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Based on the review of records, observations, and staff interviews, it was determined that the Hospital failed to provide a safe environment for patients. This Condition Level deficiency is evidenced by:

A0701-Failure to maintain the condition of the physical plant and hospital environment to promote the safety and well-being of patients.

A0724-Failure to maintain facilities, supplies, and equipment to ensure an acceptable level of safety and quality.

The cumulative effects of these systemic practices resulted in the failure of the hospital to deliver statutorily mandated compliance with Federal regulations for Physical Environment.

Based on record review, observation and interview, the hospital failed to maintain the condition of the overall hospital environment in such a manner as to promote the safety and well-being of patients. Failure to perform required maintenance on the 1. HVAC system and 2. Elevator and lifts compromises the hospital environment and poses the risk of potential equipment failure and inability to maintain safety in patient care areas of the hospital.

Findings include:

Review of policy titled "Utilities Management Plan 2023" revealed: "Maintenance of utility components is included in the hospital's work order program. Maintenance strategies include: Preventative Maintenance (PM): The schedule activities designed to extend equipment reliability...Interval Based Maintenance: The scheduled activities are based on present schedule...Corrective Maintenance (CM): Unscheduled activities are undertaken as the result of a component failure. Maintenance intervals for the utility components are maintained, documented and controlled...Maintenance, Testing, and Inspection...Utility components are categorized on the inventory as High Risk (life support/Infection Control) and Non-High Risk. Preventative maintenance on all components is done at 100% completion rate...Reporting Process...The EOC/PEOC Committee will review serious issues and make appropriate recommendations to hospital leadership."

As required by NFPA 99 and adopted standards required by ASHRAE Standard 170- 2008 Table 7.1 Design Parameters, critical and intensive care temperatures are set at 70-75 degrees Fahrenheit or 21-24 degrees Celsius and patient care areas are set at 70-75 degrees Fahrenheit or 21-24 degrees Celsius.

1. A copy of HVAC system maintenance logs and/or contract were requested. Only logs were provided.

Maintenance records revealed maintenance on Chiller 1 performed by a vendor on December 29, 2022 and February 28, 2023. The service provided addressed the chiller issue with maintaining target temperature. Vendor recommended replacing transducer if chiller continues to not maintain target temperatures.

Review of work orders on 09/19/2023 revealed annual, biannual and monthly preventative maintaince was not completed by date due for the following orders:

WO069217 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, 12 month; Tasks included "Checking cooler and condenser tubes for leaks"; Generated 01/01/2023, Due Date 01/31/2023, Completed 5/23/2023.
WO084294 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, 6 month; Generated 01/01/2023, Due Date 01/31/2023, Completed 5/19/2023.
WOA1066807 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 02/01/2023, Due Date 02/28/2023, Completed 05/19/2023.
WOA131381 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 03/01/2023, Due Date 03/31/2023, Completed 05/19/2023.
WOA160923 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 04/01/2023, Due Date 04/30/2023, Completed 05/12/2023.

Review of work orders on 09/19/2023 revealed biannual and monthly preventative maintenance was ordered but not completed for the following orders:

WOA244319 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 07/01/2023, Due Date 07/31/2023, Not completed.
WOA242744 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, 6 month; Generated 07/01/2023, Due Date 07/31/2023, Not completed.
WOA274398 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 08/01/2023, Due Date 08/31/2023, Not completed.

Review of facility document titled " Environment of Care Risk Assessment" completed on 9/15/2023 revealed that on 9/14/2023 one of the hospital's two chillers failed due to clogged tubes and repair was expected to take several days.

Facility record review revealed the facility failed to maintain temperatures in Intensive Care and Med/Surg units during a chiller outage. Temperature logs for four different patient care areas "ICU/second floor/144/116" commencing 9/14/2023 at 2200 documented temperatures above standard until 9/15/2023 1930. Documented temperatures reached a high of 81 degrees Farenheit.

2. A copy of Elevator and Lift maintenance logs and/or contract was requested and reviewed.

Review of work orders on 09/19/2023 revealed annual, biannual and monthly preventative maintaince was not completed by date due for the following orders:

WO068727 Priority 1 Emergency, Elevators and Lifts, Passenger, Monthly - 1 month; Generated 01/01/2023, Due Date 02/01/2023, Completed 5/19/2023.
WO066651 Priority 1 Emergency, Elevators and Lifts, Passenger, Monthly - 1 month; Generated 01/01/2023, Due Date 02/01/2023, Completed 5/19/2023.
WOA105034 Priority 1 Emergency, Elevators and Lifts, Passenger, Monthly - 1 month; Generated 02/01/2023, Due Date 02/28/2023, Completed 5/19/2023.
WO086665 Priority 1 Emergency, Elevators and Lifts, Passenger, 6 months; Generated 01/02/2023, Due Date 02/02/2023, Completed 5/19/2023.
WO085824 Priority 1 Emergency, Elevators and Lifts, Passenger, 12 months; Generated 01/02/2023, Due Date 02/02/2023, Completed 5/19/2023.

Review of Corrective Maintenance Logs revealed WOA119101, Start Date 2/14/2023, Completion Date 02/15/2023 reporting "Elevator Broken".

A copy of the incident report for the elevator failure was requested. None was provided.

