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Based on staff interview and document review, the facility failed to maintain the generator as evidenced by the Generator 1 transfer switch that failed. This affected twelve of twelve floors of the Main Hospital Building, and could result in the failure of the generator to start in the event of a power outage.

NFPA 101 Life Safety Code, 2012 Edition
9.1.3 Emergency Generators and Standby Power Systems.
Where required for compliance with this Code, emergency generators and standby power systems shall comply with
9.1.3.1 and 9.1.3.2.
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
NFPA 110 Standard for Emergency and Standby Power Systems, 2010 Edition
6.2 ATS Features.
6.2.1* General. Automatic transfer switches shall be capable of all of the following:
(1) Electrical operation and mechanical holding
(2) Transfer and retransfer of the load automatically
(3) Visual annunciation when " not-in-automatic "

Findings

During document review with Staff on 1/20/17, the documents for the maintenance and testing of the automatic generator were requested.

1. At 11:30 a.m., during an interview with a staff member, staff stated that on 1/09/17, during a routine generator monthly load test, the staff members observed abnormal test results. On 1/10/17 the generator vendor arrived at the facility to repair and address the facility concerns. Staff stated the vendor would have to replace the transfer switch for Generator 1.

2. At 12:04 p.m., when interviewed, a staff member stated that the Engineering staff and staff members from a contracted vendor were trained on how to manually transfer the generator in the event of a power outage, and continually monitor the transfer switch 24/7. There is a sheet for sign in and sign out of each shift. Staff members will continue to monitor the transfer switch until the automatic transfer switch has been replaced.

3. At 12:40 p.m., during an interview, staff stated PG&E had to shut off power to the facility on the street side in order for the work on the transfer switch to be completed. The automatic transfer switch cannot be replaced until PG&E and the facility can work together to complete the required work.

4. At 12:45 p.m., the facility contacted the Office of Statewide Health Planning and Development (OSHPD). The facility was informed that the project to change the automatic transfer switch is a repair to the generator, and does not require a permit from OSHPD.

5. At 1:10 p.m., facility staff stated the facility plan for the generator repair and the documents submitted to OSHPD would be provided via email. As of 1/25/17, at 4:45 p.m., no additional documents have been received.