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Based on observation, on March 15, 2011 at approximately 1:00pm onward, doors to patient rooms in third floor CCU corridor walls are equipped with bi-fold inactive door leaf. The doors require greater than a single hand motion to close and latch doors in an emergency. The inactive door leaf is not equipped with self-closing hardware and self-latching hardware.

Based on observation, on March 15, 2011 at 1:00 PM onward, the following was non-compliant:

a. the first floor door in Acute Radiology to the spiral staircase leading to ground floor CV unit was not self closing.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the following sprinkler system components were noncompliant:

a. on March 16, 2011 at approximately 5:00am onward, cross corridor smoke barrier doors are not equipped with vision panels - doors from labor and delivery located on second floor.

Based on observation, on March 16, 2011 at 8:00AM onward, the following was non-compliant:

a. in the ED department one smoke doors did not latch tight in its frame and one door was not equipped with self closing device. (center section)

Based on observation, on March 15, 2011 at approximately 1:00pm onward, hazardous areas in the following locations are non-compliant:

a. central service storage room, located on ground floor, has no fire dampers or other means to maintain required one hour enclosure at mechanical duct penetrations.

b. hot water room located on ground floor - doors are not self-closing and latching.

c. ground floor - kitchen chemical cleaning storage with flammable storage inside - doors are not self-closing and latching and door was not rated.

d. storage room at loading dock outside kitchen area is not one hour enclose or sprinklered.

e. conduit penetration in the ceiling in ground floor paper storage room was not sealed.

f. there is an excessive gap between the door and the floor to the hazardous storage room where the gallon containers of ethel alcohol are located.

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.


2. Based on observation, on March 15, 2011 at approximately 1:00pm onward, the facility is equipped with incomplete electromagnetic locking arrangements on cross corridor doors throughout as follows:

a. ED - corridor behind emergency department is equipped with incomplete access-controlled egress hardware. There is no sensor to unlock the door in the direction of egress. On March 16, 2011 at approximately 9:15am the locking system did not release with activation of the building fire alarm system - this action constitutes an immediate jeopardy to the health and safety of all occupants requiring egress in the subject area. The hospital administration was notified at approximately 1:00pm after conferral with health care survey team and supervisory authority. The immediate jeopardy was abated by hospital engineering staff at approximately 9:30am by removing noncompliant locking devices from subject doors.

b. second floor near elevators - the facility utilizes delayed egress locks and NC special locking arrangements with remote switches in the same egress path.

c. CCU unit located on third floor - lack of master release switch located at nurse's station outside of CCU Unit, and switches adjacent to doors are greater than three feet from cross corridor doors.

d. first floor near physician call room - special locking arrangement does not comply with delayed egress, access controlled or NC special locking arrangement requirements. Locks release with the activation of a push switch, fire alarm activation, and loss of power.

B. Based on observation, on March 15, 2011 at approximately 1:00pm onward, the exit discharge across fourth floor roof is incomplete. The discharge path is not bound by guardrails from the patient care area to the stair accessible from the roof.

C. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there is a steel chain secured across the handrails of stair serving fourth floor exit across roof. The chain obstructs stair egress path from the fourth level - located inside stair at third floor CCU area.

Based on observation, on March 16, 2011 at 8:00AM onward, the following was non-compliant:

a. a dead end corridor greater than 30 exists in the ED department located next to clean supply room #3

Based on observation, on March 15, 2011 at approximately 1:00pm onward, emergency lighting is incomplete in the following areas:

a. exit discharge near room 449 - single bulb, point source light fixture is not adequate for lighting to the publicway.

b. fourth floor corridor near room 421 - all lighting is controlled by wall-mounted switches. Emergency lighting is required to be connected to unswitched circuit supplied from the Life Safety Branch of the essential electrical system.

c. exit discharge from stair #4 - area is not covered by emergency lighting to the publicway.

d. interior courtyard lighting at first floor old smoking area - there are no lights connected to the Life Safety Branch of the essential electrical system. At approximately 6:00am, on March 16, 2011, the lights in operation were verified to be connected to the normal power distribution system.

e. battery operated emergency lighting was not available in the main electrical/generator room.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, exit directional signs are incomplete due to the following;

a. lack of exit sign above cross corridor fire doors near old smoking area - located in the Sutton Building.

b. lack of exit directional sign at corridor beyond first floor fire doors between hospital and business occupancy - near old smoking area.

