HospitalInspections.org

Based on observation on -4/20/2010, 10 AM onward, the following was noted:

a.The facility utilizes delayed egress locks and NC special locking systems (electromagnetic locks) on required exit doors. These systems are allowed only in facilities that are fully covered by either an automatic,supervised sprinkler system and/or an automatic,supervised smoke or heat detection system. This facility is not fully covered by either or a combination thereof.

b. The sixth (6) floor exit doors have these locks that are no longer in use. These locks must have at least one of the magnetic plates removed in order to be considered disabled.

c. In the birthing center, the path of egress directs you through a NC special locking system and then through a delayed egress system. You can not be required to pass through two (2) systems in order to exit the facility.

d. The delayed egress system on the birthing and nursery floor (2nd floor) is activated by a transmitter. If the delayed egress process is activated by pressure applied to the release device, the door must unlock and remain unlocked until manually relocked. These locks automatically relock if another transmitter is brought with in range of the door.

e. Some of these doors/locks relock if the fire alarm is placed in the silenced mode and has not been reset. These doors may not relock until the Fire Alarm has been reset.

f. There are electromagnetic locks on the first (1) floor that only have a card swipe to unlock the door ( no emergency override switch) . This also includes the exit door at the birthing area.

g. There is not a hard surface Exit discharge path from the exit at Cardiac Rehab. and Virtual Learning.

h. There are some doors on all floors that require two (2) motions of the hand in order to exit the rooms.

i. There is an electrical closet near the 6th. floor nurses station that can not be opened from the inside if the door is locked. A person can be locked out any room but they can not be locked in the room.

42 CFR 483.70 (a)
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A. Based on observation on 04/20/2010 there was an area in Telemetry that no Exit sign in view to designate the exit path..

A. Based on observation on 04/20/2010 there was no audible/visual trouble signal received when the battery back-up was disconnected in the 4th floor FACP (Fire Alarm Control Panel).

A. Based on observation on 04/20/2010 , when tested, there was a sprinkler tamper alarm that did not sound the alarm.

B. There were tamper alarms attached to the valves with "J" hooks.

Based on observation on 04/20/2010 :

A. A large amount of supplies were permanently stored in the egress corridor at #7 OR.

B. There were Computer on Wheels (C..O.W.s) (6) , B.P. machines (3) being charged in the exit egress corridor outside a nurses station.This area had been wired for this purpose.

C. There is a linen closet near room 216a that has two (2) doors that open into the egress corridor. These doors do not open 180 degrees nor do they have closers on them. These doors reduce corridor width and obstruct the exit egress path when left in the open position.
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Based on observation on 04/20/2010 :

A. There was storage in front of the electrical panel in the O.R. dark room.

B. There were two (2) surge protectors connected in tandem in the 4th (fourth ) FACP room.

C. There was a cover missing from a 4x4 junction box in the penthouse

Based on observation on -4/20/2010, 10 AM onward, the following was noted:

a.The facility utilizes delayed egress locks and NC special locking systems (electromagnetic locks) on required exit doors. These systems are allowed only in facilities that are fully covered by either an automatic,supervised sprinkler system and/or an automatic,supervised smoke or heat detection system. This facility is not fully covered by either or a combination thereof.

b. The sixth (6) floor exit doors have these locks that are no longer in use. These locks must have at least one of the magnetic plates removed in order to be considered disabled.

c. In the birthing center, the path of egress directs you through a NC special locking system and then through a delayed egress system. You can not be required to pass through two (2) systems in order to exit the facility.

d. The delayed egress system on the birthing and nursery floor (2nd floor) is activated by a transmitter. If the delayed egress process is activated by pressure applied to the release device, the door must unlock and remain unlocked until manually relocked. These locks automatically relock if another transmitter is brought with in range of the door.

e. Some of these doors/locks relock if the fire alarm is placed in the silenced mode and has not been reset. These doors may not relock until the Fire Alarm has been reset.

f. There are electromagnetic locks on the first (1) floor that only have a card swipe to unlock the door ( no emergency override switch) . This also includes the exit door at the birthing area.

g. There is not a hard surface Exit discharge path from the exit at Cardiac Rehab. and Virtual Learning.

h. There are some doors on all floors that require two (2) motions of the hand in order to exit the rooms.

i. There is an electrical closet near the 6th. floor nurses station that can not be opened from the inside if the door is locked. A person can be locked out any room but they can not be locked in the room.

42 CFR 483.70 (a)
.

A. Based on observation on 04/20/2010 there was an area in Telemetry that no Exit sign in view to designate the exit path..

A. Based on observation on 04/20/2010 there was no audible/visual trouble signal received when the battery back-up was disconnected in the 4th floor FACP (Fire Alarm Control Panel).

A. Based on observation on 04/20/2010 , when tested, there was a sprinkler tamper alarm that did not sound the alarm.

B. There were tamper alarms attached to the valves with "J" hooks.

Based on observation on 04/20/2010 :

A. A large amount of supplies were permanently stored in the egress corridor at #7 OR.

B. There were Computer on Wheels (C..O.W.s) (6) , B.P. machines (3) being charged in the exit egress corridor outside a nurses station.This area had been wired for this purpose.

C. There is a linen closet near room 216a that has two (2) doors that open into the egress corridor. These doors do not open 180 degrees nor do they have closers on them. These doors reduce corridor width and obstruct the exit egress path when left in the open position.
.

Based on observation on 04/20/2010 :

A. There was storage in front of the electrical panel in the O.R. dark room.

B. There were two (2) surge protectors connected in tandem in the 4th (fourth ) FACP room.

C. There was a cover missing from a 4x4 junction box in the penthouse