Failure to Document Required Generator Battery Test
Penalty
Summary
The facility failed to document a required battery test during the monthly inspection of the facility's generator. Specifically, the records did not include documentation of either the specific gravity of the battery fluids or the cold crank amperage for maintenance-free batteries, as required to ensure the operational condition of the generator's battery. This omission was identified during a record review conducted by surveyors. The deficiency was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of record review. The lack of proper documentation and testing could affect all 87 occupants in the event of a facility-wide power outage or fire emergency, as the generator's reliability could not be assured according to NFPA standards.
Plan Of Correction
The Maintenance Director has completed the required monthly battery test inspection of the facility's generator on June 2nd. The Maintenance Director/Designee has been educated to ensure that the monthly battery test inspection of the facility's generator is being conducted and recorded to ensure compliance with the regulation. The Maintenance Director/Designee will conduct a routine review of the life safety binder to ensure that monthly battery test inspections of the facility's generator are conducted and recorded. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.