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Morse Fall Scale: how to score fall risk
The Morse Fall Scale adds points for six items: history of falling, a secondary diagnosis, an ambulatory aid, an IV or saline lock, gait and mental status. Scores run from 0 to 125, and a common cutoff is 45 or more for high fall risk (some facilities use 51 or more).
Morse Fall Scale items
| Item | Answer | Points |
|---|---|---|
| History of falling (this admission or within 3 months) | No / Yes | 0 / 25 |
| Secondary diagnosis (more than one diagnosis) | No / Yes | 0 / 15 |
| Ambulatory aid | None, bed rest or nurse assist / crutches, cane or walker / holds onto furniture | 0 / 15 / 30 |
| IV or saline lock | No / Yes | 0 / 20 |
| Gait | Normal, bed rest or wheelchair / weak / impaired | 0 / 10 / 20 |
| Mental status | Knows own limits / overestimates or forgets limits | 0 / 15 |
Risk levels (a common version)
| Total score | Risk |
|---|---|
| 0 to 24 | Low risk |
| 25 to 44 | Moderate risk |
| 45 or more | High risk |
Worked example
- An older adult fell at home last month (25), has heart failure and diabetes (15), uses a walker (15), has a saline lock (20), walks with a weak gait (10) and knows their limits (0).
- Total: 25 + 15 + 15 + 20 + 10 + 0 = 85. High risk.
Fall precautions
- Bed in the lowest position, wheels locked, call light and personal items within reach.
- Nonskid socks or shoes, good lighting and a clear path to the bathroom.
- Scheduled toileting and hourly rounding.
- Bed or chair alarm if your facility uses them, and teach the client to call before getting up.
- Review medications that raise fall risk (sedatives, opioids, BP drugs, diuretics).
NCLEX tip: Restraints are not a fall precaution. On the NCLEX, the safest first choices are the least restrictive: lower the bed, keep the call light in reach and round frequently.
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Frequently asked questions
What Morse score is high fall risk?
45 or more is a common cutoff for high risk, and some facilities use 51 or more. Check your policy.
What is the highest Morse Fall Scale score?
125, if a client scores the maximum on all six items.
When should the Morse Fall Scale be done?
On admission, after a fall, when the client's condition or medications change, and on the schedule your facility sets.
Keep studying
Sources
- Morse Fall Scale panel (LOINC 59453-1), Regenstrief Institute
For study only, not medical advice. Ranges and protocols vary by facility; follow your program, your facility's policies and the provider's orders.