Based on Hendrich II Fall Risk Tool, what is your assessment to Mario Super? What is his score?

Scenario 5
Mario Super, 34 y/o male is admitted to surgical step down unit after having a radical prostatectomy procedure. He has history of prostate cancer, HTN and seizure disorder and is maintenance of Leviteracetam 500mgs po twice a day. He is awake, alert x4 and moves all his extremities. He is on morphine PCA for pain management, he has nasal cannula at 2 liters per minute and ETCo2 (end-tidal Co2) monitoring. Also, he has a foley catheter with blood -tinged urine output noted with 40-50 mls every hour. He has his family visiting during your rounds and asked you if it is okay for him to walk around the unit later when his family leaves.
Based on Hendrich II Fall Risk Tool, what is your assessment to Mario Super? What is his score?

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