HospitalInspections.org

1. Main Hospital, Service Level, Main Electrical room accessible from the covered breezeway outside the kitchen storage area had holes and or penetrations that were not seal in order to meet the required rating of the area.

2. Main Hospital, Service Level, IS mezzanine area, There are holes in the fire proofing covering the beams in the IS mezzanine area that were not properly repaired in order to maintain the required rating on the beams.

Behavioral Health, Administration area, the attic access door at administration did not return to the closed position after being opened.

Cardiac Imaging, the hospital based provider space; the hospital based provider space is not separated from other tenants in the building as required.

H&D at Military Cutoff, Corridor wall at back entrance, There are unsealed penetrations in the rated wall above the ceiling tile at the back wall to the back entrance of the hospital based provider space.

1. Cape Fear Hospital, Basement, Door to room B-08, the door at that location was wedged open preventing the door from being closed and latched.

2. Cape Fear Hospital, 3rd floor, Board Room & Lecture Room, There was not positive latching to the corridor doors to the board room and the lecture room on third floor.

1. Main Hospital, 1st floor, soiled utility room at CCU, the soiled utility room door at that location did not latch when tested.

2. Main Hospital, Service Level, Clean Respiratory Therapy, The corridor door from the clean respiratory therapy room required two motions of the hand to unlock and open.

3. Main Hospital, Service Level, Kitchen Area, The catering closet located next to the dry storage room had kick down stop on the door preventing the door from closing.

4. Main Hospital, Service Level, Kitchen Area, The door to the chemical closet did close latch and seal.

Women ' s and Children ' s, 2nd floor, patient doors on the corridor, the patient doors at this location have two leafs where the left leaf does not have positive latching. The left leaf if not attached to the door frame does not allow the right leaf to latch.

Main Hospital, 6th floor, North End Soiled Utility Room, The access door to the vertical chase did not close and latch and seal when tested. (Door required considerable force to close)

Main Hospital, 7th floor, chase in the visitors elevator lobby, the rated chase door in that area did not close and latch when opened during the survey.

1. Cape Fear Hospital, 1st Floor, corridor side of the switch board brake room, There were unsealed penetrations in the rated walls on the corridor side of the switch board brake room.

2. Cape Fear Hospital, bed and wheel chair repair room, there are unsealed penetrations in the rated walls on the corridor side at that location.

Main Hospital, Service Level, IS-UPS Room, There are holes in the ceiling where conduit penetrate the ceiling that were not properly sealed in order to maintain the required rating of the area.

Main Hospital, 1st floor, ED Radiology suite, The first floor emergency department radiology suite had two doors with magnetic hold open devices that were not tied to the fire alarm system. Both doors had the listed closure arm removed.

1. Women ' s and Children ' s, 2nd floor, Equipment storage between 228 and 236, the equipment door at that location did not have a door closure installed at that hazardous location.

1. Cape Fear Hospital, 3rd floor, exit egress stairwell at the Pixis/Storage room East wing, the stairwell door does not have a door closure installed to keep the door closed after being opened.

2. Cape Fear Hospital, Basement, Soiled linen room B-05, the door to this room did not close latch and seal when tested.

1. Main Hospital, 1st floor, outpatient services area, the soiled utility room door for the West area didn ' t not latch.

2. Main Hospital, 1st floor Mechanical Room Cath Lab, There are unsealed penetrations in the rated corridor wall area around the duct penetration at back top left section of the wall.

3. Main Hospital, Service Level, Kitchen Area, The dry storage room in the kitchen did not close latch and seal.

4. Main Hospital, 1st floor, classrooms/old operating rooms/storage, The small storage in the old operating rooms/classrooms was not smoke tight; the door to the area had been removed.

5. Main Hospital, 1st floor, main concourse gift shop, there was not positive latching to the gift shop door on the main concourse exit corridor.

6. Main Hospital, Service Level, Kitchen Area, The chemical closet located in the kitchen will need to be one hour and sprinkler. The area is considered a high hazard area due to chemicals and flammable fuels stored in the room.

H&D Military Cutoff, Soiled Linen room, The door at the soiled linen room does not have a door closer installed to keep this hazardous are closed after being opened.

1. Main Hospital, 1st floor, ED Behavioral Health suite, the emergency department behavioral health suite currently exits into another suite.

2. Main Hospital, 1st floor, ED main entrance, The break away doors to the 1st floor emergency department main entrance did not have signage to indicate which doors break away.

Cape Fear Hospital, Required exit for Bigford area, the required exit at this area did not have a solid non slick surface other than grass or soil from that exit.

1. Women ' s and Children ' s, 2nd floor, " A " wing on/off emergency release switch at the nurses station, The staff was not familiar with the release switch for the North Carolina Special Locking at this location.

2. Women ' s and Children ' s, Pediatrics " C " wing exit egress door, the on/off emergency release switch at the egress door was not a simple switch and did relock the door after several seconds.

3. Women ' s and Children ' s, 3rd floor elevator lobby, the two required exit doors at this location did not release with activation of and automatic fire alarm activation.

NOTE: this particular deficiency was corrected before the end of the survey.

4. Women ' s and Children ' s, 3rd floor exit egress stairwells, during the testing of the Hugs® Infant Protection System, the facility required exit doors at the stairwells did not release with activation of an automatic fire alarm activation.

