HospitalInspections.org

Based on observation and interview, it was determined the facility did not perform monthly testing on six of six line isolation panels in the facility 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 and patients receiving treatment in the Acute Treatment room in the Emergency Department. The facility performed an average of 90 surgical procedures per month. The findings follow:

A. On a tour of the Operating Suite on 02/25/13 at 1330 with the Director of Surgery revealed two line isolation panels were located in each operating room (Operating Room #1 and Operating Room #2).
B. On a tour of the Emergency Department on 02/27/13 at 1300 with the Housekeeping Director revealed the Acute Treatment Room had two line isolation panels.
C. In an interview conducted on 02/26/13 at 1030, the Maintenance Director verified there was no documentation of monthly line isolation panel testing available for review.

Based on interview, it could not be determined the generator was inspected weekly. Failure to perform weekly generator inspections had the potential to affect the health and safety of all patients because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 13 patients on 02/25/13. The findings follow:

In an interview on 02/25/13 at 1550, the Maintenance Director verified there was no documentation of weekly generator inspections available for review.

Based on observation and interview, it was determined the facility did not perform monthly testing on six of six line isolation panels in the facility 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 and patients receiving treatment in the Acute Treatment room in the Emergency Department. The facility performed an average of 90 surgical procedures per month. The findings follow:

A. On a tour of the Operating Suite on 02/25/13 at 1330 with the Director of Surgery revealed two line isolation panels were located in each operating room (Operating Room #1 and Operating Room #2).
B. On a tour of the Emergency Department on 02/27/13 at 1300 with the Housekeeping Director revealed the Acute Treatment Room had two line isolation panels.
C. In an interview conducted on 02/26/13 at 1030, the Maintenance Director verified there was no documentation of monthly line isolation panel testing available for review.

Based on interview, it could not be determined the generator was inspected weekly. Failure to perform weekly generator inspections had the potential to affect the health and safety of all patients because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 13 patients on 02/25/13. The findings follow:

In an interview on 02/25/13 at 1550, the Maintenance Director verified there was no documentation of weekly generator inspections available for review.