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

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

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:

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.