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Main Hospital Building 1st floor; Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. The office located next to freezer #2 has unsealed penetrations in the rated walls wall that were not sealed in order to maintain the require rating of the room.

2. In the steam room located in Same Day Surgery the rated wall on the right side as you enter the room had unsealed areas and does not maintain the required fire resistance rating of the area.

3. The electrical chase in CT Room #1 was not sealed in order to maintain the required fire resistance rating of the area.

4. 2nd floor, the surgery services educators office is a one hour protected space, and the doors to the space has a gap greater than 1/8th of an inch between the door and the inactive leaf next to the door.

Main Hospital Building Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. 1st floor, the corridor doors located on the hall in front of main pharmacy were found blocked open with construction crates preventing the doors from closing.

2. 2nd floor, the neuroscience nurse practitioner office had an impediment to closing the door as the door was wedged open.

3. 1st floor, the anesthesia storage room door did not close and latch when tested.

4. 1st floor, the anesthesia office door did not close and latch when tested

5. 1st floor, the pathology/ lab door did not close and latch when tested.

Outpatient Rehab Building based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. The hospital based area; the door to the waiting room was prevented from closing by a kick down installed on the door.

Main Hospital Building ; Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. 1st floor, Pre-Op Suite #8 was incomplete as it was seen on the Life Safety Plan drawings. The Pre-Op suite did not have cross-corridor smoke doors installed in order to separate the suite from the exit corridor next to Cath Lab.

2. Basement, the materials management double doors at that location did not close smoke tight as the astragal for the door prevented the door from closing smoke tight.

3. 3rd floor, there were unsealed penetrations in the rated smoke wall at the employees brake room looking to the patient room.

4. 2nd floor, there were unsealed penetrations in the rated smoke wall at the nurses managers office at the back corner wall looking at the mechanical room.

Main Hospital Buidling; Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. 1st floor, the storage room located on the right side of the Cath Lab hall next to the exit door to the main corridor was not equipped with a self closing device.

2. Basement, the Operating Room (OR) Equipment Storage Room in the basement was blocked preventing the door from closing.

3. 1st floor, the corridor door to vendor storage in the basement was wedged open preventing the door from closing.

4. 1st floor, dietary dry storage area had impediments to the door closing as there was a jacket covering the latching mechanism.

5. Basement, the large linen room in the basement had its door wedged open preventing the door from closing.

Outpatient Rehab Building based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. The hospital based area, the large storage/ linen room is greater than 100 square feet and is not a one hour protected space.

2. The hospital based area; the large gift shop storage room is greater than 100 square feet and is not a one hour protected space.

Main Hospital Building loading doc area; Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. The loading dock. The loading dock area did not have fall protection installed when trucks are not in place loading or unloading items. The path of egress lead persons to the loading dock for egress from the building.

Main Hospital Building 1st floor; Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. 1st floor, exit egress corridor was blocked from the respiratory therapy office toward the ICU area.

2. 1st floor exit egress corridor near the pharmacy was under construction and lead to a dead end corridor (this item was corrected before the end of the survey)

3. 1st floor, emergency room registration, the staff at this location was not familiar with the door release master switch at the North Carolina Special Locking doors in that area.

4. 1st floor, emergency room registration, the master door release switch at this location did not release the North Carolina Special Locking doors in that area. (This item was corrected before the end of the survey)

5. 1st floor, emergency room registration, the master door release switch for the North Carolina Special Locking at this location was not properly identified.

6. 1st floor administration, the door release mechanism in the vicinity of the North Carolina Special Locking door at administration side leading into emergency room registration did not release the door when tested. (This item was corrected before the end of the survey)

7. 1st floor administration, the North Carolina Special Locking doors leading to the emergency department registration area did not release with activation of an automatic fire alarm system when tested. The door did release with activation of emergency door release switch and under normal operation. (This item was corrected before the end of the survey)

8. 1st floor, the Access Controlled Egress doors leading to Same Day surgery from mammography did did not work when tested as the sensor provided on the egress side did not release the door at the location.

9. 1st floor, the North Carolina Special Locking systems doors leading to X-Ray from the MRI area did not have a master release switch installed at a 24 hour manned area.

10. 1st floor, the North Carolina Special Locking systems at leading from X-Ray to the emergency department had an exit directional sign leading into the suite. The North Carolina Special Locking system at that location did not have a master release switch switch installed at a 24 hour manned area.

11. 1st floor, the "PUSH TO EXIT" manual release device located at the Access Controlled Egress Doors leading to the B1 elevator from the CSR area did not release the doors when tested.

Hematology Oncology and Pain Clinic Building based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. Hospital based area; the egress emergency lighting for the hospital based area is not complete in the corridor.

Outpatient Rehab Building based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. Hospital based area; the egress emergency lighting for the hospital based area is not complete in the corridor.

Wound Healing Building based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. Hospital based area; the egress emergency lighting for the hospital based area is not complete in the corridor.