Based on observation, on March 16, 2011 at approximately 5:00am onward, the fire alarm system is noncompliant due to the following:

a. lack of smoke detector in room containing main fire alarm control panel - located in Sutton Building

b. lack of a trouble signal with disconnection of phone line from main fire alarm control panel - signal does not register at remote panel located in security room.

Based on observation, on March 16, 2011 at 8:00AM onward, the following was non-compliant:

a. the smoke duct detector located in in air handler unit #5 in mechanical room #1 was not clean and maintained in good condition.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, there are sprinklers missing in the following areas:

a. ceiling above upper stair landing, and below lower stair landing - stair #1

b. walk-in cooler and freezers in the kitchen area.

Based on observation, on March 16, 2011 at approximately 5:00am onward, there is no electrical supervision of sprinkler control valves in the following areas:

a. post indicator valve at fenced area outside of boiler room.

b. accelerator valve at new ED.

c. pressure switch valve for dry-pipe system near ER canopy.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the following sprinkler system components were noncompliant:

a. lack of greased valve stems for main sprinkler control valves located in pit serving outpatient pavilion.

b. mechanical room #10, phone room and CV Mechanical room located on ground floor, are equipped with a sprinkler head rated for 200 degrees Fahrenheit. There are no heating sources within space to justify excessive rating above expected ambient temperatures.

c. dry system near ER canopy is not equipped with low air pressure supervision and pressure gauge.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the mechanical systems are noncompliant due to the following:

a. lack of service access opening for verification of fire damper installations or other means of maintaining rated enclosure of duct penetration of central service storage room - located on ground floor.

b. air handling unit #13, and #16 does not have a manual shut-down switch at a supervised station(Sutton Building)

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the soiled linen chute is noncompliant due to the following:

a. fire door assembly is blocked open at ground floor level.

b. fire door to soiled linen room terminal room is less than 1.5 hour rated door - existing door is forty-five minute rated.(Ground floor level)

A. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there are impediments not in immediate and continuous use in the corridor near room 447.

B. Based on observation, on March 15, 2011 at approximately 1:00pm onward, cross-corridor smoke doors protrude greater than seven inches into the required egress path in the fully open position. Doors are located near room 447.

C. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there is a sink mounted on the third floor CCU Unit corridor wall - the sink obstructs required corridor width and protrudes greater than three and one-half inches from corridor wall. The unit is not designed as a patient care suite.

D. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there are impediments not in immediate and continuous use in the operating unit corridors located on the first floor. The operating room area is not designed as a patient care suite - existing corridors may not be used to store equipment and other objects.

E. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there is a rooftop unit condensate drain obstructing required rooftop egress serving the fourth floor patient area.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, medical gas systems are noncompliant due to the following:

a. the oxygen manifold system contains cylinders that are not secured individually and protected from extremes of weather - the cylinders are exposed to direct sun and drifting precipitation.

b. empty and full oxygen cylinders are stored in the same rack - located in third floor CCU soiled utility room. Cylinders must not be stored in soiled utility rooms.

Based on observation, on March 16, 2011 at 8:00AM onward, the following was non-compliant:

a. the one gallon containers of 200 proof ethel alcohol located in the pharmacy were not stored in rated cabinets.

Based on observation, on March 16, 2011 at approximately 5:00am onward, the essential electrical system is noncompliant due to the following:

a. emergency power system required approximately fifteen seconds to restore power during loss of normal power to the Life Safety Branch transfer switch.

b. generator annunciator panels located in the security room are not connected to provide audible and visual signals in accordance with NFPA 99; 1999 edition. Panel did not indicate emergency power system supplying load during loss of normal power to Life Safety Branch transfer switch.

c. generator annunciator panelboard serving the outpatient pavilion is not equipped with a test switch - panel did not indicate emergency power system supplying load during loss of normal power to the Life Safety Branch transfer switch.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the required electrical systems were incomplete due to the following:

a. broken lens on wet location rated fixture - exit discharge light serving stair #2.

b. circuit directory for Life Safety Branch panelboard serving fourth floor is not labeled to indicate devices served.

c. unit heater serving sprinkler riser room is wired to the normal power distribution system - located in outpatient pavilion.

d. circuit #16 in the Life Safety Branch panelboard serves the nurse call system - nurse call system is not permitted to be wired to the Life Safety Branch system.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, dumbwaiter area at ground level has gaps between meeting edges of dumbwaiter doors.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, doors to patient rooms in third floor CCU corridor walls are equipped with bi-fold inactive door leaf. The doors require greater than a single hand motion to close and latch doors in an emergency. The inactive door leaf is not equipped with self-closing hardware and self-latching hardware.

