People who live in a long-term care facility require considerable help from the staff members. The reasons for this vary greatly, so it’s up to the staff at the facility to learn about each resident’s needs. A fall risk assessment should be completed on each resident.
Fall risk assessments enable the staff members to determine what type of assistance the person needs when they move around the facility. People who are at risk of falls should have a plan to reduce the chance of a fall happening.
What are Points Considered in the Fall Risk Assessment?
The basic screening tool for fall risk takes several factors into account. A person who’s fallen in the past 180 days is automatically considered to have a high fall risk.
Other points that are considered include:
- Certain diseases, including Parkinson’s or dementia
- Dizziness, including medication-induced dizziness
- Use of restraints, including bed restraint
- Certain medications, including antipsychotic, antianxiety, and antidepressant medications
- Unsteady gait
- Depth perception problems
- Vision or mobility challenges
What is a Fall Risk Assessment?
A fall risk assessment tool is essentially a checklist or scoring system that is used by healthcare providers to identify a patient’s likelihood of falling. It evaluates factors such as:
- Age
- History of previous falls
- Medication use (especially sedatives or blood pressure drugs)
- Gait or balance issues
- Vision problems
- Cognitive impairments
- Use of assistive devices (canes, walkers)
Common tools include the Morse Fall Scale, Hendrich II Fall Risk Model, and STRATIFY. These tools help hospitals, nursing homes, and care providers implement fall prevention strategies for high-risk patients.
Types of Fall Risk Assessments
Morse Fall Risk Assessment (MFS)
The Morse Fall Risk Assessment (MFS) is a widely used fall risk assessment tool in hospitals to quickly evaluate a patient’s likelihood of falling. It scores six factors:
- history of falling,
- secondary medical diagnoses,
- use of ambulatory aids,
- IV therapy,
- gait, and
- mental status.
Each item is assigned a point value on the Morse Fall Risk Assessment, and the total score categorizes patients as low, moderate, or high risk. This helps clinical staff implement targeted fall prevention strategies based on the patient’s specific risk profile.
Hendrich II Fall Risk Model
The Hendrich II Fall Risk Model is a screening tool that hospitals use to identify patients at risk of falling. This fall risk assessment tool evaluates eight risk factors:
- confusion or disorientation,
- showing signs of depression, even if not diagnosed,
- altered elimination (bowel or urinary problems)
- dizziness or vertigo,
- gender (Simply being a male adds points to the total fall score because men are more likely to try and do things themselves as opposed to asking for help.),
- use of antiepileptic (used to control seizures),
- use of benzodiazepines, and
- performance on the Get-Up-and-Go test.
Each item is scored, and a total score of 5 or more indicates a high fall risk. This model is often used in acute care settings to guide fall prevention protocols.
STRATIFY: St. Thomas’s Fall Risk Assessment Tool For Elderly Patients
Hospitals use the STRATIFY tool (St. Thomas’s Risk Assessment Tool in Falling Elderly Inpatients) to predict fall risk in elderly patients. The STRATIFY fall risk assessment tool looks at five key risk factors:
- recent falls,
- agitation,
- visual impairment,
- frequent toileting needs, and
- transfer/mobility problems.
Each factor is assigned one point, and a total score of 2 or more suggests a high risk of falling. STRATIFY helps healthcare providers implement targeted fall prevention measures for older adults during hospital stays.
Johns Hopkins Fall Risk Assessment Tool (JHFRAT)
Hospitals use the comprehensive Johns Hopkins Fall Risk Assessment Tool (JHFRAT) to identify patients at risk of falling. The JHFRAT evaluates multiple factors, including
- age,
- fall history,
- medication use,
- mobility,
- cognition,
- elimination (urinary or bowel problems), and
- equipment attached to the patient.
Each category is scored, and a higher total score indicates a greater fall risk. The John Hopkins Fall Risk Assessment helps clinicians tailor fall prevention strategies based on a patient’s specific risk profile.
Hester Davis Fall Risk Assessment
Various professionals in a range of healthcare settings use the Hester Davis Fall Risk Assessment Tool. The Hester Davis Fall Risk Assessment is a dynamic, evidence-based tool. It scores multiple risk factors, including age, mobility, mental status, toileting needs, medications, and history of falls.
Each factor is weighted, and the total score determines the patient’s fall risk level. The Hester Davis tool is designed for ongoing fall risk assessments and can be updated throughout a patient’s stay to reflect changes in condition or environment.
Braden Fall Risk Assessment
While the Braden Scale is primarily used as a bedsore risk tool, the Braden tool can also help identify fall risk indirectly.
The Braden Fall Risk Assessment looks at six areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Low scores indicate greater risk for skin breakdown and immobility, which can increase the chance of falling. While not a dedicated fall risk tool, clinicians sometimes use Braden scores to support broader fall prevention strategies, especially in immobile or high-risk patients.
STEADI Fall Risk Assessment (Stopping Elderly Accidents, Deaths & Injuries)
The CDC developed the STEADI Fall Risk Assessment tool to screen and assess fall risks specifically in older adults. It includes a three-step approach: screen, assess, and intervene.
