HospitalInspections.org

Based on the observations and staff interviews on July 12, 2011 through July 13, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

There were unsealed penetrations in the fire wall masonry at the back corner of the telephone/ technology room above the ceiling tile.

Based on the observations and staff interviews on July 12, 2011 through July 13, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

The cross corridor doors leading from the laboratory hallway to the emergency department had a dead bolt on one leaf of the door and a hasp on the other leaf of the door. This condition along with North Carolina Special Locking installed on the doors now requires two motions of the hand to exit these doors with all items engaged.

Based on the observations and staff interviews on July 12, 2011 through July 13, 2011 the following Life Safety items were observed as noncompliant with the North Carolina Special Locking systems (NCSL), specific findings include:

(A) NCSL Door release switches that would relock the doors without being manually reset at the following required exit locations:

1. The Loading dock required exit.
2. The Solarium required exit.
3. The emergency department required exit on the left side of the reception desk.

(B) No NCSL door release switch at the following required exit locations:
1. Cross corridor double doors from the laboratory hallway to the emergency room
2. The emergency department required exit on the right side of the reception desk.

(C) NCSL door release switch above the required 48 inches off the finished floor.
(D) NCSL door that did not have a door release switch at a regularly manned station that services the loading dock required exit door.

NOTE: The facility can place a conveiance key pad release at each of the NCSL doors for the staff to come in and out along with placing a cover over the reqired release switch at the door.

NOTE: NCSBC 1003.3.1.8.5

Based on the observations and staff interviews on July 12, 2011 through July 13, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

During the inspection and testing of the facility fire alarm system that consisted of multiple components the loss of normal power componet was tested. During this test the power to the Fire Alarm Control Panel (FACP) was disconnected at the circuit. There was no trouble audio or visual alert notification that the power for the FACP was disconnected, and the battery back up power did not supply power during this test.

Based on the observations and staff interviews on July 12, 2011 through July 13, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

The oxygen cylinders at the loading dock area were not properly chained or supported during the survey tour. The oxygen cylinders were chained with one chain and not individually chained to prevent cylinders from accidentally being overturned.

[NFPA 99 Sections 4-3.5.2.1b (27) and 4-5.1.1.1]