NOTE: this particular deficiency was corrected before the end of the survey.

5. Women ' s and Children ' s, 3rd floor exit egress stairwells, during the testing of the Hugs® Infant Protection System, the emergency door on/off switch was not a simple switch and did relock the door after several seconds.

6. Women ' s and Children ' s, 1st floor, Triage area nurses station, There was no on/off emergency release switch a regularly manned station for the exit egress double doors at the entrance to the triage area.

7. Women ' s and Children ' s, 1st floor, Triage area, the on/off emergency switch at the exit egress double door for the triage area was not a simple switch and did relock the door after several seconds.

8. Women ' s and Children ' s, Labor and Delivery area nurses station, There was no on/off emergency release switch a regularly manned station for the exit egress door or that location.

9. Women ' s and Children ' s, 2nd floor, " A " wing exit egress door. The North Carolina Special Locking system at this location does not have an on/off emergency release switch at the door location.

1. Cape Fear Hospital, 2nd floor, four room alcove in the respiratory area, the doors for the rooms in this area had dead bolts installed and resulted in two motions of the hand for egress for these rooms.

2. Cape Fear Hospital, 1st floor, ICU, The first floor ICU suite, this area less than 5,000 square feet, has identified a second exit with signage through the adjacent suite, this exit does not meet exit egress requirements as this exit had special locking arrangements installed but was not a simple switch and did relock the door after several seconds.


3. Cape Fear Hospital, 3rd floor, storage room, the third floor storage room at the entrance of the unit had more than one range of motion to exit the door.


4. Cape Fear Hospital, 1st floor, Vendor/Contractor rooms, the vendor/contractor rooms are areas that are padlocked preventing egress from these rooms. Hospital staff does not carry keys for these areas.


5. Cape Fear Hospital, 1st floor, Cafeteria doors leading to the exit corridor, these two doors had dead bolts installed and results in more that one motion of the had to exit from that cafeteria location.

6. Cape Fear Hospital, 1st floor, Cafeteria exit corridor, The North Carolina Special locking system for the egress corridor exit did not have an on/off emergency switch at the door. The switch was momentary and would relock after several seconds.

7. Cape Fear Hospital, 1st floor, Employees entrance, The North Carolina Special locking system for this location did not have an on/off emergency switch at the door. The switch was momentary and would relock after several seconds.

1. Main Hospital, 1st floor, near the mail lobby, The exit egress doors at this location leading to the inpatient unit does not have an on/off emergency door release switch at the double doors at the required exit.

2. Main Hospital, 1st floor, Staff Bathroom at the CCU, The staff bathroom required two motions of the hand to exit that space.

3. Main Hospital, 1st floor, CCU 4 sets of double door on the egress corridor; the staff must verify the door release mechanism operation at these locations. This area does not have all the items for control access nor North Carolina Special Locking.

4. Main Hospital, Service Level, The means of egress from the AHEC exit and Service Level Concourse exit into the courtyard is not clearly marked that will direct individuals to safety.

5. Main Hospital, 1st floor, Cross Corridor doors at the CVIC area, these control access doors did not release as required, but exiting from the space was not impeded as the hardware on the door allowed exiting into the corridor.

Rehabilitation Hospital, 2nd floor, storage room doctors office, the storage room for the doctor ' s office across from the rehabilitation councilors ' office had a dead bolt installed and resulted in more that one motion of the had to exit from that location.

1. Main Hospital, Service Level, IS mezzanine area, the means of egress from the IS mezzanine area to the corridor does not have adequate lighting that would prevent the area from being left in darkness

2. Main Hospital, Service Level, Bio-Med Mezzanine the bio-med mezzanine area did not have lights connected to emergency power that would prevent the area from being left in darkness.

1. Cape Fear Hospital, Basement, exit egress near room B-14, the exit directional signage for that location is incomplete.

2. Cape Fear Hospital, 1st floor, Pre admission testing side exit, the exit directional sign at that location leads to an outside walkway with no exit directional sign at the end of that walkway.

1. Main Hospital, Mezzanine kitchen level, the exit directional signage from this area is incomplete to the egress corridor.

2. Main Hospital, EVS corridor, The East EVS exit egress corridor exit directional signage leading East to the public way was incomplete.

3. Main Hospital, Service Level, IS Mezzanine Exit and directional signage is incomplete from the mezzanine to the corridor exit.

4. Main Hospital, 1st floor, the Kona Kitchen area, the exit directional signs in this space is incomplete to the exit egress corridor.

5. Main Hospital, 1st floor, ICU entrance corridor adjacent to the emergency department near the Kona Kitchen area has exit directional signage that is blocked and is not clearly visible in the path of egress.

1. Main Hospital, 1st floor, Radiology suite, this area is covered by the fire alarm system for the hospital but failed to give an audible sound or chime when the fire alarm system was activated.

2. Main Hospital, 1st floor, Emergency Department for the women ' s clinic, this area is covered by the fire alarm system for the hospital but failed to give an audible sound or chime when the fire alarm system was activated.

Main Hospital, Service Level, Kitchen, There were three ceiling mounted smoke detectors in the kitchen that had the sensing device cover preventing proper operation.

