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Based on medical record review, document review and interview, in seven (7) of 12 incident reports of falls reviewed, it was determined the facility failed to identify, analyze and formulate effective corrective actions to minimize the risks of falls and injury to each patient. This was evident in Medical Records (MR) #s 1, 2, 3, 4, 5, 6 and 7.

These failures placed patients at risks for harm and serious injury.

Findings include:

The facility failed to conduct a complete investigation and analyses of each patient fall.
See detailed findings at A 286.


The facility failed to implement corrective actions that were effective in reducing falls and injuries to each patient.
See detailed findings at A 286.

The governing body was not effective in its role to ensure each fall is fully investigated and analyzed, and that effective corrective actions have been taken to reduce the number of falls and injuries at its facility.
See detailed findings at A 308.

Based on medical record review, document review and interview, it was determined the hospital did not conduct a complete investigation of each fall and did not identify all areas for improvement in order to minimize recurrence of falls and injuries. This was evident in MR #1 and incidents #s 2, 3, 4, 5, 6 and 7.

Findings include:

The facility "Clinical Quality and Patient Safety Performance Improvement Plan," 2022, states, the "strategy of the Mount Sinai Health System will: Examine trends in patient safety events and identify opportunities for improvement."

The policy titled "Serious Adverse Event Investigation," last reviewed April 2021 states, "the objective of huddles is to determine what happened, occurs immediately after the event, involves the staff directly involved with the event, and led by the most senior local staff member. A debrief occurs thereafter, which further clarifies the timeline of the event and assesses ongoing safety risks."

1. Review of MR #1 revealed: this elderly patient presented to the facility on 8/12/2022 at 8:25 AM after he had fallen in his home that morning, and had signs of a stroke. The neurologist documented at 8:32 AM that after a shower that morning the patient "felt dizzy, lost his balance and fell over onto a pile of linen that morning...The primary diagnoses were Lacunar Stroke Syndrome and Internuclear Ophthalmoplegia.
A Registered Nurse (RN) note revealed, at 7:32 PM on 8/12/22, "patient observed lying on the floor in the bathroom. At the time when the patient was assessed the patient was able to state his name and no visible injury noted. After the patient was assisted back to bed with assistance of four (4) staff, he became unresponsive."

Review of the facility "SafetyNet Incident" form, "last updated" 11/17/22, stated the "patient complained of headache and the nurse went out to message the MD. After a while the other nurse found the patient lying in the bathroom floor. At the time the patient was responsive, after 5 minutes, patient loss level of consciousness (LOC) and Rapid Response Team (RRT) called." The incident time was noted as 7:50 PM on 8/12/22.


The facility's SafetyNet Incident form documents the huddle, and the following were identified:

a. The details of the fall were not documented in the incident form.
b. No root cause analysis was done because according to the incident investigation, "the patient had a stroke which resulted in loss of consciousness (LOC), not the fall resulting in LOC."
c. There was no documentation of a timeline of the incident as required per the policy titled "Serious Adverse Event Investigation."
d. The Risk Grading/Risk Matric Consequence sections on the incident form were blank.


Review of the facility Incidents, identified:

2. Incident #2: The SafetyNet Incident Form stated at 2:26 AM on 1/5/2023 a "patient had an unwitnessed fall. The patient was found in the Emergency Department (ED) seizing on the floor with + head strike and a laceration."
a. There was no documentation of a "Review of the Outcome."
b. There was no documentation of the "Risk Grading" or "Risk Matrix Consequence."
c. According to the SafetyNet Incident Form, there were no progress notes in the medical record for review of the incident.
d. A huddle was conducted but the "Lessons Learned" and "Actions Taken" sections of the form were blank.
e. There was no documentation of a timeline as required by its policy.


3. Incident #3: The SafetyNet Incident Form stated: On 6/8/22 at 6:40 AM a "Patient was on the toilet and was trying to defecate. As per patient he was straining and fell forward onto the floor, hitting his head. The PCA who was in the room at the time heard the fall." The patient sustained a wound which was later sutured.
a. There was no documentation on the incident form of a "Review of the Outcome."
b. There was no documentation of the "Risk Grading" or "Risk Matrix Consequence."
c. The section for "Review Progress Notes" states, there were "no progress notes."


