Failure to Document and Complete Required Weekly Generator Inspections
Penalty
Summary
The facility failed to ensure compliance with required maintenance and testing protocols for its emergency generator system as outlined by NFPA 110, NFPA 99, NFPA 111, and NFPA 70. Specifically, during a review of facility records, it was found that documentation for weekly generator inspections over the past 12 months was incomplete. Only one weekly inspection per month was documented, rather than the required weekly inspections for each month. This deficiency was confirmed during an interview with the Maintenance Assistant at the time of the record review. The lack of proper documentation and completion of weekly generator inspections means the facility did not meet the standards necessary to ensure the emergency power system would function as required in the event of an electrical failure. The deficiency could potentially affect all occupants who rely on the emergency power source for safety and essential services during power outages, as the facility could not demonstrate that the generator was being properly maintained and inspected according to regulatory requirements.
Plan Of Correction
K918 #1 Based on record review and interview, the facility failed to ensure generators or other alternative power sources are in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70. This deficient practice could affect all occupants in the event of electrical failure requiring emergency generator power. #2 Facility Maintenance Director was educated that there must be weekly generator inspections and that there needs to be a monthly load test as well. #3 The Maintenance Director immediately corrected his inspections to weekly and will continue his monthly load test as well. Proof will be kept in the Life Safety Manual. #4 All further weekly and monthly logs will be kept in the Life Safety Manual. #5 It will be the responsibility of the Maintenance Director to ensure sustained compliance.