1. Rehabilitation Hospital, 2nd floor, EMT FACP Room, Sprinkler head in that space is blocked.

2.Rehabilitation Hospital, 2nd floor, Electrical Room, Sprinkler head in that space is blocked.

3. Rehabilitation Hospital, 2nd floor, near bathroom W9, there are splatters of paint on the sprinkler head bulb near bathroom W9

NOTE:
The facility is utilizing special locking arrangements (Delayed egress and North Carolina Special Locking , and controlled access). The facility currently has areas in buildings number 1, 3, and 9 that are not fully sprinklered nor provide smoke detection (fully automated, supervised fire suppression or fully automated, supervised fire detection system) tied into the hospital main Fire Alarm Control Panel (FACP) as required when utilizing special locking arrangements. Some areas not covered are listed below. Provider to check all spaces for verification and for submittal of Plan of Correction.



1. Main Hospital, Sprinkler heads were found in the facility were of the intermediate temperature rating of 200 degree F in place of the ordinary temperature rating of 155 degree F. Intermediate temperature heads were found in the following areas. The facility must provide documentation from the sprinkler designer noting the use of this particular rated sprinkler heads for this particular area.

Main Hospital, 6th floor mechanical, electrical room and date closet located in the center conference room.

2. Main Hospital, Service Level Concourse sprinkler heads are located above conduits and HVAC ductwork , this particular areas has sprinkler heads are being blocked not be an object on the side of the head but by the ductwork below the sprinkler heads.

3. Main Hospital, Service Level Concourse, does not have adequate sprinkler coverage. The existing sprinkler heads are located above the existing conduit and ductwork and not providing complete coverage of the corridor.

4. Main Hospital, 1st floor, ED, old electrical room/telecom room, there was not a sprinkler head in the telecom room located in the emergency department.

5. Main Hospital, document review, sprinkler system, library, the document review of the fire marshal ' s report dated July 27, 2011 from the main hospital indicated that there were sprinkler heads obstructed by book shelves. Staff indicated that the facility currently working on the issue. The facility must confirm the sprinkler coverage in the library provides adequate coverage by the sprinkler designer.


6. Main Hospital, Service level laundry and drying area, the sprinkler head near dryer # 2 is blocked by ductwork just above the light fixture in that space.


7. Rooms and/or areas were not provided with sprinkler coverage;
Main Hospital, Breezeway located outside leading from the courtyard and kitchen supply storage area.

8. Main Hospital, Service Level - Kitchen Walk-in cooler and freezes in the kitchen.

9. Main Hospital, Service Level - Kitchen) Electrical Room

10. Main Hospital, Service Level Main Electrical room accessible from the covered breezeway outside the kitchen storage area.

11. Main Hospital, Service Level - Kitchen Catering Closet next to kitchen electrical room

12. Main Hospital, Service Level - Pharmacy Walk-in cooler in the Pharmacy

13. Main Hospital, Service Level - Kitchen The Electrical closet located next to the pulper extractor

14. Main Hospital, Service Level - Concourse Electrical rooms NS001, NS002, NS003

15. Main Hospital, Service Level - Pharmacy There is an alcove located to the right of the walk-in refrigerator that is not properly covered by sprinkler coverage.

16. Main Hospital, Service Level - Pharmacy The FAP data chase outside pharmacy.

17. Main Hospital, Service Level - IS-UPS Room) The IS-UPS room.

The facility is utilizing special locking arrangements (Delayed egress and North Carolina Special Locking , and controlled access). The facility currently has areas in buildings number 1, 3, and 9 that are not fully sprinklered nor provide smoke detection (fully automated, supervised fire suppression or fully automated, supervised fire detection system) tied into the hospital main Fire Alarm Control Panel (FACP) as required when utilizing special locking arrangements. Some areas not covered are listed below. Provider to check all spaces for verification and for submittal of Plan of Correction.

1. Cape Fear Hospital, 1st floor, radiology storage, Confirm the sprinkler coverage in the first floor radiology storage room provides adequate coverage. This room was converted from an old dressing room with walls extending to the ceiling for each of the three dressing bays. The currently only one sprinkler head is in the space and is located in the back of the room.

2. Cape Fear Hospital, 3rd floor, Water Treatment room, the sprinkler head in this space is being blocked by the light fixture in that space.

3. Cape Fear Hospital, 3rd floor, the small MRI Electrical room, there was no sprinkler system coverage in the MRI electrical room. This room is not 2 hr Fire Rated Construction.

The facility is utilizing special locking arrangements (Delayed egress and North Carolina Special Locking , and controlled access). The facility currently has areas in buildings number 1, 3, and 9 that are not fully sprinklered nor provide smoke detection (fully automated, supervised fire suppression or fully automated, supervised fire detection system) tied into the hospital main Fire Alarm Control Panel (FACP) as required when utilizing special locking arrangements. Some areas not covered are listed below. Provider to check all spaces for verification and for submittal of Plan of Correction.

Zimmer Cancer Center, Microbiology area, there is no sprinkler coverage in the walk-in cooler as required.

1. Main Hospital, Sprinkler hot box for the fire pump, the tamper alarm failed to give a signal at the main fire control station that one of the four valves was in the closed position.

