Failure to Document Monthly Generator Battery Testing
Penalty
Summary
The facility failed to maintain the required testing of emergency generator components, specifically the monthly conductance testing of the generator's maintenance-free batteries. This deficiency was identified during a document review conducted on December 23, 2024, at 9:30 a.m., which revealed the absence of verifying documentation for the monthly testing. The lack of documentation indicates that the facility did not adhere to the necessary maintenance protocols for the emergency generator, which is crucial for ensuring the generator's reliability in providing essential power during emergencies. During the exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m., it was confirmed that the documentation for the monthly conductance testing was missing. This oversight affects the facility's ability to demonstrate compliance with the National Fire Protection Association (NFPA) standards, specifically NFPA 101, NFPA 110, and NFPA 111, which outline the requirements for maintaining and testing emergency power systems in healthcare facilities.
Plan Of Correction
1. On 1/3/2025 the Maintenance Supervisor completed conductance testing of the generator's maintenance free batteries. 2. On (Insert Date) the Maintenance Director revised the generator testing documentation to include monthly conductance testing. 3. On 12/30/2024 the NHA educated the maintenance team on maintaining the required testing of emergency generator components in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct audits monthly for 3 months to verify proper documentation for generator testing is present. Results of the audits will be reviewed at the QAPI meeting held monthly.