Failure to Maintain Emergency Generator and Inspect Electrical Systems
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which affected the entire facility. During a document review, it was found that the facility could not provide documentation for weekly battery voltage testing and monthly battery conductance testing. This lack of documentation was confirmed during an exit interview with the Administrator and the Maintenance Director. Additionally, an observation revealed that the remote generator annunciator panel at the Nurses' Station on the first floor had a Low Fuel alarm. This issue was also confirmed during the exit interview with the Administrator and the Maintenance Director. These deficiencies indicate a failure in maintaining the essential electrical systems as required by NFPA standards.
Plan Of Correction
The weekly battery voltage tests and monthly battery conductance testing were completed. The Maintenance Director was in-serviced on ensuring that the weekly battery voltage testing and the monthly battery conductance testing are completed accurately. The Maintenance Director will audit the accuracy and completion of the voltage testing. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.