Failure to Maintain Emergency Generator Documentation
Penalty
Summary
The facility failed to maintain proper documentation for the maintenance and testing of its emergency generator, which is a critical component of the essential electrical system. During a document review on December 23, 2024, it was discovered that the facility did not have the required documentation for the annual 90-minute load bank test of the emergency generator. This test is crucial to ensure that the generator can supply power within 10 seconds during an emergency, as stipulated by NFPA 101 and related standards. An interview with the maintenance supervisor on the same day confirmed that the documentation for the emergency generator testing was unavailable at the time of the survey. This lack of documentation indicates a failure to comply with the necessary maintenance and testing protocols outlined in NFPA 110 and NFPA 111, which are designed to ensure the reliability and readiness of emergency power systems in the facility.
Plan Of Correction
1. Maintenance Director completed and properly documented the required 90 minute annual load bank testing for the generator on 1-2-5. 2. Education will be provided to maintenance staff regarding the required testing and documentation for the yearly 90 minute load bank testing for the generator by 2-10-25. 3. From this point forward, the yearly emergency generator testing will be completed and properly documented every January. 4. Process will be monitored in QAPI meeting to ensure this process is sustained.