Morse Fall Scale

What is the Morse Fall Scale?

The Morse Fall Scale (MFS) is a tool healthcare providers use to assess an individual's fall risk. J. M. Morse developed it in the 1980s to help identify patients at high risk for falls.

The scale comprises six categories assessed to determine an individual's fall risk (Morse, Morse, & Tylko, 1989). These categories include history of falling, secondary diagnosis, ambulatory aids, intravenous therapy access, gait, and mental status. Each category is rated on a numerical scale, and the total score helps determine the individual's level of risk for falls.

The Morse Fall Scale is commonly used in hospitals, long-term care facilities, and other healthcare settings to assist in fall prevention strategies. It helps healthcare providers identify patients who may need additional support or interventions to prevent falls from occurring.

In addition to assessing an individual's fall risk, the Morse Fall Scale helps healthcare providers identify specific risk factors that may contribute to falls. Healthcare providers can use this information to develop personalized care plans and interventions for high-risk patients. It also allows for early detection of changes in fall risk, allowing for prompt interventions to prevent falls from occurring.

How does it work?

The free Morse Fall Scale Assessment is fully digital and easy to use. You can evaluate your patient using the scale in minutes. Follow these steps to get started:

Step 1: Get a copy of the assessment

Download the Morse Fall Scale using the link on this page. It's available from the Carepatron app or our practice management software's resources library.

Step 2: Print or complete digitally

You can print and complete the assessment by hand or digitally on a tablet or computer. We recommend using digital completion for easier electronic health record-keeping and access.

Step 3: Follow the instructions

The Morse Fall Scale has clear instructions that make it easy to use. Simply follow the instructions and fill in the appropriate scores based on your patient's history, medications, mobility, and mental status.

Step 4: Calculate the total score

Once all sections are completed, calculate the total score by adding each score. The maximum possible score is 125, with a higher score indicating a higher risk of falling.

Step 5: Interpret the results

The Morse Fall Scale includes guidelines for interpreting the total score and determining the patient's risk for falling. This can help with care planning and implementing interventions to prevent falls.

Morse Fall Scale scoring

The Morse Fall Scale is a quick and easy-to-use tool for assessing the risk of falls in patients. As mentioned, the scale consists of six items that are scored based on specific criteria (Brigham and Women's Hospital. n.d.):

• History of falling: If the patient fell during hospitalization and/or within the past three months, they receive a score of 25 points; otherwise, the score is zero.
• Secondary diagnosis: The score is zero if the patient has one active diagnosis or 15 points if they have multiple medical diagnoses for their current admission.
• Ambulatory aid: The score is zero if the patient can walk without aids, uses a wheelchair, or is on complete bed rest. The score is 15 if the patient uses crutches or a walker and 30 if they walk while holding furniture for support.
• Intravenous therapy: The score is zero if the patient does not have an IV, heparin (saline) lock, or any attached equipment. The score is 20 if the patient has an IV, heparin (saline) lock, or is attached to equipment, such as monitoring equipment or a Foley catheter.
• Gait: The score is zero for a patient with a normal gait, walking confidently with head held high, arms swinging freely, and a confident stride. The score is 10 for a patient with a weak gait, slightly stooped but able to lift their head without losing balance, using furniture as a guide with a light touch, and taking short steps or shuffling. Lastly, a score of 20 is given for a patient with an impaired gait, struggling to rise from a chair, walking with head down, requiring assistance, and having a short, shuffling gait.
• Mental status: The score is zero if the patient is fully oriented to time, place, and person. A score of 15 is given if the patient overestimates their abilities, forgets limitations, and has difficulty understanding instructions or responding appropriately.

To calculate the total score, add up the scores from each category. A score of 0-24 indicates no risk for falls, a score of 25-45 indicates low to moderate and a score of 46 or higher indicates high risk.

It is essential to continually assess fall risk using the Morse Fall Scale throughout a patient's hospital stay, as their risk may change over time due to risk factors such as medication changes, fatigue, or new symptoms.

