HospitalInspections.org

1. Building #1, 2nd floor, mechanical room at respiratory classroom corridor
There are unsealed penetrations in the 1 hour rated assembly above the duct work just above the entry doors

2. Building #1, 2nd floor, transformer room at the respiratory classroom corridor
There are unsealed penetrations in the 1 hour rated assembly above the door.

3. Building #1, 2nd floor middle area across from room 273
The one hour rated wall above the soiled utility room has an unsealed penetration from a pipe penetrating the wall just above the door frame on the corridor side.

1. Building #1, 1st Floor, Suite area in front of Doctor ' s charting area.
a. The corridor wall for the Suite in front of the Doctor ' s charting are was not constructed smoke tight. The corridor wall was not complete at the deck above.
b. The corridor wall to the Administration suite area was not sealed smoke tight to the deck above.

Building #2, Ground floor, between PACU and OR
The corridor walls above the ceiling outside PACU and OR suites were not sealed in order to maintain the required rating of the area.

Building #1, 3rd floor Caesarean Section room, Delivery Room and both observation rooms.
There was more than one range of motion on the above mentioned treatment area doors that do not allow single motion opening of the space into an egress corridor.

Building #1, Ground Floor, ICC & CCU corridor.
The corridor door at the entrance to the ICC & CCU suites did not close smoke tight as there was a gab greater than 1/8th of an inch during the survey.

Building #1, lower level, lab across from the receptionist desk,
There are unsealed penetrations in the rated smoke wall above the ceiling at the sprinkler pipe at the door entry area.

1. Building #2, Ground Floor, exit corridor located in front of cross corridor doors leading to the operating rooms.
There are two sets of oxygen storage room doors on that corridor.
a. one set has one of its double doors that does not latch
b. both sets have gaps grater than 1/8th of in inch not keeping the rating of the doors at that location.

2. Building #2, Ground Floor, PACU
The soiled linen room door at PACU did not close, latch, and seal when tested during the survey.

1. Wound Care, soiled linen room
The hospital based provider space does not have a one hour rated enclosure for the soiled linen room.

Building #1, lower level, lab storage room near the house keeping closet
The 1 hour rating for that space is not maintained as the door has only a 20 minute rating.

MOB Rehab Services, Transformer room
The hospital based provider space does not have a one hour rated enclosure for the transformer/electrical room.

Building #1, loading dock storage area
The loading dock landing does not have protection from falling at this location as the exit egress from this area lead to the loading dock.

1. Building #1, 3rd floor next to room M9.
The facility is utilizing delayed egress in its stairwells. These doors are normally in the locked position. These doors had a delay when opening with activation of the fire alarm system when tested.

2. Building #1, Tower birthing wing. 3rd floor
This area utilizes North Carolina special locking systems for the baby alert system and delayed egress. The North Carolina special locking system has a master lock release switch at the nurse 's station that is greater tan 48 inches off the finished floor.

3. Building #1, several egress paths
The exit egress path can be blocked as there was a floor slide bolt " shooter blocks " that can be deployed to prevent a cross corridor door from being opened at the following locations:
a. 3rd floor on the entrance hall
b. 2nd floor entrance to "2 middle" corridor entrance
c. 1st floor lobby to the administration area .

1. Building #2, Ground Floor, Outpatient Surgery area
a. The cross corridor doors leading from outpatient surgery area to the corridor in front of operating rooms is equipped with an incomplete North Carolina Special Locking system. There was no simple on or off door release mechanism/switch in the vicinity of the door. There was no simple on or off door release mechanism/switch at a regularly manned station that serves that area.
b. The door release mechanism that was in the vicinity of the door was a momentary switch that would reengage the locking mechanism attached to the door after it was released.
c. Door did not release with activation of the fire alarm system when tested.

MOB Rehab Services, Exit egress corridor and stairwell
The hospital based provider space does not have complete emergency lighting for the exit egress stairwell leading to the ground floor of the building.

Wound Care Services, Exit egress corridors
The hospital based provider space does not currently have emergency egress lighting.

