Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
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)
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, blue print review and staff interview, the facility failed to ensure the corridor system had adequate headroom on 1 of 3 floors and failed to ensure the exit access corridor was accessible at all times on 2 of 3 floors. The findings were: 1. Observation of the fire barrier double doors between surgery and outpatient services on 11/3/11 at 3:37 PM showed the doors were equipped with a magnetic locking system. Further review showed the bottom of the magnetic locks did not have the required 6 feet 8 inch headroom. The bottom of the magnetic locks were only 6 feet 5 inches above the floor. At the time of observation the facility supervisor reported he was unaware of the spacing requirement. 2. Interview with the outpatient charge nurse on 11/3/11 at 3:56 PM revealed the fire barrier double doors between surgery and outpatient services was locked each night to restrict access to the surgery department. Review of the blue prints showed the locked doors restricted access to the designated egress system. Further review showed the surgery department was not a suite and thus confirmed the access through the department can not be locked with the current configuration. At the time of observation and blueprint review the facility supervisor confirmed the egress access system was designed to pass through the surgery department. He could not explain why the access to the egress system had not been noticed and addressed. 3. Observation of the behavioral health services (BHS) department on 11/7/11 at 11:06 AM showed the treatment/counseling room required patients to exit into the dining room and then enter the exit corridor. Observation and blue print review showed the area was not constructed as a separate suite. At the time of observation the facility supervisor reported he was not aware treatment rooms, not in a suite of rooms, required exit access doors leading directly to an exit access corridor without passing through an adjoining room. 4. Observation of the double corridor doors between the BHS department and the intensive care unit (ICU) on 11/7/11 at 3:05 PM showed the doors were locked for the clinical needs of the BHS patients. Further observation showed all BHS staff members had a key to unlock the door. Review of the blue prints showed the second exit from the BHS department was through the corridor that ran though the ICU suite. Review of the ICU showed it was no longer a corridor as three of four patient room corridor doors had been removed since the area was converted into a suite. Interview with the ICU charge nurse confirmed not all ICU staff members carried keys to the double doors leading into the BHS department. Review of the blue prints showed it was 4575 square feet and requires two exit access doors located remotely from each other. Reference: NFPA 101, 2000 Edition, 19.2.1; 7.1.5* Headroom. Means of egress shall be designed and maintained to provide headroom as provided in other sections of this Code and shall be not less than 7 ft 6 in. (2.3 m) with projections from the ceiling not less than 6 ft 8 in. (2 m) nominal height above the finished floor. The minimum ceiling height shall be maintained for not less than two-thirds of the ceiling area of any room or space, provided the ceiling height of remaining ceiling area is not less than 6 ft 8 in. (2 m). Headroom on stairs shall be not less than 6 ft 8 in. (2 m) and shall be measured vertically above a plane parallel to and tangent with the most forward projection of the stair tread. 19.2.5.1 Every habitable room shall have an exit access door leading directly to an exit access corridor. Exception No. 1: If there is an exit door opening directly to the outside from the room at ground level. Exception No. 2: Exit access from a patient sleeping room with not more than eight patient beds shall be permitted to pass through one intervening room to reach the exit access corridor. Exception No. 3: Exit access from a special nursing suite shall be permitted to pass through one intervening room to reach the exit access corridor where the arrangement allows for direct and constant visual supervision by nursing personnel. Exception No. 4: Exit access from a suite of rooms, other than patient sleeping rooms, shall be permitted to pass through not more than two adjacent rooms to reach the exit access corridor where the travel distance within the suite is in accordance with 19.2.5.8. 19.2.5.9* Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies. A.19.2.5.9 Every exit or exit access should be arranged, if practical and feasible, so that no corridor, passageway, or aisle has a pocket or dead end exceeding 30 ft (9.1 m). (See also Table A.7.6.1.) 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side. Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.) Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. A.19.2.2.2.4 Exception No. 2 The intent of the provision is that a person following the natural path of the means of egress not encounter more than one delayed release device along that path of travel to an exit. Thus, each door from the multiple floors of a building that opens into an enclosed stair is permitted to have its own delayed release device, but an additional delayed release device is not permitted at the level of exit discharge on the door that discharges people from the enclosed stair to the outside. Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted. 19.2.2.2.5 Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door. 19.2.5.2 Any patient sleeping room, or any suite that includes patient sleeping rooms, of more than 1000 ft2 (93 m2) shall have not less than two exit access doors remotely located from each other.