2. Main Hospital, Basement, The distribution dry sprinkler system, the dry part of the sprinkler system has a high and low pressure valve that is not currently electrically supervised. The pressure operated flow switch valve up stream is not electrically supervised.

Cape Fear Hospital, Basement, Sprinkler tamper alarm location LIN34, The sprinkler tamper alarm at that location failed to give a signal at the fire alarm control panel when tested.

Behavioral Health, the A/B Unit regularly manned station; this area does not have an emergency shut down switch for the air handler unit that services that area.

Cape Fear Hospital, document review, smoke dampers, the documentation review of the smoke dampers for this building indicated that there were 9 out of 70 ducts within the smoke wall that did not have smoke dampers as required.

Main Hospital, 1st floor, Radiology suite, this area did not have an emergency air handler shut down switch installed for the air hander for that space.

Medical Mall, the regularly manned station for this facility; this area does not have an emergency shut down switch for the air handler unit that services the hospital based provider area.

Zimmer Cancer Center, Penthouse, The duct detector for air handler number 1 did not have and access door installed in order to view the sampling tubes at that location.

1. Main Hospital, 1st floor, MICU, STICU and SVICU, there are items stored in the corridor that are neither used or moved including beds, blood pressure machines, intravenous bag poles.

2. Main Hospital, Service Level, Kitchen Area, The catering closet corridor door located near the electrical room was not self closing.

3. Main Hospital, Service Level, The IS EUS closet corridor door did not open 180 degrees and restricted the width of the by more than 7 inches when left open. This particular door opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

4. Main Hospital, Service Level Concourse, Patient bed and other equipment was stored in the exit corridor.


5. Main Hospital, 1st floor, ED Trauma Bay suite, The means of egress, which includes two doors in a single exit discharge path, from the emergency department trauma bay suite, were blocked with storage.

1. Women ' s and Children ' s, 3rd floor, Corridor # 2, the soiled tray holding room across from room 326 has a door that opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

2. Women ' s and Children ' s, 2nd floor, pediatrics electrical room, The double doors at that location open into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

3. Women ' s and Children ' s, 2nd floor, electrical room near exam rooms 1 and 2, The double doors at that location open into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

4. Women ' s and Children ' s, 3rd floor, small cabinets on the egress corridor, The cabinet ' s right leaf door swings into the corridor without a listed closure and the door does not swing 180 degrees but leaves a projection of approximately 12" into the corridor.

5. Women ' s and Children ' s, 3rd floor, ABC wings, There were unattended blood pressure machines plugged into the egress corridor on the A, B and C wings not in use.

6. Women ' s and Children ' s, Ground floor, the storage room across from the procedure room at NICU, the door for this room opens into the egress corridor without opening 180 degrees flat to the corridor wall no has a door closure installed to keep the door closed after being opened.

Cape Fear Hospital, 2nd floor, Water Treatment room, The double doors for the water treatment room opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

Rehabilitation Hospital, 1st floor, electrical room, the door for this room opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

Surgical Pavilion, 1st floor, Operating Room Back Hall, There was storage in the back exit corridor leading from the operating rooms surgical suites. This area was outside of the suite and does not allow for storage in this particular space.

Cape Fear Hospital, 1st floor, surgery suite at the soiled linen location , the door to the surgery side of soiled linen did not have positive latching.

1. Cape Fear Hospital, oxygen storage farm, the oxygen cylinders are not individually chained. The Cylinders are not protected from rusting as they are sitting on the concrete pad. The cylinder valves are not protected from extremes from weather.

2. Cape Fear Hospital, 2nd floor, O2 storage room, the second floor oxygen storage had partial tanks mixed with full tanks.

1. Main Hospital, 9th floor Clean Linen room, the facility had a mixture of full and empty oxygen cylinders in the full location in that space.

2. Main Hospital, 4th floor Clean Linen room, the facility had a mixture of full and empty oxygen cylinders in the full location in that space.


3. Main Hospital, Mezzanine kitchen level, the facility had contractor welding cylinders not individually chained in that space.


4.Main Hospital, oxygen storage farm, not all of the oxygen cylinders are individually chained. The cylinder valves are not protected from extremes from weather.

5. Main Hospital, Service level Patient Transport, in the oxygen storage area in the patient transport area oxygen was found mixed and not labeled full and empty.

Surgical Pavilion, Basement, Medical gas distribution area, this space has several cylinders that are not individually chained to prevent cylinders from moving in the case that the current chain around them is removed.

Women ' s and Children ' s, 1st floor, Med. Gas storage, The first floor medical gas storage room has several cylinders that are not individually chained to prevent cylinders from moving in the case that the current chain around them is removed.

Zimmer Cancer Center, Lab area, the carbon dioxide large cylinders in the lab are not individually chained to prevent cylinders from moving in the case that the current chain around them is removed.

Behavioral Health, generator annunciator, the audible signal for the generator annunciator did not indicate that the generator was running after conducting the loaded generator test at the facility.

Zimmer Cancer Center, Control Room, Generator annunciator, the generator annunciator did not give an indication that the generator was running under a load during the loaded test on the generator.

Rehabilitation Hospital, 2nd floor, restorative range, the restorative rang in the independent living area was not locked out to prevent the range from being accidentally turned on.

