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Morse Fall Scale
Nursing fall risk assessment, diagnoses and interventions are based on use of the Morse Fall Scale (MFS) (Morse, 1997). The MFS is used widely in acute care settings, both in hospital and long term care inpatient settings. The MFS requires systematic, reliable assessment of a patient's fall risk factors upon admission, fall, change in status, and discharge or transfer to a new setting. MFS subscales include assessment of:
1. History of falling; immediate or
within 3 months |
No = 0
Yes = 25 |
| 2. Secondary diagnosis |
No = 0
Yes = 15 |
| 3. Ambulatory aid |
None, bed rest, wheel chair, nurse = 0
Crutches, cane, walker = 15
Furniture = 30 |
| 4. IV/Heparin Lock |
No = 0
Yes = 20 |
| 5. Gait/Transferring |
Normal, bed rest, immobile = 0
Weak = 10
Impaired = 20 |
| 6. Mental status |
Oriented to own ability = 0
Forgets limitations = 15 |
| Risk Level |
MFS Score |
Action |
| No Risk |
0 - 24 |
None |
| Low Risk |
25 - 50 |
Standard Fall Prevention Interventions |
| High Risk |
= 51 |
See High Risk Fall Prevention Interventions below |
High Risk Fall Prevention Interventions
These interventions are designed to be implemented for patients with multiple fall risk factors and those who have fallen. These interventions are designed to reduce severity of injuries due to falls as well as to prevent falls from reoccurring, supplementing standard fall prevention interventions.
Nursing Staff
Equipment:
- Consider use of: technology for fall prevention, non-skid floor mat, raised edge mattress.
To consider technologies for Fall Prevention, refer to the National Center for Patient Safety web site.
Examples include:
- Bed and/or chair alarms.
- Alarms at exits.
- Nurse call systems and communication systems.
- Low beds for patients at risk for falls.
- Video camera surveillance.
- Falls and Bedrails
Fall prevention programs emphasize bedrail reduction. Bedrails contribute to patient fall risk by creating barriers to patient transfer in and out of beds. Use of bedrails must be assessed specific to individual patient needs. When possible, use alternative pillows and positioning devices to avoid the use of bedrails.
Environment:
- Clear patient environment of all hazards
Medical Staff:
- Review medications for fall risk and adjust as indicated
- CV agents - if orthostatic (drop in systolic > 20 mm in 3 minutes) and symptomatic
• Discontinue HCTZ, liberalize sodium in diet
• If ACE inhibitor appropriate, use agent with less renal metabolism (fosinopril)
• If Calcium channel blocker - NOT nifedipine
• If ß blocker - not cardioselective / not metoprolol / atenolol; use pindolol / propranolol
- Consider referral to services such as physical medicine and rehabilitation, audiology, ophthalmology, cardiology.
- Optimize treatment of underlying medical conditions.
- Evaluate and treat for pain.
- Evaluate circumstances surrounding fall for extrinsic and intrinsic contributing factors.
Education:
- Exercise
- Nutrition
- Home safety
- Plan for emergency fall notification procedure.
Source: United States Department of Veteran Affairs, VA National Center for Patient Safety
To see the info above on the Veteran's Affairs website use the links below:
Getting Started - How to Use This Aid
http://www4.va.gov/ncps/CogAids/FallPrevention/index.html
Morse Fall Scale
http://www4.va.gov/ncps/CogAids/FallPrevention/index.html#page=page-4
High Fall Risk Interventions
http://www4.va.gov/ncps/CogAids/FallPrevention/index.html#page=page-8
Fall Risk Technology
http://www4.va.gov/ncps/CogAids/FallPrevention/index.html#page=page-13
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