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Based on document review and staff interview, it was determined that the facility failed to have a governing body that is responsible for the conduct of the hospital.

Findings include:

1. A certificate of need agreement with the New Jersey Department of Health (NJDOH) was approved with conditions on 12/15/17.

a. The transfer of ownership of the facility took place in January of 2018.

b. The certificate of need approval had a condition that required the new owner of the facility to establish a governing board within 60 days of the transfer of ownership.

2. On 11/30/18, upon request to Staff #1, the facility was unable to provide evidence of a sworn in governing board.

a. On 12/3/18, Staff #1 indicated that prospective members of the governing body met on 12/2/18. However, there was a lack of evidence that the identified members were appointed at that meeting.

b. On 12/6/18, the facility provided documentation of a meeting that took place on 12/5/18. The identified members of the governing body were sworn in at this meeting and, subsequently, the governing body bylaws were approved.

c. An organizational chart from January 2018 was provided by Staff #1 and Staff #8 on 12/5/18. The chart noted that all committees would report to Staff #7, identified as chairman of the board. Staff #1 and Staff #8 confirmed that Staff #7 was identified as the chairman of the board.

(i) Upon request, the facility was unable to provide evidence of an appointment of Staff #7 as the chairman of the board.

d. A second organizational chart, dated 11/30/18, was provided that indicated that all committees would report to a governing board.

3. During a review of facility documentation, it was determined that on 2/1/18 a quote was obtained to fix the malfunctioning damper valves in the HVAC (Heat, Ventilation, Air-Conditioning) system. During a staff interview on 11/29/18 at 1:30 PM, Staff #6 confirmed that no action had taken place to correct the malfunctioning damper valves.

4. Staff #1 confirmed on 11/30/18 that a governing body was not in place to provide oversight of the facility.

5. On 12/6/18, Staff #1 confirmed that the governing body members were sworn in on 12/5/18.

6. The facility failed to ensure there was a governing body in place to appoint members of the medical staff. (Cross refer to Tag A 046)

7. The facility failed to ensure there was a governing body in place to approve the medical staff bylaws. (Cross refer to Tag A 048)

8. The facility failed to ensure that requirements for emergency services were met. (Cross refer to Tag A 092)

Based on document review and staff interview, it was determined that there failed to be a governing body to appoint members of the medical staff.

Findings include:

1. On 11/30/18, upon request to Staff #1, the facility was unable to provide evidence of a sworn in governing board.

a. The facility had a change in ownership in January of 2018.

b. The facility failed to provide documentation of any governing body meeting minutes.

2. The facility provided evidence of credentialing committee meetings and medical executive committee meetings that discussed recommendations for credentialing and privileges within the facility.

a. An interview with Staff #1 revealed that both the credentialing committee and the medical executive committee report to the governing board.

3. On 12/4/18 and 12/5/18, the personnel files of Staff #8, Staff #17, Staff #18, Staff #19, and Staff #20 were reviewed.

a. In 3 out of 5 physician files reviewed, Staff #18, Staff #19, Staff #20, it was revealed that medical staff appointment letters were signed on behalf of the governing board by facility staff that were not identified as members of the facility's proposed governing board.

b. In 5 out of 5 physician files reviewed, Staff #8, Staff #17, Staff #18, Staff #19, and Staff #20, it was revealed that a governing board was not in place at the time of appointment and/or reappointment to the medical staff.

c. In 1 out of 5 physician files reviewed, Staff #8, it was identified that a recommendation for medical staff appointment was signed by a facility staff member that was not an identified governing board member, and the signature was not dated.

d. In 1 out of 5 physician files reviewed, Staff #8, it was identified that on 6/15/18, an appointment as provisional staff to the Department of Emergency Medicine was made on behalf of the governing board and was signed by Staff #7, noted chairman of the board.

(i) The facility was unable to provide evidence of an appointment of Staff #7 as chairman of the board.

(ii) There was no governing board in place at the time the appointment letter was dated.

4. The facility lacked evidence that a governing board approved the appointments of the medical staff prior to 12/5/18.

5. The above findings were confirmed with Staff #1 and Staff #8.

Based on document review and staff interview, it was determined that the facility failed to ensure that medical staff bylaws were approved by the governing body.