Building #1, 3rd floor, waiting room that housed stairwell " E "
There was not sufficient exit directional signage leading from this waiting room to the nurses station where other exit directional signs could lead you to a path of egress

Building #1, Ground floor near the surgical waiting room.
During the testing of the Fire Alarm Control panel and its components the cross corridor smoke doors did not release with activation a smoke detector within that particular smoke area.

MOB Rehab Services,
The Medical Office Building which houses the hospital based provider is grater than 3 stories. This space is in a sub-leased area on the third floor, and does not have a remote annunciator for the Fire Alarm Control Panel (FACP) in an area where it is likely to be heard.

NOTE: The facility does have a remote FACP annunciator panel in the main entry lobby of the building.

1. Building #1, the facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have sprinkler coverage or smoke detection in the following areas:

a. 3rd floor bath rooms in the Observation rooms 10 and 11
b. 1st floor Lab, and X-ray area

2. Building #1, Ground floor, near cardiac catheterization
The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have proper sprinkler coverage in the following area:
There were two sprinkler heads on the same side of the room leaving the opposite side without coverage in an area greater than 500 square feet.

3. Building #1, 1st Floor, Stairwell E-2
Facility at the time of the inspection could not verify the installation of sprinkler heads at the top portion of the vertical shaft accessible from stairwell E-2.

1. Building #2, Ground Floor Cold Room
The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 tower in the following areas:
a. The entrance to the cold room has incomplete sprinkler coverage

2. Building #2, Ground Floor, PACU
The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 tower in the following areas:
a. The PACU does not have 100% sprinkler coverage, and the bathroom in PACU did not have sprinkler coverage or protected with smoke detector.

3. Building #2, Ground Floor, Operating Rooms
The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 tower in the following areas:
a. The facility operating rooms 1 trough 7 do not have sprinkler coverage.

4. The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 bed tower in the following areas:
a. Bathrooms in the 1986 Tower
b. staff lounge bathrooms near the elevator lobby areas in 1986 tower
c. men and women ' s bathrooms on the 2nd floor near the assistant housekeeping managers office in the 1986 tower

Building #2, Ground Floor, Operating Rooms
The equipment storage room between operating room 1 & 2 has a defective sprinkler head where the colored fluid in the glass capsule is missing and appeared clear during the survey.

NOTE: this specific deficiency was corrected before the survey was finished.

1. Building #1, Document Review
Sprinkler System certification noted the following outstanding items that had no resolution at the date of the survey: stated the following items were non-compliant:
a. MRI preaction: water flow device does not report to main FACP.
b. Sprinkler systems are due for its five (5) year system checks
c. Dry sprinkler system drops in the kitchen are over 10 years old

2. Building #1, Document Review
Fire Pump certification noted the following outstanding item that had no resolution at the date of the survey:
a. Underground piping leading to the fire pump leaks

Building #1, Document Review
There were several outstanding items noted from the 12/10 " fire damper inspection and testing log " that were not resolved during the survey.

1. Building #2, Tower, 5th floor
The clean linen closet double doors open into the corridor 180 degrees but the left leaf of the doors protrudes into the corridor leading to the " H " stairwell

2. Building #2, 1st floor, clean linen closet
The clean linen closet double doors do not open 180 degrees into the corridor and are not equipped with door closers to keep the doors closed after being opened.

3. Building #2, 2nd floor
The clean linen closet double doors do not open 180 degrees into the corridor and are not equipped with door closers to keep the doors closed after being opened.

4. Building #2, Ground Floor, Outpatient Surgery area.
The corridor doors to the CO2 storage room located between outpatient surgery and operating room did not open 180 degrees or equipped with self-closing device to prevent the door from being left open into the egress corridor.

5. Building #2, Ground floor, Operating Rooms
There are items (equipment) in the exit egress corridor in front of the operating room #8, this area is not included in the operating room suite.

Building # 1, oxygen farm
a. The oxygen farm has cylinders that are not individually chained
b. The oxygen farm does not have the cylinder valves protected from extremes of weather
c. The oxygen farm does not have its cylinders protected from rusting as they are touching the concrete slab that they rest on.

Building #2, Ground Floor, exit corridor located in front of cross corridor doors leading to the operating rooms. The oxygen storage room located on that corridor did not have oxygen storage signage on it during the survey.

