Failure to Maintain Emergency Generator Documentation
Penalty
Summary
The facility failed to maintain the emergency generator, which affects the entire facility. During a document review on January 22, 2025, it was revealed that the facility did not provide documentation for essential generator tests for 10 out of 12 months, specifically from March to December. The missing documentation included records of weekly visual inspections and battery voltage or electrolyte levels, as well as monthly specific gravity or conductance tests, 30-minute load runs, and transfer switch tests. The maintenance supervisor confirmed during an interview on the same day that the test documentation was unavailable at the time of the survey. The facility stated that the documents were destroyed due to a water leak, which contributed to the lack of available records. This deficiency indicates a failure to adhere to the required maintenance and testing protocols for the emergency generator, as outlined by NFPA standards.
Plan Of Correction
A. Weekly visual/inspection and battery: Maintenance initiated immediate inspection of battery and voltage test, documenting findings. Maintenance will continue to document weekly inspections. NHA/Designee will educate maintenance staff by 21MAR2025 on importance of maintaining proper documentation and electric system maintenance and testing. Maintenance director/designee will conduct weekly x4 inspections of battery and voltage test and documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Monthly Specific gravity or conductance 30-min load run and transfer switch. Maintenance completed 30-minute load run specific conductance test and documented results. Maintenance to conduct monthly 30-min load run tests, results to be documented and kept on file. NHA/Designee will educate maintenance staff by 21MAR2025 on requirements to do 30-min load run and transfer switch testing monthly and document results to ensure proper function and compliance. Maintenance will complete monthly x 3 audit to remain in compliance. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.