How to Calibrate the Morse Fall Assessment Tool

Evaluate the patient and tally the scores to calibrate the Morse Fall Assessment Tool. Use six variables; history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait and mental status to score the patient's fall risk. Re-calibrate the Morse Fall Scale score for each different health care facility and unit within the same facility. A patient's score places him into one of three fall risk categories. Identify his fall risk category and make recommendations.

Instructions

• 1

  Evaluate and chart the patient's history of falling. This score is 0 if she has not fallen within three months. This score is 25 if she has a history of falling or has fallen during the present hospital admission. Check her chart for secondary diagnosis. The score is 0 unless there is more than one medical diagnosis and 15 if two or more medical diagnoses are listed. Score ambulatory aids as 0 if she walks without aid, is bedridden or uses a wheelchair. The score is 15 if she uses a walker, cane or crutches. The score is 30 if she is clutching walls and furniture for support. The score is 0 for no intravenous therapy present. The score is 20 if she has a heparin lock or intravenous apparatus inserted.

• 2

  Observe the patient's gait. Score a normal gait -- he strides without hesitation -- at 0. If he is stooped and takes short, shuffling steps, his gait is weak and scored as a 10. Score 20 if he has an impaired gait, his head is down, he has trouble rising from a chair, grasps for a walking aid and cannot walk without assistance. Measure his mental status by judging his assessment of his limitations. Ask him if he requires assistance going to the bathroom. Rate him as normal with a 0 score if he answers in a manner consistent with the ambulatory order. Score 15 if his answers are unrealistic.

• 3

  Tally and record the patient's scores to calibrate the Morse Fall Assessment Tool. Identify her fall risk level as either no intervention needed, standard fall prevention interventions needed or high-risk prevention interventions needed. A total score of 0 to 24 indicates no fall risk, and she requires only basic nursing care. A score of 25 to 50 indicates a low fall risk; implementing standard fall-prevention interventions are required. A score higher than 51 indicates a high fall risk; implementing high-risk prevention interventions are needed. Consider the health care facility, and make recommendations that place her in the safest environment possible.