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Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a and c" for this building is waivered past the follow up survey dated 9/16/2010

a. the door to room 9106 and 9262 and throughout the facility had keyed dead bolts, located above 48" above the finished floor, and a separate positive latching device that did not open with a single range of motion. (north tower)

b. the door to room 4920 and 4921 had keyed dead bolts, located above 48" above the finished floor, and a separate positive latching device that did not open with a single range of motion. ( 4th floor childrens hospital) (Corrected)

c. exit access door, from pediatric intensive care unit, is not equipped with positive latching hardware - door 5408.

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. smoke barrier, located above ceiling, in room 7602A is not complete to the underside of deck.

b. There was an unsealed penetration in room number 9143 at an unused conduit on the smoke wall. (Corrected)

c. There was an unsealed penetration in the ceiling above the cross corridor doors near room 7131. . (Corrected)

d. There was an unsealed penetration in the smoke wall above the ceiling between rooms 7316 and 7315. . (Corrected)

e. There was an unsealed penetration in the ceiling above door near room 7505.

f.. There was an unsealed penetration above the ceiling tile above cross corridor doors near room 7459 .. (Corrected)

g. There was an unsealed penetration in the smoke wall above the ceiling tile near room 6223.. (Corrected)


h. There was an unsealed penetration in the smoke wall in room 6214A above the ceiling tile at the acid waste vent piping.. (Corrected)


i. There was an unsealed penetration in the smoke wall above the ceiling tile near room 4120.. (Corrected)

j. There was an unsealed penetration in the smoke wall above the ceiling tile near room 2350.. (Corrected)


k. There was an unsealed penetration in the smoke wall in the interstitial area near air handling unit number 8. . (Corrected)

l.


08661

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

a. door 100619 between zone 5 and zone 6 in the 8th floor interstitial space did not form a smoke tight seal when closed. . (Corrected)

b. electrical room wall above panel EMC 68, in room 6402E interstitial space, had a penetration the smoke wall that was not sealed in order to maintain the required fire resistance rating of the smoke barrier. . (Corrected)

c. half door, near door 10260, in the 6th floor interstitial space did not properly close to form a smoke tight seal.. (Corrected)

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a,b and c" for this building is waivered past the follow up survey dated 9/16/2010

a) unsealed holes in smoke barrier located adjacent to room 2008(consult #2) - located above corridor ceiling in ambulatory health care center.

b) unsealed hole in cross corridor smoke barrier adjacent to room 2123 - located above ceiling in ambulatory health care center.

c) non-rated vision panel in smoke barrier wall beside preoperative area entrance.(ambulatory health care center - near room 2008)

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "b, a, b and c" for this building is waivered past the follow up survey dated 9/16/2010

a. fire door to room 9221(clean utility) is tied in the open position. (Corrected)

b. room 7603 is used as a storage room with less than forty-five minute door and listed hardware. The room is greater than one hundred square feet area.


Based on observations, on June 16, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

a. lack of fire dampers for duct penetrations of large respiratory storage room 5000C.

b. lack of one hour fire resistive enclosure for large sterile core supply room - room 3557.

c. lack of one hour fire resistive enclosure for induction room #18, and #25 - rooms are used for storage.

Based on observations, on June 18, 2010 at approximately 8:00am onward, the following item is noncompliant, specific finding include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. lack of one hour enclosure or sprinklers for storage room #130.

Based on observations, on June 21, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

NOTE: Item "b" for this building is waivered past the follow up survey dated 9/16/2010

a. unsealed holes in enclosing walls of mechanical room #167. (Item Corrected)

b) lack of one hour enclosures or sprinklers for two soiled linen storage rooms.

Based on observations, on June 21, 2010 at approximately 8:00am onward, the following items were noncompliant; specific findings include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a) three office spaces are used as storage rooms without sprinkler coverage or one hour rated enclosures.

A.Based on observations, on June 17, 2010 at approximately 1:20pm onward, incomplete electromagnetic locking arrangements are provided in cross corridor door openings in the following areas:

a. first floor Children's Health Center near room 1902

b. fifth floor corridor from Children's Health Center to PACU corridor near room 5817.

Door locking arrangements are not equipped with required switching arrangements and did not release during activation of the fire alarm system at approximately 1:20pm - this constitutes an immediate jeopardy condition, the team leader for the health survey was notified at approximately 1:30pm and hospital administration was notified at approximately 3:10pm of the immediate jeopardy condition. The immediate jeopardy for all referenced locks was abated at approximately 1:40pm, and 2:00pm by complete removal of deficient electromagnetic locking devices.

B. Based on observations, on June 16, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. incomplete delayed egress lock in the ED -Main exit - lock will rearm with card swipe after initiation of irreversible process. This action will cause excessive delay in exiting facility if action is done prior to complete removal of all occupants in an emergency.

b. dead-end corridor greater than thirty feet in area near room 5271A.

Note: Approved, listed, special locking arrangements shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7 of the Life Safety Code.

