Assessing Fall Risk Potential: The Whole Picture
While medications are a significant contributor to potential falls, fall risk is multifactorial and due diligence for fall prevention does not end with medication assessment and optimization alone.
There are other key factors that nursing home staff should incorporate into their evaluations to deduce a resident’s true fall risk. The Morse Fall Scale (MFS) is an assessment tool with accepted use as a reliable and validated measure of fall risk in the post-acute care setting. Proponents of this scale cite its sound structure for comprehensive fall risk evaluation and its relative ease of use for nursing staff to smartly perform resident evaluations. The 6-point tool is intended to be used in conjunction with clinical assessment and medication review.
1. Fall History
Considering that older adults who fall once are roughly twice as likely to fall again, it is prudent to classify any resident with a single documented fall during their stay as, at minimum, moderate fall risk (regardless of other criteria). Hence, a positive history of falls garners 25 points on the MFS.
2. Secondary Diagnosis
The presence of ≥ 2 comorbidities (15 points) increases fall risk, as both the primary etiologies and drug therapies to manage those diseases may be contributing factors. These additional diagnoses should be further evaluated, as certain conditions (e.g., Parkinson’s disease) are significant risk factors, and appropriate management of these conditions can be immensely beneficial.
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 a bed rest and does not get out of bed at all. If the patient uses crutches, a cane, or a walker, this item scores 15; if the patient ambulates clutching onto the furniture for support, score this item 30.
4. IV Therapy
Equipment for IV therapy may tether the resident and constitutes a potential trip hazard. Therefore, the MFS assigns a score of 20 if the resident has an IV apparatus or heparin lock inserted.
5. Gait
A normal gait – walking with head erect, arms swinging freely at the side, and striding without hesitancy – is scored as 0. With a weak gait (scored as 10), the resident will take short steps (may shuffle), may be stooped but is able to lift the head while walking without losing balance, and/or may seek light support from furniture while walking. With an impaired gait (score 20), the resident will have difficulty rising from the seated position, the head is often oriented down to observe the ground, and balance is sufficiently poor that the resident must firmly grasp furniture, a support person, or a walking aid.
6. Mental Status
A major pitfall for falling occurs when seniors fail to recognize their own limitations. Hence, the MFS assigns a score of 15 if the resident does not appear oriented to their own ability to ambulate. Ask the resident, “Are you able to go the bathroom alone or do you need assistance?” If their response is not consistent with nursing orders or is unrealistic for their current condition, then they may be deemed to be overestimating their capabilities.
After thorough evaluation, residents’ scores are added together to determine their overall fall risk. Residents with a score less than 25 have a low risk of experiencing a fall in the near future. Residents with scores ranging between 25 and 45 have a moderate risk of experiencing a fall, while those with a score greater than 45 are considered high risk. Residents scoring either moderate or at high risk of experiencing a fall should be referred to the attending physician to engage the interdisciplinary team on resident-specific fall prevention and risk mitigation measures.