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Based on document review, and interview, the facility failed to train staff with the protocols for shutting down the generator, and transferring power during a power outage. This was evidenced by Engineer Staff 1, that shut down the power to the transfer switch on two generators in 1 of 5 buildings. This resulted in the failure of the generators to transfer power during a power outage.

NFPA 101, Life Safety Code, 2000 Edition
9.1.3 Emergency Generators. Emergency generators, where
required for compliance with this Code, shall be tested and
maintained in accordance with NFPA 110, Standard for Emergency
and Standby Power Systems.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated 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 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby system.

NFPA 110, Standard for Emergency Power and Standby Power Systems, 1999 Edition
3-4.1.1.8 + Load Pickup. The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 34.1]

Findings:

During document review with the Executive Director of Facility Development and Operation, and the Vice President on 6/15/16, the information for the generator failure was reviewed, and a staff person was interviewed.

1. At 10:39 a.m., there was documented evidence that Engineer Staff 1 manually pressed the emergency shut down switch to the two generators on 5/29/16 at approximately 4:58 p.m. There was no documented evidence that the facility provided training to ensure that staff would not shut down the transfer of power to the generator during a power outage.

2. At 10:41 a.m., during an interview, the Executive Director of Facility Development and Operation stated that the facility did not have any training record for the specific issue that occurred. The Executive Director of Facility Development and Operation said that all staff were trained after the incident to ensure that this did not happen again.