HospitalInspections.org

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the door to critical care waiting room is less than forty inches in width. Door is approximately thirty six inches - located in Critical Care South Unit.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 1:45pm onward, there is a gap between the meeting edge of the inactive and active door leafs to room #260.

42 CFR 482.41

Based on observation, on March 12, 2014 at approximately 2:00amm onward, vertical chases are incomplete due to the following:

1. unsealed penetrations in chase located in pharmacy area.

2. fire curtain obstructed to tray conveyor chase - located on lower level pharmacy by tray cart.

3. lack of guardrail protection at each floor level of tray conveyor chase.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, hazardous areas are incomplete due to the following:

1. lack of sprinkler(s) for volunteer storage room - room exceeds 100 square feet in area. room is located on first floor.
2) The trash room door located in the kitchen was not self closing.
3) The dry storage room door was held open preventing the door from closing.
4) The corridor door to sterile processing (L057) lower level did not have positive latching.
5) The door to material management storage room was not a rated door.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 2:00am onward, there is no fireproofing of structural beams supporting steel deck - located above gas fired boiler room.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) The corridor door to the oxygen/storage room located on the rear exit hall was not self closing.
2) The mechanical room room corridor door located on the rear hall by stairwell was not self closing.

42 CFR 483.70

Based on observation, on March 12, 2014 at approximately 2:00am onward, exits are not assured due to the following:

1. incomplete electromagnetic locking arrangement on exit access door from PACU to OR corridor - system installed is not equipped with motion sensor as required for access controlled egress door.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, exit discharge is incomplete to the publicway - side exit located near front entrance.

42 CFR 482.41(a)












13743

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) The stairwell corridor door located next to the mechanical room did not close and latch and was dragging on the floor preventing the door from closing.

42 CFR 483.70

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the exit access is not assured due to the following:

1. the use of momentary contact switch beside doors equipped with special locking arrangements - located near room 3136.

2. the use of momentary contact switch beside door equipped with special locking arrangements - located at smoke barrier between connecting breezeway and existing main hospital.

4. the use of deadbolt locks located above 48 inches from finished floors on doors to the following rooms:

a. room 3134

b. room 3136

42 CFR 482.41

Based on observation, on March 12, 2014 at approximately 2:00am onward, door to TrueBeam room requires excessive force to open door in an emergency - force exceeds 30lbf to open door in the closed position. Door is located off corridor near Radiation Therapy.

42 CFR 482.41(a)


26594

Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the means of egress from the following area was not assured:
1) There are two storage cages located in the pipe access level that are equipped with pad lock that would prevent an individual from exiting the the area if the door was locked.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, there is no emergency lighting for rear exit discharge of MRI Unit.

42 CFR 482.41(a)


26594

Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the following deficiencies were noted:
1) By observation exit discharge illumination was observed as noncompliant: specific findings include that the facility could not verify that all exit discharge lighting was connected to emergency power. Lighting must be arranged to provide light from the exit discharge leading to the public way . The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area. NFPA 101 7.8.1.1, 7.8.1.3, and 7.8.1.4.
2) Exit discharge illumination was not provide for at the Same Day Surgery stairwell door.
3) Exit discharge Illumination was not provided for at the ambulance parking bay rear corridor exit.


42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, exit discharge lights connected to emergency power source are not functioning at exit discharges.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) The wall pack emergency lights located in the front corridor and one at the front entrance when tested did not operate.
2) Emergency lighting was not provided for in the main area.

42 CFR 483.70

Based on observation, on March 12, 2014 at approximately 2:00am onward, exit and directional signs are incomplete due to the following:

1. lack of exit sign at intersecting corridors - located on first floor area leading to Oncology Unit.

42 CFR 482.41(a)

2. lack of exit directional sign for ninety degree corridor area leading from MRI to Day Surgery.

42 CFR 482.41(a)


26594

Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the following deficiencies were noted:
1) Exit and directional signage was not provided in the corridor located outside plant operations located on lower level to the stairwell located outside sterile processing.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) An emergency exit directional sign is needed in the main area leading individuals to the rear exit stairwell.

42 CFR 483.70

Based on observation, on March 13, 2014 at approximately 5:00am onward, the facility fire alarm system is incomplete due to the following:

1. lack of labeling of normal power circuit breaker serving the main fire alarm control panel - circuit and panelboard must be identified on fire alarm control panel.

2. lack of smoke detector located in vicinity of main fire alarm control panel.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, the fire alarm system audible/visual signaling devices did not function properly during test - units in third floor corridor did not function at the same time.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) A remote fire alarm annunicator panel for the Fire Alarm Control Panel (FACP) was not provided for in the an area where it would be heard in case of emergency during hours of operation.

