Using Fall Risk Assessment

Tools in Care Planning

Presented by
Patricia C. Dykes, Ph.D., RN, FAAN, FACMI
Center for Patient Safety Research and Practice
Center for Nursing Excellence
Brigham and Women’s Hospital
 Welcome!
Thank you for joining this webinar about
how to use fall risk assessment tools in
care planning.

2
 A Little About Myself…
Senior Nurse Scientist and Research
Program Director in the Center for
Nursing Excellence and in the Center
for Patient Safety, Research, and
Practice at Brigham and Women’s
Hospital in Boston

3
 Today We Will Talk About
• Universal fall precautions
• Fall risk factor assessment
• Fall risk assessment tools
• How to use fall risk assessment tools in care
planning
Please make a note of your questions. Your
Quality Improvement (QI) Specialists will follow
up with you after this webinar to address them.

4
 Universal Fall Precautions
• Features of universal fall precautions
• Examples of universal fall precautions
• How to implement universal fall precautions

5
Features of Universal Fall Precautions

• Are the cornerstone

of any hospital Fall
Prevention Program
• Apply to all patients
at all times

6
Examples of Universal Fall Precautions

• Clear pathways.
• Wipe up spills
immediately.
• Provide access to call bell.
• Provide nonskid footwear.

7
 How To Implement Universal
Fall Precautions

• Train all hospital staff

who interact with
patients.
• Create a hospital
culture that values fall
prevention.

8
 Fall Risk Factor Assessment

• Features of risk
factor assessment
• Using assessment
tools universally
• Basis for risk factor
assessment

9
Features of Risk Factor Assessment
• Identifies patients at risk of falling
• Provides baseline measure of patient-specific
areas of risk
• Aids in clinical decisionmaking
• Informs personalized preventive measures, care
plans, and communication strategies
• Links strategies to counteract identified risk factors
Standardized fall risk assessment is a prerequisite to
implementing an evidence-based fall prevention protocol.

10
Using Assessment Tools Universally

• Fall risk assessment

needs to be
standardized and
ongoing.
• Ask each patient the
same key questions.
That way, staff will not
miss any fall risk
factors.

11
 Basis for Risk Factor Assessment

• Validated fall risk assessment tool

• Unit policy
• Clinical judgment

12
 Risk Factor Assessment Tools
• Criteria for selecting fall risk assessment tool
• Fall risk assessment tools
• Limitations of fall risk assessment tools
• Strategies for using fall risk assessment tools
• Limitations of fall risk scores

13
 Criteria for Selecting Fall Risk
Assessment Tool
• Prospective validation in >1 population
• Sensitivity/specificity analyses
• Good face validity
• Interrater reliability
• Transparent, simple calculation of score

14
 Fall Risk Assessment Tools
Tools include—
• STRATIFY
• Schmid Fall Risk
Assessment
• Morse Fall Scale
Today, we will focus on
the Morse Scale.

15
 Limitations of Fall Risk
Assessment Tools
• No tool has perfect predictability.
• Even patients at low risk require some
intervention.

16
Strategies for Using Risk Assessment Tools
• Use valid and reliable tools.
• Train staff in how to properly use risk
assessment tools.
• Assess all patients.
• Tailor interventions based on patient-specific
areas of risk.

All patients who fall once are likely to fall again and
under similar circumstances. Plan appropriately.

17
 Limitations of Fall Risk Scores
• Some assessment tools include a scoring
system to predict fall risk.
– If you base a patient’s individualized care
plan on their fall risk score alone, their care
plan will not be tailored to their risk factors.
– Instead, use assessment tools to identify fall
risk factors. Do not rely on scores alone.

18
 Using Fall Risk Assessment Tools in
Care Planning

• Types of falls and

how to prevent them
• Risk factors for falls
identified by the
Morse Fall Scale

19
Types of Falls and How To Prevent Them
Accidental falls
• Occur in those who have no risks for falling
• Are usually caused by an environmental
hazard or error in judgment
• Account for 14% of falls
• Are prevented through universal fall
precautions

20
Types of Falls and How To Prevent Them
Unanticipated physiological falls
• Occur in those who have no risks for falling.
• Are caused by physiologic changes, such as
seizure.
• Account for 8% of falls.
• Are the most difficult to prevent. Some may
not be preventable.

21
Types of Falls and How To Prevent Them
Anticipated physiological falls
• Occur in those who have a risk for falling:
– Morse Fall Scale includes 6 items that can
predict this type of fall.
• Account for 78% of falls
• Can be prevented through fall risk assessment
using a validated tool and tailored care
planning and interventions

22
 Risk Factors for Falls Identified by
Morse Fall Scale
• History of falling
• Secondary diagnosis
– Associated with incontinence, vision
problems, multiple medicines, orthostatic
hypotension
• Ambulatory aid
• IV therapy/heparin (saline) lock
• Gait
• Mental status

23
 Using Morse Fall Scale in Care Planning
• Morse Fall Scale
• Steps to take
• Recommended interventions
• Case study
• Using assessment tools

24
 Morse Fall Scale
Areas of Risk Numeric Values
1. History of falling No 0
Yes 25
2. Secondary diagnosis No 0
Yes 15
3. Ambulatory aid
None/bed rest/nurse assist 0
Crutches/cane/walker 15
Furniture 30
4. IV or IV access No 0
Yes 20
5. Gait
Normal/bed rest/wheelchair 0
Weak 10
Impaired 20
6. Mental status
Oriented to own ability 0
Overestimates or forgets limits 15

25
 Steps To Take
• Review areas of risk identified by the
Morse Fall Scale for a specific patient.
• Select interventions to address each area
of risk.
• Communicate the tailored fall prevention
plan to all staff who interact with the
patient.
• Share the plan with the patient and his or
her family members.

