Failure to Document Electrical Receptacle Testing
Penalty
Summary
The facility failed to provide documentation of testing and performance data for electrical receptacles at patient bed locations, as required by NFPA 99 (2012), Section 6.3.4. This deficiency was identified during a review of the facility's Life Safety Code Survey documentation binder, where the necessary documentation was not available. The surveyor requested this documentation at multiple points, including the entrance conference, document review, and exit conference, but the facility was unable to produce it. The deficiency has the potential to affect all 131 residents in the facility, as the documentation pertains to both hospital-grade and non-hospital-grade receptacles in resident rooms. An interview with a facility representative confirmed the finding and revealed that the facility could not locate the missing documentation, indicating a lapse in maintaining required records for electrical system maintenance and testing.
Plan Of Correction
Element 1 This deficiency was corrected by conducting performance tests on the receptacles. Element 2 This deficiency has the potential to affect all residents. Element 3 A Receptacle audit was conducted by the Maintenance Director or designee to ensure the facility remains in compliance with K914. This audit is being completed by making rounds within the facility. Element 4 The Receptacle audit is being monitored by the Administrator or designee once a month for six months and then performed annually on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.