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