What is the assessment that nurses use to assess fall risk?

According to the CDC, around 36 million falls are reported among older adults each year, resulting in more than 32,000 deaths. Understanding what is the assessment that nurses use to assess fall risk is critical for implementing effective prevention strategies and protecting patient safety.

Quick Summary

Nurses use a variety of validated assessment tools, including the Morse Fall Scale (MFS), the Hendrich II Fall Risk Model, and the Johns Hopkins Fall Risk Assessment Tool (JHFRAT), to systematically evaluate a patient's risk of falling based on specific factors and implement tailored prevention plans.

Key Points

• Assessment Tools: Nurses commonly use tools like the Morse Fall Scale (MFS), Hendrich II Fall Risk Model, and Johns Hopkins Fall Risk Assessment Tool (JHFRAT) to systematically evaluate a patient's likelihood of falling.

• Standardized Criteria: Each assessment tool uses a standardized set of criteria, such as a patient's history of falls, mental status, mobility, and medication use, to generate a risk score.

• Proactive Interventions: The score from a fall risk assessment directly informs the nurse and care team on the specific interventions needed to mitigate the patient's identified risk factors.

• Clinical Judgment is Key: Assessment tools are guides, not replacements, for a nurse's clinical expertise and judgment, which are crucial for a comprehensive, individualized prevention plan.

• Universal Precautions: Even patients considered low-risk should receive universal fall precautions, such as keeping beds low and the environment clutter-free, to ensure safety.

• Continuous Process: Fall risk assessment is not a one-time task but an ongoing process that requires reassessment upon patient admission, during shift changes, and with any change in the patient's condition.

• Holistic Approach: Effective fall prevention involves a holistic strategy, including patient education, environmental modifications, and interdisciplinary collaboration.

Why Fall Risk Assessment is Crucial for Patient Safety

Fall risk assessment is a fundamental component of patient care across various healthcare settings, from hospitals to long-term care facilities. The consequences of falls can range from minor bruises to severe injuries, such as hip fractures or head trauma, significantly impacting a patient's quality of life and increasing healthcare costs. By using standardized, evidence-based tools, nurses can objectively identify at-risk patients and apply targeted interventions to prevent falls before they occur. This proactive approach is a cornerstone of a robust patient safety program and a key nursing responsibility.

The Most Common Fall Risk Assessment Tools for Nurses

Different assessment tools are available, and the specific one used often depends on the facility's policy, the patient population, and the practice setting (e.g., acute care, rehabilitation). Below are some of the most widely used and validated tools.

Morse Fall Scale (MFS)

The MFS is one of the most widely used and well-validated tools for assessing fall risk in adult patients in acute care settings. It is quick and easy to administer, with nurses reporting that it takes only a few minutes to complete. The scale consists of six variables, each assigned a point value:

• History of falling: Immediate or within 3 months (yes/no).
• Secondary diagnosis: More than one medical diagnosis (yes/no).
• Ambulatory aid: Bed rest, crutches, cane, walker, or furniture.
• IV/Heparin lock: The presence of an IV.
• Gait: Normal, weak, or impaired.
• Mental status: Orientated to own ability or forgets limitations.

The total score places the patient into a category of risk (e.g., low, moderate, or high), guiding the nurse toward appropriate interventions.

Hendrich II Fall Risk Model

The Hendrich II Fall Risk Model is another reliable tool, commonly used in acute care settings. It identifies eight independent risk factors and is quick to administer. It is particularly effective for screening high-risk patients and is often used in post-fall assessments to understand contributing factors. Key risk factors assessed include:

• Confusion, disorientation, or impulsivity
• Symptomatic depression
• Altered elimination
• Dizziness or vertigo
• Male gender
• Prescribed antiepileptics
• Prescribed benzodiazepines
• Performance on the Get-Up-and-Go test

Johns Hopkins Fall Risk Assessment Tool (JHFRAT)

The JHFRAT was developed as part of a comprehensive, evidence-based fall safety initiative within the Johns Hopkins Healthcare System. This tool assesses a broader range of factors and is particularly useful for hospitalized patients over 60 years of age. It includes a screening process and a more detailed assessment for those with an unknown initial risk. The assessment covers:

• Age
• Fall history
• Bowel and bladder elimination issues
• High-risk medications
• Mobility status
• Equipment tethering the patient (e.g., IVs, chest tubes)
• Cognitive status

The total score helps nurses determine the patient's risk level and tailor a fall prevention plan accordingly.

