Failure to Conduct Annual Electrical Receptacle Inspection
Penalty
Summary
The facility failed to conduct the required annual electrical receptacle inspection in resident care areas within one of two smoke zones. During a document review on October 8, 2024, it was found that there was no documentation verifying that electrical receptacles had been tested within the last 12 months. This was confirmed in an interview with the Director of Maintenance, who acknowledged that the receptacles in patient care areas had not been tested in the past year. Further observation on December 9, 2024, revealed that the issue had not been corrected, as confirmed again by the Director of Maintenance. The lack of testing and documentation indicates a failure to comply with the NFPA 101 Electrical Systems - Maintenance and Testing requirements, specifically regarding the testing of hospital-grade receptacles in patient care areas.
Plan Of Correction
1. Facility is unable to retroactively conduct annual electrical receptacle inspection in resident care areas. 2. A facility-wide audit of electrical receptacles will be completed. Maintenance Staff will be educated on the requirement to perform annual receptacle inspections. 3. Maintenance Director will complete annual electrical receptacle inspections by 01/27/2025. 4. NHA or designee will audit Life Safety Book semi-annually to confirm completion of annual inspections and that the documentation has been completed. The results of monitoring will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.