4. Incident #4: The SafetyNet Incident Form stated: On 12/20/22 at 2:00 PM, a patient in the ED "arrived by ambulance, stated she drank the previous day, felt anxiety today and took 4 tabs of her prescribed medication winch is more than usual. The patient was ambulatory in the ED and placed in a hallway stretcher with one siderail up and waiting to be evaluated. Writer was passing by when the patient rolled off the stretcher having a seizure like activity. Sustained hematoma and laceration to right forehead." The fall assessment was not completed.
a. There was no documented " Review of the Outcome, Lessons Learned, or "Risk Grading/Risk Matrix Consequence (likelihood of recurrence)."
b. There was no documentation of the analysis of the fall on the Safety/Net Incident form.


5. Incident #5: The SafetyNet Incident Form stated: On 1/05/2023 at 10:00 PM this patient with a fall score of 95 (high risk), "was confused and pacing around, and she went to the bathroom suddenly and slip there unwitnessed" according to the SafetyNet Incident Form. The form also noted there was a post-fall huddle and that there was a "constant observation order active at the time of fall; however, day-shift RN reportedly discontinued the PCA from the assignment."
a. The details of the level and severity of harm (laceration) was not clearly specified.
b. There was no discussion or analysis to determine the cause of the fall or to identify areas for improvement.

Similar findings were noted in Incident #6: On 6/6/22, a patient with a high risk for fall was found unresponsive on the floor and Incident #7: On 1/2/2023, patient had a witnessed fall while seizing and sustained bleeding from a swelling on his head and a laceration.

There was no documentation on the SafetyNet Incident Forms of "Lessons Learned" or analysis documented in the huddles; no documented risk grading to identify the risk of recurrence or no documentation of any actions taken to reduce the number of falls with injuries.

There was no documentation on the SafetyNet Incident forms that all of the Morse Fall Scores were analyzed for appropriateness of assessment. There was no documentation in the incident form and committee's meeting minutes of precautions that were followed. There was no documentation of lessons learned in the committees meeting minutes.

There was no documentation in the Nursing Leadership Committee Meeting Minutes or QPIC [Quality Performance Improvement Committee] Meeting Minutes of analysis, tracking, trending of falls.


During an interview on 1/25/23 at 1:00 PM, the Chief Nursing Officer stated the facility had implemented five (5) new interventions in December 2022 to reduce the number of falls.
A review of facility data for falls indicated, in January 2023, there were nine (9) documented falls in the first 14 days of the month.

There was no documentation in any of the Nursing Leadership Committee Meeting Minutes that these five (5) interventions were implemented.

These findings were shared with Staff A, Chief Nursing Officer, on 1/19/2023 at 3:30 PM.

Based on medical record review, document review and interview, in seven (7) of 12 incidents of falls reviewed, it was determined the Governing Body failed to ensure (a) Nursing Leadership Committee developed and implemented a quality assurance plan to fully investigate and analyze falls, and (b) effective corrective actions have been implemented to reduce the number of falls and injuries at its facility.

Findings include:

Review of the Quality Assurance Plan titled "2022 Clinical Quality and Patient Safety Performance Improvement Plan," states "the goals, objectives and scope of the Clinical Quality and Patient Safety Performance Improvement Plan are supported and approved by the Board of Trustees. The Clinical Quality and Patient Safety Performance Improvement Plan builds upon the strategic initiatives of the hospital that are designed to achieve excellence in the delivery of patient care."

Review of the facility's falls data in comparison to National Database for Nursing Quality Indicators (NDNQI) revealed, the facility did not meet the national average of falls for each quarter from Q4 2020, to Q3 2022. For example:

Q4 2020: NDNQI data for falls 2.33 - hospital rate for falls 2.65
Q2 2021: NDNQI data for falls 2.13 - hospital rate 2.64
Q2 2022: NDNQI data for falls 2.27 - hospital rate 3.01
Q3 2022: NDNQI data for falls 2.23 - hospital rate 2.27
The data for Q4 2022 is not available at this time.


During an interview conducted on 1/19/2023 at 11:30 AM, Staff C, Vice President of Quality stated; the Nursing Leadership Committee meets every month and discusses nursing indicators, including falls. The Nursing Leadership Committee reports to the Quality Performance Improvement Committee (QPIC) only once per year, in the month of April, even though the QPIC meets every month.

Review of the Nursing Leadership Committee Meeting Minutes for the year 2022, revealed the committee met 11 times during 2022. The minutes indicate the leadership collects data and track the falls for each unit, however, there was no documentation of analysis of each fall with injuries, no documentation of analysis of the trends of the falls or areas for improvement.


Review of the Governing Body Minutes for the year 2022, revealed there was no documentation of discussion or analysis of fall with injuries, or analysis of the falls data collected at the facility.
There was no documentation of discussion of any action taken to address the high level of falls or the injuries that occured as a result of falls at any of the committee meetings.

