HospitalInspections.org

1. Main Hospital, 1st floor, ED Behavioral Health suite, the emergency department behavioral health suite currently exits into another suite. This Item is still wavered until 12/31/2012.

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. This Item is corrected

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.This Item is corrected.

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. This Item is corrected.

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. This Item is corrected.

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. This Item is corrected.

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. This Item is corrected.


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. This Item is corrected.


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. This item is wavered until 9/22/2012.

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

9. Main Hospital, Service Level - Kitchen) Electrical Room. This Item is corrected.

10. Main Hospital, Service Level Main Electrical room accessible from the covered breezeway outside the kitchen storage area. This item is wavered until 9/22/2012.

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

12. Main Hospital, Service Level - Pharmacy Walk-in cooler in the Pharmacy. This Item is corrected.

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

14. Main Hospital, Service Level - Concourse Electrical rooms NS001, NS002, NS003. This Item is corrected.

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. This Item is corrected.

16. Main Hospital, Service Level - Pharmacy The FAP data chase outside pharmacy. This Item is corrected.

17. Main Hospital, Service Level - IS-UPS Room) The IS-UPS room. This Item is corrected.

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. This item is wavered until 6/22/2013

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

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. This item is corrected

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


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. This item is wavered until 12/31/2012