Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 110 Emergency Power and Standby Power Systems (2010 Edition), Section 8. Specifically, the facility did not conduct weekly visual inspections of the generator, nor did it check the generator's battery electrolyte levels and gravity as required. This lack of maintenance and testing was identified through a review of the facility's generator documentation, which showed no evidence of the required weekly inspections or checks. During an interview, a staff member confirmed the absence of this documentation, indicating that the facility could not locate the missing records. These deficient practices had the potential to affect all 74 residents in the facility. The failure to perform these essential maintenance tasks could compromise the generator's ability to provide emergency power, which is critical for the safety and well-being of the residents. The report does not mention any specific incidents or adverse outcomes resulting from this deficiency, but it highlights the potential risk to the residents due to the facility's non-compliance with the established standards.
Plan Of Correction
4. Monitoring of Corrective Action: The Administrator will submit a report monthly x 3 months at the monthly Quality Assurance Improvement Meetings for review and recommendations. 1. Corrective Action of Areas Affected: The Director of Maintenance is completing the required weekly generator tests as well as the weekly checks of the battery electrolyte levels. Monthly checks of the battery specific gravity on the generator is being completed by the US FOIA (5)(6) has been in-serviced of the need to conduct these required inspections. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Director of Maintenance and Administrator have reviewed all other required generator tests/inspections to ensure all are routinely completed as required. Systemic Changes to Prevent Future Occurrences: The Administrator is now responsible to ensure all generator tests/inspections are completed as required by reviewing the documentation submitted by the Maintenance Director. Monitoring of Corrective Action: The Director of Maintenance will submit a weekly report on the generator test and battery electrolyte level weekly x 4 then monthly x 2. The Director of Maintenance will also submit a monthly report regarding the generator battery specific gravity x 3 months. The Administrator will submit a report monthly x 3 months at the monthly Quality Assurance Improvement Meetings for review and recommendations.