These findings were shared with Staff A, Chief Nursing Officer on 1/25/2023 at 3:00 PM.

Based on medical record review, document review and interview, in two (2) of 18 medical records reviewed, it was determined the nursing staff failed to (a) perform an accurate fall assessment of each patient and (b) formulate and implement a nursing care plan based on the patient needs, to prevent patients from falls and injuries. This was evident in MR #1 and #2.

These failures placed each patient at risk for harm and serious injury.

Findings include:

The nursing staff failed to perform an accurate fall assessment as per the facility's policy for an elderly patient.
See detailed findings at A 395.

The nursing staff failed to formulate and implement a nursing care plan based on the patient's needs to ensure the safety and well-being of each patient.
See detailed findings at A 396.

Based on medical record review, document review and interview, in one (1) of 18 medical records reviewed, it was determined the nursing staff failed to (a) accurately perform a patient fall risk assessment as per facility policy and (b) monitor a patient who was on bedrest. This failure contributed to a patient's fall. This was evident for MR #1.

Findings include:

The policy titled "Falls Prevention and Injury Reduction in the Inpatient Adult", which was last reviewed 9/2022 states, "It is the responsibility of the registered nurse to identify patients at risk for falls and falls with injury, and to identify and implement interventions for prevention." The policy also states "adult patients will be assessed for fall risk upon admission to inpatient unit/service and assessed each shift. The enhanced fall algorithm (EFA) which contains the Morse Fall Risk Screen is used in combination with a nursing falls assessment to identify key risk factors (ABCS) that place a patient for fall with an injury."

Review of MR #1 revealed this 79-year-old patient presented to the Emergency Department (ED) on 8/12/2022 at 8:25 AM with complaints of acute onset of double/blurred vision and slurred speech which started at 7:00 AM that morning when he was in the bathroom in his home. The patient also experienced generalized weakness and fell on a pile of clothing. The patient denied head injury, palpitations or loss of consciousness.
The patient had a previous medical history of Benign Prostate Hypertrophy, Diverticulitis, Anxiety and Depression.

On arrival to the hospital, the patient had double/blurred vision and minor speech deficits. The ED provider documented at 8:47 AM that the patient was alert and oriented x 3, with no sensory or motor deficits. The primary diagnoses were Lacunar Stroke Syndrome and Internuclear Ophthalmoplegia. The following sequence of events were noted in the medical record for 8/12/2022.

11:51 AM a doctor wrote an order for "Bedrest and Fall Precautions."
11:59 AM RN documentation the patient refused to use bedside commode. The patient requested to ambulate with assistance. Patient was unable to use the bathroom independently.
1:17 PM the patient arrived on the inpatient floor.
4:33 PM a registered nurse (RN) documented the Morse Fall assessment score of 35: (considered to be at moderate risk of falling). The following elements were documented as follows:
-Moderate risk for fall with a history of falls - no (no = 0) [ yes would be 25 points]
-Comorbidities - no (no= 0) [yes would be 15 points)
- Heplock 20, mental status (forgets limitations) - no (no=0) [yes =15].


RN documented that at "7:32 PM the patient was alert and oriented to person, place and time. Complained of headache and asked for Tylenol, the nurse left the room to message MD. After 5-10 minutes the patient observed lying on the floor in the bathroom. At the time when the patient was assessed the patient was able to state his name and no visible injury noted. After the patient was assisted back to bed with assistance of four (4) staff he became unresponsive. Rapid Response Team was activated (7:48 PM) and stroke team called (at 7:56 PM)."

8:10 PM, RN Morse Fall Risk Screen assessment, fall score = 70.

During an interview conducted on 1/19/2023 at 2:37 PM, Patient Care Associate (PCA) stated when the patient arrived on the floor the patient was "off balance but he kept saying he was okay. The patient seemed agitated when he came to the floor." Staff B, Patient Care Associate also stated that she told the patient's nurse that the patient may need a one-to-one monitoring and the nurse replied that she was going to inform the doctor."

The patient's primary nurse who conducted the fall assessment is a traveler nurse who no longer works at this facility and she could not be interviewed.

The nursing staff failed to accurately assess the patient to be at a high risk for fall with injury upon admission to the unit, to implement the applicable high fall risk protocols to reduce the risk.
The nursing staff failed to ensure monitoring a patient who was on bedrest.

These findings were shared with Staff A, the Chief Nursing Officer on 1/19/2023 at 3:30 PM.

