Post on 29-Dec-2021
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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
Explanation of Morse Fall Scale elements & Post Fall Documentation
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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
Explanation of Morse Fall Scale elements & Post Fall Documentation
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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.
Explanation of Morse Fall Scale elements & Post Fall Documentation
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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.
Explanation of Morse Fall Scale elements & Post Fall Documentation
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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