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Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 2 of 2 generators during 12 of the past 12 months (see tag K918).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 2 of 2 generator during 12 of the past 12 months. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. Chapter 6.4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. Chapter 6-4.4.1.3 of 2012 NFPA 99 requires batteries for on-site generators shall be maintained in accordance with NFPA 110, 2010 Edition, Standard for Emergency and Standby Power Systems. 8.3.7 requires storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. 8.3.7.2 states defective batteries shall be repaired or replaced immediately upon discovery of defects. Chapter 6.5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on record review on 06/21/22 between 9:45 a.m. and 4:45 p.m. with the Facilities Manager present, there was no monthly generator load test documentation available during the past 12 months. Based on interview at the time of record review, the Facilities Manager said the facility's generator power comes from the main hospital next door. He further said maintenance staff from the main hospital was unavailable to provide the monthly generator load testing documentation.

This finding was reviewed with the QI Director, Chief Clinical Officer, Chief Financial Officer, Facilities Manager, and Safety and Security Coordinator during the exit conference.