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NFPA 101?, Life Safety Code?, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

Based on document review, observation and interview, the facility failed to ensure that their Line Isolation Monitors (LIM) were maintained in accordance with NFPA 101 and NFPA 99. This was evidenced by the failure to test the LIM test switch monthly, and to conduct service/inspections by licensed vendors every 6 months and maintain permanent records at the facility. This affected 2 of 2 operating rooms.

NFPA 99 Standard for Health Care Facilities, 1999 Edition
3-3.3.4.2 Line Isolation Monitor Tests. The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 X V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the tests switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

7-6.2.1.2 Testing Intervals.
(a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance.
(b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General care areas-12 months
Critical care areas-6 months
Wet locations-6 months


Findings:

During document review and a tour of the facility with Hospital Staff on July 9, 2012, the Line Isolation Monitors were observed and staff was interviewed.

At 3:00 P.M., the documentation from the hospital was reviewed. Records indicated the last service of the Line Isolation Monitors was conducted on July 21, 2011. No other documentation was provided by the facility. There were no records for testing the LIMs monthly and no records for vendor testing and certification every six months as required.

The Director of Plant Operations was interviewed and stated that they had added preventative maintenance protocols to test the LIMs monthly and had scheduled a vendor to come out to the facility later that week.

At 3:25 P.M., the LIMs were observed to be in "safe" mode and were tested by the Director of Plant Operations.