Fall Prevention Nursing Guide 2026: Risk Assessment, Interventions, and Post-Fall Care
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This article was created with AI assistance.
Fall Burden and Impact
Falls are the most common adverse event in hospitalized patients. Approximately 700,000 to 1,000,000 patients fall in US hospitals each year. About 30% of falls result in injury; 4–6% cause serious injury (fractures, subdural hematomas, death). Falls are a CMS "Never Event" category — hospitals do not receive additional Medicare reimbursement for fall-related complications. The Joint Commission requires fall risk assessment at admission, after significant change in condition, and after a fall.
Fall Risk Assessment Tools
Morse Fall Scale
The Morse Fall Scale is the most widely used hospital fall risk tool:
| Factor | Scale | Score |
|---|
| History of falling (past 3 months) | No = 0; Yes = 25 | 0 or 25 |
| Secondary diagnosis | No = 0; Yes = 15 | 0 or 15 |
| Ambulatory aid | Bed rest/nurse assist = 0; crutches/cane/walker = 15; furniture = 30 | 0, 15, or 30 |
| IV or heparin lock | No = 0; Yes = 20 | 0 or 20 |
| Gait | Normal/bedrest/immobile = 0; weak = 10; impaired = 20 | 0, 10, or 20 |
| Mental status | Knows limitations = 0; forgets limitations = 15 | 0 or 15 |
Scoring: 0–24 = Low risk; 25–44 = Medium risk; ≥45 = High risk (full fall prevention protocol)
Hendrich II Fall Risk Model
Alternative tool used in many facilities; includes confusion, symptomatic depression, altered elimination, dizziness, gender (male), antiepileptic medications, benzodiazepines, and timed "Get Up and Go" test. Score ≥5 = high risk.
Fall Risk Factors
Intrinsic (Patient-Related) Risk Factors
- Age ≥65 (greatest single risk factor)
- Prior fall history (strongest predictor of future fall)
- Cognitive impairment (dementia, delirium)
- Gait/balance disorders, muscle weakness
- Orthostatic hypotension
- Urinary urgency/incontinence (frequent trips to bathroom, especially at night)
- Visual impairment
- Post-surgical status (anesthesia effects, pain medications, mobility restrictions)
Extrinsic (Environmental) Risk Factors
- Unfamiliar environment; disorientation to room layout
- Cluttered environment; tubing/equipment obstacles
- Wet or slippery floors
- Improper footwear (socks without grips, bare feet)
- Bed in high position with rails down
- Call light out of reach
- Inadequate lighting (especially at night)
Fall Prevention Bundle (Evidence-Based)
| Intervention | Implementation |
|---|
| Risk assessment on admission | Morse or Hendrich II on admission, each shift, and after falls or significant changes; document score and interventions |
| Bed in low locked position | Lowest position when not providing care; verify each time patient is left alone; bed exit alarm ON for high-risk patients |
| Call light within reach | Place at all times; orient patient AND family to call light use each shift; reinforce not to get up without calling |
| Non-slip footwear | Grip socks or non-slip footwear at all times when ambulatory; NO bare feet, NO regular socks for high-risk patients |
| Bathroom schedule | Offer toileting q2h and before sleep; address urinary urgency and incontinence proactively; night light in bathroom |
| Medication review | Review all high-risk medications; deprescribe when possible; collaborate with pharmacy and provider |
| Mobility assistance | Assist high-risk patients with all transfers and ambulation; sit-stand-walk sequence; two-person assist if needed |
| Fall-risk signage | Yellow armband and/or bed signage for high-risk patients (per facility policy); communicate fall risk in SBAR handoff |
| Education | Educate patient AND family about fall risk, call light use, orthostatic precautions; reinforce each shift |
| Hourly rounding | Intentional hourly rounding (3 P's: Pain, Position, Personal needs/toilet); reduces call light use and fall rate |
High-Risk Medications for Falls
| Category | Examples | Fall Mechanism |
|---|
| Sedatives/Hypnotics | Benzodiazepines (lorazepam, diazepam), zolpidem (Ambien), diphenhydramine (Benadryl) | Sedation, impaired cognition, balance and coordination impairment |