Findings include:

1. On 11/30/18, a copy of the facility's medical staff bylaws were provided by Staff #1.

a. The last page of the medical bylaws noted, "...President of Medical Staff and Governing Board, Chairman [Facility Name] Recommendation and Approval:..."

(i) There was no printed name or signature of the president of the medical staff or the governing board chairman to identify the persons responsible.

(ii) There was no date noted after the recommendation and approval.

b. The bylaws were noted "...Effective: 1/2018".

2. The medical bylaws lacked evidence that they were approved by the facility's governing body.

3. The above findings were confirmed by Staff #1.

A. Based on document review and staff interview, it was determined that the facility failed to ensure a method to provide adequate qualified nursing personnel in the emergency department (ED).

Findings include:

Reference: Policy, "Emergency Department Staffing," indicated, "...Purpose/Rationale: It is the policy of [Facility Name] that there be sufficient medical, nursing and other personnel provided to meet the needs of the patient in the emergency department....."

1. On 11/30/18 at 9:58 AM, an interview with Staff #11 revealed that the ED was staffed daily, as follows:
*3 Registered Nurses (RN) from 7 AM to 7 PM;
*1 RN from 11 AM to 11 PM;
*3 RN from 7 PM to 7 AM;
*1 ED technician from 7 AM to 3 PM;
*1 ED technician from 3 PM to 11 PM;
*1 ED technician from 11 PM to 7 AM.

a. The "Emergency Department Staffing" policy provided failed to specify the staffing guidelines, that were currently in use, identified by Staff #11.

b. Upon request, Staff #11 was unable to provide a staffing policy or protocol that indicated the above guidelines.

2. A review of the daily assignment sheets for the ED from the dates of 11/22/18 to 11/25/18 revealed the following:

a. Staffing levels for the above dates were not in accordance with the verbal guidelines provided by Staff #11.

b. On 11/22/18, the following staffing issues were identified:

(i) The ED had 3 RNs at the beginning of the 7 AM shift. At 11 AM, there should have been 4 RNs reflected on the schedule, but only 3 RNs were noted, indicating a deficit of 1 RN for 11 AM to 7 PM.

(ii) There was no assigned ED technician noted from 3 PM to 11 PM.

c. On 11/23/18, the following staffing issues were identified:

(i) The ED staffing assignment did not a reflect an RN for the 11 AM to 11 PM shift.

(ii) There was no assigned ED technician noted from 3 PM to 11 PM.

d. On 11/24/18, the following staffing issues were identified:

(i) The ED had 3 RNs at the beginning of the 7 AM shift. At 11 AM, there should have been 4 RNs reflected on the schedule, but only 3 RNs were noted, indicating a deficit of 1 RN for 11 AM to 7 PM.

(ii) There should have been 4 RNs reflected at the start of the 7 PM shift reflected on the schedule, but only 3 RNs were noted, indicating a deficit of 1 RN from 7 PM to 11 PM.

(iii) There should have been 3 RNs noted for the 11 PM to 7 AM shift, but only 2 were noted, indicating a deficit of 1 RN for 11 PM to 7 AM.

(iv) There was no assigned ED technician noted for the 7 AM to 3 PM shift and for the 3 PM to 11 PM shift.

e. On 11/25/18, the following staffing issues were identified:

(i) The ED had 3 RNs at the beginning of the 7 AM shift. At 11 AM, there should have been 4 RNs reflected on the schedule, but only 3 RNs were noted, indicating a deficit of 1 RN for from 11 AM to 7 PM.

(ii) There should have been 4 RNs reflected on the schedule for the 7 PM to 11 PM shift, but only 3 were noted, indicating a deficit of 1 RN from 7 PM to 11 PM.

(iii) There was no assigned ED technician for the 3 PM to 11 PM shift.

3. Upon request, Staff #11 was unable to provide evidence of a protocol to ensure adequate nurse staffing based on patient volume and acuity.

B. Based on document review and staff interview, it was determined that the facility failed to ensure ED department policies were evaluated and updated.