1. Building #1, 2nd floor, mechanical room at respiratory classroom corridor
There are unsealed penetrations in the 1 hour rated assembly above the duct work just above the entry doors

2. Building #1, 2nd floor, transformer room at the respiratory classroom corridor
There are unsealed penetrations in the 1 hour rated assembly above the door.

3. Building #1, 2nd floor middle area across from room 273
The one hour rated wall above the soiled utility room has an unsealed penetration from a pipe penetrating the wall just above the door frame on the corridor side.

1. Building #1, 1st Floor, Suite area in front of Doctor ' s charting area.
a. The corridor wall for the Suite in front of the Doctor ' s charting are was not constructed smoke tight. The corridor wall was not complete at the deck above.
b. The corridor wall to the Administration suite area was not sealed smoke tight to the deck above.

Building #2, Ground floor, between PACU and OR
The corridor walls above the ceiling outside PACU and OR suites were not sealed in order to maintain the required rating of the area.

Building #1, 3rd floor Caesarean Section room, Delivery Room and both observation rooms.
There was more than one range of motion on the above mentioned treatment area doors that do not allow single motion opening of the space into an egress corridor.

Building #1, Ground Floor, ICC & CCU corridor.
The corridor door at the entrance to the ICC & CCU suites did not close smoke tight as there was a gab greater than 1/8th of an inch during the survey.

Building #1, lower level, lab across from the receptionist desk,
There are unsealed penetrations in the rated smoke wall above the ceiling at the sprinkler pipe at the door entry area.

1. Building #2, Ground Floor, exit corridor located in front of cross corridor doors leading to the operating rooms.
There are two sets of oxygen storage room doors on that corridor.
a. one set has one of its double doors that does not latch
b. both sets have gaps grater than 1/8th of in inch not keeping the rating of the doors at that location.

2. Building #2, Ground Floor, PACU
The soiled linen room door at PACU did not close, latch, and seal when tested during the survey.

1. Wound Care, soiled linen room
The hospital based provider space does not have a one hour rated enclosure for the soiled linen room.

Building #1, lower level, lab storage room near the house keeping closet
The 1 hour rating for that space is not maintained as the door has only a 20 minute rating.

MOB Rehab Services, Transformer room
The hospital based provider space does not have a one hour rated enclosure for the transformer/electrical room.

Building #1, loading dock storage area
The loading dock landing does not have protection from falling at this location as the exit egress from this area lead to the loading dock.

1. Building #1, 3rd floor next to room M9.
The facility is utilizing delayed egress in its stairwells. These doors are normally in the locked position. These doors had a delay when opening with activation of the fire alarm system when tested.

2. Building #1, Tower birthing wing. 3rd floor
This area utilizes North Carolina special locking systems for the baby alert system and delayed egress. The North Carolina special locking system has a master lock release switch at the nurse 's station that is greater tan 48 inches off the finished floor.

3. Building #1, several egress paths
The exit egress path can be blocked as there was a floor slide bolt " shooter blocks " that can be deployed to prevent a cross corridor door from being opened at the following locations:
a. 3rd floor on the entrance hall
b. 2nd floor entrance to "2 middle" corridor entrance
c. 1st floor lobby to the administration area .

1. Building #2, Ground Floor, Outpatient Surgery area
a. The cross corridor doors leading from outpatient surgery area to the corridor in front of operating rooms is equipped with an incomplete North Carolina Special Locking system. There was no simple on or off door release mechanism/switch in the vicinity of the door. There was no simple on or off door release mechanism/switch at a regularly manned station that serves that area.
b. The door release mechanism that was in the vicinity of the door was a momentary switch that would reengage the locking mechanism attached to the door after it was released.
c. Door did not release with activation of the fire alarm system when tested.

MOB Rehab Services, Exit egress corridor and stairwell
The hospital based provider space does not have complete emergency lighting for the exit egress stairwell leading to the ground floor of the building.

Wound Care Services, Exit egress corridors
The hospital based provider space does not currently have emergency egress lighting.

