MORSE FALLS SCALE ASSESSMENT:



MORSE FALLS SCALE ASSESSMENT

Submitted by Beth Aller RN, HE Clinical Education Manager and Falls Committee Member

Starting January 4th, an updated charting screen in Horizon Clinical Documentation will be the MORSE FALLS ASSESSMENT and REASSESSMENT.

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How will the Morse Fall Scale be used?

According to the new HealthEast protocol for falls prevention, every patient will be assessed

• On admission.

• Daily on the day shift.

• When a patient’s condition changes or there has been a change in the patient’s medication regimen that could put the patient at risk for a fall.

• When a patient is transferred to another unit.

• After a fall.

Why is this change in the HealthEast Falls Prevention Program being made at this time?

This change in patient care pertaining to falls assessment has come about at this time for several reasons.

• Working toward the goals of the American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program, HealthEast has chosen to participate in the National Database of Nursing Quality Indicators (NDNQI).

• This change is also coming about because of the 2005 & 2006 JCAHO Patient Safety Goals pertaining to falls.

o The 2005 goal states “Reduce the risk of patient harm resulting from falls. Assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen, and take action to address any identified risks.”

o The 2006 goal states “Reduce the risk of patient harm resulting from falls. Implement a fall reduction program and evaluate the effectiveness of the program.

• The most compelling reason of all for this change is that a recent study done by a HealthEast staff nurse in one of the HealthEast hospitals resulted in convincing data.

o HealthEast hospitals need to improve the consistency of how falls are managed and evaluated.

o Falls do happen in HealthEast hospitals and have produced serious injury.

o Falls occur at all hours of the day and night; however, patients were most likely to fall during the nighttime hours.

o Toileting issues were found to be the leading cause of falls in HealthEast hospitals.

As a result of this study, the HealthEast Nurse Practice Committee charged a group of nurses to look into the issue of falls. The HealthEast Falls Committee was formed to develop a nursing policy and procedure with the important purpose of creating a safe environment that protects patients from harm due to falls.

Procedure:

• Obtain a Morse Fall Scale Score by using the variables and numeric values listed in the “Morse Fall Scale” table below. (Note: Each variable is given a score and the sum of the scores is the Morse Fall Scale Score. Do not omit or change any of the variables. Use only the numeric values listed for each variable. Making changes in this scale will result in a loss of validity. Descriptions of each variable and hints on how to score them are provided below.) The “Total” value obtained must be recorded in the patient’s medical record.

Morse Fall Scale

|Variables |Numeric Values |Score |

|1. History of falling |No 0 | |

| | |_______ |

| |Yes 25 | |

|2. Secondary diagnosis |No 0 | |

| | |_______ |

| |Yes 15 | |

|3. Ambulatory aid | | |

|None/bed rest/nurse assist |0 | |

|Crutches/cane/walker |15 | |

|Furniture |30 |_______ |

|4. IV or IV Access |No 0 | |

| | |_______ |

| |Yes 20 | |

|5. Gait | | |

|Normal/bed rest/wheelchair |0 | |

|Weak |10 | |

|Impaired |20 |_______ |

|6. Mental status | | |

|Oriented to own ability |0 | |

|Overestimates or forgets limitations |15 |_______ |

Morse Fall Scale Score = Total ______

Morse Fall Scale Variable Descriptions and Scoring Hints

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. 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.

3. Ambulatory aid

• 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 bed rest and does not get out of bed at all. If the patient uses crutches, a cane, or a walker, this variable scores 15; if the patient ambulates clutching onto the furniture for support, score this variable 30.

4. IV or IV Access

• This is scored as 20 if the patient has an intravenous apparatus or a saline/heparin lock inserted; if not, score 0.

5. Gait

• The characteristics of the three types of gait are evident regardless of the type of physical disability or underlying cause.

1. A normal gait is characterized by the patient walking with head erect, arms swinging freely at the side, and striding without hesitation. This gait scores 0.

2. With a weak gait (score10), the patient is stooped but is able to lift the head while walking without losing balance. If support from furniture is required, this is with a featherweight touch almost for reassurance, rather than grabbing to remain upright. Steps are short and the patient may shuffle.

3. 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 and/or bouncing (i.e., by using several attempts to rise). The patient’s head is down, and he or she watches 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. Steps are short and the patient shuffles.

4. If the patient is in a wheelchair, the patient is scored according to the gait he or she used when transferring from the wheelchair to the bed.

