HospitalInspections.org

Based on observation, interview and record review, the hospital failed to equip two of two operating rooms with Line Isolation Monitors (LIMs). This failure had the potential to affect all building occupants utilizing the operating rooms (OR). The hospital census was six.

Observation on 07/08/25 at 2:40 PM, showed the hospital utilized two operating rooms.

Record review of the hospital's maintenance records and concurrent interview, on 07/08/25 at 3:25 PM, showed no documentation of LIMs testing. Staff N, Maintenance Director, stated that the hospital did LIMs testing in their old ORs, but when the new ORs were built, it slipped his mind to restart the LIMs testing.

Review of the 2012 edition of The National Fire Protection Association (NFPA) 99, showed the following:
3.3.138* Patient Care Room. Any room of a health care facility wherein patients are intended to be examined or treated. (MED)
3.3.138.1* Basic Care Room. Room in which the failure of equipment or a system is not likely to cause injury to the patients or caregivers but can cause patient discomfort. (Category 3). (MED)
3.3.138.2* Critical Care Room. Room in which failure of equipment or a system is likely to cause major injury or death of patients or caregivers (Category 1). (MED)
3.3.138.3* General Care Room. Room in which failure of equipment or a system is likely to cause minor injury to patients or caregivers (Category 2). (MED)
3.3.138.4* Support Room. Room in which failure of equipment or a system is not likely to have a physical impact on patients or caregivers (Category 4). (MED)
6.4.1.1.4 Essential electrical systems shall have a minimum of the following two independent sources of power: a normal source generally supplying the entire electrical system and one or more alternate sources for use when the normal source is interrupted.
6.4.1.1.5 Where the normal source consists of generating units on the premises, the alternate source shall be either another generating set or an external utility service.
6.4.1.1.6 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
NFPA 70 (NEC):
Patient Bed Location. The location of a patient sleeping bed, or the bed or procedure table of a critical care area. [99:3.3.137]

517.19 Critical Care Areas.
(A) Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them.
The branch circuit serving patient bed locations shall not be part of a multi-wire branch circuit.