By Edith Murray,2014-10-17 13:34
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    Submitted by Beth Aller RN, HE Clinical Education Manager and Falls Committee Member

     thStarting January 4, an updated charting screen in Horizon Clinical

    Documentation will be the MORSE FALLS ASSESSMENT and REASSESSMENT.

How will the Morse Fall Scale be used?

    According to the new HealthEast protocol for falls prevention, every patient will be assessed

    ; On admission.

    ; Daily on the day shift.

    ; When a patient’s condition changes or there has been a change in the

    patient’s medication regimen that could put the patient at risk for a fall.

    ; When a patient is transferred to another unit.

    ; After a fall.

    Why is this change in the HealthEast Falls Prevention Program being made at this time?

    This change in patient care pertaining to falls assessment has come about at this time for several reasons.

    ; Working toward the goals of the American Nurses Credentialing Center’s (ANCC)

    Magnet Recognition Program, HealthEast has chosen to participate in the

    National Database of Nursing Quality Indicators (NDNQI).

    ; This change is also coming about because of the 2005 & 2006 JCAHO Patient

    Safety Goals pertaining to falls.

    o The 2005 goal states “Reduce the risk of patient harm resulting from falls.

    Assess and periodically reassess each patient’s risk for falling, including

    the potential risk associated with the patient’s medication regimen, and

    take action to address any identified risks.”

    o The 2006 goal states “Reduce the risk of patient harm resulting from falls.

    Implement a fall reduction program and evaluate the effectiveness of the


    ; The most compelling reason of all for this change is that a recent study done by a

    HealthEast staff nurse in one of the HealthEast hospitals resulted in convincing


    o HealthEast hospitals need to improve the consistency of how falls are

    managed and evaluated.

    o Falls do happen in HealthEast hospitals and have produced serious injury.

    o Falls occur at all hours of the day and night; however, patients were most

    likely to fall during the nighttime hours.

    o Toileting issues were found to be the leading cause of falls in HealthEast


    As a result of this study, the HealthEast Nurse Practice Committee charged a group of nurses to look into the issue of falls. The HealthEast Falls Committee was formed to develop a nursing policy and procedure with the important purpose of creating a safe environment that protects patients from harm due to falls.


    ; Obtain a Morse Fall Scale Score by using the variables and numeric values listed

    in the “Morse Fall Scale” table below. (Note: Each variable is given a score

    and the sum of the scores is the Morse Fall Scale Score. Do not omit or change

    any of the variables. Use only the numeric values listed for each variable. Making

    changes in this scale will result in a loss of validity. Descriptions of each

    variable and hints on how to score them are provided below.) The “Total”

    value obtained must be recorded in the patient’s medical record.

    Morse Fall Scale

    Variables Numeric Values Score

    1. History of falling No 0


    Yes 25

    2. Secondary diagnosis No 0


    Yes 15

    3. Ambulatory aid

     None/bed rest/nurse assist 0

     Crutches/cane/walker 15

     Furniture 30 _______

4. IV or IV Access No 0


    Yes 20

    5. Gait

     Normal/bed rest/wheelchair 0

     Weak 10

     Impaired 20 _______

6. Mental status

     Oriented to own ability 0

     Overestimates or forgets limitations 15 _______

     Morse Fall Scale Score = Total ______

Morse Fall Scale Variable Descriptions and Scoring Hints

    1. History of falling

    ; This is scored as 25 if the patient has fallen during the present hospital

    admission or if there was an immediate history of physiological falls, such as

    from seizures or an impaired gait prior to admission. If the patient has not

    fallen, this is scored 0. Note: If a patient falls for the first time, then his or her

    score immediately increases by 25.

    2. Secondary diagnosis

    ; This is scored as 15 if more than one medical diagnosis is listed on the

    patient’s chart; if not, score 0.

    3. Ambulatory aid

    ; This is scored as 0 if the patient walks without a walking aid (even if assisted

    by a nurse), uses a wheelchair, or is on bed rest and does not get out of bed

    at all. If the patient uses crutches, a cane, or a walker, this variable scores 15;

    if the patient ambulates clutching onto the furniture for support, score this

    variable 30.

    4. IV or IV Access

    ; This is scored as 20 if the patient has an intravenous apparatus or a

    saline/heparin lock inserted; if not, score 0.

    5. Gait

    ; The characteristics of the three types of gait are evident regardless of the

    type of physical disability or underlying cause.

    1. A normal gait is characterized by the patient walking with head erect,

    arms swinging freely at the side, and striding without hesitation. This gait

    scores 0.

