HospitalInspections.org

1. Based on interview, it was determined the facility failed to perform monthly tests on 5 of 5 Line Isolation Monitors in 2009 and 2010 in accordance with NFPA 99 Section 3-3.3.4.2 (b). The failed practice had the potential to affect all patients admitted for surgery and two of two patients admitted for surgery on the day of the survey as well as all patient receiving X-Ray procedures and treated in the trauma room in the Emergency Department. The findings follow:

On 06/09/10 at 1415, while touring the surgical suite a request was made to the Director of Plant Operations for documentation of monthly Line Isolation Monitor testing. The Director of Plant Operations stated weekly testing of the Line Isolation Monitors was not performed and there was no documentation of testing available for review. He also stated the facility had a total of 5 Line Isolation Monitors, with 2 located in the Trauma Room in the Emergency Department, one located in the Operating Room and one located in the Procedure Room in the surgical suite, and one located in the Purchasing Department that served Radiology.

2. Based on Generator Log Review and interview, it could not be determined weekly inspections of the emergency generator were conducted in 2009 and 2010 due to a lack of documentation. The failed practice had the potential to affect six of six patients on the day of the survey and all patients admitted to the facility. The findings follow:

A. Review of the Emergency Generator Log on 06/09/10 at 1305 revealed there was no documentation of weekly inspections of the generator on the log.
B. In an interview on 06/09/10 at 1330, the Director of Plant Operations stated he conducted daily visual inspections of the generator but did not document the results of the inspections.

1. Based on interview, it was determined the facility failed to perform monthly tests on 5 of 5 Line Isolation Monitors in 2009 and 2010 in accordance with NFPA 99 Section 3-3.3.4.2 (b). The failed practice had the potential to affect all patients admitted for surgery and two of two patients admitted for surgery on the day of the survey as well as all patient receiving X-Ray procedures and treated in the trauma room in the Emergency Department. The findings follow:

On 06/09/10 at 1415, while touring the surgical suite a request was made to the Director of Plant Operations for documentation of monthly Line Isolation Monitor testing. The Director of Plant Operations stated weekly testing of the Line Isolation Monitors was not performed and there was no documentation of testing available for review. He also stated the facility had a total of 5 Line Isolation Monitors, with 2 located in the Trauma Room in the Emergency Department, one located in the Operating Room and one located in the Procedure Room in the surgical suite, and one located in the Purchasing Department that served Radiology.

2. Based on Generator Log Review and interview, it could not be determined weekly inspections of the emergency generator were conducted in 2009 and 2010 due to a lack of documentation. The failed practice had the potential to affect six of six patients on the day of the survey and all patients admitted to the facility. The findings follow:

A. Review of the Emergency Generator Log on 06/09/10 at 1305 revealed there was no documentation of weekly inspections of the generator on the log.
B. In an interview on 06/09/10 at 1330, the Director of Plant Operations stated he conducted daily visual inspections of the generator but did not document the results of the inspections.