42 CFR 483.70

Based on observation, on March 12, 2014 at approximately 2:00 AM onward, sprinkler coverage was incomplete due to the following:
1) In the material management storage room (Lower Level) the lower duct works was blocking the overhead sprinkler head.

2) The facility utilizes Special Locking devices on required egress/exit doors - The facility is basically 100% sprinklered with the following exceptions:

By observation sprinkler heads were missing in the following areas;
a) Morgue Shower room
b) Rear Kitchen walk-in refrigeration units
c) Electrical closet in kitchen next to cookline.
d) Mechanical room, kitchen area next to rear entrance.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, maintenance of the automatic sprinkler system is incomplete due to the following:

1. heat sensitive element of pendent sprinkler is covered by lint and debris - located in ED waiting area.


42 CFR 482.41(a)


13743

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the seventh floor laundry chute was not verified to have a sprinkler installed at the top of the chute


26594

Based on observation, on March 12, 2014 at approximately 2:00am onward, sprinkler tamper alarm incomplete due to the following:
1) The sprinkler tamper alarm located on 6th floor north stairwell was equipped with an unapproved tamper alarm.

42 CFR 482.41(a)

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the call room number 3134 does not have sprinkler pass through mesh at the top of the shower curtain.

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the third floor call room number 3134 does not have the proper mesh on the shower curtain that will allow proper sprinkler cover for that space.


26594

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) The underground pit for the sprinkler backflow preventer that is also equipped with electronically supervised tamper alarms did not have a drain or other methods to keep the pit dry or from being flooded. At the time of the survey there was approximately 6 inches of water in the pit.


42 CFR 483.70

Based on observation, on March 11, 2014 at approximately 2:30pm onward, the mechanical systems are noncompliant due to the following:

1. nonlisted mechanical duct used at ceiling level in main dining room - the material doesn't meet UL duct classifications required in health care facilities.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, there is no service access opening for fire dampers located between boiler room and adjacent spaces - dampers are located in mechanical ducts at rated wall penetrations.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) There was not an Emergency HVAC Shutdown switch located in the area for use in case of an emergency.

42 CFR 483.70

Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the following deficiencies were noted:
1) On the cook lines there is an oven and other equipment cooking equipment located on the cook line that were not properly located under the hood.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, there are exposed element, high temperature portable space heaters used in the following areas:

1. office beside fastrack area on first floor.

2. pharmacy office

3. VP office located in administration area.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, the means of egress clearance is incomplete due to the following:

1. impediments by mechanical equipment in floor area to MRI - located beside anesthesia on call room.

2. impediments in means of egress - corridor area near TrueBeam room.

42 CFR 482.41(a)

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the fifth floor respiratory department had nitrous oxide cylinders that were not individually chained.

Based on observation, on March 11, 2014 at approximately 1:45pm onward, there are no smoke damper installed in the ductwork that penetrate the smoke wall above the cross corridor doors that lead into the "C" section suite.

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the essential electrical system is incomplete due to the following:

1. LS Branch panelboard ELW3 contains a smoke guard system not permitted on the Life Safety Branch of the essential electrical system - located in Pavilion electrical room on third floor.

42 CFR 482.41

Based on observation, on March 12, 2014 at approximately 2:00am onward, the emergency power system is noncompliant due to the following:

1. staff interviews revealed improper load testing of emergency power system. There was no loss of normal power to automatic transfer switches of the essential electrical system during scheduled thirty minute load test as required by NFPA 99.

2. emergency power system required greater than ten seconds to restore power during loss of normal power to emergency system transfer switches.

3. during initial test of emergency power system, there was no power restored to critical care areas of hospital after over 90 seconds of elapsed time.

4. Life Safety Branch lighting systems can be switch off by wall mounted corridor light switch - located in service corridor leading to main electrical switchgear room.

42 CFR 482.41

Based on observation, on March 12, 2014 at approximately 2:00am onward, the facility electrical system is incomplete due to the following:

1. lack of weatherproof receptacle with ground-fault interrupter protection for outlets serving Lipo Truck - located beside MRI exit.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, there are no knockout covers for missing circuit breakers in electrical panelboard GRB.

42 CFR 482.41(a)

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the document review noted that the NCDOL inspection report on 3/4/2014 had incomplete items including: cleaning oil from the car top and stop the leak at the drive machine.

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the fifth floor small nurses station chart area near room 522 had an alcohol based hand rub dispenser installed over an ignition source the light switch in that area.

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the door to critical care waiting room is less than forty inches in width. Door is approximately thirty six inches - located in Critical Care South Unit.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 1:45pm onward, there is a gap between the meeting edge of the inactive and active door leafs to room #260.

