Scoring the Morse Fall Scale
The Morse Fall Scale (MFS) assigns points across six items. For this patient, each item is scored as follows.
| MFS item | Patient finding | Points |
|---|
| History of falling within 3 months | Fell at home 2 months ago | 25 |
| Secondary diagnosis | Type 2 diabetes plus pneumonia | 15 |
| Ambulatory aid | Walks by holding on to furniture | 30 |
| IV line or saline lock | Peripheral IV line present | 20 |
| Gait | Weak gait | 10 |
| Mental status | Oriented to own ability | 0 |
Adding the item scores gives
25 +
15 +
30 +
20 +
10 +
0 =
100. This is well above the ward's high-risk cutoff of
45, so the patient is classified as high risk for falls on admission.
The single highest-scoring item here is ambulatory aid at 30 points, because holding on to furniture indicates the patient relies on unstable environmental support rather than a proper assistive device. The history of falling within the past 3 months adds another 25 points, which is clinically meaningful because a recent fall is one of the strongest predictors of a subsequent fall during hospitalization. The secondary diagnosis item is met because the patient has more than one active medical diagnosis: community-acquired pneumonia and type 2 diabetes. The IV line contributes 20 points, reflecting both the physical tether of tubing and the tendency for patients with IV access to attempt unassisted mobility while managing the line. A weak gait adds 10 points, and the patient's orientation to her own ability contributes 0 points because she can accurately assess her own mobility limitations.
Watch out! The mental status item is scored 0 when the patient is oriented to their own ability, even if the patient is older or has multiple comorbidities. This item only adds points when the patient overestimates their ability or forgets their limitations.
Key point! The MFS is a screening tool, not a diagnostic test. A score of 100 indicates high risk, but the scale alone does not identify which specific fall prevention interventions are needed. The retrospective VHA study notes that the MFS remains widely used to determine fall risk across healthcare institutions despite known limitations, which means nurses must combine the score with clinical judgment and individualized mobility assessment.
The correct total is
100 points, matching option 1.