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Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following items were noncompliant, the specific findings include:

a. Doors in the following locations did not close and latch to prevent the passage of smoke: 9152, 9165 , 5164, 5163, 5324, 5318, 4702, 4319, 3318, 3537, 1st floor kitchen stock entrance from dock, 1st floor left door for tray line entrance.
b. Soiled Utility Room #3455 had tape over the keeper hardware not allowing the door to latch.
c. Bathroom by elevator #17 & #18 was missing a strike plate and had a throw latch.
d. Dutch doors next to 2555 in behavioral health had an air gap between the top and bottom doors.

A. Based on observation on 07/27/2010 the door to the break room opens on to an egress corridor and had tape over the keeper so the door could not latch.

Based on the observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following items were noncompliant, specific findings include: There are unsealed penetrations in rated wall assemblies in the following locations:

a. above the cross corridor doors near the nurses station on the 7th floor East
b. above the cross corridor doors near the nurses station on the 6th floor East
c. above the ceiling in the bathroom area at the elevator vestibule where HVAC construction was halted
d. above the ceiling near room 6118 unsealed penetrations in the rated wall assembly.
e. above the ceiling in Central Supply.
f. in the HVAC space which is inside the main penthouse complex

Based on observation on 07/27/2010 the following items were noted as noncompliant:

a. fire doors on the sixth floor near room 6127 did not close smoke tight
b. smoke doors near the fire alarm room on the fourth floor did not close smoke tight along with other smoke doors in the facility.
c. The right leaf of fire doos near room 5324 did not close and latch.
d. There was a gap in the smoke doors next to nourishment room 4697.
e. The fire doors next to the 3rd floor stairwell and near elevators #17 & #18 did not close and latch tightly in it's frame.

Based on observation on 07/27/2010 there were hazardous areas located through out the facility that the corridor door did not close and latch to maintain the one hour rating of the space. These rooms included but are not limited to soiled linen rooms, storage rooms, and other hazardous areas

A. Based on observation on 07/27/2010 the door to the soiled linen room did not have a closer.


13743

A. Based on observation on 07/27/2010 there were three rooms in the facility that required more than one motion of the hand to exit the room.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant,

a. the code requirement was not met for exiting at the loading dock as there was a drop off of more than 30 inches with no handrail present.

Based on the observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following items were noncompliant. The facility has electromagnet locking mechanisms and systems in several locations. These special locking arrangements being utilized must comply with NFPA 101 Delayed-Egress Locks[7.2.1.6.1] or NCSBC Special Locking Arrangements [1003.3.1.8.5] specific findings include:

a. The kill switch at the door leading from endoscopy to behavioral health does not meet either requirement as it automatically relock after a few seconds after the door is closed. The door must relock only by manual means.
b. In some areas you must pass through more than one delayed egress in order to exit the facility.
c. One door did not release when pressure was applied to the release device.
d. Where N.C. Special Locking was used in some areas there were no master release switches, one master release switch failed to release the doors.
e. Some staff interviewed did not know about the door master release switch.

f. Delayed egress doors on the 9th floor would relock without being manually reset.
g. In the E.D. Blue Zone keyed electromegnetic locks were being used and the staff did not carry keys on them, the key was in a drawer on a key ring with other keys.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant, specific findings include a single bulb fixture at the 1st floor radiology imaging exit.

Based on the observations and staff interview during the survey dated 7/27/2010 onward to 8/2/2010 The following exit discharge illumination was observed as noncompliant as the specific findings include:

1. No exit discharge lighting leading from the stairwell next to the elevators to the public way.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant; the exit stairwell light in south general next to room 4324 was not functioning properly.

A. Based on observation on 08/01/2010 the following was found to be noncompliant: The exit discharge signage directing persons out the stairwells to the public way was not complete.

Based on the observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following exit directional signage was noncompliant, specific findings include:

a. The exit directional sign leading from the end of the South hall near room 4327 directs persons to the elevator vestibule and not the egress stairwell

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant,

a. Whitaker building did not have a Fire Department Connection (FDC) Sign at the fire department connection point.

A. Based on observation on 07/27/2010 the following was found to be noncompliant: there were no electrically supervised tamper alarms on the main sprinkler valves located in the pit at the street.

Based on observation on 07/27/2010 the control valves for the sprinkler back - flow preventer located in the pit in the front of the facility did not have electrically monitored tamper alarms installed on them.

Based on observation on 07/27/2010 the following was found noncompliant:

a. The back-flow preventers for the sprinkler systems that did not have tamper alarms installed on the control valves located in pits on the out side of the building along with the P.I.V. located at the loading docks.
b. The dry sprinkler system at the loading dock has a valve located up stream of the pressure operated flow switch . this valve has the handle removed but it must be electrically supervised.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant,
a. there was not a available shut down switch for the three air handling units (AHU) at a manned station.
b. The AHU on the 2nd floor outside the break area did not shut down with fire alarm activation.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant; there was not a available shut down switch for the air handling units (AHU) at a manned station.