Based on observations, on June 18, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a, b, and c" for this building is waivered past the follow up survey dated 9/16/2010

a. exit discharge is incomplete to the publicway - lack of solid, slip-resistant surface other than soil and grass.(beside stair #4)

b. incomplete electromagnetic locking arrangement installation at stair near registration desk #2, exit access door from roof area courtyard, and exit discharge near room #142. System as installed fails to comply with delayed egress locking as defined in the Life Safety Code or special locking arrangements as defined in the NC State Building Code.

c. exit sign posted over door to fitness room near room #1418 - the referenced door is exit access from the room, not egress through the room from the corridor area.

Based on observations, on June 16, 2010 at approximately 8:00 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "b" for this building is waivered past the follow up survey dated 9/16/2010

a. required eight feet corridor, as originally constructed, is reduced to six feet width in area of construction zone near room 5541. (Corrected)

b. stair S055 is identified as a required exit - corridor width leading to stairway door is much less than eight feet in width.

Note: The 1967 New Life Safety Code required a minimum eight feet corridor width in Hospitals - the level of Life Safety may not be reduced below this requirement or NC Building Code requirements.

Based on observations, on June 18, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. lack of more than a single bulb fixture at required exit discharges.

Based on observations, on June 21, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. exit discharges from stairways are equipped with single fixtures.

Based on observations, on June 18, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. lack of emergency lighting at all exit discharges.

Based on observations, on June 21, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

a. Lack of emergency lighting provided for the exits and exit discharges - existing lights are wired to switched circuits.

Based on observations, on June 21, 2010 at approximately 8:00 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. there are no smoke detectors located not greater than five feet from both sides of cross corridor smoke barrier in ambulatory health center.

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a, b, c, d, e and f " for this building is waivered past the follow up survey dated 9/16/2010

a. lack of sprinkler inside shower stall - located in room 9254T.

b. lack of sprinkler coverage for space beside nurse's station - across hall from room 9331.

c. lack of sprinkler in room 7614E.

d. lack of sprinkler coverage for shower stall 5535, and 5534.

e. walk-in coolers and freezers are not equipped with sprinklers.(kitchen area)

f. lack of sprinklers in blood gas room - located near room 3511 and operating room #16.

Based on observations, on June 16, 2010 at approximately 8:00 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "c and d" for this building is waivered past the follow up survey dated 9/16/2010

a. sprinkler tamper switch would not sound an audible alarm during test - hospital pump house #1-1008715-16 (Corrected)

b. sprinkler tamper switch would not sound an audible alarm during test - helipad room #1008785-30 (Corrected)

c. sprinkler system post indicator valve, located near front entrance, did not activate an audible signal during test.

d. tamper switch audible signals can be permanently silenced - switches can use an intermittent signal.(all switches that produced a sound with the valves closed)

e. sprinkler valve upstream of sprinkler pressure switch is not electrically supervised - stair #23. (Corrected)

Based on observations, on June 21, 2010 at approximately 8:00am onward, the following item was noncompliant, specific finding include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. dry-pipe sprinkler system alarm valve is closed with no means provided for monitoring the valve.(valve & fire pump room at North Pavilion)

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "b, a, and b" for this building is waivered past the follow up survey dated 9/16/2010

a. sprinkler is obstructed by suspended ceiling signage - corridor area near room 7459. (Corrected)

b. main sprinkler valves, located in outside hot box, are wrapped with heat tape - NFPA 13 sprinkler systems must be provided with a heat source other than heat tape; and capable of maintaining a minimum forty degree temperature inside enclosure.(entrance to Children's Health Center)

Based on observations, on June 16, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

a. sprinkler in storage room is obstructed by solid wood shelves - located across corridor from room 5830.

b. sprinklers in storage closets 5200C, and 5200D are obstructed by solid wood shelves.

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a, c, and b" for this building is waivered past the follow up survey dated 9/16/2010

a. lack of emergency shutdown switch for air handler serving 9100 unit and beyond.

b. lack of label to identify air handler shutdown switch located near 7614 nurse's station(children's cathe lab). (Corrected)

c. lack of emergency shutdown switch for air handler serving fifth floor operating rooms 1 -3.

Based on observations, on June 16, 2010 at approximately 8:00 am onward, the following items were noncompliant, specific findings include:

a. test of air handler shutdown switch would not shut down unit 5-7 in PICU. (Corrected)

b. lack of an emergency shutdown switch for air handlers serving the pharmacy, and kitchen area.

Based on observations, on June 21, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:


NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. there is no emergency shutdown switch(es) for air handler(s) serving the ambulatory health care center.