    2. With a weak gait (score10), the patient is stooped but is able to lift the

    head while walking without losing balance. If support from furniture is

    required, this is with a featherweight touch almost for reassurance, rather

    than grabbing to remain upright. Steps are short and the patient may


    3. With an impaired gait (score 20), the patient may have difficulty rising

    from the chair, attempting to get up by pushing on the arms of the chair

    and/or bouncing (i.e., by using several attempts to rise). The patient’s

    head is down, and he or she watches the ground. Because the patient’s

    balance is poor, the patient grasps onto the furniture, a support person,

    or a walking aid for support and cannot walk without this assistance.

    Steps are short and the patient shuffles.

    4. If the patient is in a wheelchair, the patient is scored according to the gait

    he or she used when transferring from the wheelchair to the bed.

    6. Mental status

    ; When using this Scale, mental status is measured by checking the patient’s

    own self-assessment of his or her own ability to ambulate. Ask the patient,

    “Are you able to go to the bathroom alone or do you need assistance?” If the

    patient’s reply judging his or her own ability is consistent with the activity

    order on the Kardex, the patient is rated as “normal” and scored 0. If the

    patient’s response is not consistent with the activity order or if the patient’s

    response is unrealistic, then the patient is considered to overestimate his or

    her own abilities and to be forgetful of limitations and is scored as 15.

Fall Risk

    ; Use the Morse Fall Scale Score to see if the patient is in the low, medium or high

    risk level. (See the “Fall Risk Level” table below to determine the level and the

    action to be taken.)

    ; Implement the interventions that correspond with the patient’s fall risk level. (See

    “Fall Risk Prevention Interventions” below.)

    ; Use the Morse Fall Scale Score to see if the patient is in the low, medium or high

    risk level. (See the “Fall Risk Level” table below to determine the level and the

    action to be taken.)


    Risk Level Morse Fall Scale Score Action

    Implement Low Risk Fall Prevention Interventions Low Risk 0 24

    Implement Medium Risk Fall Prevention Interventions Medium Risk 25 44

    Implement High Risk Fall Prevention Interventions High Risk 45 and higher

    Intervention: Score: 0-24 25-44 45-100

     (low risk) (medium (high

    risk) risk)

     1. All Admitted Patient

    yes no no Implement low risk interventions for all hospitalized patients.

     2. Communication

    yes yes yes Orient patient to surroundings and hospital routines

    ; Very important to point out location of the bathroom

    ; If patient is confused, orientation is an ongoing process

    ; Call light in easy reach make sure patient is able to use it

    ; Instruct patient to call for help before getting out of bed.

     Patient/Family Education yes yes yes

    ; Verbally inform patient and family of fall prevention interventions.

     Shift Report yes yes yes

    ; Communicate the patient’s “at risk” status.

     Plan of Care yes yes yes ; Collaborate with multi-disciplinary team members in planning care.

    ; Healthcare team should tailor patient-specific prevention strategies.

    It is inadequate to write “Fall Precautions”.

     Post a “Falls Program” sign at the entrance to the patient’s room. prn yes yes (Exception: Bethesda Behavioral units will not use the sign because of

    patient/staff safety concerns.)

     Make “comfort” rounds every 2 hours and include change in position, prn yes yes

    toileting, offer fluids and ensure that patient is warm and dry.

     Consider obtaining physician order for Physical Therapy consult.* prn prn yes*

     3. Toileting

    yes yes yes Implement bowel and bladder program.

     Discuss needs with patient. yes yes yes

    prn prn yes Provide a commode at bedside (if appropriate).

     Urinal/bedpan should be within easy reach (if appropriate). prn prn yes

     4. Medicating

    yes yes yes Evaluate medications for potential side effects.

     Consider peak effect that affects level of consciousness, gait and yes yes yes

    elimination when planning patient’s care.

     Consider having a Pharmacist review medications and supplements to prn prn yes

    evaluate medication regimen to promote the reduction of fall risk.

     5. Environment


    yes yes yes ; Low position with brakes locked, document number of side rails.

     Bedside stand/bedside table ; Personal belongings within reach. yes yes yes Room “clutter” - Remove unnecessary equipment and furniture ; Ensure pathway to the bathroom is free of obstacles and is lighted. ; Consider placing patient in the bed that is close to the bathroom. yes yes yes Use a night light as appropriate. prn yes yes

     6. Safety

    yes yes yes Nonskid (non-slip) footwear.

     Do not leave patients unattended in diagnostic or treatment areas. prn yes yes Consider placing the patient in a room near the nursing station, for prn prn yes

    close observation, especially for the first 2448 hours of admission.

     Consider patient safety alarm (tab alarm &/or pressure sensor alarm). prn prn yes ; Communicate the frequency of alarms each shift.

     If appropriate, consider using protection devices: hip protectors, a prn prn yes

    bedside mat, a “low bed” or a helmet.

     If “Fall Risk Prevention Interventions” have been initiated and are prn prn yes*

    unsuccessful, refer to HENSA Policy R-3 “Use of Restraint and


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