Based on observation on 07/27/2010 the following was found to be noncompliant:

a. There were no access doors for the duct detectors in the basement equipment room.
b. The air handlers did not shut down upon activation of the fire alarm when duct detector was tested.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following items were noncompliant:

a. soiled linen chute in room 3130, 5108, 4733 did not close and latch automatically when tested
b. trash chute in room 5109, 3109 did not close and latch automatically when tested

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following items were noncompliant,

There are doors that open into the egress corridor that do not open 180 degrees or have door closures to keep the doors closed after being opened. These locations are noted:

a. 9th floor East linen closet and electrical room in front of the nurse ' s station
b. 8th floor East linen closet
c. 7th floor East electrical room in front of the nurse ' s station
d. 5th floor East electrical room and telecommunications in front ot the nurse ' s station
e. Storage room next to room 5555
f. Storage room 4674A
g. 4th floor East clean linen and electrical room in front of the nurse ' s station
h. Environmental services door 3605
i. food cart stored unattended near room 9117
j. throughout the facility there wall mounted charting cabinets that did not retract when not in use
k. 2nd floor of Whitker had wall mounted cabinets near rooms 2603, 2607, 2615, 2619 that did not swing 180 degrees.
l. OR had items stored in the required exit areas.

Based on the observations and staff interview during the survey dated 7/27/2010 onward to 8/2/2010 The following items were observed as noncompliant as the specific findings include:

a. The compressed gas room number 2 in the blood lab did not have its cylinders individually secured.
b. oxygen storage on the North 5th floor had a mix of full and empty cylinders in the same storage rack.
c. oxygen cylinders stored at the loading dock area were not individually secured
d. the oxygen storage in theWhitaker Building had had a mix of full and empty cylinders in the same storage rack

Based on the observations and staff interview during the survey dated 7/27/2010 onward to 8/2/2010 The following was observed as noncompliant as the specific findings include:

1. The oxygen storage room on the exterior of the building did not have its cylinders individually secured.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant, the pixus unit in the OR Supply room was plugged into normal power.

Based on the observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following item was found was noncompliant, specific findings include:

a. The ground fault circuit interrupter receptacle (GFCI) did not work properly when tested in the beauty parlor located in the Whitaker building.

b. there was a 4x4 junction box with no cover above the ceiling tile near room 6123 that had wires that were not terminated properly.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following items were noncompliant, the specific findings include:

a. Doors in the following locations did not close and latch to prevent the passage of smoke: 9152, 9165 , 5164, 5163, 5324, 5318, 4702, 4319, 3318, 3537, 1st floor kitchen stock entrance from dock, 1st floor left door for tray line entrance.
b. Soiled Utility Room #3455 had tape over the keeper hardware not allowing the door to latch.
c. Bathroom by elevator #17 & #18 was missing a strike plate and had a throw latch.
d. Dutch doors next to 2555 in behavioral health had an air gap between the top and bottom doors.

A. Based on observation on 07/27/2010 the door to the break room opens on to an egress corridor and had tape over the keeper so the door could not latch.

Based on the observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following items were noncompliant, specific findings include: There are unsealed penetrations in rated wall assemblies in the following locations:

a. above the cross corridor doors near the nurses station on the 7th floor East
b. above the cross corridor doors near the nurses station on the 6th floor East
c. above the ceiling in the bathroom area at the elevator vestibule where HVAC construction was halted
d. above the ceiling near room 6118 unsealed penetrations in the rated wall assembly.
e. above the ceiling in Central Supply.
f. in the HVAC space which is inside the main penthouse complex

Based on observation on 07/27/2010 the following items were noted as noncompliant:

a. fire doors on the sixth floor near room 6127 did not close smoke tight
b. smoke doors near the fire alarm room on the fourth floor did not close smoke tight along with other smoke doors in the facility.
c. The right leaf of fire doos near room 5324 did not close and latch.
d. There was a gap in the smoke doors next to nourishment room 4697.
e. The fire doors next to the 3rd floor stairwell and near elevators #17 & #18 did not close and latch tightly in it's frame.

Based on observation on 07/27/2010 there were hazardous areas located through out the facility that the corridor door did not close and latch to maintain the one hour rating of the space. These rooms included but are not limited to soiled linen rooms, storage rooms, and other hazardous areas

A. Based on observation on 07/27/2010 the door to the soiled linen room did not have a closer.


13743

A. Based on observation on 07/27/2010 there were three rooms in the facility that required more than one motion of the hand to exit the room.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant,

a. the code requirement was not met for exiting at the loading dock as there was a drop off of more than 30 inches with no handrail present.