Review of Environmental Rounding minutes failed to reveal any discussion of elevator failure.

Interview with Employee #10 confirmed that there had been a noticeable increase in temperature within the hospital since August of 2023 and one of the hospital's chillers failed on 09/14/2023. Employee #10 also confirmed that both hospital elevators were down at the same time for a period of approximately 24 hours and transport chairs for the stairwell were deployed. During the elevator failure, food and other supplies had to be transported via the stairwell.

Interview with Employee #11 confirmed that the maintenance on the chiller was not completed as ordered and the failure of the chiller on 09/14/2023 impacted temperatures in patient care areas.

Based on record review, observation and interview, the hospital failed to perform regular maintenance to maintain the primary chiller in working order to ensure an acceptable level of safety and quality of environmental care. Failure to perform routine maintenance and checks on HVAC equipment poses a serious risk to the health and safety of patients when equipment failure results in temperatures in patient care areas extending acceptable limits.

Findings include:

Review of policy titled "Utilities Management Plan 2023" revealed: "Maintenance of utility components is included in the hospital's work order program. Maintenance strategies include: Preventative Maintenance (PM): The schedule activities designed to extend equipment reliability...Interval Based Maintenance: The scheduled activities are based on present schedule...Corrective Maintenance (CM): Unscheduled activities are undertaken as the result of a component failure. Maintenance intervals for the utility components are maintained, documented and controlled...Emergency Preparedness...in the event of utility system disruption or failure, as well as alternate sources of essential utilities...Clinical intervention during utility system disruptions are specifically addressed in hospital procedures..."

Policy named "Tempe St. Luke's Hospital EMERGENCY MANAGEMENT PLAN 2023" states "... The Hospital has developed and implemented this Emergency Management Plan in compliance with applicable regulatory requirements to describe the processes involved with this function and to effectively manage disasters and emergency response. ...Four Phases MITIGATION: These activities are designed to reduce the impact or severity of potential disasters. They include, but are not limited to: Compliance with the Life Safety Code®, NFPA 2012 Ed. (to make the facility more survivable in the event of a fire)...."

Maintenance records revealed maintenance on Chiller 1 performed by a vendor on December 29, 2022 and February 28, 2023. The service provided addressed the chiller issue with maintaining target temperature. Vendor recommended replacing transducer if chiller continues to not maintain target temperatures.

Review of work orders on 09/19/2023 revealed annual, biannual and monthly preventative maintaince was not completed by date due for the following orders:

WO069217 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, 12 month; Tasks included "Checking cooler and condenser tubes for leaks"; Generated 01/01/2023, Due Date 01/31/2023, Completed 5/23/2023.
WO084294 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, 6 month; Generated 01/01/2023, Due Date 01/31/2023, Completed 5/19/2023.
WOA1066807 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 02/01/2023, Due Date 02/28/2023, Completed 05/19/2023.
WOA131381 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 03/01/2023, Due Date 03/31/2023, Completed 05/19/2023.
WOA160923 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 04/01/2023, Due Date 04/30/2023, Completed 05/12/2023.

Review of work orders on 09/19/2023 revealed biannual and monthly preventative maintenance was ordered but not completed for the following orders:

WOA244319 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 07/01/2023, Due Date 07/31/2023, Not completed.
WOA242744 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, 6 month; Generated 07/01/2023, Due Date 07/31/2023, Not completed.
WOA274398 Priority 1 Emergency, Chiller, Centrifugal, Water-Cooled, Over 100 Tons, All Manufacturers, Monthly - 1 month; Generated 08/01/2023, Due Date 08/31/2023, Not completed.

Review of facility document titled " Environment of Care Risk Assessment" completed on 09/15/2023 revealed that "ICU, second floor medical/surgical unit" were affected by the chiller failure on 09/14/2023. Temporary measures included deploying spot chillers in patient care areas and securing a rental unit until vendor repairs were complete. The document reported that regular operations did not need to be altered and temperatures would be monitored hourly until the temporary chiller was installed.

As required by NFPA 99 and adopted standards required by ASHRAE Standard 170- 2008 Table 7.1 Design Parameters, critical and intensive care temperatures are set at 70-75 degrees Fahrenheit or 21-24 degrees Celsius and patient care areas are set at 70-75 degrees Fahrenheit or 21-24 degrees Celsius.

Review of facility records revealed the facility failed to maintain temperatures in Intensive Care (ICU) and Med/Surg units during a chiller outage. Temperature logs for four different patient care areas "ICU/second floor/144/116" commencing 09/14/2023 at 2200 documented temperatures above standard until 09/15/2023 at 1930. Documented temperatures reached a high of 81 degrees Farenheit.

Review of ICU census during the time that temperatures were above standard revealed five patients were assigned to the unit 09/14/2023 and four patients were assigned to the unit on 09/15/2023. There were no documented clinical interventions to remove the patients from the ICU during the chiller failure.

Review of census for Med/Surg unit on the second floor during the time that temperatures were above standard revealed sixteen patients were assigned to the unit on 09/14/2023 and twelve patients were assigned to the unit on 09/15/2023. There were no documented clinical interventions to remove the patients from the Med/Surge unit on the second floor during the chiller failure.

Interview with Employee #8 on 09/15/2023 confirmed that administrator failed to ensure patients were kept in a safe environment during the chiller outage.