Based on observation, on March 15, 2011 at 1:00 PM onward, the following was non-compliant:

a. the first floor door in Acute Radiology to the spiral staircase leading to ground floor CV unit was not self closing.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the following sprinkler system components were noncompliant:

a. on March 16, 2011 at approximately 5:00am onward, cross corridor smoke barrier doors are not equipped with vision panels - doors from labor and delivery located on second floor.

Based on observation, on March 16, 2011 at 8:00AM onward, the following was non-compliant:

a. in the ED department one smoke doors did not latch tight in its frame and one door was not equipped with self closing device. (center section)

Based on observation, on March 15, 2011 at approximately 1:00pm onward, hazardous areas in the following locations are non-compliant:

a. central service storage room, located on ground floor, has no fire dampers or other means to maintain required one hour enclosure at mechanical duct penetrations.

b. hot water room located on ground floor - doors are not self-closing and latching.

c. ground floor - kitchen chemical cleaning storage with flammable storage inside - doors are not self-closing and latching and door was not rated.

d. storage room at loading dock outside kitchen area is not one hour enclose or sprinklered.

e. conduit penetration in the ceiling in ground floor paper storage room was not sealed.

f. there is an excessive gap between the door and the floor to the hazardous storage room where the gallon containers of ethel alcohol are located.

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.


2. Based on observation, on March 15, 2011 at approximately 1:00pm onward, the facility is equipped with incomplete electromagnetic locking arrangements on cross corridor doors throughout as follows:

a. ED - corridor behind emergency department is equipped with incomplete access-controlled egress hardware. There is no sensor to unlock the door in the direction of egress. On March 16, 2011 at approximately 9:15am the locking system did not release with activation of the building fire alarm system - this action constitutes an immediate jeopardy to the health and safety of all occupants requiring egress in the subject area. The hospital administration was notified at approximately 1:00pm after conferral with health care survey team and supervisory authority. The immediate jeopardy was abated by hospital engineering staff at approximately 9:30am by removing noncompliant locking devices from subject doors.

b. second floor near elevators - the facility utilizes delayed egress locks and NC special locking arrangements with remote switches in the same egress path.

c. CCU unit located on third floor - lack of master release switch located at nurse's station outside of CCU Unit, and switches adjacent to doors are greater than three feet from cross corridor doors.

d. first floor near physician call room - special locking arrangement does not comply with delayed egress, access controlled or NC special locking arrangement requirements. Locks release with the activation of a push switch, fire alarm activation, and loss of power.

B. Based on observation, on March 15, 2011 at approximately 1:00pm onward, the exit discharge across fourth floor roof is incomplete. The discharge path is not bound by guardrails from the patient care area to the stair accessible from the roof.

C. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there is a steel chain secured across the handrails of stair serving fourth floor exit across roof. The chain obstructs stair egress path from the fourth level - located inside stair at third floor CCU area.

Based on observation, on March 16, 2011 at 8:00AM onward, the following was non-compliant:

a. a dead end corridor greater than 30 exists in the ED department located next to clean supply room #3

Based on observation, on March 15, 2011 at approximately 1:00pm onward, emergency lighting is incomplete in the following areas:

a. exit discharge near room 449 - single bulb, point source light fixture is not adequate for lighting to the publicway.

b. fourth floor corridor near room 421 - all lighting is controlled by wall-mounted switches. Emergency lighting is required to be connected to unswitched circuit supplied from the Life Safety Branch of the essential electrical system.

c. exit discharge from stair #4 - area is not covered by emergency lighting to the publicway.

d. interior courtyard lighting at first floor old smoking area - there are no lights connected to the Life Safety Branch of the essential electrical system. At approximately 6:00am, on March 16, 2011, the lights in operation were verified to be connected to the normal power distribution system.

e. battery operated emergency lighting was not available in the main electrical/generator room.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, exit directional signs are incomplete due to the following;

a. lack of exit sign above cross corridor fire doors near old smoking area - located in the Sutton Building.

b. lack of exit directional sign at corridor beyond first floor fire doors between hospital and business occupancy - near old smoking area.