Findings include:

1. Upon request, Staff #1 and Staff #11 provided the following policies to guide care and practice in the facility ED: "Suicidal Patients," "Admission and Discharge Patients from the E.D.," "Assessment/Reassessment of Emergency Department Patients," "EMTALA," "Emergency Department Triage Guidelines," and "Emergency Department Staffing".

a. The above policies had an effective date of 1/2018.

b. There was no revised or reviewed dates noted on the above policies.

c. There was no signature or printed name of the person(s) responsible for the approval of the policies.

2. The above findings were confirmed by Staff #1.

Based on observation, document review, and staff interview conducted on 11/29/18, 11/30/18, 12/4/18, and 12/5/18, it was determined that the facility failed to ensure the hospital is maintained for the safety of the patients.

Findings include:

1. The facility failed to ensure the overall hospital environment is maintained for the safety and well-being of patients. (Cross refer to Tag A 701.)

2. The facility failed to comply with the 2012 edition of the National Fire Protection Association's Life Safety Code. (Cross refer to Tag A 710.)

3. The facility failed to ensure proper ventilation and temperatures are maintained throughout patient care areas. (Cross refer to Tag A 726.)

Based on observation, it was determined that the facility failed to ensure the hospital environment is maintained to ensure the well-being of the patients.

Findings include:

1. On 11/30/18 at 11:10 AM in the presence of Staff #6 and Staff #13, dust was found on the top of the ice machine across from Room #355.

2. On 11/30/18 at 11:50 AM, in the Intensive Care Unit in the presence of Staff #6 and Staff #13, doors to Patient Rooms #1, #2, #3, #4, #5, #6, and #14 were chipped and cracked exposing surfaces that cannot be properly cleaned.

Based on observation, document review, and staff interviews, it was determined that the facility failed to ensure compliance with the 2012 Edition of the National Fire Protection Association's Life Safety Code (NFPA 101).

Findings include:

Reference #1: Dayton Oil Filled Heater Model 32MY13, "#2. This heater is hot when in use. . . . Keep combustible material, such as furniture, pillows, bedding, papers, clothes, and curtains at least 3 feet (.09m) from the front of the heater and keep them away from the sides and rear."

Reference #2: The American National Standards Institute/The American Society of Heating, Refrigerating and Air-Conditioning Engineers/American Society for Healthcare Engineering Standard 170-2013. ". . . Patient Room 70-75 Degrees Fahrenheit."

Reference #3: Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING. Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. NFPA 101:19.3.7.1, NFPA 101:19.3.7.2.

1. On 12/4/18 at 1:30 PM in the presence of Staff #6 and Staff #13, doors located on the fourth floor in the means of egress were equipped with magnetic hold devices to restrict ingress and egress from the Labor and Delivery Unit, Postpartum Unit, two (2) Newborn Nursery's, and the Pediatric Unit. The doors to these units unlock by the use of a properly credentialed access card. These locked units lacked the following:

a. A total (complete) smoke detection system throughout the locked space in accordance with NFPA 101:9.6.2.9 or a system to remotely unlock doors at an approved, constantly attended location within the locked space.

b. The building is not protected throughout by an approved supervised automatic sprinkler system in accordance with NFPA 101:19.3.5.1.

(i) During interview, Staff #13 confirmed the building is not protected throughout with an approved supervised sprinkler system.

c. A review of the Fire Alarm Test Report with a completion date of 11/8/18, lacked evidence that magnetic hold close devices were tested to release upon independent activation of the smoke detection system and/or activation of a waterflow switch upon fire sprinkler system activation.

B. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure access-controlled egress locks allow unobstructed egress from the egress side of the door.

Findings include:

1. On 11/30/18 at 3:00 PM in the presence of Staff #6, Staff #13, and Staff #15, one (1) of two (2) exits from the Operating Room Suite was equipped with access-controlled egress lock. The egress side of the door lacked the following:

a. Sensor above the door to automatically unlock the door upon detection of an approaching occupant.

b. Manual release device lacked the following:

(i) Sign reading "PUSH TO EXIT."

(ii) The manual release button releases the magnetic hold device while actively being pressed but immediately relocks the door. This button does not unlock the egress door for a minimum of 30 seconds as required.

c. A review of the Fire Alarm Test Report with a completion date of 11/8/18, lacked evidence that magnetic hold close devices were tested to release upon independent activation of the smoke detection system and/or activation of a waterflow switch upon fire sprinkler system activation.

