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Based on observation, interview, and record review, the facility failed to maintain and document an annual load bank test of the facility's sole emergency generator in accordance with NFPA 99, 3.4.4.1 and NFPA 110, 8.4.2. This deficient practice affected the staff, visitors and patient census of 12.

Findings included:
1. Observation on 01/07/14 at 2:00 PM, showed that a single 400 Kilowatt generator in a heated enclosed mechanical room served as the only emergency power resource for the entire hospital campus.

During an interview on 01/09/14 at 9:00 AM Staff BB, Maintenance stated that the generator had failed in July to pass the annual supplemental load bank test due to a leaking head gasket problems and possibly other related problems. He stated it had been repaired, but still had problems of unknown cause and had not been re-tested under supplemental loads since failed test in late July, 2013.

Record review of invoices for services rendered dated 07/26/13 showed the vendor tried to run a load bank test but the head gaskets failed at 75 percent load and began leaking antifreeze. The note went on to say the head gaskets would stop leaking at 50 percent of the load.

Record review of a repair estimate dated August 7, 2013 showed a proposal for supplying a portable generator for stand-by power during the repair work, tear down existing engine, replace head gaskets and perform a four hour load bank test after the work was completed.

Record review of a repair estimate dated August 30, 2013 showed a proposal to drain the cooling system, remove, rebuild and re-install radiator, refill cooling system and perform a full load bank test after all work was completed.

Record review of current test logs and repair invoices showed no documentation that the generator was repaired, successfully re-tested and could meet the NFPA 110 requirement of running under 75 percent power for a minimum of one hour.

During an interview on 01/09.14 at 9:30 AM, Staff G, Maintenance Secretary and Staff BB stated that the generator had not been successfully re-tested under a full supplemental load. Staff BB stated that, even at reduced power, the generator could sustain the facility load and had successfully passed and documented weekly exercise and monthly load tests under facility load; however staff could not find documentation to show that the generator had been re-tested with a supplemental load during the past 12 months. Staff BB stated that the estimated repairs had been completed and they really were not sure what problems, if any still existed.

Based on observation, interview, and record review, the facility failed to maintain and document an annual load bank test of the facility's sole emergency generator in accordance with NFPA 99, 3.4.4.1 and NFPA 110, 8.4.2. This deficient practice affected the staff, visitors and patient census of 12.

Findings included:
1. Observation on 01/07/14 at 2:00 PM, showed that a single 400 Kilowatt generator in a heated enclosed mechanical room served as the only emergency power resource for the entire hospital campus.

During an interview on 01/09/14 at 9:00 AM Staff BB, Maintenance stated that the generator had failed in July to pass the annual supplemental load bank test due to a leaking head gasket problems and possibly other related problems. He stated it had been repaired, but still had problems of unknown cause and had not been re-tested under supplemental loads since failed test in late July, 2013.

Record review of invoices for services rendered dated 07/26/13 showed the vendor tried to run a load bank test but the head gaskets failed at 75 percent load and began leaking antifreeze. The note went on to say the head gaskets would stop leaking at 50 percent of the load.

Record review of a repair estimate dated August 7, 2013 showed a proposal for supplying a portable generator for stand-by power during the repair work, tear down existing engine, replace head gaskets and perform a four hour load bank test after the work was completed.

Record review of a repair estimate dated August 30, 2013 showed a proposal to drain the cooling system, remove, rebuild and re-install radiator, refill cooling system and perform a full load bank test after all work was completed.

Record review of current test logs and repair invoices showed no documentation that the generator was repaired, successfully re-tested and could meet the NFPA 110 requirement of running under 75 percent power for a minimum of one hour.

During an interview on 01/09.14 at 9:30 AM, Staff G, Maintenance Secretary and Staff BB stated that the generator had not been successfully re-tested under a full supplemental load. Staff BB stated that, even at reduced power, the generator could sustain the facility load and had successfully passed and documented weekly exercise and monthly load tests under facility load; however staff could not find documentation to show that the generator had been re-tested with a supplemental load during the past 12 months. Staff BB stated that the estimated repairs had been completed and they really were not sure what problems, if any still existed.