Failure to Document Required Generator Battery Testing
Penalty
Summary
The facility failed to document a required battery test during the monthly inspection of its generators. Specifically, the monthly test did not include either the specific gravity fluids or the cold crank amperage for maintenance-free batteries, as required to ensure the operational condition of the generator cells. This omission was identified during a record review conducted on April 9, 2025, and was confirmed through an interview with the facility Maintenance Director at the time of observation. The deficiency pertains to non-compliance with NFPA 110, which mandates that such battery tests be part of the monthly generator inspection. The lack of documentation and testing could potentially affect all occupants and staff in the event of a failed generator battery during a main utility power loss, as the operational readiness of the emergency power source could not be verified.
Plan Of Correction
K918 Electrical Systems Element 1: Facility purchased tester for generator battery. Battery tested and is in operational condition. Element 2: Residents that reside in the facility have the potential to be affected by this deficient practice. Element 3: The Maintenance Department was educated by the Nursing Home Administrator on monthly generator inspections to include a documented battery test. Element 4: Facility generator checks will be audited monthly for 4 months to ensure monthly generator inspections include a documented battery test. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained compliance.