Ministry of Health Malaysia
FALLS RISK TOOL
MODULE NO. 3
ASSESSMENT
(NURSING ASSESSMENT SCREENING TOOL)
HANDOUTS
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Tools can be used to identify risk factors for falls in
hospitalized patients. The total score may be used
to predict future falls.
It is more important to identify risk factors clinically
and then plan care to address those risk factors
with the assistance of the tool.
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Morse RM,Tylko SJ.(1989). Development of a scale to identify the fall-prone patient. Can J Aging;8:366-7. NATIONAL FALL PREVENTION AND
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The Morse Fall Scale (MFS) ;
- is a rapid and simple method of assessing patients likelihood of
falling
- used widely in acute care settings, both in the hospital and long
term care inpatient settings
- is quick and easy to use
- takes less than 3 minutes to rate
It consists of six variables that are quick and easy to score,
and it has been shown to have predictive validity and interrater
reliability.
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https://networkofcare.org/library/Morse%20Fall%20Scale.pdf NATIONAL FALL PREVENTION AND
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History of falls
Secondary diagnosis
Ambulatory aids
IV Therapy / Heparin Lock (IV devices)
Gait
Mental status
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*Mental status is measured by checking the patient’s own self-assessment of
his or her own ability to ambulate.
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INPATIENT ADULT FALLS PREVENTION MEASURES
Nursing falls prevention measures for inpatients adults are based on falls risk stratification by
Morse Falls Scale.
Standard / Universal Falls Prevention should be applied for all patients, depending on the
resources of each institution:
Orientate the patient to the surrounding environment daily (or more if the patient is
confused or disoriented)
Ensure the patient uses their glasses and/or hearing aids and walking aids (if required),
and keep the patient’s personal possessions within safe reach.
Advice on the use of covered shoes or nonslip footwear to prevent slipping
Ensure that clothing is not interfering with the person’s mobility.
Secure a call bell at the bed table or bedhead (if possible). Instruct the patient to call for
assistance.
Ensure the bed or wheelchair is locked and the bed rails are up (where appropriate).
Conduct regular environmental rounds to look out for fall hazards (i.e., ensure bathroom lights
are on and the floor is dry).
Place the hospital bed in a low position when a patient is resting in bed; raise it to a
comfortable height when the patient is transferring out of bed.
Perform lying and standing blood pressure tests (where applicable).
Provide education to the patient and caregiver; communicate with the patient aboutBYtheir
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The following interventions are applied to
patients deemed moderate or high falls risk.
Moderate Falls Risk Interventions
1. Identify delirium and observe closely - if patient
confused, orientation should be an ongoing process
2. Check for postural hypotension and manage
appropriately
3. Reinforce instructions to call for assistance – discuss
need with patient
4. Supervise and assist ambulation and activities of daily
living when necessary
5. Provide urinal / bedpan/commode within easy reach (if
appropriate)
6. Conduct combined 4-hourly fall safety checks and vital
signs monitoring
7. Check the patient when visitors leave
8. Apply a Falls “MODERATE Risk” tag at the patient’s bed
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and in the medical notes
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5 FALLS Ministry of Health Malaysia
INTERVENTION
MODULE NO. 3
TASKS
(The 5 FIT )
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AUDIT
Ideally an auditor should :
1. Be someone familiar with falls interventions processes, the forms used and the overall
chart layout
1. Be carried out by an external party
2. Not audit their own work
3. Have some training or guidance
(to ensure consistency in application of organization-specific criteria)
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