Main Hospital Building 1st floor; Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. 1st floor, Exit directional sign is incomplete from the corridor between Suite 5 & 7 at the main corridor junction.
2. 1st floor, Exit directional signage is incomplete from the respiratory therapy office toward the ICU area.
3. 1st floor, the area leading from X-Ray to the emergency department has an exit directional sign that leads persons into the emergency department suit. The facility can not lead persons into a suit for egress.

Main Hospital Building Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. Fire Alarm Control Panel, the facility did not have item " c " from the North Carolina Special Locking Arrangements 1003.3.1.8.5. A wiring diagram and system components location map shall be provided under glass adjacent to the fire alarm panel.

2. 1st floor, there was no strobe activation in the hallway that includes the Family Chapel with activationof FA System.

Main Hospital Building Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. 1st floor, dietary dry storage closet has solid shelves in that space that does not allow the sprinkler head in that space to cover that area.

Wound Healing Building based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. The hospital based area; the canopy is not currently sprinklered. The separation for that canopy and the hospital based area was not verified.

Main Hospital Building Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. Documentation review, the facility could not show documentation that the 5 year obstruction test was preformed.

2. Basement, the small dry pipe sprinkler system did not have its fire alarm switch electrically supervised.

3. 3rd floor, the third floor tamper alarm on the sprinkler system in the stairwell did not give a supervisory signal when tested.

4. 2nd floor, the electrical room near the nurse ' s station has a sprinkler head in the space that had paint on the heat sensitive element.

Wound Healing Building based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. Hospital based area; the back flow preventer in the hot box near the post indicator valve does not have the valves electronically supervised.

Main Hospital Building; Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. 1st Floor, The corridor door separating the lobby from Pre-Op did not close smoke tight. There was an excessive gap between the double doors greater than 1/8 of an inch.

2. 1st Floor, 1st floor, Equipment not in use was found stored in the corridor near the Cath lab.

3. 1st floor, Equipment not in use was found stored in the corridor near the Cath lab.

4. 1st floor, There were beds and other equipment found stored in the exit corridor that were not in use at the Pre-Post OP area.

5. 1st floor, There were beds and other equipment stored in the exit corridor that wee not in use near the Radiology area.

6. 4th floor, the wall computer stations (Enovate) did not retract automatically after being opened at the station near room 4208. This condition leaves an impediment into the egress corridor all devices must be checked for this operation.

7. 3rd floor, the wall computer stations (Enovate) did not retract automatically after being opened at the station near room 3224. This condition leaves an impediment into the egress corridor all devices must be checked for this operation.

8. 4th floor the NC/TV room door did not open into the egress corridor 180 degrees flat to the adjacent wall nor was equipped with a door closure to return the door to the closed position after being opened.

9. 1st floor, There were items stored in the exit egress corridor that were not in use on the radiology corridor.

10. 1st floor, There were items stored in the exit egress corridor that were not in use on the OR back hallway.

11. 2nd floor, the wall mounted cabinet did not retract after placed in the down position near room 2228.

Pain Clinic Building based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. Pain Clinic, the pain clinic secondary exit egress had impediments to exiting in the path of egress. (Large boxes) (This item was corrected before the end of the survey)

Main Hospital Building ; Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
1. 5th floor, clean utility/ oxygen storage room had no signage noting the full and empty oxygen cylinders. (This item was corrected before the end of the survey)

2. 5th floor, clean utility/ oxygen storage room had free standing oxygen cylinder not in a proper stand in the space.

3. 2nd floor. Respiratory room had oxygen storage without proper signage noting such storage.

4. liquid oxygen storage outside, The " H " cylinders at the bulk liquid oxygen area were not protected from rusting as the cylinders at that location were not off the ground.

5. The " H " cylinders at the bulk liquid oxygen are were not protected from extremes of weather as they did not have a cover to the cylinder valves from extremes of weather.

6. 1st floor, The OR equipment room had a mixture of full and empty oxygen cylinders mixed in the same enclosure.

Main Hospital Building 1st floor; Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

1. The Smoke Dampers located in the smoke wall at the 5th floor did not close upon activation of the fire alarm by smoke head. (This items was corrected before the end of the survey)


2. The Smoke Dampers located in the smoke wall at the 4th floor did not close upon activation of the fire alarm by smoke head. . (This items was corrected before the end of the survey)


3. The Smoke Dampers located in the smoke wall at the 3rd floor did not close upon activation of the fire alarm by smoke head. . (This items was corrected before the end of the survey)


4. The Smoke Dampers located in the smoke wall at the 2nd floor did not close upon activation of the fire alarm by smoke head. . (This items was corrected before the end of the survey)

Main Hospital Building Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:

1. The generator annunciation panel did not have monitoring of the safety indications and shutdowns at a work site readily observable by personnel (regular manned station as required). The emergency power system annunciation was at the engineering department with the proper indications and shutdowns but that area is not manned in the overnight shift of the hospital.