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Based on interview, review of facility policies and procedures and review of facility documentation, it has been determined the facility has failed to execute and maintain an emergency preparedness plan based on an all-hazards facility-based and community-based risk assessment. Failure to complete, maintain and regularly update a facility and community based all-hazards risk assessment and then develop and regularly update an emergency preparedness plan to reflect the risks identified within the assessment can result in a facility not being prepared to address the hazards most likely to affect a patient and staff population.

Findings include:

A copy of St. Mary's Hospital Emergency Preparedness Plan and all accompanying documentation and drills for calendar years 2024 and 2025 were requested. "...Carondelet Health Network Emergency Operations Plan...." was provided along with a copy of accompanying HVAs (hazard vulnerability assessments) for calendar years 2024 and 2025. In a series of interviews conducted with Employee #6 on September 8 and on September 9, Employee #6 confirmed that this was St. Mary's Hospital's Emergency Preparedness Plan, and that all documentation had been provided regarding the facility's Plan.

"...Carondelet Health Network Emergency Operations Plan...." indicated: "...See Individual Hospital Hazard Vulnerability Analysis within their Emergency Preparedness binders...The Hospitals have developed appropriate Emergency Response Plans based on highest scored threat on the Hazard Vulnerability Analysis within their Emergency Preparedness binders...."

In an interview conducted with Employee #6 on September 9, 2025, Employee #6 confirmed there were no additional materials for emergency preparedness other than the provided Hazard Vulnerability Assessment and the Carondelet Health Network Emergency Operations Plan.

Although general information was provided regarding hospital response to various disasters, no specific emergency response plans based on the HVAs could be found in the provided material. No emergency preparedness binder as described in the Carondelet Health Network Emergency Operations Plan could be provided.

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Based on interview, review of facility documentation, and observation while on tour, it was determined the facility laboratory contained multiple unsafe conditions, including laboratory hoods that did not pass annual PM (preventative maintenance) checks and were therefore unsafe for use, a safety shower that was filled with boxes and had boxes obstructing the pathway to the safety shower, rendering it difficult or impossible to use if needed, and improper protection for operations requiring the use of pressure above or below ambient conditions, hazardous chemicals, cryogenic fluids and other operations requiring the use of a laboratory hood.

Findings include:

NFPA 101, 2012 Edition, Chapter 19, Section 19.3.2.2. indicated, "Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as severe hazard shall be in accordance with section 8.7 and the provisions of NFPA 99...applicable to administration, maintenance and testing."

Section 8.7.4.1 indicated, "Laboratories that use chemicals shall comply with NFPA 45...."

NFPA 45, 2011 Edition, Chapter 12, Section 12.1.12.1 indicated, "All heating of flammable or combustible liquids shall be conducted so as to minimize fire hazards." Section 12.1.3.1 indicated, "Distillation shall be conducted in equipment designed or fabricated for this use and shall be assembled with consideration being given to fire hazards from vent hazards and possible equipment breakage or failure." 12.1.4 indicated, "Filtrations, extractions, sublimations, adsorptions, evaporations, centrifuging operations, and other separation techniques that involve flammable or combustible materials shall be protected from ignition sources and shall be provided with ventilation that prevents the accumulation of an ignitable concentration of vapors in the work area." Section 12.1.5.1 indicated: "Mixing, grinding, stirring, and agitating operations involving flammable and combustible materials shall require the same precautions against fire as set forth in 12.1.4. Section 12.1.6.1 indicated: "Other laboratory operations, such as reactions at temperatures and pressures either above or below ambient conditions, shall be conducted in a manner that minimizes hazards."

Section 8.2.6 indicated, "The release of chemical vapors into the laboratory shall be controlled by enclosure(s) or captured to prevent any flammable and/or combustible concentrations of vapors from reaching any point of ignition."

During observation while on tour conducted on September 9, 2025, Compliance Officer observed two laboratory hoods in the cytology/histology area of the lab. Compliance Officer conducted an interview with Employee #12 on September 9, 2025 and asked Employee #12 if these laboratory hoods were operational because they did not appear to be functional. Employee #12 stated that they were not able to be used and presently, there was not a laboratory hood that was able to be used by Employee #12 and Employee #12's colleague.

Compliance Officer asked how they were able to conduct their laboratory work. Employee #12 pointed to an open vent located just above a countertop and stated that this was a negative pressure vent. Employee #12 stated that they were "expected" to conduct their lab work in front of this negative pressure vent in the hope that this would contain any vapors.