Building #1, 3rd floor, waiting room that housed stairwell " E "
There was not sufficient exit directional signage leading from this waiting room to the nurses station where other exit directional signs could lead you to a path of egress

Building #1, Ground floor near the surgical waiting room.
During the testing of the Fire Alarm Control panel and its components the cross corridor smoke doors did not release with activation a smoke detector within that particular smoke area.

MOB Rehab Services,
The Medical Office Building which houses the hospital based provider is grater than 3 stories. This space is in a sub-leased area on the third floor, and does not have a remote annunciator for the Fire Alarm Control Panel (FACP) in an area where it is likely to be heard.

NOTE: The facility does have a remote FACP annunciator panel in the main entry lobby of the building.

1. Building #1, the facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have sprinkler coverage or smoke detection in the following areas:

a. 3rd floor bath rooms in the Observation rooms 10 and 11
b. 1st floor Lab, and X-ray area

2. Building #1, Ground floor, near cardiac catheterization
The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have proper sprinkler coverage in the following area:
There were two sprinkler heads on the same side of the room leaving the opposite side without coverage in an area greater than 500 square feet.

3. Building #1, 1st Floor, Stairwell E-2
Facility at the time of the inspection could not verify the installation of sprinkler heads at the top portion of the vertical shaft accessible from stairwell E-2.

1. Building #2, Ground Floor Cold Room
The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 tower in the following areas:
a. The entrance to the cold room has incomplete sprinkler coverage

2. Building #2, Ground Floor, PACU
The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 tower in the following areas:
a. The PACU does not have 100% sprinkler coverage, and the bathroom in PACU did not have sprinkler coverage or protected with smoke detector.

3. Building #2, Ground Floor, Operating Rooms
The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 tower in the following areas:
a. The facility operating rooms 1 trough 7 do not have sprinkler coverage.

4. The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 bed tower in the following areas:
a. Bathrooms in the 1986 Tower
b. staff lounge bathrooms near the elevator lobby areas in 1986 tower
c. men and women ' s bathrooms on the 2nd floor near the assistant housekeeping managers office in the 1986 tower

Building #2, Ground Floor, Operating Rooms
The equipment storage room between operating room 1 & 2 has a defective sprinkler head where the colored fluid in the glass capsule is missing and appeared clear during the survey.

NOTE: this specific deficiency was corrected before the survey was finished.

1. Building #1, Document Review
Sprinkler System certification noted the following outstanding items that had no resolution at the date of the survey: stated the following items were non-compliant:
a. MRI preaction: water flow device does not report to main FACP.
b. Sprinkler systems are due for its five (5) year system checks
c. Dry sprinkler system drops in the kitchen are over 10 years old

2. Building #1, Document Review
Fire Pump certification noted the following outstanding item that had no resolution at the date of the survey:
a. Underground piping leading to the fire pump leaks

Building #1, Document Review
There were several outstanding items noted from the 12/10 " fire damper inspection and testing log " that were not resolved during the survey.

1. Building #2, Tower, 5th floor
The clean linen closet double doors open into the corridor 180 degrees but the left leaf of the doors protrudes into the corridor leading to the " H " stairwell

2. Building #2, 1st floor, clean linen closet
The clean linen closet double doors do not open 180 degrees into the corridor and are not equipped with door closers to keep the doors closed after being opened.

3. Building #2, 2nd floor
The clean linen closet double doors do not open 180 degrees into the corridor and are not equipped with door closers to keep the doors closed after being opened.

4. Building #2, Ground Floor, Outpatient Surgery area.
The corridor doors to the CO2 storage room located between outpatient surgery and operating room did not open 180 degrees or equipped with self-closing device to prevent the door from being left open into the egress corridor.

5. Building #2, Ground floor, Operating Rooms
There are items (equipment) in the exit egress corridor in front of the operating room #8, this area is not included in the operating room suite.

Building # 1, oxygen farm
a. The oxygen farm has cylinders that are not individually chained
b. The oxygen farm does not have the cylinder valves protected from extremes of weather
c. The oxygen farm does not have its cylinders protected from rusting as they are touching the concrete slab that they rest on.

Building #2, Ground Floor, exit corridor located in front of cross corridor doors leading to the operating rooms. The oxygen storage room located on that corridor did not have oxygen storage signage on it during the survey.