Cape Fear Hospital, 1st floor, surgery suite, soiled linen room, the ABHR (Alcohol Base Hand Rub) in this room was located directly above an ignition source the light switch for that room.

1. Main Hospital, Service Level, Main Electrical room accessible from the covered breezeway outside the kitchen storage area had holes and or penetrations that were not seal in order to meet the required rating of the area.

2. Main Hospital, Service Level, IS mezzanine area, There are holes in the fire proofing covering the beams in the IS mezzanine area that were not properly repaired in order to maintain the required rating on the beams.

Behavioral Health, Administration area, the attic access door at administration did not return to the closed position after being opened.

Cardiac Imaging, the hospital based provider space; the hospital based provider space is not separated from other tenants in the building as required.

H&D at Military Cutoff, Corridor wall at back entrance, There are unsealed penetrations in the rated wall above the ceiling tile at the back wall to the back entrance of the hospital based provider space.

1. Cape Fear Hospital, Basement, Door to room B-08, the door at that location was wedged open preventing the door from being closed and latched.

2. Cape Fear Hospital, 3rd floor, Board Room & Lecture Room, There was not positive latching to the corridor doors to the board room and the lecture room on third floor.

1. Main Hospital, 1st floor, soiled utility room at CCU, the soiled utility room door at that location did not latch when tested.

2. Main Hospital, Service Level, Clean Respiratory Therapy, The corridor door from the clean respiratory therapy room required two motions of the hand to unlock and open.

3. Main Hospital, Service Level, Kitchen Area, The catering closet located next to the dry storage room had kick down stop on the door preventing the door from closing.

4. Main Hospital, Service Level, Kitchen Area, The door to the chemical closet did close latch and seal.

Women ' s and Children ' s, 2nd floor, patient doors on the corridor, the patient doors at this location have two leafs where the left leaf does not have positive latching. The left leaf if not attached to the door frame does not allow the right leaf to latch.

Main Hospital, 6th floor, North End Soiled Utility Room, The access door to the vertical chase did not close and latch and seal when tested. (Door required considerable force to close)

Main Hospital, 7th floor, chase in the visitors elevator lobby, the rated chase door in that area did not close and latch when opened during the survey.

1. Cape Fear Hospital, 1st Floor, corridor side of the switch board brake room, There were unsealed penetrations in the rated walls on the corridor side of the switch board brake room.

2. Cape Fear Hospital, bed and wheel chair repair room, there are unsealed penetrations in the rated walls on the corridor side at that location.

Main Hospital, Service Level, IS-UPS Room, There are holes in the ceiling where conduit penetrate the ceiling that were not properly sealed in order to maintain the required rating of the area.

Main Hospital, 1st floor, ED Radiology suite, The first floor emergency department radiology suite had two doors with magnetic hold open devices that were not tied to the fire alarm system. Both doors had the listed closure arm removed.

1. Women ' s and Children ' s, 2nd floor, Equipment storage between 228 and 236, the equipment door at that location did not have a door closure installed at that hazardous location.

1. Cape Fear Hospital, 3rd floor, exit egress stairwell at the Pixis/Storage room East wing, the stairwell door does not have a door closure installed to keep the door closed after being opened.

2. Cape Fear Hospital, Basement, Soiled linen room B-05, the door to this room did not close latch and seal when tested.

1. Main Hospital, 1st floor, outpatient services area, the soiled utility room door for the West area didn ' t not latch.

2. Main Hospital, 1st floor Mechanical Room Cath Lab, There are unsealed penetrations in the rated corridor wall area around the duct penetration at back top left section of the wall.

3. Main Hospital, Service Level, Kitchen Area, The dry storage room in the kitchen did not close latch and seal.

4. Main Hospital, 1st floor, classrooms/old operating rooms/storage, The small storage in the old operating rooms/classrooms was not smoke tight; the door to the area had been removed.

5. Main Hospital, 1st floor, main concourse gift shop, there was not positive latching to the gift shop door on the main concourse exit corridor.

6. Main Hospital, Service Level, Kitchen Area, The chemical closet located in the kitchen will need to be one hour and sprinkler. The area is considered a high hazard area due to chemicals and flammable fuels stored in the room.

H&D Military Cutoff, Soiled Linen room, The door at the soiled linen room does not have a door closer installed to keep this hazardous are closed after being opened.

1. Main Hospital, 1st floor, ED Behavioral Health suite, the emergency department behavioral health suite currently exits into another suite.

2. Main Hospital, 1st floor, ED main entrance, The break away doors to the 1st floor emergency department main entrance did not have signage to indicate which doors break away.

Cape Fear Hospital, Required exit for Bigford area, the required exit at this area did not have a solid non slick surface other than grass or soil from that exit.

1. Women ' s and Children ' s, 2nd floor, " A " wing on/off emergency release switch at the nurses station, The staff was not familiar with the release switch for the North Carolina Special Locking at this location.

2. Women ' s and Children ' s, Pediatrics " C " wing exit egress door, the on/off emergency release switch at the egress door was not a simple switch and did relock the door after several seconds.

3. Women ' s and Children ' s, 3rd floor elevator lobby, the two required exit doors at this location did not release with activation of and automatic fire alarm activation.

NOTE: this particular deficiency was corrected before the end of the survey.