| Opioids | Morphine, oxycodone, hydromorphone, fentanyl | Sedation, orthostatic hypotension, dizziness, impaired coordination |
| Antihypertensives | Beta-blockers, calcium channel blockers, ACE inhibitors, alpha-blockers (tamsulosin) | Orthostatic hypotension (especially alpha-blockers used for BPH); bradycardia |
| Diuretics | Furosemide, hydrochlorothiazide, spironolactone | Orthostatic hypotension from volume depletion; urgency causing rushing to bathroom |
| Antipsychotics | Haloperidol, quetiapine, olanzapine | Sedation, orthostatic hypotension, extrapyramidal effects (gait disturbance) |
| Antiepileptics | Phenytoin, carbamazepine, gabapentin, levetiracetam | Dizziness, ataxia, sedation, double vision |
| Laxatives/Stool softeners | Polyethylene glycol, bisacodyl, senna | Urgency and frequency causing rapid bathroom trips; diarrhea |
The Beers Criteria (American Geriatrics Society) lists medications that are INAPPROPRIATE for older adults due to fall/injury risk. Key high-fall-risk Beers medications: benzodiazepines, tricyclic antidepressants, diphenhydramine, antipsychotics, zolpidem.
Post-Fall Assessment
Immediate Response (within minutes)
- Do NOT move patient until assessment is complete (cervical or spinal injury possible)
- Assess level of consciousness and orientation
- Check vital signs including orthostatic BP if patient can tolerate position change
- Assess for injuries: head-to-toe survey; palpate skull, spine, extremities; assess for pain, deformity, bruising, swelling
- Assess range of motion cautiously; immobilize if fracture suspected
- If on anticoagulants, aspirin, or warfarin: heightened concern for internal bleeding, especially intracranial
- Notify provider; document time, circumstances, and assessment findings
- Notify family as per facility policy
Subsequent Actions
- Document circumstances of fall (what was patient doing, where, witnesses)
- Neurological checks q1h x4, then q2h x4 for any patient who hit their head or is on anticoagulants
- Imaging per provider orders (skull X-ray/CT head if head injury; hip/extremity X-ray if fracture suspected)
- Incident/occurrence report per facility policy (NOT part of the medical record)
- Root cause analysis and care plan revision to prevent future falls
- Reassess and intensify fall prevention interventions
Documentation Requirements
- Admission fall risk score (Morse or Hendrich II) and specific risk factors identified
- Interventions implemented (document each fall prevention measure)
- Patient/family education provided and patient response
- Post-fall: exact time, location, and circumstances; witnessed or unwitnessed; what patient was trying to do; immediate assessment findings; provider notified (time); family notified (time); imaging ordered; ongoing monitoring plan
- Incident report: facility-specific tool; NOT in the medical record; do NOT document that an incident report was filed in the medical record
NEVER document "patient fell while unattended" or "incident report filed" in the medical record. These phrases create legal liability. Document clinical facts only (time, circumstances, assessment, interventions).
NCLEX High-Yield Points
- Strongest predictor of future falls = history of previous falls; always document and act on this
- Morse Fall Scale: ≥45 = high risk; prior fall = 25 points alone
- Highest priority intervention for fall prevention: bed in LOW position, call light within reach, non-slip footwear
- Urinary urgency is a major fall precipitant — proactive toileting schedule q2h prevents rush-to-bathroom falls
- Do NOT restrain patients as fall prevention — restraints INCREASE injury and delirium
- Post-fall head injury + anticoagulants: q1h neuro checks; immediate CT head concern
- Incident report does NOT go in the medical record; do not document that one was filed in the chart
- Beers Criteria: benzodiazepines, diphenhydramine, antipsychotics, zolpidem = high fall risk in elderly; avoid or minimize
- Orthostatic hypotension: check BP lying → sitting → standing; drop of ≥20 mmHg systolic or 10 mmHg diastolic with position change = positive; educate patient to sit before standing
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