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. corridor impediments near room 9205 - computers on wheels, and soiled linen carts were left unattended and were not in immediate and continuous use. Corrected)

b. pedestal sign located in required means of egress near Unit 71 entrance area. (Corrected)

c. unattended equipment in corridor area between rooms 7302, and 7303.Corrected)

d. equipment unattended in corridor area near Cath Lab #1 - 7434. Corrected)

e. bulk supplies are impeding exit discharge at basement level - near loading dock. Corrected)

f. corridor obstructed by dry wall compound, carts, and other construction supplies in area near room 5406. Corrected)

g. furniture stored in corridor area - in front of ICN waiting area.(fifth floor) Corrected)

h. impediments in the means of egress near stair S073. Corrected)


08661

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

a. cabinet and sink doors on the 9100, 9300, 6300 units swing into the corridor without a listed closure and the door does not swing 180 degrees but leaves a projection of approximately 12" into the corridor. NFPA 7.2.1.4.4 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.

b. wall mounted chart holders on the 6100 unit did not fully retract. Corrected)

c. door 1420 to storage room was not equipped with a listed closure device. Corrected)

d. corridor impediments in the 1400 exit at Radiology- six large cameras, trash can and other storage items were left unattended and were not in immediate and continuous use. Corrected)

e. corridor impediments in the round hallway 8th floor near the four bank and the transport elevators. On Tuesday at 1500 hours there was 2 dirty beds, 2 clean beds & a clean cart. On Thursday at 1100 hours there was 2 dirty beds, 1 dirty storage & a large materials cart. Corrected)


f. corridor impediments in the loading dock hallway exit, at stair 5, including two tables and four chairs. (childrens hospital) Corrected)

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item is waivered past the follow up survey dated 9/16/2010


a. oxygen cylinders freestanding on the floor of room 9000A. There were no carts, bases or other secure device to support cylinders. (Corrected)

b. There were unsecure oxygen bottles at the entry to main operating rooms located on third floor. (Corrected)


08661

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

Full and empty oxygen cylinders were stored together without signage. If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)] (6300 unit, 6214A, and radiology & main diagnostics)

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "b" for this building is waivered past the follow up survey dated 9/16/2010

a. medical gas piping is not labeled in 9100 DDS shaft. Corrected

b. lack of a canopy or other enclosure to protect nitrous oxide bank from extremes of weather.

c. unsecured oxygen cylinders in room 0063 - near loading dock. Corrected


08661

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

a. medical gas piping is not labeled in 6100 shaft, across from room 6131, at nurses station. Corrected

Based on observations, on June 21, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:


NOTE: Item "a, b and c" for this building is waivered past the follow up survey dated 9/16/2010

a. duplex receptacle providing power to heaters in sprinkler valve box is not connected to the critical branch of the essential electrical system.(located beside emergency generator - North Pavilion)

b. there is no unitary light with battery backup located at the generator set.

c. there are no lights identified as connected to the essential electrical system - generator set location.

Based on observations, on June 16, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

NOTE: Item "a and b" for this building is waivered past the follow up survey dated 9/16/2010

a. medication refrigerator is not connected to a critical branch circuit - medication room located near room 5222B.

b. means of egress lighting in the PACU area can be switched off by wall-mounted snap switches. Means of egress lighting connected to the Life Safety Branch of the essential electrical system must not be switched from wall switches within the means of egress.

Based on observations, on June 21, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:


NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. circuit supplying power to the main fire alarm control panel could not be verified as connected to the Life Safety Branch panelboard of the essential electrical system. (Panelboard ERT, circuit #2, in North Pavilion)

Based on observations, on June 15, 2010 at approximately 11:30 am onward, the following items were noncompliant, specific findings include:

NOTE: Item "b and b " for this building is waivered past the follow up survey dated 9/16/2010

a. electrical junction box knockout was not equipped with a knockout plug - lighting circuit adjacent to Helicopter pad exit. (Corrected)

b. The pyxis machine was not verified as being on the emergency circuit at the Short Stay nurses station


c. There was an open electrical junction box above the cross corridor doors near room 7505. (Corrected)

d. There was an open electrical junction box above ceiling tile and near the exit sign at room 7461. (Corrected)

e. There was an open electrical junction box in the mechanical room 1818. (Corrected)


Based on observations, on June 16, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:

a. There is no protective bushing between fixture wires and electrical junction box - wall mounted light fixture located in patient room 5717. (Corrected)


b. There is a multioutlet power tap used in patient care area - room 5509.


c. Medication refrigerator is wired to a branch circuit protected by a twenty amp overcurrent protection device - manufacturer's specifications require a maximum fifteen amp overcurrent protection device. Medication preparation area located near room 5327, and other similar spaces throughout North Building. (Corrected)


d. Electrical circuit supplying the medication refrigerator, referenced in item(c) above, is not identified in the critical branch panelboard of the Essential Electrical System. (Corrected)

Based on observations, on June 21, 2010 at approximately 8:00am onward, the following items were noncompliant, specific findings include:


NOTE: Item "a" for this building is waivered past the follow up survey dated 9/16/2010

a. receptacles supplying power to the heaters in the main sprinkler hot box are not identified as emergency power receptacles - receptacles were verified by hospital staff as connected to normal power distribution system.

b. forty-two pole electrical panelboard is equipped with a twenty-seven pole circuit directory - all devices are not identified in panelboard LH2.(located in room 2015) (Corrected)

c. panelboard LSP2 - circuit directory is not completely labeled to show devices served. (Corrected)

d. panelboard located in generator set enclosure - circuit directory is not completely labeled to show devices served. (Corrected)