26
 Recommended Interventions
History of falling (in past 3 months)
• Use safety precautions.
• Communicate risk status via plan of care,
change of shift report, and signage.
• Document circumstances of previous falls.

27
 Recommended Interventions
Secondary diagnosis
• Think about factors that may
increase risk for falls related to
multiple medical problems:
– Illness/multiple medicines
– Side effects such as dizziness,
frequent urination, and
unsteadiness
– Vision problems

28
 Recommended Interventions
Ambulatory aid
• Use an ambulatory aid at the
patient’s bedside if needed.
• Review dangers of using
furniture or hospital
equipment as ambulatory
aids.
• Think about a PT consult.

29
 Recommended Interventions
IV therapy/heparin (saline) lock
• Implement a toileting/rounding schedule.
• Tell the patient to call for help with toileting.
• Review side effects of IV medicines.

30
 Recommended Interventions
Gait
• Help the patient get out
of bed.
• Consider a PT consult.

Normal gait: Walks with head erect, arms swinging freely at the side, striding without hesitation.
Weak gait: Stooped, but able to lift head without losing balance. If furniture is needed, uses it
as a guide (feather-weight touch). Short steps; may shuffle.
Impaired gait: Difficulty rising from a chair (needs to use arms; several attempts to rise). Head
down; watches ground while walking. Cannot walk without assist; grabs at furniture or
whatever is available. Short, shuffling gait.

31
 Recommended Interventions
Mental status
• Use a bed or chair
alarm.
• Place the patient in a
visible location.
• Encourage family
presence.
• Do frequent
rounding.

Mental status test: “Are you able to go to the bathroom alone, or do you need assistance?”
• Normal: Patient response is consistent with orders or kardex.
• Overestimates/forgets limits: Patient response is inconsistent with orders or unrealistic.

32
 Case Study
• An 82-year-old man with type 2 diabetes was
admitted to the telemetry unit with chest pain and
shortness of breath on exertion.
• On admission, the patient was alert and oriented to
place, person, and time. He had an IV of saline 0.45%
and was placed on a cardiac monitor.
• During his admission interview, the patient reported
that with his cane, he was independent with
ambulation and transfers. However, the admitting
nurse noted that the physician’s order was for
ambulation with a cane and assistance.

33
 Case Study
• With further questioning, the patient reported that
he had fallen at home several times over the past
year, most recently last month.
• As the nurse assisted the patient to the bathroom,
she noted that initially he used the bedside table and
other furniture as a guide and needed to be
reminded to use his cane.
• Once he was given his cane, the patient walked with
short, steady steps to the bathroom.

34
Case Study: Morse Fall Scale
Areas of Risk Numeric Values
1. History of falling No 0
Yes 25
2. Secondary diagnosis No 0
Yes 15
3. Ambulatory aid
None/bed rest/nurse assist 0
Crutches/cane/walker 15
Furniture 30
4. IV or IV access No 0
Yes 20
5. Gait
Normal/bed rest/wheelchair 0
Weak 10
Impaired 20
6. Mental status
Oriented to own ability 0
Overestimates or forgets limits 15
Total Score: 115

35
 Using Assessment Tools
Assessment tools should be used—
• By staff nurses
• In conjunction with clinical assessment and
medicine review
• To identify a patient’s fall risk factors
• To plan care that addresses these factors
If your hospital has an electronic health record
system, integrate tools into the system.

36
 Today We Talked About
• Universal fall precautions
• Fall risk factor assessment
• Fall risk assessment tools
• Using fall risk assessment tools in care
planning

37
 Any Questions?
• Thank you for being such great listeners.
• Please refer any questions to your QI
Specialists.

38
 Resources
• Ganz DA, Huang C, Saliba D, et al. Preventing falls in hospitals: a toolkit for improving quality of
care. (Prepared by RAND Corporation, Boston University School of Public Health, and ECRI
Institute under Contract No. HHSA290201000017I TO #1.) Rockville, MD: Agency for Healthcare
Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF.
– Tool 3B: Scheduled Rounding Protocol
– Tool 3F: Orthostatic Vital Sign Measurement
– Tool 3G: STRATIFY Scale for Identifying Fall Risk Factors
– Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors
– Tool 3I: Medication Fall Risk Scale and Evaluation Tools
– Tool 3J: Delirium Evaluation Bundle
– Tool 3K: Algorithm for Mobilizing Patients
– Tool 3L: Patient and Family Education
– Tool 3M: Sample Care Plan
• Morse JM. Predicting patient falls. CA: Sage Publications; 1997.
• Morse JM. Preventing patient falls. 2nd ed. New York: Springer; 2009.
• Wyatt JC, Altman DG. Prognostic models: clinically useful or quickly forgotten? BMJ 1995;311(9):
1539-41.

39