Understanding the Morse Fall Scale
The Morse Fall Scale (MFS) is a rapid and reliable tool widely used by healthcare professionals to assess a patient's risk of falling. Developed by Dr. Janice Morse, the scale is designed to be easily and consistently applied in various healthcare settings, including hospitals, long-term care facilities, and rehabilitation centers. The assessment evaluates a patient's risk across six key variables, assigning points for each factor. A cumulative score then places the patient into one of three risk categories: low, moderate, or high. This tiered system allows healthcare providers to prioritize patients who require the most immediate and intensive interventions to ensure their safety.
The Six Key Components and Scoring
The MFS is composed of six sub-items that are evaluated by the healthcare worker. The scores are tallied to determine the patient's overall risk level. Here is a breakdown of each component and its corresponding point value:
- History of Falling (25 points): A patient receives 25 points if they have a history of falling within the past three months, or if they have fallen during their current hospital admission. A patient with no recent history receives 0 points.
- Secondary Diagnosis (15 points): This refers to the presence of multiple or additional medical diagnoses. A patient with more than one medical condition on their chart is given 15 points, while a patient with a single diagnosis receives 0 points. Multiple conditions can increase risk due to cumulative effects or polypharmacy.
- Ambulatory Aid (0, 15, or 30 points): The type of assistive device, if any, the patient uses affects their score. A patient using a crutch, cane, or walker scores 15 points. A patient who ambulates by holding onto furniture for support receives 30 points, indicating significant instability. Patients who are on bed rest, immobile, or require nursing assistance to ambulate score 0.
- IV/Heparin Lock (20 points): The presence of an intravenous line or a heparin lock is considered a risk factor, as it can interfere with a patient’s mobility and increase the risk of tripping or entanglement. A patient with either receives 20 points; otherwise, they receive 0 points.
- Gait (0, 10, or 20 points): This item assesses the patient’s walking ability. A normal gait scores 0 points. A patient with a weak gait, characterized by shuffling or unsteady movement, receives 10 points. An impaired gait, involving significant difficulty or poor balance, scores 20 points.
- Mental Status (0 or 15 points): The patient’s awareness of their own limitations is assessed. A patient who is oriented and understands their limitations, such as needing assistance to stand, scores 0 points. A patient who forgets their limitations or overestimates their abilities receives 15 points, as they are more likely to attempt risky maneuvers.
Interpreting the Risk Score
The cumulative score from the six variables determines the patient's fall risk level. The final score can range from 0 to 125, with higher scores correlating with a greater likelihood of a fall. The interpretation is categorized as follows:
| Morse Fall Scale Score | Risk Level | Required Action |
|---|---|---|
| 0–24 | Low Risk | Standard fall prevention interventions. |
| 25–45 | Moderate Risk | Implement standard fall prevention measures with increased vigilance. |
| 45+ | High Risk | Implement high-risk fall prevention protocols and increased supervision. |
As the table illustrates, the healthcare worker should identify as being at the highest risk for a fall any patient who scores 45 or higher based on the Morse Fall Scale. This patient requires the most attention and the most comprehensive interventions to prevent a fall.
Characteristics of a High-Risk Patient
Identifying a patient at the highest risk means recognizing a combination of factors that significantly increase their likelihood of falling. A patient scoring 45 or more is not just an arbitrary number; it signifies a serious and immediate threat to their safety. For example, a patient with a recent fall history (25 points), an impaired gait (20 points), and who uses furniture for support (30 points) would score 75 points, clearly placing them in the high-risk category. Similarly, a patient with a secondary diagnosis (15 points), an IV lock (20 points), and who forgets their limitations (15 points) would accumulate a score of 50, also categorizing them as high risk.
Implementing Fall Prevention Strategies
For high-risk patients, a layered approach to fall prevention is essential. Interventions must be tailored to the specific risk factors identified by the MFS and adapted to the patient’s evolving condition. Here are some strategies for high-risk patients:
- Enhanced Surveillance: Increase the frequency of patient rounds and place the patient in a room closer to the nursing station for easier monitoring. Consider using bed or chair alarms to alert staff when the patient attempts to get up unassisted.
- Environmental Modifications: Ensure the patient's room is free of clutter and that frequently used items, such as the call light, telephone, and water, are within easy reach. Ensure adequate lighting and install grab bars in bathrooms.
- Assistive Devices: For patients with gait issues, ensure appropriate assistive devices like canes or walkers are available, correctly fitted, and that the patient is properly trained on their use by a physical or occupational therapist.
- Patient and Family Education: Educate the patient and their family about their specific risk factors and the importance of using the call button for assistance. Reinforce that attempting to get up alone is dangerous. Consistent reinforcement from family can be a crucial safety net.
- Medication Review: Collaborate with the physician and pharmacist to review the patient's medication list. Identify and, if possible, reduce or eliminate medications that cause drowsiness, dizziness, or orthostatic hypotension, which can contribute to falls.
- Physical and Occupational Therapy: Engage therapy services early to address underlying issues like muscle weakness or impaired balance through targeted exercises and training.
Conclusion: Prioritizing Patient Safety with the Morse Fall Scale
The Morse Fall Scale is a vital tool for healthcare workers dedicated to patient safety. By providing a clear and standardized method for assessing fall risk, it helps professionals quickly identify which patient should the healthcare worker identify as being at the highest risk for a fall based on the Morse fall scale—the patient with a score of 45 or higher. This initial identification is the critical first step in a proactive fall prevention strategy. Effective use of the MFS, combined with tailored and consistent interventions, is essential for reducing the incidence of falls, improving patient outcomes, and ensuring a safer care environment for all.
For more detailed information on fall prevention strategies and the use of the Morse Fall Scale, resources from reputable organizations like Medbridge provide valuable insights for healthcare professionals and caregivers alike. Free Morse Fall Risk Assessment Tool PDF Download
