Fall Risk Assessment
Fall Risk Assessment
Alex Chen
Chen, Alex
42 years old · #50923147 · L4-L5 lumbar laminectomy
Morse Fall Scale

Score Her Fall Risk

Using what you know about Alex, score each item on the Morse Fall Scale. Night shift report covered all of these details, if you get stuck, tap the hint on any item to hear it again.
History of Falling
No documented fall within the last 3 months.
No fall history is documented for this admission. Score = 0.
Secondary Diagnosis
Alex has a history of generalized anxiety disorder.
Generalized anxiety disorder counts as a secondary diagnosis. Score = 15.
Ambulatory Aid
Alex is using a walker since surgery.
She's using a walker post-operatively. Score = 15.
IV / Heparin Lock
Alex has an IV in place for her PCA.
An active IV line is present for her PCA. Score = 20.
Gait / Transferring
Alex is weak and unsteady with transfers since surgery, but able to bear weight.
Weak but not fully impaired describes her post-op state. Score = 10.
Mental Status
Alex is alert, oriented, and aware of her own physical limitations.
She's oriented and aware of her limitations, unlike patients who overestimate what they can safely do. Score = 0.
0
Total Morse Fall Scale Score
Fall Precautions

Who Does What?

Alex's score places her in the high-risk category. Sort each fall precaution into where it belongs.
Activate the bed alarm and document the score
Communicate fall risk status at hand-off
Explain to Alex that she is at risk for falls and what that means for her
Ensure non-skid socks stay on
Keep the bed in the lowest, locked position
Keep the call light within reach
Assist with ambulation using her walker, per the established plan
Apply the fall-risk identification wristband

Stays with the RN

+ tap to add

Delegate to CNA

+ tap to add
Activate the bed alarm and document the score: RNEstablishing the safety bundle is a nursing responsibility that requires documentation.
Communicate fall risk status at hand-off: RNHand-off communication of clinical risk stays with the nurse.
Explain to Alex that she is at risk for falls and what that means for her: RNPatient education requires nursing judgment to tailor and deliver, so teaching stays with the RN.
Ensure non-skid socks stay on: CNARoutine upkeep of an already-established precaution is appropriate CNA scope.
Keep the bed in the lowest, locked position: CNAMaintaining an established safety measure can be delegated.
Keep the call light within reach: CNAA routine environmental safety check within CNA scope.
Assist with ambulation using her walker: CNAOnce the plan of care is established, routine assisted ambulation is appropriate to delegate.
Apply the fall-risk identification wristband: CNAApplying an already-ordered wristband is a routine task, appropriate to delegate.
Great Job Keeping Her Safe
You have implemented all of the fall precautions and followed up with the CNA that the delegated tasks were complete.
Take Card #81