The document outlines various fall risk assessment tools used in healthcare, such as the Morse Fall Scale and the Berg Balance Scale, which evaluate patients' risk of falling based on criteria like medical history, mobility, and mental status. Strategies for fall prevention include standardized assessments, patient education, environmental modifications, and the use of technology to monitor risk. It emphasizes the importance of individualized care, continuous staff training, and family involvement in ensuring patient safety.

1. Falls
Prevention
This Photo by Unknown author is licensed under CC BY.
Sandhya Jayathunga
PhD(OUM)(Reading), MSc in Nursing (OUM), BSc in Nursing
(OUSL), RN ( Dip in Nursing), RM ( Dip in Midwifery)
Lecturer ( Probationary )

2. Morse Fall Scale (MFS)
Based on six criteria:
• History of falling
• Secondary diagnosis
• Ambulatory aid
• IV therapy or heparin lock
• Gait/Way of walking
• Mental status.
Each criterion is assigned a score, and the total score
determines the patient's fall risk category.

3. Morse Fall Scale (MFS)
History of Falling:
No history of falling: 0 points
One or more falls in the past three months: 25 points
Secondary Diagnosis:
No secondary diagnosis: 0 points
One or more secondary diagnoses (e.g., diabetes, heart
disease): 15 points

4. Morse Fall Scale (MFS)
Ambulatory Aid:
Independent or uses assistive devices appropriately: 0 points
Uses an ambulatory aid (e.g., cane, walker, crutches): 15 points
IV Therapy or Heparin Lock:
No IV therapy or heparin lock: 0 points
IV therapy or heparin lock in place: 20 points

5. Cane

6. Walkers

7. Crutches

8. Morse Fall Scale (MFS)
Gait:
Normal (steady and coordinated): 0 points
Weak or impaired (e.g., unsteady, shuffling, limited range of
motion): 10 points
Mental Status:
Oriented to own ability: 0 points
Sometimes forgets limitations: 15 points
Forgetful or confused: 30 points

9. • Unsteady/unstable/අස්ථිර
• Shuffling/ආසනයෙහි නොසන්සුන්ව සිටිනවා ; කකුල්
අද්දවාගෙන යනවා
- A type of gait (walking) characterized by by dragging
one's feet along or without lifting the feet fully from the
ground.

10. Range of Motion ( ROM )
• The extent or limit to which a part of the body can be moved
around a joint or a fixed point; the totality of movement a
joint is capable of doing.
• Limited range of motion is a term meaning that a joint or
body part cannot move through its normal range of motion.

12. Flexion
• A movement that is characterized by a decrease in the
angle between two or more bones that form a joint.
• In simple terms, flexion involves bending a joint.

13. Extension
An act or instance of extending, lengthening, stretching
out, or enlarging the scope of something. the state of
being extended, lengthened, or stretched out.

14. Abduction
The movement of a limb or other part away from the
midline of the body, or from another part.

15. Adduction
The movement of a limb or other part towards the
midline of the body or towards another part.

18. Morse Fall Scale (MFS)
Low Risk: Total score 0-24
Moderate Risk: Total score 25-45
High Risk: Total score 46 or higher

19. STRATIFY Fall Risk Assessment Tool:
• Based on five criteria:
• A history of falls
• Mobility problems
• Mental status
• Incontinence
• Age.
Each criterion is assigned a score, and the total score
categorizes the patient's risk level.

20. Downton Fall Risk Index:
Assesses fall risk in older adults and is based on six factors:
• Age
• Sex
• Mental confusion
• Impaired vision
• Incontinence
• Medications.
Each factor is assigned a score, and the total score
determines the patient's risk level.

21. Johns Hopkins Fall Risk Assessment Tool:
Based on various factors
• Medications
• mental status
• Mobility
• Continence
It assigns a score to each factor, and the total score indicates the
patient's fall risk.

22. Tinetti Performance-Oriented Mobility
Assessment (POMA):
Assesses a patient's gait and balance through a series of tasks
• Rising from a chair
• Walking
• Turning
• Maintaining balance.
Each task is scored, and the total score determines fall risk.

23. Hendrich II
Fall Risk
Model:
Based on eight factors:
• Confusion
• Dizziness or vertigo
• Poor vision
• Male gender
• Impaired step
• Antianxiety or antidepressant medications
• Antiepileptic or antipsychotic medications
• A history of falling.
Each factor is assigned a score, and the total
score indicates the risk level.

