| 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) |
| K0145 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 The Type I EES is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2. This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure circuit directories were accurate and failed to ensure the Essential Electrical System (EES) was divided into a Life Safety Branch and a Critical Branch on 3 of 3 floors. The findings were: 1. Observation of the Equipment Branch panel "EMC" on 11/3/11 at 11:50 AM showed the circuit directory was labeled differently than the labeling tape next to several circuits. Circuit #1 was lined out on the directory, but the labeling tape next to the circuit showed "tank monitor". Circuit #3 was lined out on the directory, but the labeling tape showed "Exhaust ATS". Circuit #5 was lined out on the directory, but the labeling tape showed "Gas Pump". Circuit #6 and #8 was a two pull circuit and was lined out on the directory, but the labeling tape showed "Panel EMC1-B". At the time of observation the facility supervisor reported he was aware of the requirement and that several panels were not labeled correctly. He also reported the facility was working on correcting the issue, but could not explain why the directories had not been updated when they were originally changed. 2. Observation of the Critical Branch electrical panel "EMV" on 11/3/11 at 12:46 PM showed the panel supplied power to Life Safety Branch equipment. Circuit #13 and #15 supplied power to "fire/smoke dampers". At the time of observation the facility supervisor reported he was unaware the "EES" panels could only supply power to specific equipment. 3. Observation of the Life Safety Branch electrical panel "EMU" on 11/3/11 at 12:48 PM showed the panel supplied power to Critical Branch equipment. Circuit #2 and #4 supplied power to "pharmacy lights". Circuit #9 supplied power to "EM storage lights". Circuit #12 supplied power to "pixis material storage". 4. Observation of the Critical Branch electrical panel "EMQ" on 11/3/11 at 2:05 PM showed the panel supplied to Life Safety Branch equipment. Circuit #6 supplied power to "PBX medical gas panel". 5. Observation of the Critical Branch electrical panel "EMAA" on 11/3/11 at 2:28 PM showed the panel supplied power to Life Safety Branch equipment. Circuit #13 supplied power to "phone board in the communication room". 6. Observation of the Life Safety Branch electrical panel "EMA" on 11/4/11 at 9:01 AM showed the panel supplied to Critical Branch equipment. Circuit #4 supplied power to "card reader and clock". Circuit #6 and #8 supplied power to the "lab reagent refrigerator". Circuit #17 supplied power to the "admitting door access card reader". 7. Observation of the Life Safety Branch panel "EMN" on 11/4/11 at 10:13 AM showed circuit #6 supplied power to the "fire alarm control panel". The circuit director and the circuit itself were not colored with red markings. At the time of observation the facility supervisor was not aware of the aforementioned requirement. Reference: NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition; 384-13 ...All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. Article 517-30 Essential Electrical Systems for Hospitals. Article 517-31 Emergency System Article 517-32 Life Safety Branch Article 517-33 Critical Branch Article 517-34 Equipment System |