Morse Fall Scale

Download a free Morse Fall Scale template and example. Discover how to use this scale to assess fall risk factors in patients.

By Ericka Pingol on Jul 15, 2024.

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Fact Checked by Ericka Pingol.

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What is the Morse Fall Scale?

The Morse Fall Scale is a tool healthcare providers use to assess an individual's fall risk. It was developed in the 1980s by J. M. Morse to help identify patients who are 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, 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 prompts 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. 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 0-5 indicates no risk for falls, a score of 6-13 indicates low risk, a score of 14-24 indicates moderate risk, and a score of 25 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 factors such as medication changes, fatigue, or new symptoms.

When should you use the Morse Fall Scale?

Here are several scenarios where you can utilize the Morse Fall Scale to identify patients at risk for falls:

  • Upon admission: You can use the Morse Fall Scale as a baseline for assessing fall risk upon admission to the hospital. This will help you track changes in fall risk throughout the patient's stay.
  • After a fall: If a patient has experienced a fall, assessing their fall risk using the Morse Fall Scale is essential. The evaluation can help identify any contributing factors to the fall and determine the appropriate interventions.
  • Ongoing assessment: Fall risk is not static, and it can change over time. Therefore, it is essential to continue assessing a patient's fall risk using the Morse Fall Scale throughout their hospital stay.
  • Medication changes: Certain medications can increase a patient's risk for falls. It is vital to reassess their fall risk using the Morse Fall Scale after medication changes or additions.
  • Change in condition: A patient's condition, such as increased fatigue or new symptoms, can also affect their fall risk. Continuing to assess their fall risk using the Morse Fall Scale will help identify any changes and allow for appropriate interventions.
  • Discharge planning: You can also use the Morse Fall Scale to determine if a patient needs additional support or interventions after leaving the hospital. This can help prevent falls and promote a safe transition back to their home environment.
  • Educating patients and caregivers: The Morse Fall Scale is beneficial for healthcare professionals and can be used as an educational tool for patients and their caregivers. Patients and caregivers can better understand fall prevention and take necessary precautions to reduce fall risk by explaining the different risk factors and interventions.

What are the benefits of using the Morse Fall Scale?

The Morse Fall Risk Scale is a valuable and effective tool for assessing and predicting patient fall risk in various healthcare settings.

A study by Jewell et al. (2020) highlighted its effectiveness in acute care hospitals, demonstrating its ability to predict falls over four months. The scale identified vital factors such as gender and specific diagnoses, enabling healthcare professionals to tailor interventions and potentially reduce patient falls and hospital stays.

In Korean medical settings, the study by Baek, Piao et al. (2014) further supported the scale's predictive solid performance. It emphasized the importance of identifying high-risk patients using the Morse Fall Scale to implement focused nursing interventions until discharge.

Furthermore, research conducted by Bóriková et al. (2018) illustrated the scale's utility in evaluating fall risk factors among older adults in long-term care facilities. It successfully identified various risk factors and their correlations with high fall risks according to the Morse Fall Scale, enabling nurses to plan targeted preventive strategies.

Overall, using the Morse Fall Scale is instrumental in promoting patient safety and delivering high-quality care, which leads to higher patient satisfaction. Its simple scoring system allows for straightforward interpretation and communication among healthcare professionals, facilitating prompt decision-making and swift interventions to prevent falls.

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

Is the Morse Fall Scale a diagnostic tool?
Is the Morse Fall Scale a diagnostic tool?

Commonly asked questions

Is the Morse Fall Scale a diagnostic tool?

No, the Morse Fall Scale is not a diagnostic tool. It is a screening tool to assess a patient's fall risk and determine appropriate fall prevention interventions. The scale should be used with other fall prevention strategies and assessments.

What is the recommended frequency for using the Morse Fall Scale?

The frequency of using the Morse Fall Scale should be determined by the healthcare facility's fall prevention protocol and the patient's needs. It is recommended to use the scale upon admission, during any changes in condition, and at regular intervals as determined by the healthcare team.

Who typically uses the Morse Fall Scale?

Healthcare professionals, such as nurses and occupational therapists, use the Morse Fall Scale in acute care settings. However, other healthcare team members may also use the scale as part of their collaborative efforts to prevent falls.

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