Patients answer questions about previous falls, balance issues, and fear of falling on the STEADI fall risk assessment form. Clinicians then assess gait, strength, and balance with tests like the Timed Up and Go (TUG). Based on the results, providers implement personalized interventions such as strength training, medication review, or vision correction to reduce fall risk.
Timed Up and Go Test (TUG)
Medical providers in hospitals, outpatient clinics, and senior care facilities use the Timed Up and Go (TUG) Test to measure a patient’s mobility and fall risk. The healthcare professional times the patient as they rise from a chair, walk 10 feet, turn around, walk back, and sit down. A time of 12 seconds or more typically indicates a higher risk of falling.
Wilson Sims Fall Risk Assessment
While less commonly used, the Wilson Sims Fall Risk Assessment Tool evaluates a patient’s likelihood of falling based on factors such as age, mental status, mobility, medication use, and prior fall history.
Each risk factor is assigned a score, and the total score helps determine whether the patient is at low, moderate, or high risk for falls. Most of the time, long-term care facilities and rehab centers use the Wilson Sims Fall Risk Assessment to support early intervention and fall prevention planning.
Schmid Fall Risk Assessment Tool
Hospitals use the Schmid Fall Risk Assessment Tool when they need to screen patients quickly and efficiently. It evaluates five key factors: mobility, mental status, toileting, fall history, and medication use. Each category is scored, and the total score determines the level of fall risk. A higher score on the Schmid Fall Risk Assessment indicates a greater risk, prompting implementation of fall prevention protocols such as bed alarms, assistive devices, or increased monitoring.
Berg Balance Scale (BBS)
Hospitals use the Berg Balance Scale (BBS) to assess a patient’s balance and risk of falling, especially in older adults or those recovering from injury or surgery. The BBS consists of 14 tasks, such as sitting, standing, turning, and reaching, each scored from 0 to 4. The maximum score is 56, with lower scores indicating greater fall risk. The Berg Balance scale helps measure balance performance over time and guide fall prevention or rehabilitation strategies.
Tinetti Performance-Oriented Mobility Assessment (POMA)
The Tinetti Performance-Oriented Mobility Assessment (POMA) evaluates balance and gait to determine fall risk. It includes two sections:
- balance (sitting, standing, turning)
- gait (step length, symmetry, stability)
Each item is scored from 0-2, with a total possible score of 28 points.
Scores below 19 indicate a high risk of falling, while scores of 19–24 suggest a moderate risk. The Tinetti Performance-Oriented Mobility Assessment (POMA) is widely used in both clinical and rehabilitation settings to assess mobility limitations and plan interventions.
Conley Scale
Generally, hospitals and nursing homes use the Conley Scale to identify patients at risk of falling. The Conley Scale evaluates two primary factors: fall history and cognitive impairment.
Patients who have fallen recently or exhibit signs of confusion, disorientation, or poor judgment score higher. The tool is simple to administer, helping caregivers quickly determine whether fall prevention strategies should be implemented immediately.
MAHC-10 Fall Risk Assessment Tool
The MAHC-10 Fall Risk Assessment Tool was designed to be used in home healthcare settings. While developed in Missouri, this is used around the United States.
The MAHC-10 consists of 10 yes-or-no questions, each addressing a known fall risk factor such as:
- History of falls
- Medications
- Impaired mobility
- Cognitive status
- Pain affecting function
- Incontinence
- Vision problems
The patient receives one point for every “yes” answer. A total score of 4 or more indicates an increased risk of falling.
Edmonson Psychiatric Fall Risk Assessment
The Edmonson Psychiatric Fall Risk Assessment Tool recognizes that traditional fall risk assessment tools don’t totally capture the unique risks associated with psychiatric patients. It evaluates:
- mental status,
- impulsivity,
- specific medication side effects,
- mobility, and
- recent changes in behavior.
The Edmonson Psychiatric Fall Risk Assessment Tool helps psychiatric care teams implement tailored interventions, like increased observation or environmental adjustments, to prevent falls in mental health settings.
Need a Fall Risk Assessment PDF?
Here are links for common fall risk assessments that are in downloadable PDF formats:
John Hopkins Fall Risk Assessment Tool PDF
Morse Fall Risk Assessment PDF
STEADI Fall Risk Assessment PDF
Edmonson Psychiatric Fall Risk Assessment PDF
Wilson Sims Fall Risk Assessment Tool PDF
Schmid Fall Risk Assessment Tool PDF
Hendrich Fall Risk Assessment Tool PDF
MAHC 10 Fall Risk Assessment Tool PDF
Pediatric Fall Risk Assessment Tool
Pediatric fall risk assessment tools are used to identify fall risk in children across hospital settings.
Humpty Dumpty Fall Risk Assessment Tool (HDFS)
Hospitals use the Humpty Dumpty Fall Risk Assessment Tool (HDFS) to evaluate fall risks in pediatric patients.
