MORSE FALL RISK ASSESSMENT
SCALE
The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient’s likelihood of falling in
Adult. It consists of six variables that are quick and easy to score.
S.NO. RISK FACTOR SCALE SCORE
History of Falls in immediately within Yes 25
1
6 months No 0
Secondary Diagnosis Yes 15
2
(Two or More medical diagnosis)
No 0
Furniture 30
Crutches/Walker/Cane 15
3 Ambulatory Aid
None/Bed Rest/Wheel chair/
0
Nurse
Yes 20
4 IV/Heparin Lock
No 0
Impaired 20
5 Gait Transfering Weak 10
Normal/Bed Rest/ Immobile 0
Forgets limitations 15
6 Mental Status
Oriented to own ability 0
Patient is on any of the
medications mentioned below
20
or has been under the effect of
7 Medications / Other Conditions like Anaesthesia/Narcotics
Does not fall into any of the
0
criteria
Yes 10
8 Physical Restraints
No 0
Yes 10
9 Fluid Restrictions
No 0
TOTAL SCORE
FALL SCORE
High Risk 45 and Higher
Moderate Risk 25 - 44
Low Risk 0 - 24
1.History of Falling:
This is scored as 25 if the patient has fallen during the present hospital admission or if there was an
immediate history of physiological falls, such as from seizures or an impaired gait prior to admission. If the
patient has not fallen, this is scored 0.
IMPORTANT NOTE :
If a patient falls for the first time, then his or her score immediately increases by 25
2.Secondary diagnosis:
This is scored as 15 if more than one medical diagnosis is listed on the patient’s chart, if not, score 0.
Ex: HTN, CAD, DM, Parkinson's disease, Seizures, Vertigo, Loss of limb (s), Fractures, Osteoporosis,
Arthritis, COPD/Asthma
IMPORTANT NOTE :
If a patient is diagnosed as CVA (Crebro vascular accident) and had history of
Hypertension and DM, primary diagnosis is CVA & Secondary diagnosis is HTN,
DM.
3.Ambulatory aids:
♣ This is Scored as 0 if the patient walks without a walking aid (even if assisted by a nurse), uses a
wheelchair, or is on a bed rest and does not get out of bed at all.
♣If the patient uses crutches, a cane, or a walker, this item scores 15
♣ If the patient ambulates clutching onto the furniture for support, Score this item 30.
4. IV/Heparin Lock:
This is scored as 20 if the patient has an intravenousapparatus or a
heparin lock inserted; if not, score 0.
5. Gait Transferring:
♣ A Normal gait(score as 0)is characterized by the patient
walking with head erect, arms swinging freely at the side,
and striding without hesitant.
♣ With a weak gait (score as 10), the patient is stooped
but is able to lift the head while walking without losing balance.
Steps are short and the patient may shuffle.
♣ With an impaired gait (score 20), the patient may have difficulty
rising from the chair, attempting to get up by pushing on the arms
of the chair/or by bouncing (i.e., by using several attempts to rise).
The patient’s head is down, and he or shewatches the ground.
Because the patient’s balance is poor, the patient grasps onto the
furniture, a support person, or a walking aid for support and cannot
walk without this assistance.
6. Mental status:
♣ When using this Scale, mental status is measured by checking the patient’s own selfassessment of his or
her own ability to ambulate. Ask the patient, “Are you able to go the bathroom alone or do you need
assistance?” If the patient’s reply judging his or her own ability is consistent with the ambulatory order,
the patient is rated as “normal” and scored 0.
♣ If the patient’s response is not consistent with the nursing orders or if the patient’s response is unrealistic,
then the patient is considered to overestimate his or her own abilities and to be forgetful of limitations and
scored as 15.
7. Medication/ Other Conditions:
♣ Patient is on any of the medications as Hypoglycemic, Diuretics, Anti-seizure, Laxatives, Anaesthetics,
Benzodiazepines, Narcotics, Sedatives, Hypnotics, Psychotropics, Epiduralor has been under the effect of
Anaesthesia/Narcotics it scored as 20
♣ If not related to this criteria scored as 0
8. Physical Restraints:
Preventing a person from placing themselves in a dangerous situation or harming themselves or others.
