HospitalInspections.org

Based on Operating Room Policy and Procedure Manual review, Line Isolation Monitor testing preventative maintenance documentation review and interview, it was determined the facility did not perform monthly testing for 17 of 17 line isolation monitors in accordance with NFPA 99, Section 3-3.3.4.2 (b) (1999 edition). Failure to test line isolation panels monthly had the potential to affect the health and safety of all patients in the surgical areas served by the monitors because proper functioning of the monitors to prevent electrical shock was not monitored and assured. The failed practice had the potential to affect all surgical patients. The facility performed an average of 380 surgical procedures per month. The findings follow:

A. Review of Line Isolation Monitor preventative maintenance documentation on 12/11/12 at 1015 revealed the line isolation monitors were tested on a quarterly schedule.
B. Review of the Operating Room Policy and Procedure Manual on 12/11/12 at 1430 revealed "the line isolation monitor is tested once a month by the Engineering Department."
C. In an interview conducted on 12/12/12 at 0940 the Clinical Engineering Manager verified the facility had a total of 17 line isolation monitors (13 in the Operating Room suite, 2 in the Post-Anesthesia Care Unit, and 2 in the Labor and Delivery department). She also verified the testing was performed on a quarterly schedule and there was no further documentation available for review.

Based on Operating Room Policy and Procedure Manual review, Line Isolation Monitor testing preventative maintenance documentation review and interview, it was determined the facility did not perform monthly testing for 17 of 17 line isolation monitors in accordance with NFPA 99, Section 3-3.3.4.2 (b) (1999 edition). Failure to test line isolation panels monthly had the potential to affect the health and safety of all patients in the surgical areas served by the monitors because proper functioning of the monitors to prevent electrical shock was not monitored and assured. The failed practice had the potential to affect all surgical patients. The facility performed an average of 380 surgical procedures per month. The findings follow:

A. Review of Line Isolation Monitor preventative maintenance documentation on 12/11/12 at 1015 revealed the line isolation monitors were tested on a quarterly schedule.
B. Review of the Operating Room Policy and Procedure Manual on 12/11/12 at 1430 revealed "the line isolation monitor is tested once a month by the Engineering Department."
C. In an interview conducted on 12/12/12 at 0940 the Clinical Engineering Manager verified the facility had a total of 17 line isolation monitors (13 in the Operating Room suite, 2 in the Post-Anesthesia Care Unit, and 2 in the Labor and Delivery department). She also verified the testing was performed on a quarterly schedule and there was no further documentation available for review.