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)
K0076 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards 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. NFPA 99 4.3.1.1.2, 19.3.2.4


This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to ensure electrical receptacles and switches were installed at minimum heights in oxygen storage locations on 1 of 3 floors. The findings were: Observation of the cardiopulmonary oxygen storeroom on 11/7/11 at 9:52 AM showed the electrical receptacle behind the oxygen storage rack was installed 20 inches above the floor. Further review showed this was the standard height of receptacle throughout the room. Review of the light switch showed it was installed 48 inches above the floor, not the require 60 inches for all receptacles and switches. At the time of observation the facility supervisor was unaware of the height requirement in oxygen storage locations. Reference: NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition; 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). (a) Nonflammable Gases (any Quantity; In-storage, Connected, or Both) 3. Provisions shall be made for racks or fastening to protect cylinders from accidental damage or dislocation. 4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electrical wall fixtures, switches and receptacles shall be installed in fixed locations not less than 5 ft above the floor as a precaution against their physical damage.