HospitalInspections.org

Based on interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice affected all smoke compartments of the building and all of the occupants. The facility census was 5 patients.

Findings are:
Review of documentation and interview on 12-22-10 at 1:44 pm with Maintenance A revealed:

Documentation review on 12-22-10 revealed the faciliyt failed to verify the monthly testing of the generator under a 30% load.

During an interview on 12-22-10 at 1:44 pm, Maintenance A confirmed the facility failed to be aware of the generator testing requirements.

NFPA Standard:
Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

NFPA Standard:
Inspection and Testing of Level 3 generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b). 1999 NFPA 99, 3-6.4.1.1

NFPA Standard:
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: 1999 NPPA 110, 6-4.2
a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
c) The date and time of day for required testing shall be decided by the owner, based on facility operations