Falls are the most common adverse event in hospitals and roughly a third of them cause injury. Score the Morse Fall Scale and the Timed Up and Go, then decide the first five minutes after a patient hits the floor — and build a restraint plan with the order limits, the monitoring interval and the knot that a chart audit will actually look for.
Morse Fall Scale
Six items, total 0 to 125. Score it on admission, at every transfer of care, after any change in condition, after a fall, and at least each shift.
Timed Up and Go
Rise from a standard armchair, walk 10 feet (3 m), turn, walk back and sit down.
Medications on the list today
0215You walk into room 412 and find an 82-year-old woman on warfarin sitting on the floor at the right side of the bed. The bed is low, the call light is clipped to the rail, she has nonskid socks on. She says, “I was going to the bathroom.” Nobody saw her fall.
Now choose everything that belongs in the immediate response
Some of these will hurt her. Choose deliberately.
Is it a restraint?
A restraint is any manual method, device, material or equipment that immobilizes or reduces a patient’s ability to move freely, or any drug used to manage behavior that is not standard treatment for their condition.
Build the restraint plan
Technique and paperwork
Score the six itemsTotal runs 0 to 125.
02545125
The score is not the plan. A Morse of 50 tells you the patient is high risk. It does not tell you whether the reason is orthostasis, urinary urgency, poor lighting, a new opioid or an unfamiliar walker. Interventions must match the mechanism.
She is on the floorWhat is your first move?
How to chart itVague: Patient found on floor. Incident report filed. Provider notified. Precise: 0215 Unwitnessed fall. Patient found sitting on floor at right side of bed, bed in low position, call light on bed rail, nonskid socks on. Patient states ‘I was going to the bathroom.’ Alert and oriented x3, denies head strike, denies LOC. No deformity; ROM intact all extremities; reports 4/10 right hip pain with movement. VS 138/76, HR 92, RR 18, T 36.8 C, SpO2 96 percent RA, CBG 104. Neuro checks initiated q15 min x 4. Assisted to bed with 2 staff and full-body lift. Dr. Okonkwo notified 0222 via SBAR; hip and pelvis x-ray ordered. Morse rescored 55; bed alarm activated, scheduled toileting q2h initiated. Daughter notified 0240.
Notice what is absent: an occurrence or incident report is a quality document and is never referenced in the medical record.
Restraints are a last resortCall the eight items, then build the plan.
The most common restraint error on the unit is tying to the side rail because it is closer. When the rail drops for a bath or an emergency, the wrist goes with it — traction injury, joint damage, crushing. Secure to a part of the movable bed frame, always, with a quick-release knot you can open with one hand in a single pull. Never a square knot.