Patient Safety Assessment
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Osman, Faadumo
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Morse Fall Scale
Select the best option for each item based on Faadumo's current presentation
Use what you have gathered from your assessment and the other cards in this case. Each item reflects a specific clinical finding.
History of falling (within 3 months)
A fall is any unplanned descent to the floor or lower surface, with or without injury. Count falls from the past 3 months only — not lifetime history.
Faadumo: This is an acute admission with no documented fall history in the past 3 months.
Secondary diagnosis
A secondary diagnosis is any additional medical condition beyond the primary reason for admission. If the patient has two or more diagnoses listed in the chart, score 15.
Faadumo: Her primary presenting issue is acute confusion. Her documented medical history includes CKD and HTN.
Ambulatory aid
Consider what the patient is currently using to move around — or would use if they were up. If they require no assistive device and are currently on bed rest or nurse-assisted, score 0.
Faadumo: No ambulatory aid is documented. She is in bed on admission and has not ambulated.
IV access / heparin lock
Any active IV line or saline/heparin lock counts here, regardless of what is infusing. IV tubing creates a fall hazard during ambulation or position changes.
Faadumo: She has an IV line running 0.9% NS at 125 ml/hr, placed on admission.
Gait
Observe or consider how the patient moves. Normal = steady, no assistive device needed. Weak = stooped or slow but recovers independently. Impaired = shuffling, jerky, unsteady — needs support or has difficulty with balance.
Faadumo: She is acutely confused and repeatedly attempting to climb out of bed without regard for her safety or surroundings.
Mental status
Ask: does the patient know their own physical limitations right now? "Oriented to own ability" means they understand they need help. "Overestimates ability" means they believe they can do more than they safely can.
Faadumo: She is disoriented to place and situation. She believes she is hosting a celebration and must get out of bed to attend to her guests.
Faadumo scores 70 on the Morse Fall Scale — high risk. She is actively attempting to climb out of bed. A patient sitter has been requested. For each intervention below, decide how it should be handled.
Implement now (nurse)
Delegate to sitter
Not indicated
Safety measures in place.
You identified Faadumo's fall risk accurately and assigned the right interventions to the right people. The safety bundle is active.
Take card #5
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