Section 8.13.1 indicated, "When installed or modified and at least annually thereafter, chemical fume hoods, chemical fume hood exhaust systems, and laboratory special exhaust systems, shall be inspected and tested as applicable..." Section 8.13.2 indicated, "Deficiencies in hood performance shall be corrected, or one of the following shall apply: 1) The activity within the hood shall be restricted to the capability of the hood; 2) The hood shall not be used."

PM (Preventative Maintenance) reports were requested for calendar years 2024 and 2025 for laboratory hoods located in the laboratory. A PM report dated 12/16/2024 was provided. Six laboratory hoods were identified in this report. One laboratory hood, SWV-001, passed according to manufacturer's specifications. But this hood still had low exhaust readings.

Three hoods had a "low pass-poor" rating with comments. SMH-02 had below range exhaust flow. SWV-003 had a "low pass-poor" rating with comments. It had low airflow indicating exhaust air fan issues. 60114 failed. The unit only had inward airflow and had no exhaust capacity. Microbiology hood also failed due to poor inflow and filtration that was not appropriate for the lab environment.

Documentation of correction of the deficiencies for the lab hoods was requested but could not be provided.


Section 6.6.3.1(5) indicated, "Plans for laboratory emergencies shall be developed, which shall include...non-fire hazards."

"Carondelet Health Network" Emergency Operations Plan Code Orange-Hazard Materials Spills Plan indicated, "Wash hands, face, and other exposed parts of your body that may have been contaminated...."

During observation conducted while on tour on September 9, 2025 in the laboratory, a safety shower was observed in the laboratory. A metal shelf was obstructing the pathway to the safety shower that was covered in boxes. Some items appeared to be stored within the safety shower, including a telephone.

Based on record review, the facility failed to provide documented evidence that the kitchen hood system was cleaned and inspected semi-annually in accordance with NFPA 96. Failing to inspect and clean the kitchen hood and vents semi-annually will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 11, Section 11.2 Inspection and Testing, and Maintenance of Fire Extinguishing Systems. Section 11.4 Inspection for grease buildup. The entire exhaust system shall be inspected for grease buildup by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction and in accordance with Table 11.4. Systems serving moderate-volume cooking operations. Inspection frequency semi-annually."

Findings include:

Documentation of semi-annual kitchen hood system cleaning and inspection was requested for calendar years 2024 and 2025. A kitchen hood inspection conducted by Hiller on 03/21/2025 and a cleaning conducted by Sun Devil Hoods on 07/30/2025 was provided. No services conducted in 2024 could be found or were provided regarding semi-annual inspection and cleaning of the kitchen hoods.

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Based on observation and interview, the facility failed to ensure that all exposed electrical wiring was protected. Failure to ensure exposed wiring could cause accidental damage or possibly a fire, which could cause harm to patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage." In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface."


Findings include:

During observation while on tour conducted on September 8 and September 9, 2025, the following was observed:

-A thermostat cover missing in 35ED (emergency department) leaving wiring exposed
-A communications panel with a cover that could not be closed in an electrical room that entered through the exterior of the facility leaving wiring exposed
-A communications panel on the 4th floor with a broken cover that could not be closed leaving wiring exposed
-Exposed wiring hanging from the wall in the clean utility room about 1 (one) foot from the floor in the DOC (Department of Corrections) area
-An electrical panel with no cover in the electrical storage room near the mobile CT (computed tomography) area
-An open junction box near the chillers
-An open junction box in the interstitial space on the second floor of the west building
-A second open junction box in the interstitial space on the second floor of the west building with the cover hanging adjacent to it; this junction box was nestled amidst a large quantity of insulation in the ceiling
-An open junction box with the cover hanging off the bottom of it in the ATS (automatic transfer switch) room
-An open junction box in the elevator room
-Exposed wiring in the mechanical room on the 2nd floor.
-Hanging wires in 5807

Employees #2, 5, 6 & 11 participated in the tour and were able to observe and acknowledge the deficiencies at the time they were found. During an exit interview conducted on September 9, 2025, administrative staff acknowledged the deficiencies.

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Based on observation while on tour, review of facility documentation and interview, the Department has determined the Administrator failed to ensure that the hospital HVAC systems were maintained in working order. Failure to ensure that the HVAC system is maintained in working order can result in discomfort for staff and patients and can result in adverse outcomes for patients.

Findings include:

NFPA 101 Life Safety Code, 2012 Edition Chapter 19, Section 19.5.2, "Heating Ventilating and Air Conditioning." Section 19.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 91.

