HospitalInspections.org

Based on observation and interview with the Facilities Director during a tour of the facility, it was observed that the facility did not maintain the proper fire-rated separations for hazardous areas. Specifically:
On 11/16/10 at 10:00am, there was an unsealed penetration through the mechanical closet on 3 North.

Based on observation and interview with the Facilities Director during a tour of the facility, the hospital did not maintain the exits in a clear and unobstructed manner. Specifically:
On 11/17/10 at 11:00 am, there were three IV poles stored in the exit corridor from the first floor Massry building.

Based on observation and interview with the Facilities Director during a tour of the facility , the sprinkler system was not installed and maintained properly. Specifically:
On 11/17/10 at 10:30am in Central Sterile Supply, two sprinkler heads were installed above the level of the suspended ceiling.
On 11/16/10 at 4:00pm in the Radiology Department, two corridor storage closets had items on the top shelves stored less than 18 inches below the sprinkler heads.

Based on observation and interview with the Facilities Director during a tour of the facility, it was determined that the piped-in hospital medical gas system does not comply with NFPA 99, Chapter 4.
Specifically, on 11/15/10 at 2:30pm, during a tour of the 6th and 5th floors, it was observed that the labels for the medical gas controls do not accurately reflect which areas or rooms the gas shut-offs control. In some instances the shut-offs were disconnected, but still labeled as operable.