Understanding the Morse Fall Scale (MFS)
The Morse Fall Scale (MFS) is one of the most widely used tools for assessing a patient's likelihood of falling, particularly in acute and long-term care settings. The scale evaluates six key variables, assigning a point value to each. The scores are then totaled to determine the patient's overall risk level. The full range of the MFS is from 0 to 125.
MFS scoring categories
The six variables considered in the MFS include:
- History of falling: A recent history of falls, within the last three months, adds 25 points.
- Secondary diagnosis: Having more than one medical diagnosis adds 15 points.
- Ambulatory aid: Points are assigned based on the type of aid, from 0 for independent walking to 30 for using furniture for support.
- IV therapy/heparin lock: The presence of an IV or heparin lock adds 20 points.
- Gait: A weak or impaired gait scores 10 to 20 points, respectively, while a normal gait scores 0.
- Mental status: An overestimation of one's own abilities or forgetting limitations adds 15 points.
MFS interpretation of risk
Based on the total score, the MFS classifies a patient's risk into three levels:
- Low/No Risk (0–24 points): Indicates a minimal risk of falling. Standard, basic nursing care and universal fall prevention interventions are appropriate.
- Moderate Risk (25–44 points): Suggests an increased risk, requiring closer observation and specific fall prevention interventions.
- High Risk (45 points or more): Identifies a significant risk of falling, necessitating aggressive fall prevention protocols.
Exploring the Hendrich II Fall Risk Model (HIIFRM)
Another respected clinical tool, the Hendrich II Fall Risk Model (HIIFRM), is often used in acute care hospitals to screen adult patients. It evaluates eight specific risk factors, plus a "Get-Up-and-Go" test. The total score for the HIIFRM ranges from 0 to 16, with a specific cutoff used to identify high-risk individuals.
HIIFRM scoring categories
- Confusion/disorientation/impulsivity: Scores 4 points.
- Symptomatic depression: Scores 2 points.
- Altered elimination: Scores 1 point.
- Dizziness/vertigo: Scores 1 point.
- Male gender: Scores 1 point.
- Antiepileptic medications: Scores 2 points.
- Benzodiazepines: Scores 1 point.
- "Get-Up-and-Go" test: Points are assigned based on performance, from 0 for a single movement to 4 for being unable to rise without assistance.
HIIFRM interpretation of risk
Unlike the multi-tiered risk levels of the MFS, the HIIFRM uses a single cut-off point.
- At Risk (5 points or greater): Any patient with a total score of 5 or higher is considered at high risk for falls and requires fall prevention interventions.
- Not at Risk (4 points or less): Patients scoring below the cut-off are not flagged as being at high risk based on the model's criteria.
Comparison of Fall Risk Assessment Scales
| Feature | Morse Fall Scale (MFS) | Hendrich II Fall Risk Model (HIIFRM) |
|---|---|---|
| Scoring Range | 0 to 125 | 0 to 16 |
| Variables | 6 variables: history of falls, secondary diagnosis, ambulatory aid, IV/heparin lock, gait, and mental status. | 8 variables plus a physical test: confusion, depression, elimination, dizziness, male gender, medications (antiepileptics, benzodiazepines), and "Get-Up-and-Go" test. |
| Risk Levels | Categorized into Low (0-24), Moderate (25-44), and High (≥45). | Uses a single cut-off point, typically 5 or greater, to indicate high risk. |
| Focus | Widely applicable across many inpatient settings, including acute and long-term care. | Designed specifically for acute care hospital settings, screening for key risk factors. |
| Primary Use | Quick and simple risk assessment for various patient populations. | Screens for specific risk factors in hospitalized adult patients. |
The Role of Interpretation and Clinical Judgement
While fall risk assessment scales offer valuable numerical data, they are not a substitute for comprehensive clinical judgment. The scoring ranges provide a standardized starting point, but healthcare providers must also consider other factors not captured by the scale, such as environmental hazards, medications, and the patient's individual functional capacity.
Interventions are tailored based on the identified risk factors. For a patient with a moderate MFS score due to a weak gait, physical therapy and gait training may be the priority. For a patient with a high HIIFRM score driven by confusion and medication use, environmental modifications and more frequent observation are crucial. Effective fall prevention relies on a holistic approach that combines standardized assessments with personalized care planning.
Conclusion
Understanding the range of a fall risk assessment scale is critical for interpreting the results and guiding patient care. The Morse Fall Scale, with its 0–125 range and multi-level risk classification, is suitable for many settings, while the Hendrich II Fall Risk Model, with its 0–16 range and specific cut-off score, is tailored for acute hospital patients. Healthcare providers should use these tools as a foundation, incorporating clinical judgment and comprehensive patient factors to develop an effective, individualized fall prevention strategy. The ultimate goal is to move beyond the numbers and implement targeted interventions that enhance patient safety and minimize the risk of injury. For further reading, an authoritative resource on fall prevention is the CDC's STEADI program, which provides comprehensive guidelines and assessment tools.
