A fall is an unplanned descent to the floor (or another lower surface), with or without injury. Falls are among the most common adverse events in hospitals and long-term care, and the leading cause of injury-related death in older adults. About one in three falls in hospitals causes some injury; hip fracture and intracranial bleeding (especially in clients on anticoagulants) are the most feared outcomes.
Falls rarely have a single cause. Risk comes from the interaction of the client, the medications, and the environment.
Intrinsic (client) risk factors
- History of a previous fall — the strongest single predictor
- Age 65 or older, frailty, muscle weakness
- Impaired gait, balance, or mobility; use of an assistive device
- Cognitive impairment: delirium, dementia, confusion, impulsivity, poor safety awareness
- Orthostatic hypotension, dizziness, vertigo
- Urinary urgency, frequency, nocturia, or incontinence (rushing to the bathroom)
- Impaired vision or hearing, peripheral neuropathy, foot problems
- Acute illness, dehydration, anemia, hypoglycemia, postoperative state
Medications that increase fall risk ("fall-risk-increasing drugs")
- Sedative-hypnotics and benzodiazepines, opioids, antipsychotics, antidepressants, antiepileptics
- Diuretics (urgency, volume depletion) and antihypertensives (orthostatic hypotension)
- Insulin and sulfonylureas (hypoglycemia), anticholinergics, first-generation antihistamines (e.g., diphenhydramine)
- Polypharmacy (commonly 5 or more medications; some fall tools use 4 or more)
Extrinsic (environmental) risk factors
- Wet or slippery floors, clutter, cords, poor lighting
- Beds in a high position, unlocked wheels, call light out of reach
- No grab bars in the bathroom, unfamiliar surroundings
- Tethers: IV lines, urinary catheters, oxygen tubing, drains
- Poorly fitting footwear or socks without grip, loose slippers
Other accident types in health care settings include burns (hot liquids, heating pads), electrical injury, poisoning, choking or aspiration, wrong-client events, and fire. General prevention rests on assessment, a safe environment, supervision, and client education.
Screen every client on admission, after any change in condition, after a fall, on transfer, and per facility policy (often every shift).
Focused fall-risk assessment
- Fall history (number, circumstances, injuries), fear of falling
- Gait and balance: observe the client rise from a chair and walk
- Orthostatic vital signs: blood pressure and pulse lying (after about 5 minutes supine), then standing at 1 and 3 minutes. A drop of 20 mmHg systolic or 10 mmHg diastolic is orthostatic hypotension
- Cognition and delirium screening, vision, footwear
- Elimination needs (urgency, nocturia, diuretic timing)
- Medication review for fall-risk-increasing drugs
- Anticoagulant or antiplatelet use (raises risk of serious injury, not the chance of falling)
Morse Fall Scale (MFS) — the most widely used hospital tool.
| Item | Scoring |
|---|
| History of falling (within 3 months or this admission) | No 0 · Yes 25 |
| Secondary diagnosis (more than one medical diagnosis) | No 0 · Yes 15 |
| Ambulatory aid | None, bed rest, or nurse assists 0 · Crutches, cane, or walker 15 · Furniture (holds on to furniture to walk) 30 |
| IV therapy or saline lock | No 0 · Yes 20 |
| Gait | Normal, bed rest, or wheelchair 0 · Weak 10 · Impaired 20 |
| Mental status | Oriented to own ability 0 · Overestimates or forgets limitations 15 |
- Total 0–125; the highest single item score is "furniture" for ambulatory aid (30)
- Cutoffs are set by each facility and vary by setting. A common scheme is 0–24 low, 25–44 moderate, 45 or higher high risk; some facilities use 25–50 moderate and above 50 high. Always follow the local cutoff
Hendrich II Fall Risk Model — scores confusion/disorientation/impulsivity, symptomatic depression, altered elimination, dizziness or vertigo, male sex, antiepileptics, benzodiazepines, and the Get Up and Go test (ability to rise from a chair). A score of 5 or more indicates high risk.
Timed Up and Go (TUG) test — the client rises from a standard chair, walks 3 meters (10 feet) at a normal pace, turns, walks back, and sits. Taking 12 seconds or longer suggests increased fall risk (CDC STEADI). The client may use their usual walking aid.
Other: STRATIFY (hospital), 30-second chair stand and 4-stage balance test (community), post-fall evaluation for injury (imaging as ordered).
Fall prevention is a multidisciplinary responsibility, not the nurse's alone.
| Team member | Role |
|---|
| Nurse | Risk screening, individualized plan, hourly rounding, toileting, education, reassessment |
| Physician / advanced practice provider | Treat underlying causes (orthostasis, delirium, infection), deprescribe or adjust high-risk drugs |
| Pharmacist | Medication review, identify fall-risk-increasing drugs and interactions |
| Physical therapist | Gait and balance training, strength exercise, choice of assistive device |
| Occupational therapist | Activities of daily living, home safety, adaptive equipment |
| Client and family | Participation, reporting needs, supervision, home modification |
| Facilities management | Lighting, flooring, grab bars, equipment maintenance |
Medication management
- Reduce or stop benzodiazepines, sedative-hypnotics, and anticholinergics where possible (Beers Criteria); taper benzodiazepines rather than stopping abruptly to avoid withdrawal seizures
- Time diuretics for the morning; review antihypertensive doses if orthostatic
- Treat vitamin D deficiency; screen for osteoporosis to reduce fracture risk
Listed in priority order.