Based on the observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following items were noncompliant. The facility has electromagnet locking mechanisms and systems in several locations. These special locking arrangements being utilized must comply with NFPA 101 Delayed-Egress Locks[7.2.1.6.1] or NCSBC Special Locking Arrangements [1003.3.1.8.5] specific findings include:

a. The kill switch at the door leading from endoscopy to behavioral health does not meet either requirement as it automatically relock after a few seconds after the door is closed. The door must relock only by manual means.
b. In some areas you must pass through more than one delayed egress in order to exit the facility.
c. One door did not release when pressure was applied to the release device.
d. Where N.C. Special Locking was used in some areas there were no master release switches, one master release switch failed to release the doors.
e. Some staff interviewed did not know about the door master release switch.

f. Delayed egress doors on the 9th floor would relock without being manually reset.
g. In the E.D. Blue Zone keyed electromegnetic locks were being used and the staff did not carry keys on them, the key was in a drawer on a key ring with other keys.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant, specific findings include a single bulb fixture at the 1st floor radiology imaging exit.

Based on the observations and staff interview during the survey dated 7/27/2010 onward to 8/2/2010 The following exit discharge illumination was observed as noncompliant as the specific findings include:

1. No exit discharge lighting leading from the stairwell next to the elevators to the public way.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant; the exit stairwell light in south general next to room 4324 was not functioning properly.

A. Based on observation on 08/01/2010 the following was found to be noncompliant: The exit discharge signage directing persons out the stairwells to the public way was not complete.

Based on the observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following exit directional signage was noncompliant, specific findings include:

a. The exit directional sign leading from the end of the South hall near room 4327 directs persons to the elevator vestibule and not the egress stairwell

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant,

a. Whitaker building did not have a Fire Department Connection (FDC) Sign at the fire department connection point.

A. Based on observation on 07/27/2010 the following was found to be noncompliant: there were no electrically supervised tamper alarms on the main sprinkler valves located in the pit at the street.

Based on observation on 07/27/2010 the control valves for the sprinkler back - flow preventer located in the pit in the front of the facility did not have electrically monitored tamper alarms installed on them.

Based on observation on 07/27/2010 the following was found noncompliant:

a. The back-flow preventers for the sprinkler systems that did not have tamper alarms installed on the control valves located in pits on the out side of the building along with the P.I.V. located at the loading docks.
b. The dry sprinkler system at the loading dock has a valve located up stream of the pressure operated flow switch . this valve has the handle removed but it must be electrically supervised.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant,
a. there was not a available shut down switch for the three air handling units (AHU) at a manned station.
b. The AHU on the 2nd floor outside the break area did not shut down with fire alarm activation.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant; there was not a available shut down switch for the air handling units (AHU) at a manned station.

Based on observation on 07/27/2010 the following was found to be noncompliant:

a. There were no access doors for the duct detectors in the basement equipment room.
b. The air handlers did not shut down upon activation of the fire alarm when duct detector was tested.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following items were noncompliant:

a. soiled linen chute in room 3130, 5108, 4733 did not close and latch automatically when tested
b. trash chute in room 5109, 3109 did not close and latch automatically when tested

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following items were noncompliant,

There are doors that open into the egress corridor that do not open 180 degrees or have door closures to keep the doors closed after being opened. These locations are noted:

a. 9th floor East linen closet and electrical room in front of the nurse ' s station
b. 8th floor East linen closet
c. 7th floor East electrical room in front of the nurse ' s station
d. 5th floor East electrical room and telecommunications in front ot the nurse ' s station
e. Storage room next to room 5555
f. Storage room 4674A
g. 4th floor East clean linen and electrical room in front of the nurse ' s station
h. Environmental services door 3605
i. food cart stored unattended near room 9117
j. throughout the facility there wall mounted charting cabinets that did not retract when not in use
k. 2nd floor of Whitker had wall mounted cabinets near rooms 2603, 2607, 2615, 2619 that did not swing 180 degrees.
l. OR had items stored in the required exit areas.

Based on the observations and staff interview during the survey dated 7/27/2010 onward to 8/2/2010 The following items were observed as noncompliant as the specific findings include:

a. The compressed gas room number 2 in the blood lab did not have its cylinders individually secured.
b. oxygen storage on the North 5th floor had a mix of full and empty cylinders in the same storage rack.
c. oxygen cylinders stored at the loading dock area were not individually secured
d. the oxygen storage in theWhitaker Building had had a mix of full and empty cylinders in the same storage rack

Based on the observations and staff interview during the survey dated 7/27/2010 onward to 8/2/2010 The following was observed as noncompliant as the specific findings include:

1. The oxygen storage room on the exterior of the building did not have its cylinders individually secured.

Based on the observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant, the pixus unit in the OR Supply room was plugged into normal power.

Based on the observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following item was found was noncompliant, specific findings include:

a. The ground fault circuit interrupter receptacle (GFCI) did not work properly when tested in the beauty parlor located in the Whitaker building.

b. there was a 4x4 junction box with no cover above the ceiling tile near room 6123 that had wires that were not terminated properly.