Failure to Conduct Triennial Generator Testing
Penalty
Summary
The facility failed to perform the required triennial four-hour test for the emergency generator, as evidenced by the lack of documentation verifying the test was conducted. This deficiency was identified during a documentation review on December 4, 2024, at 8:45 a.m. The absence of this critical documentation indicates that the facility did not adhere to the NFPA 101 and NFPA 110 standards, which mandate that generator sets be exercised once every 36 months for four continuous hours. An interview conducted with the Facility Administrator, Regional Nursing Consultant, and Maintenance Assistant on the same day at 11:30 a.m. confirmed that the documentation for the triennial generator testing was not available at the time of the survey. This oversight suggests a lapse in the facility's maintenance and testing procedures for their essential electrical systems, which are crucial for ensuring the safety and reliability of power in emergency situations.
Plan Of Correction
The facility cannot retroactively correct the inability to locate the documentation verifying that the triennial four-hour test on the emergency generator maintenance testing was performed. The log has since been located. Nursing Home Administrator/Designee will educate maintenance staff on maintaining the log in a location that is easily located. Maintenance staff/Designee will audit the log monthly to ensure proper location of information and date of last emergency generator maintenance testing is documented. The results of these audits will be forwarded to the Quality Assurance and Performance Improvement committee for review. Word for word duplicate. See above Deficiency #0918.