NFPA 91 Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Particulate Solids, Chapter 10, Maintenance Program, Section 10.6.1 indicated, "....All system components shall be maintained in good operating condition...." Section 10.6.5 indicated: "...Serious deficiencies shall require immediate attention...."

During observation while on tour conducted on September 8, 2025, Compliance Officers observed standing water pooled on the floor around an air handler unit on the second floor identified in an interview conducted on September 8, 2025 by Employee #8 as SB-002. In an interview conducted with Employee #5 on September 8, 2025, Employee #5 stated the cause of the water pooled on the floor around SB-002 was likely to be condensation from the Air Handler Unit. Employee #5 asserted that personnel conducted daily walkthroughs of the hospital which included a visual inspection of Air Handler Units.

During observation while on tour conducted on September 9, 2025, Compliance Officers observed standing water pooled on the floor around an air handler unit located in Room #1278 located near biohazard storage identified as NB-005. In an interview conducted with Employee #5 on September 9, 2025, Employee #5 stated the cause of the water pooled on the floor around NB-005 was likely caused by condensation from the Air Handler Unit.

According to an interview conducted with Employee #8 on September 8, 2025, St. Mary's Hospital has 41 Air Handler Units. An observation tour was conducted of Air Handler Units by Compliance Officers on September 8 and September 9, 2025. No other Air Handler Units were observed to have condensation in the form of pools of water surrounding the Air Handler Units.

HVAC 1 Work Orders" and "HVAC 2 Work Orders" revealed 221 (two hundred and twenty-one) work orders submitted regarding temperature and humidity issues in surgery and operating rooms between April 1, 2024 and January 25, 2025.

In an interview conducted with Employee #5 on September 8, 2025, Employee #5 explained that work orders are typically addressed as they are received and employees are provided an email confirming a work order has been addressed once the work order is closed; however, during observation while on tour conducted on September 8, 2025, Employee #5 stated that dehumidifiers were installed "about two weeks ago" to address the humidity issues in the operating room and surgery area.

Temperature and humidity logs for operating and surgery areas were requested and were provided for January 1, 2025 to present.\

Each day, temperature and humidity was measured in 24 (twenty-four) areas. 864 (eight hundred and sixty-four) temperature and humidity readings were reviewed from random sample sheets taken from March, May, June, and July 2025. Of these, 334 readings (three-hundred and thirty-four) were out of range, approximately one-third of readings taken.

Documentation was requested but not provided regarding the installation of dehumidifiers; however, documentation was provided regarding thermostat calibration issues for the operating and surgical rooms with emails beginning on August 25, 2025 and ending on September 4, 2025 that indicated adjustments are still ongoing.

HVAC 1 Work Orders" and "HVAC 2 Work Orders" revealed 73 (seventy-three) complaints of the air conditioner not working or of rooms being too hot on the 4th floor of the hospital between June 1, 2024 and September 1, 2025 with an additional 8 (eight) complaints regarding thermostats not working. 7 (seven) of these complaints were regarding medication room 4513 or 4W that were submitted between Mary 23, 2025 and July 11, 2025.

During observation while on tour conducted on September 9, 2025 of the 4th floor of the hospital, Compliance Officer observed a medication room in an area of the hospital undergoing renovation. This medication room was in a patient care area of the hospital containing the room number previously known as 4513. Upon entering the medication room, Compliance Officer noted the room seemed hotter than the corridor. A thermostat on the wall indicated the temperature of the room was 80 degrees. Medical supplies and oxygen canisters were stored within the room. A check of the ambient temperature of the room indicated the ambient air temperature to be 82 degrees.

HVAC 1 Work Orders" and "HVAC 2 Work Orders" revealed 53 (fifty-three) complaints of the air conditioner not working or of rooms being too hot on the 3rd floor of the hospital between March 1, 2024 and September 1, 2025 with an additional 3 (three) complaints regarding thermostats not working. Of these complaints, 9 (nine) were regarding medication rooms being too hot.

Repair orders were requested for all HVAC systems. Other than repairs to chillers, no repairs were found that would have affected the operating room areas or 4th floor areas. One repair was found relevant to the 3rd floor. The following repairs were made during this timeframe:

On August 22, 2024, an issue with the chiller 2 valve was reported. The issue was temporarily addressed, but not resolved. A plastic water bottle was placed over the chill water flow switch to prevent water dripping on the switch. Subsequent service calls for chiller 2 were made on September 15 and September 19, 2024.

During observation while on tour conducted on September 8, 2025, the water bottle was observed to still be in place over the water flow switch on chiller 2.

On September 30, 2024, a repair was made to chiller 3.

On October 8, 2024, a repair was made to the MRI chiller.

