Morse Fall Scale elements & Post Fall Documentation

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Fall Risk Assessment:

Type of fall (Past fall)

Accidental fall- Pt at low risk (MFS score of 0-24) for fall takes a fall (i.e. slips on spilled water or trips over something) Unanticipated physiologic fall- Pt at low risk (MFS score of 0-24) for fall takes a fall (i.e. seizes, hypoglycemia, or knee gives out and falls) Anticipated physiologic fall (78% of falls)- Pts at moderate to high risk (MFS score of 25+) of falls who falls (i.e. expected to have a fall due to individual risk factors and is largely preventable with fall prevention interventions)

History of fall:

Yes = 25 points

Secondary Diagnosis is often

missed: Please Mark “Yes” for

any diagnoses other than the

primary reason for admission,

i.e. HTN, DM2, CKD, and COPD

Consider current

medications as contributors

to fall risk

Yes = 15 points


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Normal gait: Walks with head erect, arms swinging freely at the side, striding without hesitation = 0 points

Weak gait: Stooped, but able to lift head without losing balance. If furniture required, uses as a guide (featherweight touch). Short steps, may shuffle =10 points

Impaired gait: Difficulty rising from chair (needs to use arms; several attempts to rise. Head down; watches ground while walking. Cannot walk without assist; grabs at furniture or whatever available. Short, shuffling gait =20 points

Use of Ambulatory Aid:

No aid, bedrest, wheelchair = 0 points

Crutches etc. =15 points

Furniture=30 points

This answer must also

align with provider‘s

order and RN

observation rather than

patient statement

IV or IV lock:

Yes=20 points


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Please refer to the “Falls Prevention in the Adult Inpatient” policy for interventions based on the MFS score

Mental Status:

Oriented = 0 points

Forgets limitations=15 points

0: No risk for falls <25: Low risk

25-45: Moderate risk >46: High risk

Please note: In Millennium you must document all responses in the scale to obtain score. Double click in the Morse Fall Score field for system to calculate score. We anticipate that those with moderate and high fall risk may fall and we aim to prevent these falls.


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Summary of MFS scores

Post Fall Evaluation:

Once “Type of Fall” is entered, required fields will be in yellow. Please fill the Post Fall Status.

Type of fall (Current fall)

Accidental fall- Pt at low risk (MFS score of 0-24) for fall takes a fall (i.e. slips on spilled water or trips over something) Unanticipated physiologic fall- Pt at low risk (MFS score of 0-24) for fall takes a fall (i.e. seizes, hypoglycemia, or knee gives out and falls) Anticipated physiologic fall (78% of falls)- Pts at moderate to high risk (MFS score of 25+) of falls who falls (i.e. expected to have a fall due to individual risk factors and is largely preventable with fall prevention interventions). Morse, JM (1997). Preventing Patient

Falls. Thousand Oaks: Sage

publications.

Morse, JM (2009). Preventing Patient

Falls. 2nd Ed. New York: Springer.


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References: Morse, JM (1997). Preventing Patient Falls. Thousand Oaks: Sage publications.

Morse, JM (2009). Preventing Patient Falls. 2nd ed. New York: Springer.

Post fall Evaluation includes assessment of VS, pain, LOC, Accucheck and a physical exam.

Post fall Re-evaluation includes VS, pain, LOC and a physical exam.

Post fall to do list:

1. Document the Post Fall Evaluation includes the story of the fall as well as

assessment of VS, pain, LOC, Accucheck and a physical examination.

2. Document the Post fall Re-Evaluation (using same band in Millennium) that

includes a physical examination.

3. Have a Post Fall Huddle & fill the Post-Fall Huddle form.

4. Enter a narrative nurse’s note.

5. Re-score Morse Fall Scale after a fall.

6. Keep IPOC updated.

7. Document Patient/Family Education

8. Complete MIDAS event Report

explanation of morse fall scale elements & post fall

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