HospitalInspections.org

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 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