The HDFS scores factors such as age, diagnosis, cognitive impairments, mobility, medication use, and response to surgery or sedation. Each category is assigned points, and a total score of 12 or higher indicates a high risk of falling. The Humpty Dumpty Fall Risk Assessment is commonly used in children’s hospitals to trigger targeted fall prevention strategies based on developmental needs.
CHAMPS Pediatric Fall Risk Assessment Tool
CHAMPS stands for Child’s age, History of falls, Ambulatory status, Medications, Physical/physiological status, and Surgical/diagnostic procedures.
Each category on the CHAMPS Pediatric Fall Risk Assessment Tool contributes to a cumulative score, helping healthcare professionals identify high-risk pediatric patients.
Little Schmidy Pediatric Fall Risk Assessment Tool
The Little Schmidy Pediatric Fall Risk Assessment Tool was adapted from the adult Schmid Fall Risk Assessment.
It evaluates five main areas of pediatric patients: mobility, mental status, elimination, prior fall history, and medication use. Each factor is scored, and a higher total score indicates increased fall risk.
Medicare Fall Risk Assessment
The Medicare Fall Risk Assessment is a key part of preventive care for elderly patients. Medicare doctors generally conduct this during the patient’s Medicare Annual Wellness Visit. Medicare Fall Risk Assessments are evaluated through the Medicare Health Outcomes Survey.
This helps track fall risk factors by assessing seniors’ mobility, balance, medication use, history of falls, and environmental safety. Physicians may use a standardized fall risk assessment tool, such as the STEADI toolkit, to determine risk levels.
The results will guide the fall prevention strategies moving forward. These can include physical therapy, home modifications, and medication adjustments.
Why are Reliable Fall Risk Assessments Needed in Assisted Living Organizations?
Reliable fall risk assessments are essential in assisted living organizations because they help identify residents at higher risk of falling before they end up hurting themselves.
In many cases, elderly populations have more mobility issues, stronger medications, chronic conditions, and many have cognitive impairments that inherently increase the risk of falling. Without consistent and valid assessments, the assisted living staff could overlook warning signs. This opens them up to liability in the event of personal injury or death.
Accurate fall risk tools allow long-term care facilities to implement necessary interventions.
What is the Best Fall Risk Assessment Tool?
There isn’t a single “best” fall risk assessment tool. Each is designed for a specific type of patient. However, we’ve broken these down so that readers can see which is the best tool for their situation.
- Best for Psychiatric Patients: Edmonson Psychiatric Fall Risk Tool
- Best for Home Health: MAHC-10 (meets CMS requirements)
- Best for Hospital Inpatients: Morse Fall Scale (MFS)
- Best for Geriatric Rehab: Tinetti Performance-Oriented Mobility Assessment (POMA)
- Best for Balance Evaluation: Berg Balance Scale (BBS)
- Best for Quick Screening in Hospitals: Hendrich II Fall Risk Model
- Best for General Pediatric Patients: Humpty Dumpty Fall Risk Assessment
- Best for Young Children in Hospitals: Little Schmidy Pediatric Fall Risk Tool
How Often Should Fall Risk Assessment Be Conducted in Texas?
The fall risk assessment isn’t a one-and-done event. Instead, residents will need to be reevaluated periodically. They should also undergo another assessment if they have a significant change in their medical, psychiatric, or mobility profile. The nursing staff at the facility should be vigilant to watch for signs that a resident is at risk of falling. Nursing home neglect can take many forms.
Residents of long-term care facilities who suffer an injury due to a fall should be provided with immediate medical care. These individuals might opt to pursue a claim for compensation if the fall was due to the negligence of the facility’s staff members. Working with someone who’s familiar with these matters can help to reduce the stress associated with this process.
Contact a San Antonio nursing home falls attorney for a free consultation to learn more.
Symptoms to Look For After a Fall: Elderly Patients
Symptoms to look for after a fall include:
- Headache, confusion, or loss of consciousness: brain injury or concussion
- Dizziness, blurred vision, or slurred speech: stroke or head trauma
- Severe or worsening pain: especially in the hips, back, neck, or joints
- Swelling, bruising, or deformity: fracture or internal bleeding
- Inability to move a limb or bear weight: broken bones or joint dislocation
- Incontinence or sudden confusion: spinal injury or neurological damage
- Shortness of breath or chest pain: rib fracture or internal injury
- Numbness or tingling: nerve damage or spinal injury
What to Look For if Your Child Falls
If your child falls, watch closely for signs that may indicate a serious injury. These can include:
- Loss of consciousness or confusion: concussion or head injury
- Persistent crying or irritability: needs to be looked into
- Vomiting after the fall: major head trauma
- Drowsiness or difficulty waking: brain injury
- Limping or refusal to walk: sprain, fracture, or joint damage
- Swelling, bruising, or visible deformity: broken bones
- Bleeding from the child’s ears or nose: skull fracture
- Unusual behavior or coordination issues: neurological damage
Español de México