| 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) |
| K0051 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 A fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system is by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations in patient sleeping areas may be omitted provided that manual pull stations are within 200 feet of nurse's stations. Pull stations are located in the path of egress. Electronic or written records of tests are available. A reliable second source of power is provided. Fire alarm systems are maintained in accordance with NFPA 72 and records of maintenance are kept readily available. There is remote annunciation of the fire alarm system to an approved central station. 19.3.4, 9.6 This STANDARD is not met as evidenced by: Based on record review and staff interview, the facility failed to ensure smoke detectors were properly installed, failed to ensure the sprinkler system was fully monitored by the fire alarm system, failed to ensure pull stations were installed properly and failed to ensure the corridors had complete smoke detection coverage on 2 of 3 floors. The findings were: 1. Periodic observation of the fire alarm system on 11/3-7/11 showed the smoke detectors in the sterile processing clean room, the sterile processing dirty room, the material management mail room, the engineering copy room, the dialysis waiting room, the stress test room, and the pediatrics nurses' station were installed closer than 36 inches from ventilation diffusers. On 11/3/11 at 11:20 AM the facility supervisor reported he was unaware of the spacing requirement and assumed the fire alarm contractor would inspect for proper spacing. 2. Observation of the 547 generator sprinkler system on 11/3/11 at 11:32 AM showed two isolation valves were not supervised by the fire alarm system. At the time of observation the facility supervisor reported he was unaware the sprinkler system isolation valves were required to be supervised. Furthermore he reported the system had been installed for more than ten years, and the last annual inspection, 4/11/11, had not indicated the lack of supervision. 3. Observation of the admitting foyer on 11/4/11 at 9:50 AM showed the entrance vestibule had an outer and inner door. Further observation showed the vestibule was not monitored by a smoke detector. At the time of observation the facility supervisor reported he was aware smoke detectors were required in the corridor system. He reported the system was inspected annually by an outside contractor and the lack of the smoke detector was not indicated during their last inspection, 4/11/11. 4. Observation of the admitting foyer on 11/4/11 at 9:55 AM showed the entrance vestibule had an outer and inner door. The facility supervisor reported the inner door was locked at night when the area was not supervised. Further observation showed the manual fire alarm pull station was located inside of the inner door, more than 5 feet from the entrance. At the time of observation, the facility supervisor reported he was unaware pull stations were required to be installed a maximum of 5 feet from the exit doorway opening. 5. Observation of the behavioral health services group room on 11/7/11 at 10:24 AM showed a strobe light harness was installed above the television set, but the device had been removed. At the time of observation the facility supervisor could not explain why the device had been removed. Reference: NFPA 101, 2000 Edition, 19.3.4.5.1 Corridors. An approved automatic smoke detection system shall be installed in all corridors of limited care facilities. Such system shall be in accordance with Section 9.6. Exception No. 1: Where each patient sleeping room is protected by an approved smoke detection system, and a smoke detector is provided at smoke barriers and horizontal exits in accordance with Section 9.6, the corridor smoke detection system shall not be required on the patient sleeping room floors. Exception No. 2: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2. 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 19.3.4.1, 9.6.1.4; NFPA 13, 1999 Edition; 5-14.1.1.3 Valves on connections to water supplies, sectional control and isolation valves, and other valves in supply pipes to sprinklers and other fixed water-based fire suppression systems shall be supervised by one of the following: (1) Central station... (2) Local signaling service that will cause the sounding of an audible signal at a constantly attended point. NFPA 72, 1999 Edition; 2-8.2.2 Manual Fire alarm boxes shall be located within 5 ft of the exit door opening at each exit on each floor. 4-4.1 there are two methods of visible signaling. These are methods in which the message of notification of an emergency condition is conveyed by direct viewing of the illuminating appliance or by means of illumination of the surrounding area. Public mode signaling shall meet the requirements of Section 4-4 using visible notification appliances. 5.7.4.1* In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. A 5.7.4.1 Detectors should not be located in a direct airflow or closer than 1 m (3 ft) from an air supply diffuser or return air opening ... |