Falls are the most common adverse event reported in hospitals, and about a quarter of inpatient falls cause injury. The score is not the intervention — the score tells you to act. Score a real patient on the Morse Fall Scale, build the plan that score demands, write the note the way a chart should read, and apply the hard legal limits that govern restraints.
Morse Fall Scale
Screen on admission, on transfer, after a change in condition, after a fall, and at least each shift per policy. Load a patient, or score one yourself.
Orthostatic vital signs
Do these on any patient who reports dizziness on standing. Measure supine, then again within three minutes of standing.
Mr. Halloran scores 100. Build his plan.
Tick every measure you would put in place for this high-risk patient. Some belong on every patient, some are the high-risk add-ons — and some are things a nurse must never do in the name of fall prevention.
0215. He is on the floor.
You did not see him go down. You have assessed him in place, taken vital signs and returned him to bed. Now decide what goes in the medical record. Tick every line that belongs; leave the ones that must never be written.
Is this a restraint?
A restraint is any manual method, physical device, material or equipment that immobilizes or reduces a patient’s ability to move freely, or any drug used as a restriction to manage behaviour that is not standard treatment for their condition.
The order you are working under
Restraint law turns on the category of behaviour and on age. Pick the situation to see the limits that bind you.
Morse total
0of 125 pointsLow risk
Answer each of the six items. The Morse Fall Scale scores history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait and mental status.
Bands. 0–24 low risk · 25–44 moderate risk · 45 or higher is high risk. The Hendrich II Fall Risk Model is the other validated tool you will meet: it flags confusion, depression, altered elimination, dizziness, male sex, antiepileptics, benzodiazepines and a timed get-up-and-go, and a score of 5 or greater is high risk. Whichever tool your facility uses, a number in a box has never prevented a fall. The score exists to trigger the plan.
The plan, audited
Tick the measures you want, then press Check my plan. Watch what happens to the two side-rail answers.
Most inpatient falls happen on the way to the bathroom. That is why purposeful hourly rounding uses the four Ps — pain, potty, position, possessions. You are not checking on the patient; you are removing the four reasons they were about to get up alone. Review the medication list too: benzodiazepines, opioids, antipsychotics, antihypertensives, diuretics, hypoglycaemics and anticholinergics all raise risk, and four or more medications of any kind raises it further.
Raising all four side rails is a restraint, not a fall precaution. Two or three rails up for mobility and positioning is standard. Four rails up confines the patient, and if they climb over, you have converted a two-foot fall out of bed into a four-foot fall onto the head.
What a chart is for
The medical record describes what happened to the patient and what you did about it. Tick the lines that belong, then press Check the note.
Two rules students get wrong constantly. First, you still chart the clinical facts of the event and your assessment in the medical record — the event report does not replace the note. Second, you never write “incident report completed” or “error made” in the record. The event report is a parallel internal quality document, and referencing it in the chart can strip its protected status.
Assess in place — do not lift them first. Level of consciousness, airway, breathing, circulation, pain, obvious deformity, head strike, neurologic status, then a full set of vital signs. If the patient is anticoagulated or struck their head, escalate immediately for imaging and neurologic checks per protocol. Then move them with a mechanical lift and adequate staff, and complete the event report separately.
Look for the injury you can miss. A bruise or a developing haematoma may not read as purple or blue on deeply pigmented skin — it can appear simply darker than the surrounding tissue, or show only as swelling. Use natural or high-intensity white light, compare with the opposite side, palpate for swelling, induration and warmth, and treat the patient’s report of tenderness as the finding it is.
Restraint calls
Decide each item, then press Check my calls.
The legal limits
Alternatives first, and document that you tried them. Reorient the patient, move them closer to the nurses’ station, provide a sitter or family presence, treat pain, address hunger and toileting, reduce noise and light at night, offer a diversional activity or activity apron, review deliriogenic medications, and camouflage lines under clothing or a stockinette. Delirium, not defiance, drives most of the pulling at tubes — so treat the delirium.
Technique that keeps a restraint from becoming an injury. Tie limb restraints to the movable bed frame, never to a side rail — a rail that is lowered will wrench the limb. Use a quick-release knot that unties with a single pull, never a square knot or a bow that can jam. You should be able to slide two fingers between the restraint and the skin. Never restrain a patient prone, and never restrain the arms above the head. Use the least restrictive effective method and discontinue at the earliest possible time.