DIRECT Impact Standards:
EC.02.03.01 EP1
EC.02.03.05 EP4
EC.02.05.09 EP1
LS.01.01.01 EP2
LS.02.01.20 EP1,EP13

INDIRECT Impact Standards:
EC.02.06.01 EP1,EP26
LS.02.01.10 EP5
LS.02.01.30 EP11
LS.02.01.35 EP6

DIRECT Impact Standards:

Standard: EC.02.03.01 – EP 1
§482.51(b) – (A-0951) – §482.51(b) Standard: Delivery of Service

Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care.
This Standard is NOT MET as evidenced by:

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.

In the Women and Children center, on the 3rd floor, above the ceiling in the Soiled Holding Room #WC3132 there is an electrical junction box. The cover to the junction box is missing and electrical wires are exposed.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the Ground floor in Stairway #3 there are two 4″ x 4″ electrical junction boxes connected with 3/4″ conduit. The electrical junction boxes and the conduit connecting them do not serve the required utility systems inside the stairway.

Standard: EC.02.03.05 – EP 4
§482.41(c)(2) – (A-0724) – (2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.
This Standard is NOT MET as evidenced by:
Observed in Document Review at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
During the Document Review session, annual testing documentation for each visual and audible fire alarm notification device was not available.

Observed in Document Review at Cape Fear Campus (5301 Wrightsville Avenue, Wilmington, NC) site for the Hospital deemed service.
During the Document Review session, annual testing documentation for each visual and audible fire alarm notification device was not available.

Standard: EC.02.05.09 – EP1
Observed in Document Review at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site. During the Document Review session the Preventive Maintenance records for the Medical Air Compressor system that serves the ICU Unit and ED Department were compared to the manufactures recommendations. The Facilities Manager confirmed the Medical Air System is on their utilities equipment inventory and is Life Support Equipment. The Preventive Maintenance task assigned to this Medical Air System did not match with the manufactures recommendations. Several of the manufacture’s recommended items were omitted from the Preventive Maintenance task, for example: inspection of
the motor starter contacts and 10,000 hour required maintenance. The Facilities Manager was not able to provide a risk assessment document for omitting the manufacture recommended items from the Preventive Maintenance task assigned to this equipment.

Standard: LS.01.01.01 – EP 2

§482.41(b)(1)(i) – (A-0710) – (i) The hospital must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA 101®2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.

Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. If any changes in this edition of the Code are incorporated by reference, CMS will publish notice in the Federal Register to announce the changes.
This Standard is NOT MET as evidenced by:
Observed in Building Tour at Cape Fear Campus (5301 Wrightsville Avenue, Wilmington, NC) site for the Hospital deemed service.
During the Life Safety building tour at the Cape Fear Campus, the SOC Life Safety Drawings provided by the Facilities Manager were used to survey the hospital.The drawings identified the Surgery Department as a “suite”. The drawings were not up to date, the “suite” boundary was identified to not include the Central Supply area; however, the Central Supply area is not separated by walls or doors, it is open to the Surgery Department. One set of double corridor doors identified as the “ICU entrance into the Surgery Department” were identified as the boundary of the “suite”, these doors are not equipped with positive latching hardware.

Standard: LS.02.01.20 – EP1,EP13
EP 1
§482.41(b)(1)(i) – (A-0710) – (i) The hospital must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA 101®2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.

Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. If
any changes in this edition of the Code are incorporated by reference, CMS will publish notice in the Federal Register to announce the changes.
This Standard is NOT MET as evidenced by:
Observed in Building Tour at Cape Fear Campus (5301 Wrightsville Avenue, Wilmington, NC) site for the Hospital deemed service.
During the Life Safety building tour at the Cape Fear Campus, the egress doors in the ED Department identified as the Ambulance Entrance have the ability to be locked preventing egress. When the lock is activated the “break-away” feature is not operable.

EP 13
§482.41(b)(1)(i) – (A-0710) – (i) The hospital must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA 101®2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.

Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. If
any changes in this edition of the Code are incorporated by reference, CMS will publish notice in the Federal Register to announce the changes.
This Standard is NOT MET as evidenced by:
Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 3rd floor, in Stairway #3 an evacuation chair is mounted to the wall.

Observed in Building Tour at Cape Fear Campus (5301 Wrightsville Avenue, Wilmington, NC) site for the Hospital deemed service.
During the Life Safety building tour at the Cape Fear Campus, the egress corridor outside exam rooms 12 & 13 in the ED Department is restricted to < 8' by the placement of several Pyxis machines positioned side by side totaling approximately 8' in length . The ED Department is not identified as a "suite" on the facilities SOC Life Safety
drawings.

INDIRECT Impact Standards:

Standard: EC.02.06.01 – EP1, EP26
EP1
§482.41(c)(2) – (A-0724) – (2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.
This Standard is NOT MET as evidenced by:
Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the first floor, in the ED Department’s public corridor there is an electrical panel, labeled “TRN1″ that is not locked.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the first floor, in the ED Department’s public corridor there is an electrical panel, labeled “TR2″ that is not locked.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the first floor, in the ED Department’s public corridor there is an electrical panel, labeled “TR1″ that is not locked.

