Brookdale Hospital Medical Center

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 36207 Based on observation, staff interview, and document review, the facility failed to maintain a comfortable physical environment for patients. The facility’s failure to maintain appropriate temperatures contributed to patient discomfort and may negatively impact recovery, particularly for medically vulnerable patients. Findings include: The Facility Guidelines Institute (FGI), 2018 Edition, Table 7-1, identifies acceptable temperature ranges as: “Operating/procedure rooms: 68°F - 73°F Patient rooms: 70°F - 75°F Maintaining appropriate temperature and relative humidity (RH) is essential to promote patient comfort, inhibit microbial growth, and reduce the risk of infection.” The facility’s policy, “Temperature Monitoring and Response Policy for Patient Care Areas” (dated 08/2025), states: “Inpatient areas: 68°F - 75°F Emergency Department (ED): 70°F - 75°F.” During a facility tour conducted on 03/10/2026 between 11:00 AM and 1:00 PM (outdoor temperature: 60°F), temperatures were measured using a Fluke 62-Max Infrared Thermometer on the 8th floor, 6th floor, and in the ED. 8th Floor (Psychiatric Units): 8E, Room 13: 77°F 8E Lounge: 76.2°F 8W, Room 11: 76°F 8W, Room 3: 77°F 6th Floor (Rehabilitation/Detox Unit - 6E): Room 609: 85.4°F (table fan in use) Room 619: 84°F (table fan in use) During interview, Staff D (Nurse Manager, 6E) stated that patients requested fans due to excessive heat. These observations were made in the presence of Staff A ( Engineering Leadership)and Staff B (Engineering Staff). Emergency Department: Nurse’s station: 80.4°F Bay 18: 80°F ED Bay 1: A patient stated, “It’s burning up over here.” Portable space heaters were observed in ED Bay 1 and the ambulance bay; however, they were not in use at the time of the observation. On 03/10/2026 at 12:15 PM, Staff K (Medical Resident) stated that portable space heaters are used during the winter months. Review of temperature logs revealed abnormal room temperatures with no permanent resolution. 03/09/2026 (ED): 77°F - corrective action: thermostat adjusted 03/10/2026 (6E): 80°F - corrective action: fans provided 03/10/2026 (ED): 79°F - corrective action: dampers adjusted On 03/11/2026 at 11:30 AM, Staff A stated that the HVAC (Heating, Ventilation, and Air Conditioning) system was operating in heating mode and is scheduled to switch to air conditioning on April 15, 2026. Staff A acknowledged that this seasonal limitation makes it difficult to maintain appropriate temperatures during unseasonably warm or cold days.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 36207 Based on observation, staff interview, and document review, the facility failed to provide a safe physical environment for patients. The use of portable space heaters in patient care areas poses a significant fire safety hazard. Findings include: Review of the National Fire Protection Association (NFPA) 101, 2012 Edition, Section 19.7.8 (Portable Space-Heating Devices) identifies that portable space-heating devices are prohibited in all health care occupancies. During a tour of the facility’s Emergency Department (ED) on 03/10/2026 at approximately 12:30 PM, a portable space-heating unit was observed in ED Bay 1 and another in the ambulance bay. Although the units were not in use at the time of observation (outdoor temperature: 60°F), their presence in patient care areas was noted. On 03/10/2026 at 12:15 PM, Staff K ( Medical resident) stated that portable space heaters are used during the winter months. On 03/11/2026 at 11:30 AM, Staff A (Engineering Leadership) stated that the facility’s HVAC system is outdated and that portable heaters are used to maintain patient comfort during colder conditions.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 28406 . Based on observation, interview, and record review, in one (1) of fifteen (15) medical records (MR) reviewed, the hospital failed to implement the Emergency Department policy for the initial evaluation of obstetrical patients presenting to the ED (Patient #15). Findings: A review of the Emergency Department (ED) Policy titled “Initial evaluation of obstetric patients presenting to the ED and L&D (Labor & Delivery),” effective 10/21, stated, “all stable pregnant patients greater than 16 weeks gestational age who are experiencing a non-life-threatening complaint will be evaluated in Labor and Delivery. If the patient arrives to the ED via ambulance or walk in, she will be assessed by the ED staff. Documentation will be placed in the EMR. A handoff report will be provided by the nurse (in ED) to the nurse (on L&D). Once the patient is evaluated by the provider and stabilized, she will be transferred to L&D. All pregnant patients presenting with a communicable disease will be referred directly to the (Main) ED. The labor and delivery staff will be notified and will be responsible for evaluating the patient in the emergency department. If the patient is in active labor, she will be transferred to a labor room but kept in isolation, and all necessary precautions will be taken. A physician (Resident or Attending) or mid-level provider will examine the patient and determine the disposition of the patient. If it is determined that the patient is in the wrong location (e.g., the patient is in the ED, and it is determined that they should be in L&D, or the patient is in L&D and it is determined that they should be in the ED) the Attending in the present