On August 29, 2024, a fuse was replaced in an air handler unit described as the "janitorial air handler unit."

On September 6-7, 2024, service was provided for an air handler unit described as being on the third floor.

On September 20, 2024, a rooftop air handler unit was replaced described as being in the MRI area.

On October 8, 2024, an air handler unit was replaced described as Kitchen AHU-32.

Maintenance records for air handler units were entered in as work orders. In order to evaluate frequency of air handler unit servicing, two air handler units were selected--AHU #4033 (039434) designated as servicing the hallway going to 4700, and AHU WB-23 (02296) designated as servicing operating rooms 8 and 9.

#4033(039434)
02/05/2024-Air Induction Unit
04/29/2024-Air Induction Unit
08/05/2024-Air Induction Unit
11/04/2024-Air Induction Unit
05/05/2025-Air Induction Unit
06/30/2025-Air Induction Unit


WB-23(02296)
05/27/2024-Exhaust Fan
05/27/2024-Exhaust Fan (It should be noted that two lists of work orders were provided, HVAC 1 and HVAC 2, which were for two separate technicians. These two entried were both timed for 11:11 p.m. on the same date and indicated one hour of work).
08/26/2024-Exhaust Fan
08/25/2025-Exhaust Fan

These maintenance entries do not indicate a regular maintenance schedule. In interviews conducted with Employees #5 and 8, Employees #5 and 8 stated on September 8 that regular maintenance was performed on air handler units in the facility.

Based on observation while on tour and review of facility policy and procedure, it has been determined the facility failed to ensure that positive-pressure gases are properly and securely stored. Failure to securely and properly store positive-pressure gases can result in a fire, leading to potential harm to patients or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities."

NFPA 99 Section 5.1.3.1 Subsection A.5.1.3.3.2(7) indicated: ".Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:..They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty...."

Findings include:

Facility policy titled, "Compressed Gas Cylinder Management" indicated: "Cylinders...shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full or empty...Oxidizing gases...shall not be stored with any flammable gas, liquid or vapor."


During observation while on tour conducted on September 9, 2025, in the medical gas storage room, a large medical nitrogen canister that was on top of a wheeling platform was observed to be chained to 13 (thirteen) other canisters of assorted medical gases with one single chain, including carbon dioxide, nitrous oxide, oxygen and one canister of gas of an unknown type in a red canister.

Based on observation while on tour and interview, it has been determined the facility failed to ensure that flammable and/or combustible liquids were safely stored to prevent the likelihood of fire. Failure to ensure flammable and/or combustible liquids are safely stored can increase the likelihood of a fire event, leading to injury or death of patients and/or staff.

NFPA 99 (2012), Chapter 15, Section 15.3.1, "The storage and handling of flammable liquids or gases shall be in accordance with the following applicable standards...NFPA 30, Flammable and Combustible Liquids."

Section 14.4.1 indicated, "The design and construction of a locker shall...be subject to the approval of the authority having jurisdiction." Section 14.5.1 indicated, "Lockers shall be located on a designated approved site on the property." Section 14.5.2 indicated, "The designated site shall be arranged to provide minimum separation distances specified in Table 14.5.2...from locker to important buildings on the same property...Area of Designated site...[less than or equal to] 100 ft [squared]...From Locker to Important Buildings on the Same Property...5 feet...." Section 14.6.5 indicated, "Miscellaneous combustible materials, including but not limited to idle pallets, excessive vegetation and packing materials shall not be permitted within 5 ft. of the designated site approved for lockers. Section 14.6.6 indicated: "Warning signs for lockers shall be in accordance with local, state, and federal regulations or with NFPA 704...."

Findings include:

During observation while on tour conducted on September 9, 2025, a hazardous material locker was observed outside the back of the hospital roughly across from the cooling tower. The locker was positioned in close proximity to the hospital main building. The locker was rusted with faded signs. Although it did have papers contained within transparent sleeves, it did not bear a visible 704 diamond. There was vegetation growing up above the height of the bottom of the door frame.

In an interview conducted on September 9, 2025, Employee #6 stated the hazardous material locker contained Xylene. At the request of the Compliance Officer, the locker was opened. Inside were 9 (nine) large containers of violet hued liquid, one yellow barrel, one orange barrel, one large white barrel with a red top and numerous cardboard boxes. The containers of violet liquid were leaking inside the locker.

On September 10, 2025, Compliance Officer contacted the Tucson Fire Department. According to the Tucson Fire Department, they were not notified about the installation of the hazardous material locker and did not approve its placement.