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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.

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.

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)

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, 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. 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.

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. 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, 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

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.

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.

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.

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.

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.

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.