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Adult Fall Risk Assessment Tool

This document contains an adult fall risk assessment and prevention plan. It includes a 10 item modified Morse Fall Scale to assess risk level as low, medium, or high. It outlines interventions for each risk level, with low risk getting observation, medium risk adding toileting assistance and ensuring comfort, and high risk triggering physical/occupational therapy consultation and medication review. Spaces are provided to document fall risk reassessment if the patient's condition changes.

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anumol
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500 views1 page

Adult Fall Risk Assessment Tool

This document contains an adult fall risk assessment and prevention plan. It includes a 10 item modified Morse Fall Scale to assess risk level as low, medium, or high. It outlines interventions for each risk level, with low risk getting observation, medium risk adding toileting assistance and ensuring comfort, and high risk triggering physical/occupational therapy consultation and medication review. Spaces are provided to document fall risk reassessment if the patient's condition changes.

Uploaded by

anumol
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Place patient identification label/or write

below
Name:
Sex:

Adult Fall Risk Assessment and Prevention Plan DOB:


Date:
Diagnosis:
Nursing care plan implementation codes : I: Initiated , O: Ongoing, R: Resolved N/A: Not applicable

Post procedure
On admission

On Discharge
Nursing Diagnosis: “Safety Concerns” Adult patient at risk for injury related to fall
Expected Outcome/Goals: □ Patient will be discharged free from injury
Modified Morse Fall Score Interventions/Approach
1. History of falling 1. Low Risk Interventions
No history of falls 0 observation patients with fall risk score 0-24.
Illness related falls 15 interventions.
In the last 12 months 25
2. Age 14-60 Years Old 0
More than 60 years old 15
3. Secondary Diagnosis
No 0
Yes 15
4. Ambulatory Aid/ Transfer Needs
None/ Nurse assist 0
Require use assistive device 15
Unable to ambulate/ transfer 30
need include use of slip sheets
5. Elimination Independent 0
Independent but with frequency/ 10 elimination when planning patient’s care.
diarrhea/ Nocturia/ urgency
of side rails.
Require assistance with toileting 20
6. IV or IV Access
No 0
Yes 20
7. Medication
None/ No High-Risk Medication 0
Antihypertensive/Diuretics 10
Psychotropic/ Anticonvulsant 15
Antiparkinson/ Diazepines/ Opioids/ 25 2. Medium Risk Interventions:
Sedatives to the following medium risk interventions for observation patients with fall risk score 25-
8. Sensory Status 50.
No deficits 0
Sensory Deficit/ visual/ neuropathy 20
9. Gait
Normal 0
toileting, offer fluids and ensure that patient is warm and dry.
Weak 10
Impaired 20
10. Developmental Status
Alert and Oriented to own ability 0
Coma/ unresponsive 0 3. High Risk Interventions
History of confusion/ altered level of
consciousness/ overestimates or risk interventions for all observation patients with fall risk score higher than 50.
forgets limitations.
15
Periodic/ Noted Confusion 30
Initial Total score therapy consultation.
Risk Level Morse Fall Score
□ Low Risk 0 – 24
□ Medium Risk 25 – 50
supplements to evaluate medication regimen to reduce of fall risk.
□ High Risk Higher than 50
Signature and

Indication for Fall Risk Reassessment Time Fall Risk Score


□ Change in ambulation □ Immediately post-procedure
□ Change in level of consciousness or mental status
ID #

□ Post fall event


□ Medication effects (Narcotic/ sedation administration)
Time

□ On Transfer or discharge
KHH/MRS59/22

0 15 25 2. Age 14-60 Years Old 0 15 0 15 0 15 30 5. Elimination Independent 0 10 20 0 20 7. Medication 0 10 15 25 0 20 0 10 2

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