EP 26
§482.41(c)(2) – (A-0724) – (2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.
This Standard is NOT MET as evidenced by:
Observed in Tracer Activities at Cape Fear Campus (5301 Wrightsville Avenue, Wilmington, NC) site for the Hospital deemed service.
It was noted that temperatures were only monitored for the blanket compartment of the dual fluid & blanket warmer located in the main corridor outside the operating suites. The maximum temperature range listed on the warmer was
100F, while the maximum listed on the log was 150F. Multiple entries on the log were above 100F. ECRI and AORN
guidelines limits fluid warmer temperature to a maximum of 110F and blanket warmer temperature to a maximum of
130F.

Observed in Tracer Activities at Cape Fear Campus (5301 Wrightsville Avenue, Wilmington, NC) site for the Hospital deemed service.
It was noted that the maximum temperature range listed on a blanket warmer in the PACU was 150F and the temperature at the time of the tracer was 140F. ECRI and AORN guidelines limits blanket warmer temperature to a maximum of 130F.

Observed in Tracer Activities at Cape Fear Campus (5301 Wrightsville Avenue, Wilmington, NC) site for the Hospital deemed service.
It was noted during a tour of the MRI / CT area of the Cape Fear site that a blanket warmer was set to 140F. ECRI
and AORN guidance limits blanket warmer temperatures to 130F.

Standard: LS.02.01.10 – EP 5
§482.41(b)(1)(i) – (A-0710) – (i) The hospital must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA 101®2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.

Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. If
any changes in this edition of the Code are incorporated by reference, CMS will publish notice in the Federal Register to announce the changes.
This Standard is NOT MET as evidenced by:
Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 3rd floor, the Soiled Holding Room #WC3132 door has a > 3/4″ undercut.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 3rd floor, the Soiled Holding Room #WC3132 has an access panel in the wall, above the suspended ceiling. The door to the access panel is not self-closing.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 3rd floor, the door that connects the Penthouse with the room labeled “WC Stair #3″ has a > 3/4″ undercut.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 4th floor, the Penthouse stair door has a > 3/4″ undercut.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 1st floor, the Stairway #3 door has a > 3/4″ undercut.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 1st floor, in stairway #3 there is an access panel in the ceiling, the door to the access panel is not self-closing.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the Ground floor in the Light House Cafe’ the Storage Room door does not close and does not positively latch. The Storage Room is identified on the SOC Life Safety drawings as a one-hour fire rated room.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the Ground floor in the Gift Shop the Storage Room rear door has a > 3/4″ undercut. The Storage Room is identified on the SOC Life Safety drawings as a one-hour fire rated room.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the Ground floor, the South Door in the two-hour fire rated enclosure does not latch.

Standard: LS.02.01.30 – EP 11
§482.41(b)(1)(i) – (A-0710) – (i) The hospital must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA 101®2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.

Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. If any changes in this edition of the Code are incorporated by reference, CMS will publish notice in the Federal Register to announce the changes.
This Standard is NOT MET as evidenced by:
Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 3rd floor, door to patient room 311 has a >1/8″ gap between meeting edges.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
On the 1st floor, the Triage ED Room has a sliding door leading directly to the egress corridor that is not equipped with a positive latch. This area is not identified as a suite on the SOC drawings.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
On the 1st floor, in the ED Department the Trauma Room has a sliding door leading directly to the egress corridor that is not equipped with a positive latch. This area is not identified as a suite on the SOC drawings.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
On the 1st floor, in the ED Department the room labeled “D-Rooms 18-23″ has a sliding door leading directly to the egress corridor that is not equipped with a positive latch. This area is not identified as a suite on the SOC drawings.

Observed in Building Tour at Cape Fear Campus (5301 Wrightsville Avenue, Wilmington, NC) site for the Hospital deemed service.
During the Life Safety building tour at the Cape Fear Campus, on the third floor patient room #310, the door leading to the egress corridor did not have a functioning positive latch.

Observed in Building Tour at Cape Fear Campus (5301 Wrightsville Avenue, Wilmington, NC) site for the Hospital deemed service.
During the Life Safety building tour at the Cape Fear Campus, on the 1st floor in the ICU Unit, patient rooms 1 thru 8 have sliding glass doors that open directly to the egress corridor. These patient rooms are not equipped with positive latches and the ICU Unit is not identified as a “suite” on the facilities Life Safety drawings.

Standard: LS.02.01.35 – EP 6

§482.41(b)(1)(i) – (A-0710) – (i) The hospital must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA 101®2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.

Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. If any changes in this edition of the Code are incorporated by reference, CMS will publish notice in the Federal Register to announce the changes.
This Standard is NOT MET as evidenced by:
Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the Ground floor, in the Main Pharmacy there is < 18″ of open space maintained below the sprinkler deflector to the top of the NH Bulk Freezer.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 1st floor, in the ED Department there is < 18″ of open space maintained below the sprinkler deflector to the top of the Pyxis machines for the “C Pod”.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 1st floor, in the ED Department there is < 18″ of open space maintained below the sprinkler deflector to the top of the Pyxis machines for the “A Pod”.

Observed in Building Tour at New Hanover Regional Medical Center (2131 South 17th Street, Wilmington, NC) site for the Hospital deemed service.
In the Women and Children center, on the 1st floor, in the ED Department there is < 18″ of open space maintained below the sprinkler deflector to the top of the Pyxis machines for the “Trauma Pod”.