42 CFR 482.41

Based on observation, on March 12, 2014 at approximately 2:00amm onward, vertical chases are incomplete due to the following:

1. unsealed penetrations in chase located in pharmacy area.

2. fire curtain obstructed to tray conveyor chase - located on lower level pharmacy by tray cart.

3. lack of guardrail protection at each floor level of tray conveyor chase.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, hazardous areas are incomplete due to the following:

1. lack of sprinkler(s) for volunteer storage room - room exceeds 100 square feet in area. room is located on first floor.
2) The trash room door located in the kitchen was not self closing.
3) The dry storage room door was held open preventing the door from closing.
4) The corridor door to sterile processing (L057) lower level did not have positive latching.
5) The door to material management storage room was not a rated door.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 2:00am onward, there is no fireproofing of structural beams supporting steel deck - located above gas fired boiler room.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) The corridor door to the oxygen/storage room located on the rear exit hall was not self closing.
2) The mechanical room room corridor door located on the rear hall by stairwell was not self closing.

42 CFR 483.70

Based on observation, on March 12, 2014 at approximately 2:00am onward, exits are not assured due to the following:

1. incomplete electromagnetic locking arrangement on exit access door from PACU to OR corridor - system installed is not equipped with motion sensor as required for access controlled egress door.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, exit discharge is incomplete to the publicway - side exit located near front entrance.

42 CFR 482.41(a)












13743

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) The stairwell corridor door located next to the mechanical room did not close and latch and was dragging on the floor preventing the door from closing.

42 CFR 483.70

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the exit access is not assured due to the following:

1. the use of momentary contact switch beside doors equipped with special locking arrangements - located near room 3136.

2. the use of momentary contact switch beside door equipped with special locking arrangements - located at smoke barrier between connecting breezeway and existing main hospital.

4. the use of deadbolt locks located above 48 inches from finished floors on doors to the following rooms:

a. room 3134

b. room 3136

42 CFR 482.41

Based on observation, on March 12, 2014 at approximately 2:00am onward, door to TrueBeam room requires excessive force to open door in an emergency - force exceeds 30lbf to open door in the closed position. Door is located off corridor near Radiation Therapy.

42 CFR 482.41(a)


26594

Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the means of egress from the following area was not assured:
1) There are two storage cages located in the pipe access level that are equipped with pad lock that would prevent an individual from exiting the the area if the door was locked.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, there is no emergency lighting for rear exit discharge of MRI Unit.

42 CFR 482.41(a)


26594

Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the following deficiencies were noted:
1) By observation exit discharge illumination was observed as noncompliant: specific findings include that the facility could not verify that all exit discharge lighting was connected to emergency power. Lighting must be arranged to provide light from the exit discharge leading to the public way . The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area. NFPA 101 7.8.1.1, 7.8.1.3, and 7.8.1.4.
2) Exit discharge illumination was not provide for at the Same Day Surgery stairwell door.
3) Exit discharge Illumination was not provided for at the ambulance parking bay rear corridor exit.


42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, exit discharge lights connected to emergency power source are not functioning at exit discharges.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) The wall pack emergency lights located in the front corridor and one at the front entrance when tested did not operate.
2) Emergency lighting was not provided for in the main area.

42 CFR 483.70

Based on observation, on March 12, 2014 at approximately 2:00am onward, exit and directional signs are incomplete due to the following:

1. lack of exit sign at intersecting corridors - located on first floor area leading to Oncology Unit.

42 CFR 482.41(a)

2. lack of exit directional sign for ninety degree corridor area leading from MRI to Day Surgery.

42 CFR 482.41(a)


26594

Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the following deficiencies were noted:
1) Exit and directional signage was not provided in the corridor located outside plant operations located on lower level to the stairwell located outside sterile processing.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) An emergency exit directional sign is needed in the main area leading individuals to the rear exit stairwell.

42 CFR 483.70

Based on observation, on March 13, 2014 at approximately 5:00am onward, the facility fire alarm system is incomplete due to the following:

1. lack of labeling of normal power circuit breaker serving the main fire alarm control panel - circuit and panelboard must be identified on fire alarm control panel.

2. lack of smoke detector located in vicinity of main fire alarm control panel.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, the fire alarm system audible/visual signaling devices did not function properly during test - units in third floor corridor did not function at the same time.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) A remote fire alarm annunicator panel for the Fire Alarm Control Panel (FACP) was not provided for in the an area where it would be heard in case of emergency during hours of operation.