24. Hendrich II Fall Risk Model:
Confusion:
• No confusion: 0 points
• Some or occasional confusion: 4 points
• Frequently confused or disoriented: 5 points
Symptomatic Depression:
• No symptoms of depression: 0 points
• Symptoms of depression present: 2 points

25. Hendrich II Fall Risk Model:
Altered Elimination:
• Continent or self-aware of the need to void: 0 points
• Occasional incontinence (e.g., stress incontinence): 2 points
• Frequent incontinence (e.g., urge incontinence): 3 points
Dizziness or Vertigo:
• No dizziness or vertigo: 0 points
• Occasional dizziness or vertigo: 1 point
• Frequent dizziness or vertigo: 2 points

26. Hendrich II Fall Risk Model:
Male Gender:
• Female: 0 points
• Male: 1 point
Impaired Mobility:
• No impairment in mobility: 0 points
• Slightly impaired (e.g., mild gait impairment): 1 point
• Severely impaired (e.g., requires assistance to move): 2 points

27. Hendrich II Fall Risk Model:
Antianxiety or Antidepressant Medications:
• No antianxiety or antidepressant medications: 0 points
• Currently taking antianxiety or antidepressant medications: 2
points
Antiepileptic or Antipsychotic Medications:
• No antiepileptic or antipsychotic medications: 0 points
• Currently taking antiepileptic or antipsychotic medications: 2 points

28. Hendrich II Fall Risk Model:
History of Falling:
No history of falling: 0 points
One or more falls in the past year: 3 points
Low Risk: Total score 0-4
Moderate Risk: Total score 5-6
High Risk: Total score 7 or higher

29. Timed Up and Go (TUG) Test:
• A simple and quick assessment that evaluates a patient's
mobility and balance.
• It involves having the patient rise from a chair, walk three
meters, turn around, walk back to the chair, and sit down.
• The time taken to complete the task is used to assess fall risk.

30. Timed Up and Go (TUG) Test:
1. Uses particularly in geriatric care, to assess an individual's
functional mobility and balance.
2. The TUG test measures the time it takes for a person to
complete a specific set of movements
• standing up from a seated position
• walking a short distance
• turning around
• walking back
• sitting down again.

31. Timed Up and Go (TUG) Test:
Preparation:
Provide the patient with clear instructions on the test.
Ensure that the patient is wearing appropriate footwear, and any mobility
aids they regularly use.
Setting:
Place a chair with a backrest (standard chair height) against a wall.
Place a marker, such as a piece of tape, on the floor about 3 meters
(approximately 10 feet) in front of the chair.

32. Timed Up and Go (TUG) Test:
Procedure:
• Ask the patient to sit in the chair with their back against the
backrest and their arms resting on the armrests, if present.
• Explain that you will say the word "Go," and the patient should
stand up, walk to the marker on the floor, turn around, walk back,
and sit down again.
• Say "Go," and start timing as soon as the patient begins to rise
from the chair.

33. Timed Up and Go (TUG) Test:
Scoring:
• Measure the time in seconds it takes for the patient to
complete the task from the moment they start rising from
the chair until they are seated again.
• Record the time.

34. Timed Up and Go (TUG) Test:
A commonly used guideline is as follows:
• Less than 10 seconds: Generally considered normal and
low fall risk.
• 10 to 20 seconds: Suggests a moderate fall risk.
• More than 20 seconds: Indicates a high fall risk.

35. The Berg Balance Scale:
• A more comprehensive assessment tool that evaluates a
patient's balance and risk of falling.
• It consists of 14 balance-related tasks, such as standing on
one foot and reaching for objects, each scored on a scale.
• The total score indicates the patient's fall risk.

36. The Berg Balance Scale
• Developed by Katherine Berg in the early 1990s
• Uses in rehabilitation and geriatric care.
• Consists of 14 different balance-related tasks
1. Each task is scored on a scale from 0 to 4
2. With 0 indicating that the task cannot be performed
3. Indicating 4 the highest level of performance.

37. The Berg Balance Scale:
Sitting to Standing:
The ability to transition from a seated to a standing
position without using one's arms for support.
Standing to Sitting:
The ability to sit down from a standing position without
using one's arms for support.
Sitting without Back Support:
The ability to sit unsupported for two minutes.

38. The Berg Balance Scale:
Standing Unsupported:
The ability to stand unsupported for two minutes.
Standing with Eyes Closed:
The ability to maintain balance while standing with eyes
closed for 10 seconds.
Reaching Forward with Outstretched Arm:
The ability to reach forward with an outstretched arm while
maintaining balance.

39. The Berg Balance Scale:
Retrieving an Object from the Floor:
The ability to bend down, pick up an object from the floor, and
return to an upright position while maintaining balance.
Turning 360 Degrees:
The ability to turn in a full circle without losing balance.
Placing Alternate Foot on a Stool:
The ability to stand on one leg while placing the other foot on a
stool.

40. The Berg Balance Scale:
Standing on One Leg:
The ability to stand on one leg without support for 10 seconds.
Turning to Look Behind:
The ability to turn the upper body to look behind while standing
on one leg.
Turning 360 Degrees with Alternate Foot Raise:
The ability to turn in a full circle while alternately lifting each foot.

41. The Berg Balance Scale:
Stool Stepping:
The ability to step onto and off a stool repeatedly.
Tandem Stance:
The ability to stand with one foot directly in front of the
other foot (tandem position) for 10 seconds.