location must call the Attending in the receiving location to discuss the patient and make arrangements for the transfer. After the involved Attendings agrees to the transfer, the nurse in the present location must call the nurse in the receiving location to discuss the patient and make arrangements for the transfer; after all, parties have been notified and agreed, an order is written by the Attending in the present location to transfer the patient. Patient transport is called, and the patient is transferred to the new location.” A review of the Emergency Medical Services (EMS) Pre-Hospital Care (PHC) report dated 8/17/24 at 12:56 AM indicated that Patient #15 requested to be taken to the hospital for respiratory distress. The patient had been positive for COVID-19 for four days and had a history of asthma; the patient was 19 weeks pregnant and denied any associated obstetric complaints. Review of the MR for Patient #15 revealed that the patient presented to the Emergency Department (ED) on 08/17/2024 at 1:09 AM. The Triage Nurse documented at 1:18 AM, “Patient #15 arrived at the ED with a chief complaint of shortness of breath.” The ED Nurse documented that a Physician (ED Attending) examined the patient, including listening to breath sounds, and determined that the patient’s disposition was to L&D. There was no documented evidence that a provider conducted a medical examination, including auscultation of the lungs, and there was no documented evidence in the MR of a written order by the attending physician to transfer the patient to L&D. During the interview on 1/08/25 at 11:40 AM, Staff J (Medical Chair ED) explained that all patients, regardless of gestation, will undergo a medical evaluation because only the physician can give the orders to move a patient to the L&D. In an interview on 1/09/25 at 10:00 AM, Staff E (Attending Main ED) stated, “I did not see this patient or evaluate them because my usual practice is to open the computer and drop the template, and then I go to see the patient and start the H&P (history and physical exam) of the patient ...and because I don’t have anything written that is how I know I didn’t see or evaluate the patient. I don’t know why the nurse wrote that I did see and evaluate the patient when I did not.” The Emergency Department policy titled, “Triage Adult and Pediatric,” effective 5/23/2023, stated that “EMS triage procedures are that the ambulance triage nurse will take a report from 1 crew member while the other crew member presents patient demographic information to the designated registrar at the information desk. Pregnant patients presenting to the ED are evaluated for obstetrical emergencies, and medical evaluation and clearance will be conducted prior to transferring to Labor and Delivery.” The ED Nurse did not implement ED procedures for the immediate isolation and evaluation of a COVID-positive, asthmatic patient presenting with complaints of respiratory distress. Patient #1 MR had an incomplete Triage, and there was no documented evidence on 8/17/24 that the ED Staff screened for recent illness, foreign travel, or sick contacts. As per the interview on 1/9/25 at 10:10 AM, Staff D (Triage Nurse-Main ED) stated, “I remember the patient was here with asthma...and her respiratory complaints were because of her asthma...she didn’t have Covid ...and no one told me she had Covid ...I took her vital signs and I called the doctor over, (Staff H), so he came over and listened to her lungs and he said “she doesn’t have any wheezing send her to L&D.” ...but the patient decided she didn’t want to go to L&D and she left the ED before I could complete triage ...the EMS crew had already left ...I don’t have the authority to tell someone to go to L&D and that is why I needed the doctor to tell me...” Staff D acknowledged that the patient’s triage was incomplete: “I wasn’t told the patient was Covid positive ... the risk assessments and screening questions including recent travel history and contact with others with communicable disease were not asked and addressed and the immediate isolation of the patient wasn’t implemented ...” There is no documented evidence that the Triage Nurse assigned to the Ambulance Bay area of the Main ED called the nurse in the receiving location (L&D) to discuss the patient and make arrangements for their transfer. During an interview on 1/10/25 at 11:00 AM, Staff L (L&D Triage Nurse) stated, “The patient arrived at L&D Unit at about 2:00 AM in a wheelchair with EMS and had a diagnosis of Covid and complaints of difficulty breathing ...I didn’t expect her and no one had called me to tell me she was coming over to us ...so I said she needs to be in the main ED because she doesn’t have any problems or issues with her pregnancy ...the patient got very upset when she heard that and said “no, she wasn’t going back and forth from the ED to L&D and back again to the ED and then she got up and left.” EMS seemed shocked and just stood there after the patient got out of the wheelchair and left...” Interviews with Staff D and Staff L were inconsistent. While Staff D reported that “the patient decided she didn’t want to go to L&D, and she left the ED before I could complete triage, and the EMS crew had already left,” Staff L reported that the patient left L&D in the presence of EMS when they were told to return to the ED for evaluation. On 1/10/25 at 3:15 PM, facility Administration and Leadership (Staff A, [Nursing], B [Quality], and C [Risk], acknowledged these findings.”