Which assessment tool is commonly used on admission to identify fall risk?

• A. Morse Fall Scale
• B. Braden Scale
• C. Glasgow Coma Scale
• D. Mini-Mental State Exam

Answer: (A)

The main idea is to identify fall risk right when a patient is admitted so safety measures can be put in place immediately. The Morse Fall Scale is designed for quick, on-admission screening of fall risk and is commonly used in hospitals for this purpose. It assesses several key factors that influence fall likelihood, including whether the patient has a history of falling, the presence of a secondary diagnosis, what kind of ambulatory aid the patient uses, whether an IV or traction is in place, the patient’s gait, and their mental status. The total score helps determine how aggressively to implement fall precautions, such as assistance with mobility, keeping bed or chair alarms within reach, using non-slip footwear, and arranging closer monitoring.

The other tools measure different concerns. The Braden Scale evaluates risk for pressure ulcers, not falls. The Glasgow Coma Scale measures level of consciousness and neurologic status, which is important for overall safety but isn’t a fall-risk screening tool. The Mini-Mental State Exam screens cognitive function, which can influence fall risk, but it isn’t the standard tool used specifically to identify fall risk at admission.