Missing Emergency Generator Testing Documentation
Penalty
Summary
The facility failed to provide documentation of required annual and three-year testing for the emergency generator that serves the entire facility. During a document review, it was found that records for the annual 90-minute load bank test and the three-year 4-hour load bank test were missing. These tests are mandated to ensure the generator and associated equipment can supply power within the required timeframe and are maintained according to NFPA standards. At the time of the exit conference, both the Director of Nursing and the Director of Maintenance confirmed that the facility was unable to supply the necessary test results for the emergency generator. The deficiency was identified solely through document review and staff interview, with no mention of specific residents or patient conditions related to the deficiency.
Plan Of Correction
1. The facility is unable to retroactively perform this testing. 2. Testing will be completed for the annual, 90-minute load bank and the 3-year, 4-hour load bank. 3. The Environmental Services Director was re-educated on the requirements of K0918. 4. The NHA or designee will complete an annual audit of the annual testing yearly in August. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.