6. Mental status

• When using this Scale, mental status is measured by checking the patient’s own self-assessment of his or her own ability to ambulate. Ask the patient, “Are you able to go to the bathroom alone or do you need assistance?” If the patient’s reply judging his or her own ability is consistent with the activity order on the Kardex, the patient is rated as “normal” and scored 0. If the patient’s response is not consistent with the activity order 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 is scored as 15.

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Fall Risk

• Use the Morse Fall Scale Score to see if the patient is in the low, medium or high risk level. (See the “Fall Risk Level” table below to determine the level and the action to be taken.)

• Implement the interventions that correspond with the patient’s fall risk level. (See “Fall Risk Prevention Interventions” below.)

• Use the Morse Fall Scale Score to see if the patient is in the low, medium or high risk level. (See the “Fall Risk Level” table below to determine the level and the action to be taken.)

Level

|Risk Level |Morse Fall Scale Score |Action |

|Low Risk | 0 – 24 |Implement Low Risk Fall Prevention Interventions |

|Medium Risk | 25 – 44 |Implement Medium Risk Fall Prevention Interventions |

|High Risk | 45 and higher |Implement High Risk Fall Prevention Interventions |

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|Intervention: Score: | 0-24 | 25-44 |45-100 |

| |(low risk) |(medium risk) |(high risk) |

|1. All Admitted Patient | | | |

|Implement low risk interventions for all hospitalized patients. |yes |no |no |

|2. Communication | | | |

|Orient patient to surroundings and hospital routines |yes |yes |yes |

|Very important to point out location of the bathroom | | | |

|If patient is confused, orientation is an ongoing process | | | |

|Call light in easy reach – make sure patient is able to use it | | | |

|Instruct patient to call for help before getting out of bed. | | | |

|Patient/Family Education |yes |yes |yes |

|Verbally inform patient and family of fall prevention interventions. | | | |

|Shift Report |yes |yes |yes |

|Communicate the patient’s “at risk” status. | | | |

|Plan of Care |yes |yes |yes |

|Collaborate with multi-disciplinary team members in planning care. | | | |

|Healthcare team should tailor patient-specific prevention strategies. It is inadequate to write “Fall | | | |

|Precautions”. | | | |

|Post a “Falls Program” sign at the entrance to the patient’s room. |prn |yes |yes |

|(Exception: Bethesda Behavioral units will not use the sign because of patient/staff safety concerns.) | | | |

|Make “comfort” rounds every 2 hours and include change in position, toileting, offer fluids and ensure |prn |yes |yes |

|that patient is warm and dry. | | | |

|Consider obtaining physician order for Physical Therapy consult.* |prn |prn |yes* |

|3. Toileting | | | |

|Implement bowel and bladder program. |yes |yes |yes |

|Discuss needs with patient. |yes |yes |yes |

|Provide a commode at bedside (if appropriate). |prn |prn |yes |

|Urinal/bedpan should be within easy reach (if appropriate). |prn |prn |yes |

|4. Medicating | | | |

|Evaluate medications for potential side effects. |yes |yes |yes |

|Consider peak effect that affects level of consciousness, gait and elimination when planning patient’s |yes |yes |yes |

|care. | | | |

|Consider having a Pharmacist review medications and supplements to evaluate medication regimen to promote |prn |prn |yes |

|the reduction of fall risk. | | | |

|5. Environment | | | |

|Bed | | | |

|Low position with brakes locked, document number of side rails. |yes |yes |yes |

|Bedside stand/bedside table | | | |

|Personal belongings within reach. |yes |yes |yes |

|Room “clutter” - Remove unnecessary equipment and furniture | | | |

|Ensure pathway to the bathroom is free of obstacles and is lighted. | | | |

|Consider placing patient in the bed that is close to the bathroom. |yes |yes |yes |

|Use a night light as appropriate. |prn |yes |yes |

|6. Safety | | | |

|Nonskid (non-slip) footwear. |yes |yes |yes |

|Do not leave patients unattended in diagnostic or treatment areas. |prn |yes |yes |

|Consider placing the patient in a room near the nursing station, for close observation, especially for the|prn |prn |yes |

|first 24–48 hours of admission. | | | |

|Consider patient safety alarm (tab alarm &/or pressure sensor alarm). |prn |prn |yes |

|Communicate the frequency of alarms each shift. | | | |

|If appropriate, consider using protection devices: hip protectors, a bedside mat, a “low bed” or a helmet.|prn |prn |yes |

|If “Fall Risk Prevention Interventions” have been initiated and are unsuccessful, refer to HENSA Policy |prn |prn |yes* |

|R-3 “Use of Restraint and Seclusion”.* | | | |

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