Assessment
Morse Fall Scale Risk Assessment
Scoring fall history, secondary diagnoses, ambulation aids, IV therapy, gait, and mental status to target fall precautions.
Morse scoring elements
The Morse Fall Scale assigns weighted points: history of falling, secondary diagnosis count, ambulatory aid use, IV or hep lock presence, gait quality, and mental status regarding own ability to transfer. The CDC STEADI initiative promotes systematic fall risk identification in older adults—tools like Morse operationalize that screening in hospitals.1
A patient who fell in the last year scores higher even if current injury is unrelated. Secondary diagnoses include anything in the chart—heart failure, CVA, orthostatic hypotension—not only admission diagnosis. Gait is observed: weak or impaired gait scores more than normal or bedrest/chairfast categories when gait is untested.
Interventions matched to risk
Total Morse scores guide precaution levels: yellow wristband, bed alarms, hourly rounding, toileting schedules, non-skid footwear, and keeping call light within reach. High scores with impulsive mental status (“forgets limitations”) need closer supervision than high scores with normal cognition who use walkers reliably.2
Re-score after change in condition—new sedating medication, postoperative day zero mobility, or syncope episode. Falls are sentinel events; post-fall assessment includes vitals, neuro check, injury survey, and root-cause review. LPNs document Morse on admission and per policy, implementing precautions without waiting for physician orders when protocol allows standing fall bundles.
Practice this skill
Apply what you read with a hands-on Morse Fall Scale drill — instant feedback on every scenario.