42. Tandem/Staggered Stance
• Place right foot in front of the left foot, directly in front of
the other, with the right heel touching the toes of the left
foot.
• Think of placing them as if you were trying to walk on a
balance beam.

44. The Berg Balance Scale:
• Range from 0 (severe impairment) to 56 (excellent balance).
• Higher scores indicate better balance
• A lower risk of falling, while lower scores suggest impaired
balance and a higher fall risk.

45. Preventive Strategies
Fall Risk Assessment:
• Conduct fall risk assessments for all patients upon admission
and periodically(from time to time)during their hospital stay.
• Use standardized assessment tools to identify individuals at
higher risk of falling.

46. Preventive Strategies
Patient and Family Education:
• Educate patients and their families about the importance
of fall prevention.
• Provide information on how to call for assistance
• Use assistive devices
• Encourage patients to ask for help when needed.

47. Preventive Strategies
Bed Alarms and Chair Alarms:
• Use bed alarms and chair alarms for patients identified as
high risk.
• These alarms notify staff when a patient attempts to get
out of bed or a chair without assistance.

48. Preventive Strategies
Bedside Safety Measures:
• Utilize bed rails when appropriate to prevent patients
from falling out of bed.
• Adjust bed heights to facilitate safe transfers.
• Ensure that call bells and personal belongings are within
easy reach of patients.

49. Preventive Strategies
Environmental Modifications:
• Maintain well-lit and uncluttered(organized) patient rooms and hallways.
• Keep floors dry and promptly clean up spills.
• Ensure that handrails are available and in good condition in
hallways(lobbies, passages) and bathrooms.

50. Preventive Strategies
Medication Management:
• Review and adjust medications that may increase fall risk, such
as sedatives, hypnotics, or medications affecting blood pressure.
• Monitor patients on medications that can cause dizziness or
unsteadiness.

51. Sedatives and Hypnotics Differences
• Sedatives are drugs that decrease activity and have a
calming, relaxing effect. At higher doses, sedatives
usually cause sleep.
• Drugs used mainly to cause sleep are called hypnotics.

52. Preventive Strategies
Assist with Mobility:
• Encourage patients to request assistance when getting out of
bed or moving around.
• Provide appropriate mobility aids like walkers or canes as
needed.
• Consider physical therapy or rehabilitation for patients with
mobility issues.

53. Preventive Strategies
Regular Patient Rounds:
• Implement regular rounding by healthcare staff to check on
patients and assist them with their needs.
• Ensure that staff responds promptly to patient calls for
assistance.

54. Preventive Strategies
Use of Technology:
Consider the use of electronic health records and patient
monitoring systems to track fall risk and interventions.

56. Preventive Strategies
Fall Prevention Protocols:
• Develop and implement fall prevention protocols tailored
to the specific needs and risk factors of each patient.
• Communicate these protocols to all members of the
healthcare team.

57. Preventive Strategies
Family and Caregiver Involvement:
• Involve family members and caregivers in fall prevention
discussions and strategies.
• Encourage them to participate in the patient's care plan.
Post-Fall Assessment:
• Conduct a thorough assessment after any patient fall to identify the
cause and make necessary adjustments to prevent future falls.

58. Preventive Strategies
Continuous Education and Training:
• Provide ongoing education and training to healthcare staff
regarding fall prevention strategies and best practices.
Quality Improvement:
• Regularly review and analyze fall-related incidents to identify
areas for improvement and implement changes accordingly.

59. Key components of a successful fall prevention program
Patient-Centered Care:
• Involve patients in their care plan and decisions regarding fall prevention
interventions
• Considering their individual preferences and needs.
• Regular assessments
• Education
• Environmental modifications
• Timely interventions

60. Universal Fall Precautions
• Allow your patient to become familiarized with their
hospital room because falls are more common in
unfamiliar environments.
• Teach your patient how to use the call light and allow them
to demonstrate how to use it. If your patient knows how to
call for assistance, they will be less likely to get out of bed
on their own and possibly fall.

61. Universal Fall Precautions
• Keep the call light and your patient’s personal belongings within
reach, so your patient doesn’t need to get up to reach them.
• Answer call lights promptly, so your patient doesn’t get
impatient and try to ambulate on their own.
• Keep the floors clean and dry. Promptly clean up any spills.
• Also, keep the floors free of clutter to reduce your patient’s risk
of tripping.

62. Universal Fall Precautions
• Bright lighting and nightlights make it easier for your
patients to see while walking.
• Non-slip footwear (shoes or socks) keep patients from
slipping.
• Grab bars offer support in your patient’s room, bathroom,
and hallway.
• Lower the hospital bed when your patient is resting, in case
of falls, and raise the bed when transferring for easier
transfers.

63. Universal Fall Precautions
• Keep the brakes locked on hospital beds to keep them in place.
• And keep the brakes locked on patient wheelchairs when they
are stationary.
• Follow safe patient handling guidelines to keep yourself and
your patients safe.
• Follow other universal fall precautions in place at your facility.