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Based upon staff interviews, and review of facility documents, it was determined the Governing Body failed to develop and implement policies and procedures that ensure the Chief Executive Officer is effective at providing a safe physical environment for patients, the public, and staff, in accordance with facility Bylaws.

Findings include:

The facility failed to ensure a functioning governing body was established to maintain oversight of safe operations of the hospital. (Cross Refer to Tag 0057)

Based on staff interviews, and review of facility documents, it was determined the Governing Body failed to develop and implement policies and procedures that maintain a safe physical environment for patients, the public, and staff.

Findings include:

The facility failed to 1) ensure that one (1) of three (3) elevators were maintained to ensure the safety of the patients, visitors, and staff and 2) ensure that safety hazards are reported to the Safety Committee. (Cross Refer to Tag 0701)

Based on staff interview and document review, it was determined the facility failed to ensure a functioning governing body was established to maintain oversight of safe operations of the hospital.

Findings include:

During an interview on 10/17/23 at 10:25 AM, the surveyor asked who the Governing Body was at the Hospital? Staff #1 (S1), the Chief Executive Officer, stated, "There is one Governing Body which oversees all of Kessler's properties. I report to the Main Governing Body." S1 was asked if the elevator maintenance for elevator #2 was reported to the Governing Board, and S1 replied, "No."

On 10/2/23 at 10:00 AM, in the presence of S1 and S2 (Director of Plant Maintenance), maintenance records for the facility's three (3) elevators were reviewed. The maintenance records indicated elevator number two (#2) had uncorrected deficiencies from the last state elevator inspection and lacked a valid Certificate of Compliance by the New Jersey Department of Community Affairs, Division of Codes and Standards, Elevator Safety Unit.

The last state elevator inspection was conducted November 18, 2022 by the New Jersey Department of Community Affairs, Division of Codes and Standards, Elevator Safety Unit. The inspection report stated the following: "Elevator device(s) with items marked Lock Out will remain locked out until the repairs/corrections on items marked Lock Out are satisfactorily completed, the device is re-inspected, and applicable certificate is received. . . .."

The inspection report, dated November 18, 2022, stated the following: "Elevator #2, Citation Code: 1965-A17.1 2.212.9.d, ... Description: Needs rope shortening only 2 inches runby and ropes are rouge indicating wear, Lockout: YES. ..."

During an interview on 10/2/23 at 10:15 AM, the Surveyor asked S2, "Was the elevator ever locked out and were the repairs ever made?" S2 replied, "No, I was unaware that the elevator needed to be locked out. I'm not sure if I was present for the inspection." S2 added, "I'm not sure when I received the inspection report. I was not the Director of Facilities at the time of that elevator inspection."

During an interview on 10/2/23 at 10:18 AM, the Surveyor asked S2 if he/she, or anyone at the facility, was informed that elevator #2 needed to be locked out in November of 2022. S2 replied, "I was not the Director of Facilities at the time of the inspection. I am not aware that anyone was notified."

During an interview on 10/2/23 at 10:20 AM, the Surveyor asked S1, if he/she was notified that elevator #2 needed to be locked out?" S1 replied, "Not sure." This surveyor asked S1 if the November 2022 elevator report, or any elevator reports, were reported to the Governing Body. S1 stated, "no."

Reference: The Kessler Institute For Rehabilitation, Inc. Governing Board By-laws, dated January 2023, stated, "... Page 1, Definitions, ... #4. Governing Board' means the governing body of Kessler Institute for Rehabilitation, Inc. which is responsible for the oversight of the operations of Hospital at the local level. ... 3.4 Members: The following individuals shall serve as ex office Members of the Governing Board by virtue of their Hospital or Medical Staff office, with full voting rights. President of Hospital . ... Vice President, Operations of Inpatient Rehab Division . . . Chief Operating Officer of Hospital ... Chief Medical Officer of Hospital ... Regional Director of Finance ... President of Outpatient Division ... Legal Department Representative ... and Chief Quality Officer, Inpatient Rehab Division ... 3.9 Responsibilities: ... 3.9-27 Ensuring that the Hospital provides a safe physical plant that is equipped and staffed to maintain the facility and services."

Based on staff interviews and document review, it was determined the facility failed to 1) ensure that one (1) of three (3) elevators were maintained to ensure the safety of the patients, visitors, and staff and 2) ensure that safety hazards are reported to the Safety Committe.

Findings include:

1) On 10/2/23 at 10:00 AM, in the presence of Staff #1 (S1), the Chief Executive Officer (CEO), and S2, the Director of Plant Operations (DPO), the maintenance records for the facilities three (3) elevators were reviewed. Elevator number two (#2) was found to have uncorrected deficiencies from the last state elevator inspection and lacked a valid Certificate of Compliance by the New Jersey Department of Community Affairs, Division of Codes and Standards, Elevator Safety Unit.

The last state elevator inspection was conducted November 18, 2022 by the New Jersey Department of Community Affairs, Division of Codes and Standards, Elevator Safety Unit. Elevator #2, also known on the report as "Device ID# 02-2," stated the following: "Elevator device(s) with items marked Lock Out will remain locked out until the repairs/corrections on items marked Lock Out are satisfactory completed, the device is re-inspected, and applicable certificate is received."

The inspection report, dated November 18, 2022, stated the following: "Citation Code: 1965-A17.1 2.212.9.d, ... Description: Needs rope shortening only 2 inches runby and ropes are rouge indicating wear, Lockout: YES."

During an interview on 10/2/23 at 10:15 AM, the Surveyor asked S2, "Was the elevator ever locked out and were the repairs ever made?" S2 replied, "No, I was unaware that the elevator needed to be locked out. I'm not sure if I was present for the inspection." S2 added, "I'm not sure when I received the inspection report."

