| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 530025 | (X3) Date Survey Completed 11/07/2011 |
| Name of Provider or Supplier Ivinson Memorial Hospital | Street Address, City, State 255 N 30th, Laramie, 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) |
| K0018 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant on 1 of 3 floors. The findings were: Observation of the material management corridor double door on 11/7/11 at 11:26 AM showed one of the doors was equipped with a steel astragal. When the doors were released from the magnetic hold open devices, the door with the astragal closed first preventing the doors from being smoke resistant. Further observation showed the doors were not equipped with a sequencing device. At the time of observation the facility supervisor could not explain why the closing speed of the doors had not been noticed and a sequencer installed during the semi-annual inspections. |