4. Women ' s and Children ' s, 3rd floor exit egress stairwells, during the testing of the Hugs® Infant Protection System, the facility required exit doors at the stairwells did not release with activation of an automatic fire alarm activation.

NOTE: this particular deficiency was corrected before the end of the survey.

5. Women ' s and Children ' s, 3rd floor exit egress stairwells, during the testing of the Hugs® Infant Protection System, the emergency door on/off switch was not a simple switch and did relock the door after several seconds.

6. Women ' s and Children ' s, 1st floor, Triage area nurses station, There was no on/off emergency release switch a regularly manned station for the exit egress double doors at the entrance to the triage area.

7. Women ' s and Children ' s, 1st floor, Triage area, the on/off emergency switch at the exit egress double door for the triage area was not a simple switch and did relock the door after several seconds.

8. Women ' s and Children ' s, Labor and Delivery area nurses station, There was no on/off emergency release switch a regularly manned station for the exit egress door or that location.

9. Women ' s and Children ' s, 2nd floor, " A " wing exit egress door. The North Carolina Special Locking system at this location does not have an on/off emergency release switch at the door location.

1. Cape Fear Hospital, 2nd floor, four room alcove in the respiratory area, the doors for the rooms in this area had dead bolts installed and resulted in two motions of the hand for egress for these rooms.

2. Cape Fear Hospital, 1st floor, ICU, The first floor ICU suite, this area less than 5,000 square feet, has identified a second exit with signage through the adjacent suite, this exit does not meet exit egress requirements as this exit had special locking arrangements installed but was not a simple switch and did relock the door after several seconds.


3. Cape Fear Hospital, 3rd floor, storage room, the third floor storage room at the entrance of the unit had more than one range of motion to exit the door.


4. Cape Fear Hospital, 1st floor, Vendor/Contractor rooms, the vendor/contractor rooms are areas that are padlocked preventing egress from these rooms. Hospital staff does not carry keys for these areas.


5. Cape Fear Hospital, 1st floor, Cafeteria doors leading to the exit corridor, these two doors had dead bolts installed and results in more that one motion of the had to exit from that cafeteria location.

6. Cape Fear Hospital, 1st floor, Cafeteria exit corridor, The North Carolina Special locking system for the egress corridor exit did not have an on/off emergency switch at the door. The switch was momentary and would relock after several seconds.

7. Cape Fear Hospital, 1st floor, Employees entrance, The North Carolina Special locking system for this location did not have an on/off emergency switch at the door. The switch was momentary and would relock after several seconds.

1. Main Hospital, 1st floor, near the mail lobby, The exit egress doors at this location leading to the inpatient unit does not have an on/off emergency door release switch at the double doors at the required exit.

2. Main Hospital, 1st floor, Staff Bathroom at the CCU, The staff bathroom required two motions of the hand to exit that space.

3. Main Hospital, 1st floor, CCU 4 sets of double door on the egress corridor; the staff must verify the door release mechanism operation at these locations. This area does not have all the items for control access nor North Carolina Special Locking.

4. Main Hospital, Service Level, The means of egress from the AHEC exit and Service Level Concourse exit into the courtyard is not clearly marked that will direct individuals to safety.

5. Main Hospital, 1st floor, Cross Corridor doors at the CVIC area, these control access doors did not release as required, but exiting from the space was not impeded as the hardware on the door allowed exiting into the corridor.

Rehabilitation Hospital, 2nd floor, storage room doctors office, the storage room for the doctor ' s office across from the rehabilitation councilors ' office had a dead bolt installed and resulted in more that one motion of the had to exit from that location.

1. Main Hospital, Service Level, IS mezzanine area, the means of egress from the IS mezzanine area to the corridor does not have adequate lighting that would prevent the area from being left in darkness

2. Main Hospital, Service Level, Bio-Med Mezzanine the bio-med mezzanine area did not have lights connected to emergency power that would prevent the area from being left in darkness.

1. Cape Fear Hospital, Basement, exit egress near room B-14, the exit directional signage for that location is incomplete.

2. Cape Fear Hospital, 1st floor, Pre admission testing side exit, the exit directional sign at that location leads to an outside walkway with no exit directional sign at the end of that walkway.

1. Main Hospital, Mezzanine kitchen level, the exit directional signage from this area is incomplete to the egress corridor.

2. Main Hospital, EVS corridor, The East EVS exit egress corridor exit directional signage leading East to the public way was incomplete.

3. Main Hospital, Service Level, IS Mezzanine Exit and directional signage is incomplete from the mezzanine to the corridor exit.

4. Main Hospital, 1st floor, the Kona Kitchen area, the exit directional signs in this space is incomplete to the exit egress corridor.

5. Main Hospital, 1st floor, ICU entrance corridor adjacent to the emergency department near the Kona Kitchen area has exit directional signage that is blocked and is not clearly visible in the path of egress.

1. Main Hospital, 1st floor, Radiology suite, this area is covered by the fire alarm system for the hospital but failed to give an audible sound or chime when the fire alarm system was activated.

2. Main Hospital, 1st floor, Emergency Department for the women ' s clinic, this area is covered by the fire alarm system for the hospital but failed to give an audible sound or chime when the fire alarm system was activated.

Main Hospital, Service Level, Kitchen, There were three ceiling mounted smoke detectors in the kitchen that had the sensing device cover preventing proper operation.