42 CFR 483.70

Based on observation, on March 12, 2014 at approximately 2:00 AM onward, sprinkler coverage was incomplete due to the following:
1) In the material management storage room (Lower Level) the lower duct works was blocking the overhead sprinkler head.

2) The facility utilizes Special Locking devices on required egress/exit doors - The facility is basically 100% sprinklered with the following exceptions:

By observation sprinkler heads were missing in the following areas;
a) Morgue Shower room
b) Rear Kitchen walk-in refrigeration units
c) Electrical closet in kitchen next to cookline.
d) Mechanical room, kitchen area next to rear entrance.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, maintenance of the automatic sprinkler system is incomplete due to the following:

1. heat sensitive element of pendent sprinkler is covered by lint and debris - located in ED waiting area.


42 CFR 482.41(a)


13743

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the seventh floor laundry chute was not verified to have a sprinkler installed at the top of the chute


26594

Based on observation, on March 12, 2014 at approximately 2:00am onward, sprinkler tamper alarm incomplete due to the following:
1) The sprinkler tamper alarm located on 6th floor north stairwell was equipped with an unapproved tamper alarm.

42 CFR 482.41(a)

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the call room number 3134 does not have sprinkler pass through mesh at the top of the shower curtain.

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the third floor call room number 3134 does not have the proper mesh on the shower curtain that will allow proper sprinkler cover for that space.


26594

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) The underground pit for the sprinkler backflow preventer that is also equipped with electronically supervised tamper alarms did not have a drain or other methods to keep the pit dry or from being flooded. At the time of the survey there was approximately 6 inches of water in the pit.


42 CFR 483.70

Based on observation, on March 11, 2014 at approximately 2:30pm onward, the mechanical systems are noncompliant due to the following:

1. nonlisted mechanical duct used at ceiling level in main dining room - the material doesn't meet UL duct classifications required in health care facilities.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, there is no service access opening for fire dampers located between boiler room and adjacent spaces - dampers are located in mechanical ducts at rated wall penetrations.

42 CFR 482.41(a)

Based on observation on 3/13/14 at approximately 6:00 AM onward the following deficiencies were noted:
1) There was not an Emergency HVAC Shutdown switch located in the area for use in case of an emergency.

42 CFR 483.70

Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the following deficiencies were noted:
1) On the cook lines there is an oven and other equipment cooking equipment located on the cook line that were not properly located under the hood.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, there are exposed element, high temperature portable space heaters used in the following areas:

1. office beside fastrack area on first floor.

2. pharmacy office

3. VP office located in administration area.

42 CFR 482.41(a)

Based on observation, on March 12, 2014 at approximately 2:00am onward, the means of egress clearance is incomplete due to the following:

1. impediments by mechanical equipment in floor area to MRI - located beside anesthesia on call room.

2. impediments in means of egress - corridor area near TrueBeam room.

42 CFR 482.41(a)

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the fifth floor respiratory department had nitrous oxide cylinders that were not individually chained.

Based on observation, on March 11, 2014 at approximately 1:45pm onward, there are no smoke damper installed in the ductwork that penetrate the smoke wall above the cross corridor doors that lead into the "C" section suite.

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the essential electrical system is incomplete due to the following:

1. LS Branch panelboard ELW3 contains a smoke guard system not permitted on the Life Safety Branch of the essential electrical system - located in Pavilion electrical room on third floor.

42 CFR 482.41

Based on observation, on March 12, 2014 at approximately 2:00am onward, the emergency power system is noncompliant due to the following:

1. staff interviews revealed improper load testing of emergency power system. There was no loss of normal power to automatic transfer switches of the essential electrical system during scheduled thirty minute load test as required by NFPA 99.

2. emergency power system required greater than ten seconds to restore power during loss of normal power to emergency system transfer switches.

3. during initial test of emergency power system, there was no power restored to critical care areas of hospital after over 90 seconds of elapsed time.

4. Life Safety Branch lighting systems can be switch off by wall mounted corridor light switch - located in service corridor leading to main electrical switchgear room.

42 CFR 482.41

Based on observation, on March 12, 2014 at approximately 2:00am onward, the facility electrical system is incomplete due to the following:

1. lack of weatherproof receptacle with ground-fault interrupter protection for outlets serving Lipo Truck - located beside MRI exit.

42 CFR 482.41(a)

Based on observation, on March 13, 2014 at approximately 5:00am onward, there are no knockout covers for missing circuit breakers in electrical panelboard GRB.

42 CFR 482.41(a)

Based on observation, on March 11, 2014 at approximately 1:45pm onward, the document review noted that the NCDOL inspection report on 3/4/2014 had incomplete items including: cleaning oil from the car top and stop the leak at the drive machine.