2. On 12/4/18 at 11:15 AM in the presence of Staff #6 and Staff #13, the exit door near receiving was held closed by magnetic hold devices and lacked any egress hardware or equipment on the egress side of the door to release the locks in an emergency.

a. The egress side of the door lacked the following:

(i) Sensor above the door to automatically unlock the door upon detection of an approaching occupant.

(ii) Manual release device

(iii) Sign reading "PUSH TO EXIT."

(iv) A manual release button that unlocks the egress door for a minimum of 30 seconds.

(v) During interview, Staff #6 confirmed the above items did not exist.

b. A review of the Fire Alarm Test Report with a completion date of 11/8/18, lacked evidence that magnetic hold close devices were tested to release upon independent activation of the smoke detection system and/or activation of a waterflow switch upon fire sprinkler system activation.

3. On 11/30/18 at 11:10 AM in the presence of Staff #1, Staff #6, and Staff #13, the cross-corridor smoke barrier door near Room #361 was locked with a magnetic hold device and lacked the following:

a. Sensor above the door to automatically unlock the door upon detection of an approaching occupant.

b. Manual release device lacked the following:

(i) Sign reading "PUSH TO EXIT."

(ii) A manual release button that unlocks the egress door for a minimum of 30 seconds.

c. A review of the Fire Alarm Test Report with a completion date of 11/8/18, lacked evidence that magnetic hold close devices were tested to release upon independent activation of the smoke detection system and/or activation of a waterflow switch upon fire sprinkler system activation.

4. On 12/4/18 at 11:00 AM in the presence of Staff #6 and Staff #13, the following doors in the exit passage for Stairwell #6 did not self-close and latch:

a. 90-minute fire rated door for the Laboratory failed to close and latch when tested by the surveyor from the fully open position.

b. 90-minute fire rated door for the Facilities Office was held open by a wooden wedge.

5. On 12/4/18 at 11:30 AM in the presence of Staff #6 and Staff #13, the pair of 90-minute fire rated doors for exit passage for Stairwell #5 were disconnected from their self-closure devices and did not self-close and latch.

6. On 12/4/18 at 11:45 AM in the presence of Staff #6 and Staff #13, the pair of 90-minute fire rated cross corridor doors outside the Kitchen were disconnected from their self-closure devices and did not self-close.

7. On 12/5/18 at 11:10 AM in the presence of Staff #6 and Staff #13, the 90-minute fire rated door separating the Kitchen from the Corridor did not self-close.

8. On 12/4/18 at 11:50 AM in the presence of Staff #6 and Staff #13 in the Laboratory, no illumination of the Rear Exit Discharge was provided for non-emergency or emergency use.

9. During a review of Facility Approved Plan # 5179-13 on 12/5/18, the following smoke compartments were identified:

a. 3-North: 22,560 square feet. As per Reference #3, the size of the compartment cannot exceed 22,500 square feet.

b. 4-North: 24,803 square feet. As per Reference #3, the size of the compartment cannot exceed 22,500 square feet.

10. On 11/30/18 at 11:35 AM in the presence of Staff #1 and Staff #6, Intensive Care Unit in-patient sleeping Room #12 lacked a window or door to the outside.

11. On 11/29/18 at 10:36 AM in the presence of Staff #1 and Staff #2, an electric oil filled portable space heater was located in occupied patient sleeping Room #382.

a. During interview, Patient #1 stated, "At night, it gets very cold. I can feel the breeze through the windows. I was very cold, so the staff brought me a space heater."

b. The space heater was located approximately two (2) inches from the patient's mattress and blankets, not "at least 3 feet from the front of the heater...," as indicated in Reference #1.

c. During interview, Staff # 2 confirmed space heaters were being utilized in patient sleeping rooms #330, 382, 385, 388, 391, 394, and 396 while the rooms were occupied.

d. During a review of facility documentation, it was determined on 2/1/18 that a quote was obtained to fix malfunctioning damper valves in the HVAC (Heat, Ventilation, Air-Conditioning) system.

e. During interview on 11/29/18 at 1:30 PM, Staff #6 confirmed that no action had taken place to correct the malfunctioning damper valves.