When should you use the Morse Fall Scale?

The Morse Fall Scale is a widely used fall risk assessment tool designed to evaluate a patient's likelihood of falling. Healthcare providers should utilize it in specific clinical scenarios to ensure effective fall prevention.

• During patient admission: Evaluating a patient’s fall risk at admission is crucial. The MFS serves as an effective fall risk assessment tool, identifying patients at high risk for falls. Immediate identification enables the implementation of targeted fall prevention strategies.
• Following a patient fall: The MFS should be used after a patient falls to reassess fall risk factors. A new fall risk assessment is crucial in determining if additional fall prevention interventions are necessary and adjusting care plans accordingly.
• When patients have secondary diagnoses: Patients with secondary diagnoses such as dementia or osteoporosis are often at a higher risk of falls. The MFS helps assess mental status and other risk factors, allowing for more accurate and specific fall prevention planning.
• In high-risk settings: The MFS is vital in settings where patients are inherently at a high risk of falls, like geriatric wards or rehabilitation units. Regular use ensures proactive fall prevention.

Consistently utilizing the MFS as a fall risk assessment tool is crucial for effective fall prevention and patient safety.

What are the benefits of using the Morse Fall Scale?

The Morse Fall Risk Scale is one of the widely recognized fall risk assessment tools in various settings. It helps prevent inpatient falls and improves care quality.

Effective for hospitalized patients

The Morse Fall Scale is a valuable fall risk assessment tool for hospitalized patients, especially in acute care settings. Research by Jewell et al. (2020) showed that the scale could predict falls effectively over a four-month period by identifying risk factors such as gender and specific diagnoses. This enables healthcare professionals to implement tailored interventions, reducing inpatient falls and hospital stays.

Beneficial for elderly patients

The Morse Fall Scale helps elderly patients assess fall risk by identifying different risk factors. Bóriková et al. (2018) demonstrated its utility in long-term care settings, where it aids in evaluating fall risk factors among older adults. This targeted approach allows for planning fall prevention strategies and enhancing patient safety and care quality.

Useful in diverse healthcare settings

The Morse Fall Scale is adaptable across various healthcare environments, from hospitals to long-term care facilities. Baek, Piao et al. (2014) emphasized its importance in Korean medical settings for fall-prone patients. Identifying high-risk patients early allows healthcare teams to implement focused nursing interventions promptly.

Promotes interprofessional collaboration

The scale’s simple scoring system facilitates easy communication among healthcare professionals. This helps in swift decision-making and timely implementation of fall prevention strategies, promoting overall patient safety.

References

Baek, S., Piao, J., Jin, Y., & Lee, S.-M. (2014). Validity of the Morse Fall Scale implemented in an electronic medical record system. Journal of Clinical Nursing, 23, 2434–2441. https://doi.org/10.1111/jocn.12359

Bóriková, I., Žiaková, K., Tomagová, M., & Záhumenská, J. (2018). The risk of falling among older adults in long-term care: Screening by the Morse Fall Scale. Kontakt, 20(2), e111-e119. https://doi.org/10.1016/j.kontakt.2017.11.006

Brigham and Women's Hospital. (n.d.). Fall Tips Toolkit: Morse Fall Scale Training Module [PDF document]. https://www.brighamandwomens.org/assets/BWH/medical-professionals/pdfs/fall-tips-toolkit-mfs-training-module.pdf

Jewell, V. D., Capistran, K., Flecky, K., Qi, Y., & Fellman, S. (2020). Prediction of Falls in Acute Care Using The Morse Fall Risk Scale. Occupational Therapy in Health Care, 34(4), 307–319. https://doi.org/10.1080/07380577.2020.1815928

Morse, J. M., Morse, R. M., & Tylko, S. J. (1989). Morse Fall Scale (MFS) [Database record]. APA PsycTests.https://doi.org/10.1037/t24759-000