HospitalInspections.org

Based on record review and interview the facility failed to ensure the maintenance of essential operating equipment for emergency power. According to the facility's most recent certified generator inspection report, the generators that would be needed in the event of loss of power were not in good working order. Specifically, the generator inspector considered the system's functionality to be suspect, and noted that they were at risk for starting a fire if used. Failure to act upon the certified technician recommendations: 1) placed all patients at risk for immediate loss of power to equipment that may have been used to sustain life; and 2) placed all patients at risk of exposure to smoke and fire.

During the telephone exit on 7/16/15 at 5:35 pm the Administrator was informed the concerns involving the facility's generators constituted an Immediate Jeopardy level citation. A prompt abatement plan was requested and received. Findings:


During an interview on 7/16/15 at 8:00 am Maintenance Staff #1 was provided with a list containing required documents to be reviewed by the Surveyor for the Long Term Care re-certification and licensing survey. Maintenance Staff #1 delegated the acquisition of the documents to staff just prior to the start of the facility tour.

During an interview at the conclusion of the LSC tour on 7/16/15 at 11:05 am, Engineering Staff #1 stated he would need a "couple of hours" to prepare the documents requested for review.

During the exit interview for the health survey on 7/16/15 at 1:30 pm the Administrator/CEO was informed the LSC documentation had not been provided at the conclusion of the LSC survey. At this time, the Administrator was instructed to email the documents listed on the LSC list to the Surveyor by 8:00 am on 7/17/15 for review, and after that review, this Surveyor would exit via telephone the LSC survey.

Review of the "Generator Set Inspection Report," dated 11/11/14 for generator #89460 received by the State Agency from Engineer #1 on 7/15/15 at 4:44 pm revealed:

- "During load test, it was found that the generator would climb outside of its heating specifications over 85 percent load or higher. This could indicate that the radiator is partially plugged I internally. Recommend having the radiator gone through or replaced as well as additional cooling system recommendations already made ...

- Repairs and testing of switchgear have not been corrected since last year's inspection, [2013]. Reverse power problems, rolled droop ct ..., the new repairs needed in combination with the old repairs and testing needed to fulfill code, indicates that this emergency power source cannot be considered viable."

In addition, the 11/11/14 report for generator #89460 revealed multiple failures related to the cooling system, fuel system and the generator back up battery.

Review of the " Generator Set Inspection Report, " dated 11/11/14 for generator #G6B00978 received by the State Agency from Engineer #1 on 7/15/15 at 4:44 pm revealed:

- " Switchgear problems have not been rectified from last year and regulator has not been replaced with manufacturer recommended paralleling capable regulator ...

- Customer has not performed annual transfer test or (black out) testing of system and is not complete to code. Adding the repairs needed to the fact that repairs have not been addressed for over a year, this system cannot be considered a viable emergency power source. "

In addition, the 11/11/14 report for generator #G6B00978 revealed multiple failures related to the air filter system, cooling system, batteries, and ventilation.

During a telephone interview on 7/17/17 at 2:45 pm the NC Machinery Inspector who conducted the inspection on 11/11/14 stated the he was not confident the generators would function as intended for emergency backup power and was concerned the generator would overheat and cause a fire. In addition, the inspector stated the facility had failed to act on inspection findings in previous years.