Based on medical record review, document review and interview, in two (2) of 18 medical records reviewed, it was determined the nursing staff (a) failed to implement the facility's policy and develop a patient care plan as soon possible but no longer than 24 hours after admission and (b) failed to follow the physician's order for constant observation This was identified in MR #1 and #2.

Findings including:

The policy titled "Care Plan, Nursing", which was last reviewed 8/20 states, "the Registered Nurse will: 1. Initiate care planning in conjunction with the Admission Assessment at the time of patient assessment and develop a Patient Care Plan as soon as possible but no longer than 24 hours post admission. 2. Delegate specific and appropriate components of the implementation of the care plan to the LPN/PCA, consistent with the policies of the Department of Patient Care Services, job description and the assessed competency of the staff member. 3. Update the care plan throughout the patient's hospitalization. Care plans will be reviewed daily."

1. Review of Medical Record (MR) #1 identified this 79- year-old patient presented to the Emergency Department on 8/12/2022 at 8:25 AM with acute onset of double/blurred vision and slurred speech which started at 7:00 AM that morning when he was in his bathroom. He also experienced generalized weakness and fell on a pile of clothing. On arrival to the hospital, he had double/blurred vision and minor speech deficits.
The following sequence of events were noted on 8/12/22:

At 11:51 AM a doctor wrote an order for "Bedrest and Fall Precautions."
At 11:59 AM RN documented the patient refused to use bedside commode. The patient requested to ambulate with assistance. The patient was unable to use the bathroom independently.
At 1:17 PM the patient arrived on the inpatient floor.
At 4:33 PM RN documented the Morse Fall assessment score of 35: (considered to be at moderate risk of falling)
At 7:32 PM RN documented the "patient was alert and oriented to person, place and time. The patient complained of headache and asked for Tylenol, the nurse left the room to message MD. After 5-10 minutes the patient observed lying on the floor in the bathroom. At the time when the patient was assessed the patient was able to state his name and no visible injury noted. After the patient was assisted back to bed with assistance of four (4) staff he became unresponsive. Rapid Response Team activated (7:48 PM), stroke team called (at 7:56 PM) and the patient was intubated and attached to a ventilator then transferred to CT-Scan and then MICU.
8:10 PM, RN Morse Fall Risk Screen assessment, fall score = 70.

There was no documented evidence in the medical record that a Nursing Care Plan was formulated or implemented to minimize the patient's high risks of a fall until 8/20/2022, eight (8) days after the patient's arrival at the facility.


2. This 90-year-old patient was triaged at the facility on 1/3/23 at 6:13 PM because she had not eaten in three (3) days. The ED doctor documented at 9:15 PM that the "patient had been left home alone after her husband went to a rehabilitation facility after his admission to a hospital before Christmas. The patient was brought to the hospital for placement but on arrival was found to be Hyponatremia and was asymptomatic COVID-19 +.
The patient's previous medical history included Dementia, Hypertension, Diabetes Mellitus, Meniere's Disease, Poor Balance, Peripheral Vascular Disease and Bilateral Cataract Extraction. The patient was oriented to self and person but was otherwise confused.
The patient stated to the social worker that she wanted to kill herself so 1:1 was ordered."

The doctor wrote an order for 1:1 constant observation on 1/3/2023 at 9:09 PM.

The psychiatrist documented on 1/4/23 at 9:53 AM and on 1/5/23 at noon, the patient had "fallen multiple times, most recently in the streets. The patient had visual hallucinations at home and in the hospital. The patient would benefit from observation for high fall risk."

On 1/5/23 8:00 PM, RN Morse Fall Risk Screen assessment, fall score = 95

On 1/5/23 at 12:24 AM, the RN's documentation on the patient care plan noted a problem for the patient's safety and that the patient's goal was "the patient will remain free from falls." This plan includes increase observation and surveillance and seven (7) other interventions.

Review of the facility's SafetyNet Incident form indicated, on 1/05/2023 at 10:00 PM, the patient "was confused and pacing around, and she went to the bathroom suddenly and slip there unwitnessed."
The form also noted there was a post-fall huddle and that there was a "constant observation order active at the time of fall; however, day-shift RN reportedly discontinued the PCA from the assignment."

A doctor documented at 11:19 PM on 1/5/23 that the patient had fallen and sustained a hematoma, abrasion/superficial laceration, swelling and blood on the scalp (right parietal area) and pain in her lower back and right hip since the fall.

The nursing staff failed to follow the physician's order for constant observation of the patient to reduce the risk of a fall and injury.

These findings were shared with Staff A, the Chief Nursing Officer on 1/19/2023 at 3:30 PM.