| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 531311 | (X3) Date Survey Completed 11/15/2011 |
| Name of Provider or Supplier Crook County Hospital | Street Address, City, State 713 Oak Street, Sundance, WY | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| K0027 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Door openings in smoke barriers have at least a 20-minute fire protection rating or are at least 1¾-inch thick solid bonded wood core. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Doors are self-closing or automatic closing in accordance with 19.2.2.2.6. Swinging doors are not required to swing with egress and positive latching is not required. 19.3.7.5, 19.3.7.6, 19.3.7.7 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure one smoke barrier door was resistant to the passage of smoke in 1 of 4 smoke compartments. The findings were: Observation on 11/15/11 at 12:48 PM revealed the cross corridor smoke barrier double doors between the laundry and physical therapy were held open with maglocks. However, upon release, the doors were unable to close completely. The maintenance manager confirmed the finding at the time of the observation. Reference: NFPA 101, Life Safety Code, 2000 edition 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self closing or automatic closing in accordance with 19.2.2.2.6. 8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be withour undercuts, louvers, or grilles. |
| K0047 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure 6 of 14 emergency exit lights were properly illuminated. The findings were: Observations on 11/15/11 between 11:45 AM and 2:48 PM revealed six emergency exit lights had one of two light bulbs burned out in the following locations: a. Over the door between the kitchen and the staff dining room. b. Over the door between the kitchen and the main hallway. c. Over the main entrance into the reception area. d. In the hallway by the administration office and cross corridor doors. e. Over the door between the emergency room hallway and the ambulance area. f. Over the door between the ambulance area and the ambulance garage. Interview with the maintenance manager at the time of the observations confirmed the bulbs were burned out. Reference: NFPA 101, Life Safety Code, 2000 edition. 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10. 7.10.5.1 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Setion 7.8. 7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less that 0.2 ft-candles. |
| K0062 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5 This STANDARD is not met as evidenced by: Based on record review and staff interview the facility failed to ensure the fire suppression (sprinkler) system was properly maintained in 1 of 4 smoke compartments. The findings were: Observations on 11/15/11 at 1:48 PM revealed a ceiling mounted sprinkler head was blocked by moping materials in the janitor's store room (mop/washer room). Interview with the maintenance manager at the above time confirmed the observation. Ref: 2000 NFPA 101 Section 18.3.5.1; 9.7.1.1; NFPA 13, 1999 edition 5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in or greater. |
| K0064 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Portable fire extinguishers are provided in all health care occupancies in accordance with 9.7.4.1. 19.3.5.6, NFPA 10 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to inspect 4 of 25 portable fire extinguishers during the previous year in accordance with NFPA 10 Section 4-4.1. The findings were: Observation of facility fire extinguishers on 11/15/11 between 11:45 AM and 2:48 PM revealed an inspection tag dated 2009 was attached to the fire extinguishers located in the lab, the maintenance room and the procedure room. In addition, an inspection tag dated 2008 was attached to the fire extinguisher in the central supply room. Interview with facility manager at the times listed above confirmed the extinguishers were improperly tagged. NFPA 101, Life Safety Code, 2000 edition. Sections 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10. 4-4.1 Maintenance Frequency. Extinguishers shall be subjected to maintenance not more than one year apart or when specifically indicated by an inspection. |
| K0147 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure compliance with the National Electric Code in 2 of 4 smoke compartments. The findings were: Observations on 11/15/11 between 11:45 AM and 2:48 PM revealed a surge protector was plugged into another surge protector in the emergency services office, in the nursing office, and in the medical records office. Plugged into the surge protectors were business machines, including computers, printers. In addition, a dimmer wall light switch was missing an electrical cover in the xray procedure room and the wall light switch in resident room #7 was cracked. Interview with the maintenance manager at the time of the observations confirmed the above findings. Reference: NFPA 70, National Electrical Code, 1999 Edition. Article 400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure. Article 370-28 Pull and Junction Boxes. Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d) of this section. (c) Covers. All pull boxes shall be provided with covers compatible with the box. |
| K0211 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Where Alcohol Based Hand Rub (ABHR) dispensers are installed in a corridor: o The corridor is at least 6 feet wide o The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms) o The dispensers have a minimum spacing of 4 ft from each other o Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet. o Dispensers are not installed over or adjacent to an ignition source. o If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure an alcohol based hand rub (ABHR) dispenser was not installed over an ignition source in 1 of 4 smoke compartments. The findings were: Observation on 11/15/11 at 9:48 AM revealed one ABHR dispenser was attached to the wall directly over a light switch in the outpatient entrance. Interview with the maintenance manager at the time of the observation confirmed the dispenser was located over a possible ignition source. Reference: NFPA 101, Life Safety Code, 2000 edition, Section 19.3.2.7. CFR 403.744. |