Based on observation, on March 16, 2011 at approximately 5:00am onward, the fire alarm system is noncompliant due to the following:

a. lack of smoke detector in room containing main fire alarm control panel - located in Sutton Building

b. lack of a trouble signal with disconnection of phone line from main fire alarm control panel - signal does not register at remote panel located in security room.

Based on observation, on March 16, 2011 at 8:00AM onward, the following was non-compliant:

a. the smoke duct detector located in in air handler unit #5 in mechanical room #1 was not clean and maintained in good condition.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, there are sprinklers missing in the following areas:

a. ceiling above upper stair landing, and below lower stair landing - stair #1

b. walk-in cooler and freezers in the kitchen area.

Based on observation, on March 16, 2011 at approximately 5:00am onward, there is no electrical supervision of sprinkler control valves in the following areas:

a. post indicator valve at fenced area outside of boiler room.

b. accelerator valve at new ED.

c. pressure switch valve for dry-pipe system near ER canopy.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the following sprinkler system components were noncompliant:

a. lack of greased valve stems for main sprinkler control valves located in pit serving outpatient pavilion.

b. mechanical room #10, phone room and CV Mechanical room located on ground floor, are equipped with a sprinkler head rated for 200 degrees Fahrenheit. There are no heating sources within space to justify excessive rating above expected ambient temperatures.

c. dry system near ER canopy is not equipped with low air pressure supervision and pressure gauge.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the mechanical systems are noncompliant due to the following:

a. lack of service access opening for verification of fire damper installations or other means of maintaining rated enclosure of duct penetration of central service storage room - located on ground floor.

b. air handling unit #13, and #16 does not have a manual shut-down switch at a supervised station(Sutton Building)

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the soiled linen chute is noncompliant due to the following:

a. fire door assembly is blocked open at ground floor level.

b. fire door to soiled linen room terminal room is less than 1.5 hour rated door - existing door is forty-five minute rated.(Ground floor level)

A. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there are impediments not in immediate and continuous use in the corridor near room 447.

B. Based on observation, on March 15, 2011 at approximately 1:00pm onward, cross-corridor smoke doors protrude greater than seven inches into the required egress path in the fully open position. Doors are located near room 447.

C. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there is a sink mounted on the third floor CCU Unit corridor wall - the sink obstructs required corridor width and protrudes greater than three and one-half inches from corridor wall. The unit is not designed as a patient care suite.

D. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there are impediments not in immediate and continuous use in the operating unit corridors located on the first floor. The operating room area is not designed as a patient care suite - existing corridors may not be used to store equipment and other objects.

E. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there is a rooftop unit condensate drain obstructing required rooftop egress serving the fourth floor patient area.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, medical gas systems are noncompliant due to the following:

a. the oxygen manifold system contains cylinders that are not secured individually and protected from extremes of weather - the cylinders are exposed to direct sun and drifting precipitation.

b. empty and full oxygen cylinders are stored in the same rack - located in third floor CCU soiled utility room. Cylinders must not be stored in soiled utility rooms.

Based on observation, on March 16, 2011 at 8:00AM onward, the following was non-compliant:

a. the one gallon containers of 200 proof ethel alcohol located in the pharmacy were not stored in rated cabinets.

Based on observation, on March 16, 2011 at approximately 5:00am onward, the essential electrical system is noncompliant due to the following:

a. emergency power system required approximately fifteen seconds to restore power during loss of normal power to the Life Safety Branch transfer switch.

b. generator annunciator panels located in the security room are not connected to provide audible and visual signals in accordance with NFPA 99; 1999 edition. Panel did not indicate emergency power system supplying load during loss of normal power to Life Safety Branch transfer switch.

c. generator annunciator panelboard serving the outpatient pavilion is not equipped with a test switch - panel did not indicate emergency power system supplying load during loss of normal power to the Life Safety Branch transfer switch.

Based on observation, on March 15, 2011 at approximately 1:00pm onward, the required electrical systems were incomplete due to the following:

a. broken lens on wet location rated fixture - exit discharge light serving stair #2.

b. circuit directory for Life Safety Branch panelboard serving fourth floor is not labeled to indicate devices served.

c. unit heater serving sprinkler riser room is wired to the normal power distribution system - located in outpatient pavilion.

d. circuit #16 in the Life Safety Branch panelboard serves the nurse call system - nurse call system is not permitted to be wired to the Life Safety Branch system.