Examples of physical restraints
1. Shackles and handcuff or mittens
2. Soft wrist restraints
3. Soft ankle restraints
♣ If patient is on use of Physical restraints score as 10
♣ If no use of Physical Restraints scored as 0
9. Fluid Restrictions:
Fluid is in few disorders like Ex: Congestive Heart Failure (CHF), Kidney disorders
♣ If fluids are restrictedScored as 10
♣ If no restriction Scored as 0
WHEN TO ASSESS THE PATIENT:
♣ On Admission
♣ On receiving patient from other Unit
♣ When patients condition changes (Eg:Post operative,Changes in Consciousness etc)
♣ When Patients treatment plan changes (Eg: I.V Therapy, Drugs etc)
♣ Regularly in each 3 shift
CASE SCENARIO:
Mr. Jaya vardhan a 42‐year‐old man who works in the construction industry. He has a history of
unstable angina and his cardiac catheterization revealed coronary artery disease in 3 vessels. He is admitted
for bypass surgery which will occur in the morning. Mr. Jones has no other medical history. He does take
atorvastatin for high cholesterol. He is alert and oriented, ambulates without difficulty, and has no IV at this
time.
S.NO. RISK FACTOR SCALE SCORE PATIENT
SCORE
History of Falls in immediately Yes 25
1 0
within 6 months No 0
Yes 15
Secondary Diagnosis(Two or More
2 0
medical diagnosis) No 0
Furniture 30
Crutches/Walker/Cane 15
3 Ambulatory Aid 0
None/Bed Rest/Wheel chair/
0
Nurse
Yes 20
4 IV/Heparin Lock 0
No 0
Impaired 20
5 Gait Transfering Weak 10 0
Normal/Bed Rest/ Immobile 0
Forgets limitations 15
6 Mental Status 0
Oriented to own ability 0
Patient is on any of the
medications mentioned
below or has been under the 20
7 Medications / Other Conditions effect of 20
Anaesthesia/Narcotics
Does not fall into any of the
0
criteria
Yes 10
8 Physical Restraints 0
No 0
Yes 10
9 Fluid Restrictions 10
No 0
TOTAL SCORE 30
INTERVENTION: Moderate risk
HIGH RISK FALL PREVENTION INTERVENTIONS TO BE FOLLOWED FOR THE
FOLLOWING PATIENTS
✔ Critical Ward Patients
✔ Casuality
✔ Labour Unit
✔ Recovery Room
✔ Renal Unit
✔ Completely Paralyzed
✔ Immobilized
✔ Vulnerable Patients
PREVENTION INTERVENTIONS OF FALLS
STANDARD/LOW RISK FALL MODERATE RISK FALL HIGH RISK FALL
Lock all moveable equipment before Implement all Standard fall prevention Implement all standard and low fall risk
transfering interventions prevention interventions
Side Rails up Instruct patient to call for help before getting Safety first board placement
out of bed
Provide adequate lighting Place assistive devices within reach
Place bed Pan/Urinal within easy reach
Orient patient to surroundings and hospital Develop a schedule for turning and positioning
routines Position the bed at low level with brakes
Increase frequency of patient rounds
locked/position the foot stool in place
Orient patient about the call bell and make sure
Instruct the patient on side effects of drugs
patient is able to use it Instruct the patient and family about the
significance of fall prevention program Instruct housekeeping supervisor to keep
pathway clear from obstacles and keep toilet
Teach patient to use grab bars
floor dry
Consider obtaining doctor's order for
physiotherapy consult.
QUESTIONS FOR PRACTICE
1 . In modified morse scale, score of 30 determine________ risk.
a) Mild
b) Moderate
c) Severe
d) Intense
2. Parameters of Modified Morse scale DOES NOT include:
a) History of fall > 2year
b) Secondary Diagnosis
c) Gait
d) Mental Status
3. Which scale is used to assess fall risk?
a) MEWS
b) Wong baker’s
c) Modified Morse
d) Braden scale
4. In modified morse scale, score of 20 determine________ risk.
a) Mild
b) Moderate
c) Severe
d) Intense
5. In modified morse scale, score of 50 determine________ risk.
a) Mild
b) Moderate
c) Severe
d) Intense
ANSWERS
1. b
2. a
3. c
4. a
5. c
