What is a high risk score on the Morse Fall Scale?

A score of 45 or higher is categorized as 'High Risk' on the Morse Fall Scale, requiring immediate implementation of high-risk fall prevention protocols.

What are the 6 variables of the Morse Fall Scale?

The six variables are: History of falling, Secondary diagnosis, Ambulatory aid, IV/Heparin lock, Gait, and Mental status.

INPATIENT SAFETY PROTOCOL

Morse Fall Scale Pro

Standardized Risk Stratification & Nursing Care Plan Generator

1. History of Falling (3 Months)

2. Secondary Diagnosis (>1)

3. Ambulatory Aid

4. IV Therapy / Heparin Lock

5. Gait / Transferring

6. Mental Status

Complete 6 variables to
generate Inpatient Care Plan

EMR SOAP NOTE

High-Risk Alert

According to US Hospital Safety Standards, a Morse score exceeding 45 requires immediate implementation of a 'Fall Bundle,' including bed alarms and non-slip identifiers.

Morse Fall Scale Scoring Matrix

Category	Score	Clinical Action
No Risk	0 - 24	Basic safety precautions.
Low Risk	25 - 44	Standard fall precautions.
High Risk	≥ 45	High-risk prevention protocol.

Recommended Nursing Interventions

Select risk factors to view care plan recommendations...

Frequently Asked Questions

When should the Morse Fall Scale be administered?

In acute care settings, it is performed upon admission, once per shift, following a transfer between units, and immediately after any fall event.

How does 'Secondary Diagnosis' impact the score?

The presence of more than one medical diagnosis (Secondary Diagnosis) adds 15 points, as it indicates complex pathology that often contributes to physiological instability.

Clinical Bibliography

1. Morse JM. Preventing Patient Falls. Thousand Oaks, CA: Sage Publications. 1997.
2. O'Connell B, Myers H. The sensitivity and specificity of the Morse Fall Scale. Applied Nursing Research. 2002.

Dr. Nikhil Mahajan, PT

MPT-Ortho | Clinical Reviewer

CLINICAL RESOURCE