|Electrical Systems - Maintenance and Testing|
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 126.96.36.199.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 188.8.131.52.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Name: BUILDING 03 - Component: 03 - Tag: 0914
Based on document review, observation and inteview, the facility failed to maintain line isolation monitors at two of two systems.
1. Document review on December 3, 2019, at 10:25 a.m., revealed the facility lacked documentation that the Operating Room suite line isolation monitors meet required testing.
Interview with the maintenance director and facility director on December 3, 2019, at 10:25 a.m., confirmed the above line isolation monitor testing documentation was not available at the time of the survey.
2. Observation on December 3, 2019, at 10:30 a.m., revealed the "Microlimb" line isolation monitor panel audible alarm and visual lamps were not functioning.
Interview with the maintenance director and facility director on December 3, 2019, at 10:25 a.m., confirmed the above line isolation monitor panel audible and visual indicators were not functioning.
| ||Plan of Correction - To be completed: 02/15/2020|
The outside contractor has been contacted and is being scheduled to come, test and repair any faults in the line of the isolation monitors. To be completed by 2-15-2020.
On December 9, 2019, an outside service company was contacted to get a quote for service to these line isolation monitors. On December 10, 2019, we authorized the service company to review the issues with the line isolation monitors and do any needed repairs and they are scheduled to be on-site on December 19, 2019. The OR staff has been in-serviced on the importance of these monitors and will do a monthly audit to see that we remain in compliance.