| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 531311 | (X3) Date Survey Completed 10/05/2016 |
| 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) |
| K0000 | This STANDARD is not met as evidenced by: Requirements for Hospitals Section 42 CFR 482.41 (b) except as otherwise provided in the section, the facility must meet the applicable provisions of the 2000 Edition of the Life Safety Code, Existing Health Care of the National Fire Protection Association. The facility was a fully sprinklered, one-story building of Type II (111) construction built in 1960. The building was equipped with a supervised automatic wet sprinkler and dry sprinkler system with an addressable fire alarm system. The facility had a capacity of 18 certified Medicare and Medicaid beds with a census of 4. |
| K0033 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Exit enclosures (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1 This STANDARD is not met as evidenced by: . Based on observation and staff interview the facility failed to provide rated construction for an exit stairwell in accordance with NFPA 101. The findings were: 1. Observation on 10/05/2016 at 8:46 AM located at the exit stairwell adjacent to the Back 40 storage revealed that the stair well was open to the lower medical clinic. Further observation revealed a childs play room in the exit stairwell that was not separated from the stairwell by a fire rating of at least 1 hour. Interview with the Facility Maintenance Manager at time of observation acknowledged the childs play room was open to the exit stairwell. 2. Observation on 10/05/2016 at 8:45 AM located at the exit stairwell adjacent to the Back 40 storage revealed a non continuous path of egress. Further observation revealed obstruction such as combustible storage goods in the exit stairwell obstructing egress. Interview with the Facility Maintenance Manager at the time of observation acknowledged that there were storage items within the means of egress. Ref: 2000 NFPA 101, Sections 19.3.1.1 and 8.2.5.2 |
| K0038 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1 This STANDARD is not met as evidenced by: . Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times. The findings were: 1. Observation on 10/05/2016 from 8:36 AM to 10:20 AM located in the Maintenance Office (Main level), IT Room, Boiler room, and throughout the facility revealed door locks that required tight pinching, and more than one releasing operation to make the door operable. Interview with the Facility Maintenance Manager at the time of the observation acknowledged the door lock required more than one operation to open. 2. Observation on 10/05/2016 at 8:46 AM located at the Back 40 Storage room revealed a door labeled exit (Door opened into exit stairwell) that was locked and required a key to open. Further observation revealed that limited staff had the key to the exit door. Interview with the Facility Maintenance Manager at the time of observation acknowledged the door was locked against egress and that only a select few had the keys. Ref: 2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4 |
| K0076 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. 4-3.1.1.2 (NFPA 99), 8-3.1.11.1 (NFPA 99), 18.3.2.4, 19.3.2.4 This STANDARD is not met as evidenced by: . Based on observation and staff interview, the facility failed to store oxygen in accordance with NFPA 99. The findings were: Observation on 10/05/2016 at 9:56 AM located in the Oxygen storage room revealed that there was more than 3,000 cubic feet of O2 storage. Further observation revealed a natural ventilation system, but the vent minimum opening was not 72 square inches. Interview with the Facility Maintenance Manager at the time of observation was not aware of the requirement. Ref: 1999 NFPA 99, Section 4-3.1.1.2 (b) 4 |
| K0147 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1 This STANDARD is not met as evidenced by: . Based on observation and staff interview, the facility failed to meet electrical wiring in accordance with NFPA 70. The findings were: Observation on 10/05/2016 at 10:25 AM located in rooms 4, 5, 6, 7, and 8 revealed receptacles approximately 2 feet away from sinks that were not equipped with a ground-fault circuit-interrupter. Interview with the Facility Maintenance Manager at the time of observation acknowledged the missing ground-fault circuit-interrupters. Ref: 1999 NFPA 70, Article 210.8 |