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Evidence-Based Practices for Conducting Effective Fall Risk Assessments

Written by: Michael Fragala, PhD, MBA, RN, WCC, CSPHP, AMS

Falls are a leading cause of injury in skilled nursing facilities, resulting in severe consequences for patients, including disability, chronic pain, reduced quality of life, and even death. Skilled nursing facilities also face severe consequences from patient falls, potentially impacting staff satisfaction and facility reputation and decreasing reimbursements, fines, and even litigation.

To ensure a safe environment for residents and staff, skilled nursing facilities should use evidence-based fall risk assessments to identify the fall risk of each patient. A consistent, evidence-based assessment tool allows nursing leaders to reduce fall risks, avoiding the many potential downsides falls can create.

5 Evidence-Based Fall Risk Assessment Strategies

Fall risk assessments must be evidence-based, using clinically-validated methods that are well-established. There are many different proven assessment tools that can be used to reduce the risk of falls. Which one a skilled nursing facility uses will depend on the unique needs of that facility.

Morse Fall Scale (MFS)

The Morse Fall Scale (MFS) is a fall risk assessment tool used to evaluate and monitor a patient’s fall risk. It can be used on both hospitalized and ambulatory patients. It consists of six items that measure the patient’s history of falling, secondary diagnoses, use of ambulatory aids, IV access, gait, and mental status.

The MFS has been proven to be a reliable and valid predictor of the likelihood of falls in hospitalized patients. It is also helpful in determining the most appropriate interventions for preventing falls and assessing the need for fall-related interventions. The score obtained from the MFS can help healthcare professionals identify patients at risk for falls to provide appropriate care.

STRATIFY Risk Assessment Tool

The STRATIFY Risk Assessment Tool is widely used in healthcare to identify patients at risk for falls. It is a reliable, validated tool that helps nurses determine which patients are at high risk of falling and proactively implement fall prevention interventions.

The STRATIFY Tool evaluates five risk factors, including the patient’s history of falls, cognitive function, visual impairment, toileting frequency, and mobility. It assesses patient fall risk and has been associated with a reduction in fall rates and outcomes, making it a commonly-use fall prevention assessment tool.

Timed Up and Go (TUG) Test

The Timed Up and Go (TUG) test is a commonly used assessment tool for measuring a person’s mobility and risk of falls. The test involves asking a person to stand up from a chair, walk a distance of three meters, turn around, walk back to the chair, and sit down again. The time it takes the person to complete this task and any observations about the patient’s gait and stability are recorded.

The results of the TUG test can provide valuable information for healthcare professionals working with older adults or those with mobility issues. It can identify those at risk of falls and indicate if further evaluation or interventions are needed to improve their safety and independence.

Berg Balance Scale

The Berg Balance Scale is another commonly used clinical tool for assessing older adults’ balance abilities. It consists of 14 tasks requiring an individual to maintain varying degrees of balance while performing everyday movements such as standing, turning, and reaching.

The scale is graded on a four-point rating system, with scores ranging from 0 (unable to perform) to 4 (able to complete the task independently and safely). This reliable and valid assessment tool helps nurses and other clinicians identify balance deficits, develop targeted treatment plans, and track progress over time.

Tinetti Assessment Tool

Another fall risk assessment tool commonly used to evaluate the risk of falls for older adults is the Tinetti Assessment Tool. This tool assesses a person’s gait, balance, and other essential factors to identify their likelihood of falling.

The Tinetti Assessment Tool is easy to administer and takes only a few minutes to perform. It is also quite reliable, with high interrater and test-retest reliability scores. The information gathered from this tool can help staff develop a prevention plan and minimize a patient’s risk of falling.


Using a practical, evidence-based fall risk assessment tool to assess fall risks is crucial for promoting safety for the vulnerable patients that skilled nursing facilities serve. By choosing and implementing the evidence-based tool that best meets the need of their facilities, nursing leaders can help prevent falls and reduce the risk of injury. Joerns is committed to supporting nursing leaders in their fall-prevention efforts by providing state-of-the-art equipment that ensures patient safety during transfers. Contact us today to learn more!

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