This calculator is for general information and education. It is not medical advice and does not replace the judgment of a doctor, nurse or pharmacist who knows the full clinical picture.
Why assess fall risk
Falls are among the most common adverse events in hospitals and nursing homes. They can cause fractures, head injuries and a loss of confidence that leads to further decline. Identifying the patients most at risk lets nurses focus prevention where it matters. The Morse Fall Scale, developed by nurse researcher Janice Morse in 1989, takes a minute or two and is used in many hospitals worldwide.
The six items
| Item | Points |
|---|---|
| History of falling, now or in the last 3 months | No 0, yes 25 |
| Secondary diagnosis, more than one medical diagnosis | No 0, yes 15 |
| Ambulatory aid | None, bed rest, wheelchair or nurse assist 0; crutches, cane or walker 15; furniture 30 |
| Intravenous therapy or saline lock | No 0, yes 20 |
| Gait | Normal, bed rest or wheelchair 0; weak 10; impaired 20 |
| Mental status | Knows own limits 0; overestimates or forgets limits 15 |
The total ranges from 0 to 125.
Interpretation
Commonly used levels are:
- 0 to 24: low risk, basic nursing care
- 25 to 44: moderate risk, standard fall prevention
- 45 or more: high risk, high-risk fall prevention
Morse’s original thresholds were 0 to 24, 25 to 50 and 51 or more. Because the right cut-off depends on the patients and the setting, each facility should choose and test its own.
Example
A patient with no recent fall, several diagnoses, a walker, no IV line, a weak gait and a good sense of their limits:
- 0 + 15 + 15 + 0 + 10 + 0 = 40, moderate risk
Prevention measures
- For everyone: orient the patient to the room, keep the call bell and personal items within reach, use non-slip footwear, keep floors dry and lit.
- Moderate risk: regular toileting rounds, walking aids within reach, review of medication that causes drowsiness or low blood pressure.
- High risk: low bed, bed or chair alarms, a room near the nursing station, supervised walking and, where available, hip protectors.
Limits
No fall scale predicts falls perfectly, and the Morse scale was developed in acute care settings. Clinical judgment, a medication review, vision, continence and footwear checks, and the patient’s own concerns remain essential. Reassess after any fall or change in condition.