Failure to Conduct and Document Emergency Generator Inspections
Penalty
Summary
The facility failed to conduct and document the necessary inspections and tests of the emergency generator, which is crucial for the entire component's operation. During a review of documentation and an observation conducted on October 8, 2024, it was found that the facility did not perform the required weekly visual inspections, nor did they record the battery voltage weekly. Additionally, the monthly load test and operation of the transfer switch were not conducted, and the annual fuel quality test was not performed. Furthermore, the facility did not complete the required 3-year, 4-hour load bank test. An interview with the Director of Maintenance confirmed that the facility could not provide verification that these essential generator inspections and tests had been performed. This lack of documentation and testing indicates a failure to comply with the standards set forth by NFPA 101 and related guidelines, which are critical for ensuring the reliability of the emergency power system in the event of a power failure.
Plan Of Correction
1. Facility is unable to retroactively conduct inspections and tests of the emergency generator. 2. GenServ-DynaTech will be contacted to complete the following required inspections before 01/06/25. Tests of the emergency generator will be completed with corresponding documentation kept on file: a. Weekly visual inspection b. Weekly recording of the battery voltage c. Monthly load test and operation of the transfer switch d. Annual fuel quality test e. 3-year, 4-hour load bank 3. Maintenance Director will complete audits. Maintenance Director and Maintenance staff will be educated on and complete the required weekly, monthly, annual, and tri-annual inspection, as required by regulation. 4. NHA or Designee will complete monthly audits of the Life Safety Book to ensure that inspections and tests are being completed weekly, monthly, annually, and tri-annually per regulation. Audits will be done quarterly once substantial compliance is achieved.