1. Rehabilitation Hospital, 2nd floor, EMT FACP Room, Sprinkler head in that space is blocked.

2.Rehabilitation Hospital, 2nd floor, Electrical Room, Sprinkler head in that space is blocked.

3. Rehabilitation Hospital, 2nd floor, near bathroom W9, there are splatters of paint on the sprinkler head bulb near bathroom W9

NOTE:
The facility is utilizing special locking arrangements (Delayed egress and North Carolina Special Locking , and controlled access). The facility currently has areas in buildings number 1, 3, and 9 that are not fully sprinklered nor provide smoke detection (fully automated, supervised fire suppression or fully automated, supervised fire detection system) tied into the hospital main Fire Alarm Control Panel (FACP) as required when utilizing special locking arrangements. Some areas not covered are listed below. Provider to check all spaces for verification and for submittal of Plan of Correction.



1. Main Hospital, Sprinkler heads were found in the facility were of the intermediate temperature rating of 200 degree F in place of the ordinary temperature rating of 155 degree F. Intermediate temperature heads were found in the following areas. The facility must provide documentation from the sprinkler designer noting the use of this particular rated sprinkler heads for this particular area.

Main Hospital, 6th floor mechanical, electrical room and date closet located in the center conference room.

2. Main Hospital, Service Level Concourse sprinkler heads are located above conduits and HVAC ductwork , this particular areas has sprinkler heads are being blocked not be an object on the side of the head but by the ductwork below the sprinkler heads.

3. Main Hospital, Service Level Concourse, does not have adequate sprinkler coverage. The existing sprinkler heads are located above the existing conduit and ductwork and not providing complete coverage of the corridor.

4. Main Hospital, 1st floor, ED, old electrical room/telecom room, there was not a sprinkler head in the telecom room located in the emergency department.

5. Main Hospital, document review, sprinkler system, library, the document review of the fire marshal ' s report dated July 27, 2011 from the main hospital indicated that there were sprinkler heads obstructed by book shelves. Staff indicated that the facility currently working on the issue. The facility must confirm the sprinkler coverage in the library provides adequate coverage by the sprinkler designer.


6. Main Hospital, Service level laundry and drying area, the sprinkler head near dryer # 2 is blocked by ductwork just above the light fixture in that space.


7. Rooms and/or areas were not provided with sprinkler coverage;
Main Hospital, Breezeway located outside leading from the courtyard and kitchen supply storage area.

8. Main Hospital, Service Level - Kitchen Walk-in cooler and freezes in the kitchen.

9. Main Hospital, Service Level - Kitchen) Electrical Room

10. Main Hospital, Service Level Main Electrical room accessible from the covered breezeway outside the kitchen storage area.

11. Main Hospital, Service Level - Kitchen Catering Closet next to kitchen electrical room

12. Main Hospital, Service Level - Pharmacy Walk-in cooler in the Pharmacy

13. Main Hospital, Service Level - Kitchen The Electrical closet located next to the pulper extractor

14. Main Hospital, Service Level - Concourse Electrical rooms NS001, NS002, NS003

15. Main Hospital, Service Level - Pharmacy There is an alcove located to the right of the walk-in refrigerator that is not properly covered by sprinkler coverage.

16. Main Hospital, Service Level - Pharmacy The FAP data chase outside pharmacy.

17. Main Hospital, Service Level - IS-UPS Room) The IS-UPS room.

The facility is utilizing special locking arrangements (Delayed egress and North Carolina Special Locking , and controlled access). The facility currently has areas in buildings number 1, 3, and 9 that are not fully sprinklered nor provide smoke detection (fully automated, supervised fire suppression or fully automated, supervised fire detection system) tied into the hospital main Fire Alarm Control Panel (FACP) as required when utilizing special locking arrangements. Some areas not covered are listed below. Provider to check all spaces for verification and for submittal of Plan of Correction.

1. Cape Fear Hospital, 1st floor, radiology storage, Confirm the sprinkler coverage in the first floor radiology storage room provides adequate coverage. This room was converted from an old dressing room with walls extending to the ceiling for each of the three dressing bays. The currently only one sprinkler head is in the space and is located in the back of the room.

2. Cape Fear Hospital, 3rd floor, Water Treatment room, the sprinkler head in this space is being blocked by the light fixture in that space.

3. Cape Fear Hospital, 3rd floor, the small MRI Electrical room, there was no sprinkler system coverage in the MRI electrical room. This room is not 2 hr Fire Rated Construction.

The facility is utilizing special locking arrangements (Delayed egress and North Carolina Special Locking , and controlled access). The facility currently has areas in buildings number 1, 3, and 9 that are not fully sprinklered nor provide smoke detection (fully automated, supervised fire suppression or fully automated, supervised fire detection system) tied into the hospital main Fire Alarm Control Panel (FACP) as required when utilizing special locking arrangements. Some areas not covered are listed below. Provider to check all spaces for verification and for submittal of Plan of Correction.

Zimmer Cancer Center, Microbiology area, there is no sprinkler coverage in the walk-in cooler as required.

1. Main Hospital, Sprinkler hot box for the fire pump, the tamper alarm failed to give a signal at the main fire control station that one of the four valves was in the closed position.