During an interview on 10/2/23, S1, the CEO, stated that the Director of Plant Operations is responsible for reviewing the elevator inspection reports.

During an interview on 10/2/23 at 10:18 AM, the Surveyor asked S2, the DOP, if the he was informed that elevator #2 needed to be locked out? S2 replied, "I was not the Director of Facilities at the time of the inspection. I was not aware." S2 stated that the Director of Plant Operations, that was present during the November 2022 elevator inspection, is no longer employed by the facility. S2 was unable to confirm if anyone was aware of the November 2022 elevator report, prior to this Surveyor requesting the last elevator inspection report from the current Director of Plant Operations. The facility was unable to provide any evidence that the November 2022 elevator report, indicating the elevator needed repairs and should have been locked out, was reported to anyone.

On 10/2/23 the elevator monthly maintenance reports were reviewed. There was evidence that the elevator contractor conducted "Regular" monthly maintenance on elevator #2 on 1/11/23, 2/23/23, 3/14/23, 4/20/23, 5/25/23, 6/6/23, 7/3/23, 8/24/23, and 9/20/23. There was no evidence that elevator #2 was locked out on these dates or that any repairs were made during these regular monthly servicing's.

On 10/17/23 at 10:45, S2 confirmed that checking for a valid Certificate of Compliance is not part of the routine monthly inspections.

During an interview on 10/17/23 at 10:55 AM, S2 stated, "The current elevator contractor acquired the previous elevator contract. The new elevator contractor continues to provide services under the original contract signed by the previous elevator company."

The Service Contract was reviewed on 10/17/23 at 11:00 AM. The Service Contract for elevator maintenance, dated January 1, 2020, stated the following: "... The Company agrees to monthly service the elevator equipment on the following terms and conditions: Furnish lubricants, lubricate the elevator equipment, examine, adjust, repair, or replace pump motors, pumps, operating valves, belts, plunger packing's, magnet coils, contacts, resistance, rectifiers, shunts and insulators, car door contacts, car door operator components, car guide shoe liners, & control circuit trailing cables. Periodically examine all safety devices. ... The Term of the Agreement shall be one (1) year from January 1, 2020, and shall automatically renew each year. ... " S1 confirmed the contract is valid.

On 10/17/23 at 11:05 AM, S2 stated, "The Elevator Contractor never told me the elevator should be locked out. Never told me there were corrections needed."

2) During an interview on 10/17/23 at 11:45 AM, S1 confirmed the Environment of Care Committee (EOC) did not report on any elevator inspections or deficiencies for the last two quarters.

On 10/17/23 at 11:50 AM, the 2022 Annual Evaluation of the Environment of Care and 2023 Action Plan with a revised date of November 2022 were reviewed. The Action Plan states, "... Organization of the Environment of Care Function, Objective: The EOC committee provides overall oversight to maintain the safety plans of the hospitals to address all elements of safety including the physical environment, security, hazardous material safety, fire safety, safe utilities, and safe medical equipment."

On 10/17/23 at 11:50 AM, a review of the Environment of Care Quarterly Meeting Minutes dated 4/11/23 and 7/20/23, made no mention of the State Elevator Inspection that was conducted November 18, 2022, and the report that was issued November 21, 2022, which indicated Elevator #2 had a deficiency, creating a safety hazard that required the elevator to be locked out.

On 10/2/23 at 10:45 AM, a review of the most recent state elevator inspection conducted November 18, 2022, by the New Jersey Department of Community Affairs, Division of Codes and Standards, Elevator Safety Unit, identified a deficiency to Elevator #2 that required Elevator #2 to be locker out. This inspection report stated, "Elevator device(s) with items marked Lock Out will remain locked out until the repairs/corrections on items marked Lock Out are satisfactorily completed, the device is re-inspected, and applicable certificate is received."

The inspection report of Elevator #2, dated November 18, 2022, stated the following: "Citation Code: 1965-A17.1 2.212.9.d, ... Description: Needs rope shortening only 2 inches runby and ropes are rouge indicating wear, Lockout: YES."

During an interview on 10/2/23 at 10:35 AM, S1, the CEO, stated that on September 28, 2023, the elevator was on the First floor and as the visitor entered the elevator, the elevator began to move upward with the doors open. The visitor fell forward causing his/her legs to protrude out of the elevator door. The visitor's legs became wedged between the elevator and the elevator shaft walls, causing the elevator to become jammed, stopping the upward movement. The visitor was extricated from the elevator by the Fire Department and transported by Emergency Medical Services to the hospital.

During an interview on 10/2/23 at 11:30 AM, S2, the DPO, stated, "The elevator should have been locked out until the repairs were made and a new certificate was received. We don't know when we received the inspection report."

Reference: The Kessler Institute For Rehabilitation, Inc. Governing Board By-laws, dated January 2023, stated, "... Page 1, Definitions, ... #4. Governing Board' means the governing body of Kessler Institute for Rehabilitation, Inc. which is responsible for the oversight of the operations of Hospital at the local level. ... 3.4 Members: The following individuals shall serve as ex office Members of the Governing Board by virtue of their Hospital or Medical Staff office, with full voting rights. President of Hospital . ... Vice President, Operations of Inpatient Rehab Division . . . Chief Operating Officer of Hospital ... Chief Medical Officer of Hospital ... Regional Director of Finance ... President of Outpatient Division ... Legal Department Representative ... and Chief Quality Officer, Inpatient Rehab Division ... 3.9 Responsibilities: ... 3.9-27 Ensuring that the Hospital provides a safe physical plant that is equipped and staffed to maintain the facility and services."