HospitalInspections.org

This Standard is not met as evidenced by:
Based on interviews, observations, and review of records

1) That an ongoing program for quality improvement and patient safety,
including the reduction of medical errors, is defined, implemented, and maintained .
(2) That the hospital-wide quality assessment and performance improvement efforts
address priorities for improved quality of care and patient safety and that all
improvement actions are evaluated.
(5) That the determination of the number of distinct improvement projects
is conducted annually

Findings include:
Interview with the Chief Nursing Officer 12/31/2024 415 PM
The issues of the Wound Care area has been discussed in the past. I don't remember any specific plans
in the past though the present leadership is looking at changes.

Interview with Plant Operations Manager 12/31/2024 interviews completed between 10:50 AM and 4:45 PM
Plant Operations maintains monitoring of the Wound Care area, we monitor the negative air,
we monitor the exhaust system to keep the humidity level low. We are waiting until January to
get contractors in to get estimates for repair and asbestos removal, my staff can then start to work on mold.
We do not have a written plan at this time.

Interview with the Director of Clinical Quality 12/31/2024 11: AM who indicated she had
only been made aware of the issues regarding Life Safety after the survey completed
in May of 2024. She stated that she had not really understood or been involved in the
process.

The minutes from the Performance Improvement (Quality Council) Committee meeting
dated August 2024 under Section VI Regulatory & Compliance Life safety: findings in wound care
area; report received-response sent - Action Plan includes weekly rounding of the area for safety and
proposal sent to Steward corporate.

Performance Improvement Committee Minutes dated September 26, 2024 at 1:00 PM
Section VI. Regulatory Compliance Regulatory Visits
AHCA on site visit on 5/23/2024- Response sent on 8/12/2024
Environmental Operations Committee (EOC) rounds conducted weekly from a safety perspective. No issues to report
during rounds. Any findings will be reported to EOC committee.

AHCA onsite visit on 9/06/2024 Life Safety Survey Follow Up
Final: Report Received on 10/23/2024

Review of the Medical Oversite Committee Minutes (MOC) date October 9, 2024
Section VI Regulatory & Compliance
AHCA onsite visit on 5/13/2024 ...Life Safety: findings in wound care area, report received-response sent.

PowerPoint presentation from August 22 2024
Section Environment of Care - Wound Care Center Updates
7/23/2024 - Vendor proposal submitted to Stewart corporate-Approval pending
Weekly rounds continue to identify containment issues-none identified at this time.
Area will continue to be monitored by plant operations team and any issues found
during rounding will be reported via the Environment of Care meeting (EOC)

Observations of the Wound care area on the second floor 12/31/2024 3:00 to 345 PM

The double doors, closed have signs indicating No Exit on the wall atop the door and on the right had door.
Both doors have signage saying Closed. Once past the front door the area has an Isolation barrier that is
zipped down, an air monitor is on the right hand wall monitoring the air quality. Next is another door to go
through. You are then in an area which to the left shows where some work was previously done to remove
walls. Going forward to see the intact walls with black mold down the hallway and in the rooms. In several
rooms there are exhaust fans sealed to the walls to keep the moisture level down in the are., there are fire
extinguishers in their cases and the fuses boxes and connections are in locked installations on the walls.

Down the hallway to the end of the hall where the initial leak occurred there is black mold on all the walls..
The asbestos tiles are still in a lot of the ceiling.. Going into the area that has been gutted there is an office area
that is full of unused sealed mattress that will be disposed of according to the Plant Manager when a plan is made.

This Standard is not met as evidenced by:
Based on interviews, observations, and review of records

1) That an ongoing program for quality improvement and patient safety,
including the reduction of medical errors, is defined, implemented, and maintained .
(2) That the hospital-wide quality assessment and performance improvement efforts
address priorities for improved quality of care and patient safety and that all
improvement actions are evaluated.
(5) That the determination of the number of distinct improvement projects
is conducted annually

Findings include:
Interview with the Chief Nursing Officer 12/31/2024 415 PM
The issues of the Wound Care area has been discussed in the past. I don't remember any specific plans
in the past though the present leadership is looking at changes.

Interview with Plant Operations Manager 12/31/2024 interviews completed between 10:50 AM and 4:45 PM
Plant Operations maintains monitoring of the Wound Care area, we monitor the negative air,
we monitor the exhaust system to keep the humidity level low. We are waiting until January to
get contractors in to get estimates for repair and asbestos removal, my staff can then start to work on mold.
We do not have a written plan at this time.

Interview with the Director of Clinical Quality 12/31/2024 11: AM who indicated she had
only been made aware of the issues regarding Life Safety after the survey completed
in May of 2024. She stated that she had not really understood or been involved in the
process.

The minutes from the Performance Improvement (Quality Council) Committee meeting
dated August 2024 under Section VI Regulatory & Compliance Life safety: findings in wound care
area; report received-response sent - Action Plan includes weekly rounding of the area for safety and
proposal sent to Steward corporate.

Performance Improvement Committee Minutes dated September 26, 2024 at 1:00 PM
Section VI. Regulatory Compliance Regulatory Visits
AHCA on site visit on 5/23/2024- Response sent on 8/12/2024
Environmental Operations Committee (EOC) rounds conducted weekly from a safety perspective. No issues to report
during rounds. Any findings will be reported to EOC committee.

AHCA onsite visit on 9/06/2024 Life Safety Survey Follow Up
Final: Report Received on 10/23/2024

Review of the Medical Oversite Committee Minutes (MOC) date October 9, 2024
Section VI Regulatory & Compliance
AHCA onsite visit on 5/13/2024 ...Life Safety: findings in wound care area, report received-response sent.

PowerPoint presentation from August 22 2024
Section Environment of Care - Wound Care Center Updates
7/23/2024 - Vendor proposal submitted to Stewart corporate-Approval pending
Weekly rounds continue to identify containment issues-none identified at this time.
Area will continue to be monitored by plant operations team and any issues found
during rounding will be reported via the Environment of Care meeting (EOC)

Observations of the Wound care area on the second floor 12/31/2024 3:00 to 345 PM

The double doors, closed have signs indicating No Exit on the wall atop the door and on the right had door.
Both doors have signage saying Closed. Once past the front door the area has an Isolation barrier that is
zipped down, an air monitor is on the right hand wall monitoring the air quality. Next is another door to go
through. You are then in an area which to the left shows where some work was previously done to remove
walls. Going forward to see the intact walls with black mold down the hallway and in the rooms. In several
rooms there are exhaust fans sealed to the walls to keep the moisture level down in the are., there are fire
extinguishers in their cases and the fuses boxes and connections are in locked installations on the walls.

Down the hallway to the end of the hall where the initial leak occurred there is black mold on all the walls..
The asbestos tiles are still in a lot of the ceiling.. Going into the area that has been gutted there is an office area
that is full of unused sealed mattress that will be disposed of according to the Plant Manager when a plan is made.