f. Ambient room temperatures readings were taken by surveyors in rooms not equipped with portable space heaters and found to be below ANSI/ASHRAE/ASHE Standard 170-2013, "...Patient Room 70 - 75 Degrees Fahrenheit." These rooms were as follows:

(i) Room #393: 69 Degrees Fahrenheit

(ii) Room #480: 68.8 Degrees Fahrenheit

(iii) Room #482: 68 Degrees Fahrenheit

g. During an interview on 11/29/18 at 1:30 PM, Staff #2 confirmed that policy and/or procedures had not been developed for the use of space heaters in the facility.

(i) Staff #2 also confirmed that staff had not been educated in the proper use of the space heaters.

h. During an interview on 11/29/18 at 3:00 PM, Staff #5 confirmed the inpatient census to be 38 patients.

(i) During an interview on 11/29/18 at 3:05 PM, Staff #4 confirmed 15 out of 38 inpatients were provided with portable space heaters.

12. On 12/4/18 at 11:00 AM in the presence of Staff #6 and Staff #13, the Exit Passageway was being used for storage which could interfere with the means of egress. The following items were stored in the Exit Passageway for Stairwell #6 which:

a. Two (2) rolling carts with empty biohazard containers,

b. One (1) commercial display style refrigerator,

c. Three (3) rolling trash cans for shredded paper,

d. One (1) empty linen cart,

e. One (1) broken wheel chair,

f. Three (3) Rolling trash carts full of trash.

13. On 12/4/18 at 11:05 AM in the presence of Staff #6 and Staff #13, fourteen (14) boxes were stored inside Stairwell #6 on the first-floor landing.

14. On 12/4/18 at 11:30 AM in the presence of Staff #6 and Staff #13, two (2) wooden and eight (8) metal doors were stored inside Stairwell #5 on the first-floor landing.

Based on observation and staff interviews, it was determined that that the facility failed to ensure proper ventilation and temperatures are maintained throughout patient care areas.

Findings include:

Reference: Dayton Oil Filled Heater Model 32MY13, "#2. This heater is hot when in use. . . . Keep combustible material, such as furniture, pillows, bedding, papers, clothes, and curtains at least 3 feet (.09m) from the front of the heater and keep them away from the sides and rear."

1. On 11/29/18 at 10:36 AM in the presence of Staff #1 and Staff #2, an electric oil filled portable space heater was located in occupied patient sleeping Room #382.

a. During interview, Patient #1 stated, "At night, it gets very cold. I can feel the breeze through the windows. I was very cold, so the staff brought me a space heater."

b. The space heater was located approximately two (2) inches from the patient's mattress and blankets, not "at least 3 feet from the front of the heater...," as indicated in the above reference.

c. During interview, Staff # 2 confirmed space heaters were being utilized in patient sleeping rooms #330, 382, 385, 388, 391, 394, and 396 while the rooms were occupied.

d. During a review of facility documentation, it was determined on 2/1/18 that a quote was obtained to fix malfunctioning damper valves in the HVAC (Heat, Ventilation, Air-Conditioning) system.

e. During interview on 11/29/18 at 1:30 PM, Staff #6 confirmed that no action has taken place to correct the malfunctioning damper valves.

f. Ambient room temperatures readings were taken by surveyors in rooms not equipped with portable space heaters and found to be below ANSI/ASHRAE/ASHE Standard 170-2013, "...Patient Room 70 - 75 Degrees Fahrenheit." These rooms were as follows:

i. Room #393: 69 Degrees Fahrenheit

ii. Room #480: 68.8 Degrees Fahrenheit

iii. Room #482: 68 Degrees Fahrenheit

g. During an interview on 11/29/18 at 1:30 PM, Staff #2 confirmed no policy and/or procedures have been developed for the use of space heaters.

i. Staff #2 also confirmed, staff has not been educated in the proper use of the space heaters.

h. During an interview on 11/29/18 at 3:00 PM, Staff #5 confirmed the inpatient census to be 38 patients.

i. During an interview on 11/29/18 at 3:05 PM, Staff #4 confirmed 15 out of 38 inpatients were provided with portable space heaters.