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Use of a fall risk assessment tool

The Joint Commission (TJC) recognizes falls with serious injury to be consistently among the top 10 sentinel events. Analysis of Sentinel Events involving falls with serious injuries revealed inadequate fall risk assessment to be a leading contributing factor.

•TJC Sentinel Event Alert #55: Requirements for the prevention of falls and fall-related injuries in health care facilities.

Provision of Care, Treatment, and Services (PC)
PC.01.02.08 : The hospital assesses and manages the patient’s risk for falls.
EP 1 : The hospital assesses the patient’s risk for falls based on the patient population and setting.
EP 2 : The hospital implements interventions to reduce falls based on the patient’s assessed risk.

•TJC Sentinel Event Alert #55 recommendations:

Use of a standardized, validated tool to identify risk factors for falls (e.g. , Morse Fall Scale or Hendrich II Fall Risk Model), preferably integrated into the electronic medical record. In addition to the tool, a comprehensive, individualized assessment for falls and injury risk should be performed. In addition, the patient’s age, gender, cognitive status, and level of function are to be included in the assessment. Staff is to be trained to use the tool to ensure inter-rater reliability (the degree of consistency among raters).

Rapid fall risk screening tools

The Morse Fall Scale (MFS) is focuses on six risk factors. Each risk factor is scored and those scores are totaled. A total score of 125 is possible. The MFS is divided into ranges: a low fall risk score is below 25, a medium risk is between 25 and 50 and high risk for falling is 51 or higher.

The MFS has shown sensitivity scores between 72% and 88% and specificity scores between 29% and 83% (Eagle et al. 1999; O’Connell & Meyers, 2002; Kim, Siti, Wong, Devi & Evans, 2007). A recent test of specificity (Kim et al., 2007) reported a specificity score of only 48.3%. According to Morse the inter-rater reliability was found to be 96%.

Fall Risk Screening Using the Morse Fall Scale (Morse, 1997) for Inpatients
Risk Factor	Scale	Pt. Score
History of falls	Yes	25
History of falls	No	0
Secondary diagnosis	Yes	15
Secondary diagnosis	No	0
Ambulatory aides	Furniture	30
	Crutches/ Cane/ Walker	15
	None/Bed rest/Wheelchair/Nurse	0
IV/Heparin lock	Yes	20
IV/Heparin lock	No	0
Gait/Transferring	Impaired	20
	Weak	10
	Normal / Bed rest / Immobile	0
Mental status	Forgets limitations	15
Mental status	Oriented to personal limitations	0
Evaluating Patient Scores	Low risk 0-24, Moderate risk 25-50, High risk >51,
Evaluating Patient Scores	Total Patient score

The Hendrich II Fall Risk Model screens of eight fall risk factors plus gate and balance. A total score of 5 or greater indicates high risk for falls. Sensitivity in the 2003 report by Hendrich was 74.9% and specificity 73.9%. In a 2007 study by Kim et al, the sensitivity score was 70% with the specificity score of 61.5%.

Hendrich II Fall Risk Model
Risk Factors	Score
• Confusion, disorientation, and impulsivity	If yes	4
• Symptomatic depression	If yes	2
• Altered elimination	If yes	1
• Dizziness, vertigo	If yes	1
• Male gender	If yes	1
• Antiepileptic medications (administered, stopped	If yes	2
• Benzodiazepines medications	If yes	1
• Get-Up-and-Go test		+
*Able to rise in a single movement – No loss of balance with steps		0
*Pushes up, successful in one attempt	If yes	1
*Multiple attempts, but successful	If yes	3
*Unable to rise without assistance during test	If yes	4
A total score of 5 or greater indicates a high fall risk

While a fall risk assessment on admission for every patient is recognized as the standard of care, when to reassess the patient’s risk for fall injury is less consistent. There is support in the literature for reassessment after the following events:

When a fall occurs
When a significant change in patient condition or medication occurs
When a patient is transferred to a new area

In addition very high risk patients should be assessed each day or even at every change of shift.

Instant feedback

The Morse Fall Risk Scale scores a patient with a history of falling as a Moderate fall risk.

References

The Joint Commission (TJC). (2015). Sentinel Event Alert Preventing falls and fall-related injuries in health care facilities. Issue 55, September 28, 2015. 12/10/2015 retrieved from
http://www.jointcommission.org/assets/1/18/SEA_55.pdf
Eagle, D. J., Salama, S., Whitman, D., Evans, L. A., Ho, E. & Olde, J., (1999). Comparison of three instruments in predicting accidental falls in selected inpatients in a general teaching hospital. Journal of Gerontological Nursing, 25 (7), 40-45.
O’Connell, B. & Meyers, H. (2008). Evidence-based practice: a falls prevention program that continues to work. MedSurg Nursing. 12/10/2015 retrieved fromhttp://findarticles.com/p/articles/mi_m0FSS/is_4_17/ai_n28571799/?tag=content;col1
Morse, J. M. (1997). Preventing patient falls. Sage Publications, Thousand Oaks.
Hendrich, A. (2007). Predicting patient falls: using the Hendrich II Fall Risk Model in clinical practice. Am J NURS, 107(11), 50-4.
Kim, N., Siti, Wong, H Devi, K & Evans, D. (2007).Evaluation of three fall-risk assessment tools in an acute care setting. J Adv Nurs, 60 (4), 427-435