Objective To explore the practice of multi-level nursing based on fall assessment tools in the inhospital safety management of elderly orthopedic patients. Methods A total of 100 elderly orthopedic patients admitted to Xianyou County General hospital from February 2021 to February 2024 were randomly divided into two groups (1?1 ratio). The control group received routine nursing care, while the observation group received multi-level nursing based on fall assessment tools. The intervention effects of the two groups were compared. Results The overall compliance rate with treatment and getting out of bed in the observation group (96.00%) was significantly higher than that in the control group (82.00%) (P ＜ 0.05). Fourteen days after the intervention and before discharge, the SAFFE scores in the observation group were lower than those in the control group, while joint function scores were higher, and NRS and PSQI scores were lower (P ＜ 0.05). The incidence of adverse events in the observation group (2.00%) was significantly lower than that in the control group (16.00%) (P ＜ 0.05). Conclusions Multi-level nursing based on fall assessment tools demonstrates significant intervention effects in the treatment of elderly orthopedic patients. It can improve patients’ compliance with treatment and activities, improve patients’ mental state and sleep quality, reduce patients, pain during treatment, and minimize adverse events. Further clinical application and promotion are recommended.