2. Main Hospital, Basement, The distribution dry sprinkler system, the dry part of the sprinkler system has a high and low pressure valve that is not currently electrically supervised. The pressure operated flow switch valve up stream is not electrically supervised.

Cape Fear Hospital, Basement, Sprinkler tamper alarm location LIN34, The sprinkler tamper alarm at that location failed to give a signal at the fire alarm control panel when tested.

Behavioral Health, the A/B Unit regularly manned station; this area does not have an emergency shut down switch for the air handler unit that services that area.

Cape Fear Hospital, document review, smoke dampers, the documentation review of the smoke dampers for this building indicated that there were 9 out of 70 ducts within the smoke wall that did not have smoke dampers as required.

Main Hospital, 1st floor, Radiology suite, this area did not have an emergency air handler shut down switch installed for the air hander for that space.

Medical Mall, the regularly manned station for this facility; this area does not have an emergency shut down switch for the air handler unit that services the hospital based provider area.

Zimmer Cancer Center, Penthouse, The duct detector for air handler number 1 did not have and access door installed in order to view the sampling tubes at that location.

1. Main Hospital, 1st floor, MICU, STICU and SVICU, there are items stored in the corridor that are neither used or moved including beds, blood pressure machines, intravenous bag poles.

2. Main Hospital, Service Level, Kitchen Area, The catering closet corridor door located near the electrical room was not self closing.

3. Main Hospital, Service Level, The IS EUS closet corridor door did not open 180 degrees and restricted the width of the by more than 7 inches when left open. This particular door opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

4. Main Hospital, Service Level Concourse, Patient bed and other equipment was stored in the exit corridor.


5. Main Hospital, 1st floor, ED Trauma Bay suite, The means of egress, which includes two doors in a single exit discharge path, from the emergency department trauma bay suite, were blocked with storage.

1. Women ' s and Children ' s, 3rd floor, Corridor # 2, the soiled tray holding room across from room 326 has a door that opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

2. Women ' s and Children ' s, 2nd floor, pediatrics electrical room, The double doors at that location open into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

3. Women ' s and Children ' s, 2nd floor, electrical room near exam rooms 1 and 2, The double doors at that location open into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

4. Women ' s and Children ' s, 3rd floor, small cabinets on the egress corridor, The cabinet ' s right leaf door swings into the corridor without a listed closure and the door does not swing 180 degrees but leaves a projection of approximately 12" into the corridor.

5. Women ' s and Children ' s, 3rd floor, ABC wings, There were unattended blood pressure machines plugged into the egress corridor on the A, B and C wings not in use.

6. Women ' s and Children ' s, Ground floor, the storage room across from the procedure room at NICU, the door for this room opens into the egress corridor without opening 180 degrees flat to the corridor wall no has a door closure installed to keep the door closed after being opened.

Cape Fear Hospital, 2nd floor, Water Treatment room, The double doors for the water treatment room opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

Rehabilitation Hospital, 1st floor, electrical room, the door for this room opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

Surgical Pavilion, 1st floor, Operating Room Back Hall, There was storage in the back exit corridor leading from the operating rooms surgical suites. This area was outside of the suite and does not allow for storage in this particular space.

Cape Fear Hospital, 1st floor, surgery suite at the soiled linen location , the door to the surgery side of soiled linen did not have positive latching.

1. Cape Fear Hospital, oxygen storage farm, the oxygen cylinders are not individually chained. The Cylinders are not protected from rusting as they are sitting on the concrete pad. The cylinder valves are not protected from extremes from weather.

2. Cape Fear Hospital, 2nd floor, O2 storage room, the second floor oxygen storage had partial tanks mixed with full tanks.

1. Main Hospital, 9th floor Clean Linen room, the facility had a mixture of full and empty oxygen cylinders in the full location in that space.

2. Main Hospital, 4th floor Clean Linen room, the facility had a mixture of full and empty oxygen cylinders in the full location in that space.


3. Main Hospital, Mezzanine kitchen level, the facility had contractor welding cylinders not individually chained in that space.


4.Main Hospital, oxygen storage farm, not all of the oxygen cylinders are individually chained. The cylinder valves are not protected from extremes from weather.

5. Main Hospital, Service level Patient Transport, in the oxygen storage area in the patient transport area oxygen was found mixed and not labeled full and empty.

Surgical Pavilion, Basement, Medical gas distribution area, this space has several cylinders that are not individually chained to prevent cylinders from moving in the case that the current chain around them is removed.

Women ' s and Children ' s, 1st floor, Med. Gas storage, The first floor medical gas storage room has several cylinders that are not individually chained to prevent cylinders from moving in the case that the current chain around them is removed.

Zimmer Cancer Center, Lab area, the carbon dioxide large cylinders in the lab are not individually chained to prevent cylinders from moving in the case that the current chain around them is removed.

Behavioral Health, generator annunciator, the audible signal for the generator annunciator did not indicate that the generator was running after conducting the loaded generator test at the facility.

Zimmer Cancer Center, Control Room, Generator annunciator, the generator annunciator did not give an indication that the generator was running under a load during the loaded test on the generator.

Rehabilitation Hospital, 2nd floor, restorative range, the restorative rang in the independent living area was not locked out to prevent the range from being accidentally turned on.