Comparison of Common Fall Risk Assessment Tools

Feature	Morse Fall Scale (MFS)	Hendrich II Fall Risk Model	Johns Hopkins Fall Risk Assessment Tool (JHFRAT)
Primary Use	General adult population in acute and long-term care	Adults in acute care settings	Adults over 60, in hospital settings
Key Factors	History of falls, secondary diagnosis, ambulatory aid, IV, gait, mental status	Confusion, depression, elimination, dizziness, gender, medications, Get-Up-and-Go	Age, fall history, elimination, medications, equipment, mobility, cognition
Scoring	Points assigned to each factor, totaling a final risk score	Points assigned to risk factors, including medications and the Get-Up-and-Go test	Comprehensive point system with a screening component
Ease of Use	Considered quick and easy by nurses	Designed for rapid administration	More detailed, comprehensive assessment
Validation	Widely validated in various studies	Validated in a large acute care facility	Validated through an evidence-based initiative

The Nurse's Role Beyond the Assessment Tool

Simply administering a fall risk assessment tool is not enough. The nurse's professional judgment is a critical complement to any scoring system. A holistic, individualized, and multi-faceted approach to fall prevention is essential.

1. Perform Comprehensive Patient Evaluations: Beyond the tool, nurses must consider other risk factors, including environmental hazards, vision impairment, and a patient's own perception of their fall risk. Regular reassessments are vital, especially after changes in a patient's condition, medication, or environment.

2. Develop Individualized Care Plans: Based on the assessment, the nurse creates a tailored plan of care. For example, a patient with impaired gait might be referred to a physical therapist, while a patient on high-risk medication might require increased monitoring and education.

3. Implement Universal Precautions: Regardless of a patient's risk score, all patients benefit from universal fall precautions. These include ensuring the patient's bed is in a low position, personal belongings and the call light are within reach, the room is free of clutter, and the patient has non-slip footwear.

4. Engage Patients and Families: Educating patients and their families about fall risks and prevention strategies is crucial for success. Involving them in the care plan fosters adherence and empowers them to be active participants in their safety.

5. Utilize Technology and Environmental Modifications: Simple changes like providing nightlights, adding grab bars, or using bed alarms can significantly reduce fall risk. Nurses play a key role in advocating for and implementing these modifications.

For more information on evidence-based fall prevention strategies, nurses and healthcare organizations can consult resources from the Agency for Healthcare Research and Quality (AHRQ).

Post-Fall Assessment and Debriefing

If a fall occurs, the nurse's role continues with a post-fall assessment. This involves a thorough evaluation of the patient for any injuries and a debriefing to understand the contributing factors. This process helps to refine the fall prevention plan and prevent future incidents by identifying systemic issues or overlooked risks. The information gathered is vital for both immediate patient care and continuous quality improvement within the healthcare facility.

Conclusion: A Cornerstone of Quality Nursing Care

Fall risk assessment is more than just a box-ticking exercise; it is an essential, dynamic process that combines the use of validated tools with expert clinical judgment and continuous intervention. By diligently performing assessments with tools like the MFS, Hendrich II, or JHFRAT, nurses are at the forefront of preventing patient harm. This dedication to proactive safety measures is a defining characteristic of high-quality, patient-centered senior care and a vital part of healthy aging.

Frequently Asked Questions

What is the assessment that nurses use to assess fall risk for older adults specifically?

While several tools are used across different age groups, the Morse Fall Scale (MFS) is very common for adults, and the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) was specifically designed and validated for hospitalized patients aged 60 and older.

How often is a fall risk assessment performed by a nurse?

The frequency depends on the facility's policy and the patient's condition. Assessments are typically done upon admission, at every shift change, and whenever there is a significant change in the patient's status, mobility, or medication regimen.

What happens after a nurse assesses a patient's fall risk?

Based on the assessment score, the nurse implements a tailored plan of care. This can include universal fall precautions for all patients, as well as specific interventions like increased monitoring, assistance with ambulation, bed alarms, or referrals to therapy services.

Are all fall risk assessment tools the same?

No, different tools like the Morse Fall Scale, Hendrich II, and JHFRAT have unique criteria and scoring methods. The choice of tool often depends on the clinical setting (e.g., acute care, long-term care) and the specific patient population.

Can a patient's family help with the fall risk assessment?

Yes. Family members can provide valuable input, especially regarding a patient's mental status, mobility at home, or history of falls. Engaging family members in the assessment and prevention plan can significantly improve patient safety.

What factors are commonly assessed in these fall risk tools?

Commonly assessed factors include a history of previous falls, presence of secondary diagnoses, mental and cognitive status, ambulatory ability, use of mobility aids, presence of IV lines or other equipment, and the types of medications being taken.

What are universal fall precautions?

Universal fall precautions are standard interventions applied to all patients, regardless of their risk score. Examples include keeping the patient's bed in a low position, ensuring the call light and personal items are within reach, and maintaining a clear and dry environment.