- Immediate response to a fall
- Stay with the client and assess before moving them: airway, breathing, circulation, level of consciousness, pain, obvious injury (deformity, shortening and external rotation of a leg suggests hip fracture), head strike
- Call for help; do not lift the client until injury is excluded; use a lift device or several staff
- Neurologic checks and vital signs per post-fall protocol, especially with head injury or anticoagulant use — delayed bleeding can occur
- Notify the provider and the family; document objectively; complete an incident report
- Hold a post-fall huddle to identify what happened and what to change
- Universal fall precautions (all clients)
- Bed in the lowest position, wheels locked
- Call light and personal items within reach
- Non-slip footwear; clear pathways; adequate lighting, night light
- Orient the client to the room and bathroom
- Interventions for moderate to high risk
- Visual identifiers (wristband, sign) per policy
- Scheduled toileting and purposeful hourly rounding (pain, position, possessions, potty)
- Bed or chair exit alarms; low bed with floor mats for clients at risk of rolling out
- Assist with all transfers and ambulation; use gait belt
- Cluster care and keep high-risk clients close to the nursing station
- Continuous observation (sitter or video monitoring) for confused, impulsive clients
- Side rails — do not keep all side rails up routinely. A client may climb over or become entrapped, and rails that prevent a client from leaving the bed voluntarily can count as a restraint. Two upper rails often assist with repositioning; the decision is individualized.
- Avoid restraints and routine sedation for confused clients — both increase injury, delirium, and deconditioning. Restraints are a last resort (see Topic 15).
- Early mobility — deconditioning itself raises fall risk; walk the client with assistance as tolerated.
- Other accident prevention
- Check temperature of bath water and heat applications; inspect electrical equipment
- Fire response: RACE (Rescue, Alarm, Confine, Extinguish/Evacuate) and extinguisher use PASS (Pull, Aim, Squeeze, Sweep)
- Store medications and chemicals securely; supervise meals for clients with dysphagia
Incident reporting — the purpose is learning and system improvement, not blame. Reports feed root-cause analysis, quality indicators, and a just culture. Do not document "incident report completed" in the client's chart; document the facts and care provided.
- Change position slowly: sit on the edge of the bed for a minute or two, dangle the feet, then stand; sit or lie down at once if dizzy
- Call for help before getting up when told to do so; do not rush to the bathroom — use the call light early or ask for a scheduled toileting plan
- Wear well-fitting, closed-heel, non-slip footwear; avoid loose slippers and walking in socks
- Keep glasses and hearing aids on; use the walker or cane prescribed
- Home safety: remove loose rugs and clutter, secure cords, install grab bars by the toilet and in the shower, use night lights and bright stair lighting, keep frequently used items within easy reach
- Review medications with the provider or pharmacist, including over-the-counter sleep aids and antihistamines; avoid alcohol with sedating drugs
- Exercise for strength and balance (e.g., tai chi, supervised programs)
- Annual vision check; report new dizziness or falls
| Complication | What to watch for |
|---|
| Head injury / intracranial bleed | Headache, vomiting, drowsiness, confusion, unequal pupils — urgent, especially on anticoagulants; may be delayed |
| Hip fracture | Groin or hip pain, inability to bear weight, shortened and externally rotated leg |
| Other fractures | Wrist (fall on outstretched hand), vertebral, rib |
| Long lie after a fall | Rhabdomyolysis, pressure injury, hypothermia, dehydration |
| Post-fall syndrome | Fear of falling → activity restriction → deconditioning → more falls |
| Unrecognized cause | New fall may signal infection, delirium, stroke, hypoglycemia, dysrhythmia |
- Previous fall is the strongest predictor of another fall
- After a fall: assess the client first, do not lift immediately, then notify and document
- Morse Fall Scale: furniture use = 30 points (highest single item); history of falling 25; IV or saline lock 20; impaired gait 20
- High-risk cutoff varies by facility (commonly 45 or more)
- Hendrich II includes confusion, depression, altered elimination, dizziness, male sex, antiepileptics, benzodiazepines, and Get Up and Go
- Timed Up and Go: 3 m (10 ft); 12 seconds or longer = increased risk
- Bed lowest, wheels locked, call light within reach, non-slip footwear, hourly rounding, scheduled toileting
- Do not raise all side rails routinely — it can be a restraint and increases injury
- Diuretics, antihypertensives, benzodiazepines, sedatives, antipsychotics raise fall risk
- Fall prevention is multidisciplinary; incident reports are for learning, not blame
Country Notes
United States
- CDC's STEADI initiative (Stopping Elderly Accidents, Deaths and Injuries) provides screening questions, the TUG test, and community fall-prevention tools.
- Under the CMS Hospital-Acquired Conditions policy, falls and trauma acquired in the hospital do not qualify a stay for a higher-paying diagnosis group; accurate risk assessment and documentation are emphasized.
- Teaching often uses feet and inches (e.g., 10-foot walk for the TUG test).
Philippines
- Many hospitals rely on family members ("bantay") to stay at the bedside; include them in fall-prevention teaching and make clear that they must call the nurse before helping the client out of bed.
- Homes may have steps between rooms, wet bathroom floors, and no grab bars; stress non-slip mats, lighting, and clearing floors during home-safety teaching.