HospitalInspections.org

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1.STICU Room # 11629 - Inactive leaf with no self closing device and self- latching. Exit access doors must provide latching with a single hand motion.(Approx 29 rooms/ and 2 add'l floors)

2. Family waiting room - STICU : Master switch will not release exit access door near 11681 Conf Room. Door did release as required with sensor and push pad.

3. Dutch doors to Pharmacy Office 10682 had no self closing and self-latching device on inactive leaf. Door must be arranged to provide latching with a single hand motion.

4. Corridor doors to patient rooms # 9130 and 7133 would not latch/nor smoke tight.

5. Patient Room 6020 - Corridor door inactive leaf is not self-closing and self-latching - (12 rooms on 6th floor).


Based on observation on follow-up survey 5/5/11 Remaining Waiver item:
Waiver Date 03/2/12

1.STICU Room # 11629 - Inactive leaf with no self closing device and self- latching. Exit access doors must provide latching with a single hand motion.(Approx 29 rooms/ and 2 add'l floors)

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. This facility utilizes Special Locking (Magnetic) devices through out in various locations (Delayed egress, Access Control, and NC Special Locking):

The facility is not equipped through-out (100%) with an automatic, supervised fire suppression system (Sprinkler) or an automatic, supervised smoke detection section or a combination there-of.

Note:The facility has budgeted and prepared design drawings to be submitted to DHSR-Construction Section for review and approval to complete 100% sprinkler system covering remaining areas (approx 25%) within the next 4 years.

2. Corridor doors near room 10660 equipped with delayed egress lock - lock required more than 15 lbs of pressure to activate unlocking mechanism. When activated the Card swipe would reactivate/interrupt the locking device during the 15 seconds delayed egress time frame. Delayed egress doors near Elev 33 & 34 @ Rm 3669 would auto relock when card reader was activated by staff card.

3. Delayed egress lock @ entry to NSICU near room 9672 Required excessive force (more than 15 lbs) to activate unlocking mechanism.

4. Incomplete dynalock on stairway door near room 9929 - device is an electromagnetic locking device used as a signaling device - device is capable of being altered and used as a locking device.

5. Corridor 9-A, Exit door equipped with Magnetic Locking device found not to be activated. If not utilized, magnetic hardware must be removed so not to be accidently re-activated.

6. Exit Stairwell # 18, T-wing, Exit discharge door required greater than 15 lbs of pressure to open door. (No magnetic lock involved)

7. 3 rd floor - Fire doors @ Cardiology Registration were equipped with NC Special Locking with no override switch @ the door or Master switch @ Nurses' station

8. Loading Docks - No guard rails @ when delivery trucks were not present.


Based on observation on follow-up survey 5/5/11 Remaining Waiver item:
Waiver Date 03/4/2016

1. This facility utilizes Special Locking (Magnetic) devices through out in various locations (Delayed egress, Access Control, and NC Special Locking):

The facility is not equipped through-out (100%) with an automatic, supervised fire suppression system (Sprinkler) or an automatic, supervised smoke detection section or a combination there-of.

Note:The facility has budgeted and prepared design drawings to be submitted to DHSR-Construction Section for review and approval to complete 100% sprinkler system covering remaining areas (approx 25%) within the next 4 years.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Stairway #18, Level 2 - No signage to indicate continuance of egress to exit discharge.

2. Stairway #18 - Exit discharge contains less than 6 ft 8 inches of headroom from top of stair tread to landing above. The height between the finished floor and ceiling of stair landing is less than seven feet and six inches as required under the 1982 Life Safety Code; NFPA 101 edition. This area of the facility was constructed in year 1991 according to hospital data; and serves multiple patient floors.

3. Stair # 24, Fire Door will not latch, Beside room 1660.

4. 6th Floor , 6-L/S, Door to Stairwell 6th floor to 5th floor did not close/latch/seal as required.

Based on observation on follow-up survey 5/5/11 Remaining Waiver item:
Waiver Date 03/4/2012

2. Stairway #18 - Exit discharge contains less than 6 ft 8 inches of headroom from top of stair tread to landing above. The height between the finished floor and ceiling of stair landing is less than seven feet and six inches as required under the 1982 Life Safety Code; NFPA 101 edition. This area of the facility was constructed in year 1991 according to hospital data; and serves multiple patient floors.

Based on observation and staff records on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Relative humidity levels were found to be less than 35% in OR# 1 and OR #2. This data was provided by hospital reports.


Based on observation on follow-up survey 5/5/11 Remaining Waiver item:
Waiver Date 12/31/2012