Fall Prevention
Morse Fall Scale scoring and fall risk intervention bundle
Rajan Mehta, 75M — HIGH fall risk (Morse 85). All fall prevention interventions must be in place.
Rajan Mehta, 75M · ICU-1
Morse Score: 85 · Last assessed: 23 Jun 2026, 06:00
High Risk
| Risk Factor | Score |
|---|---|
| History of falling | 25 |
| Secondary diagnosis (> 1 diagnosis) | 15 |
| Ambulatory aid | 15 |
| IV/Heparin lock | 20 |
| Gait | 10 |
| Mental status | 0 |
| Total | 85 |
Intervention Bundle
0/10
Morse Fall Scale score documented every shift
HIGH FALL RISK sign displayed at bedside and above bed
Call bell within reach at all times
Bed in lowest position, brakes locked
Non-slip footwear provided and worn
Ensure clear path to bathroom — no clutter
Night light and clear path to bathroom at night
Bed rails up (2 or 4 depending on risk level)
Patient and family educated on fall prevention
Toileting schedule offered every 2 hours