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Based on record review and interview it was determined that the facility failed to maintain battery powered emergency lighting according to NFPA standards.

The findings include:

Record review on 06/23/2010 at 1:25 PM revealed that the facility could not produce documented 30 second, monthly and 90 minute, yearly inspections of the battery powered emergency lighting. The Engineering Manager was present during record review.

Interview on 06/23/2010 at 1:25 PM with the Engineering Manager revealed that the facility does an inspection monthly on the battery powered emergency lighting but does not document that it is for 30 seconds monthly or that it is 90 minutes yearly.


7.9.3 Periodic Testing of Emergency Lighting Equipment.

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on observation, record review and interviews the facility failed to ensure that the emergency generator was maintained according to NFPA standards.

The findings include:

Record review on 06/23/2010 at 1:30 PM revealed that the facility did not have written documentation that the facility inspected the generator battery weekly. The Engineering Manager was present during the record review.

Interview on 06/23/2010 at 1:30 PM with the Engineering Manager revealed that the facility did not provide weekly inspection of the generator's batteries.

Observation on 06/23/2010 at 1:45 PM with the Engineering Manager revealed that the emergency generator annuciator panel had a warning light indicating trouble with the generator.

Interview on 06/23/2010 at 1:45 PM with the Engineering Manager revealed that he was unaware of the trouble light. The Engineering Manager stated that when the remote annunciator alarm panel for the emergency generator at the ER registration desk is activated that staff are to notify him.

Observation on 06/23/2010 at 1:50 PM revealed that the remote annunciator alarm panel for the emergency generator at the ER registration desk had a warning light illuminated, but the remote annunciator alarm panel had been placed into silenced mode. The Engineering Manager asked staff at the ER registration desk if they were aware of any problems with the generator. The staff was not aware of any problems with the generator nor was staff aware of when the remote annunciator alarm panel for the emergency generator was placed into silenced mode.

Interview on 06/23/2010 at 2:06 PM with the Business office Manager revealed that the staff on duty is responsible per policy to contact maintenance immediately when the remote annunciator panel for the emergency generator alarms. The Business Manager contacted staff that had been scheduled to work at the ER registration desk to track down the time when the remote annunciator panel first alarmed. The Business manager talked to staff on duty 06-22-2010 and it was determined that the remote annunciator panel first alarmed on 06-22-2010 at 9:00 PM. The Engineering Manager was unaware of the remote annunciator panel for the emergency generator showing a trouble light until the Life safety Code survey on 06-23-2010.


Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer ' s recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

6-4.2*
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:
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 .The date and time of day for required testing shall be decided by the owner, based on facility operations.

6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on record review and interview it was determined that the facility failed to maintain battery powered emergency lighting according to NFPA standards.

The findings include:

Record review on 06/23/2010 at 1:25 PM revealed that the facility could not produce documented 30 second, monthly and 90 minute, yearly inspections of the battery powered emergency lighting. The Engineering Manager was present during record review.

Interview on 06/23/2010 at 1:25 PM with the Engineering Manager revealed that the facility does an inspection monthly on the battery powered emergency lighting but does not document that it is for 30 seconds monthly or that it is 90 minutes yearly.


7.9.3 Periodic Testing of Emergency Lighting Equipment.

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on observation, record review and interviews the facility failed to ensure that the emergency generator was maintained according to NFPA standards.

The findings include:

Record review on 06/23/2010 at 1:30 PM revealed that the facility did not have written documentation that the facility inspected the generator battery weekly. The Engineering Manager was present during the record review.

Interview on 06/23/2010 at 1:30 PM with the Engineering Manager revealed that the facility did not provide weekly inspection of the generator's batteries.

Observation on 06/23/2010 at 1:45 PM with the Engineering Manager revealed that the emergency generator annuciator panel had a warning light indicating trouble with the generator.

Interview on 06/23/2010 at 1:45 PM with the Engineering Manager revealed that he was unaware of the trouble light. The Engineering Manager stated that when the remote annunciator alarm panel for the emergency generator at the ER registration desk is activated that staff are to notify him.

Observation on 06/23/2010 at 1:50 PM revealed that the remote annunciator alarm panel for the emergency generator at the ER registration desk had a warning light illuminated, but the remote annunciator alarm panel had been placed into silenced mode. The Engineering Manager asked staff at the ER registration desk if they were aware of any problems with the generator. The staff was not aware of any problems with the generator nor was staff aware of when the remote annunciator alarm panel for the emergency generator was placed into silenced mode.

Interview on 06/23/2010 at 2:06 PM with the Business office Manager revealed that the staff on duty is responsible per policy to contact maintenance immediately when the remote annunciator panel for the emergency generator alarms. The Business Manager contacted staff that had been scheduled to work at the ER registration desk to track down the time when the remote annunciator panel first alarmed. The Business manager talked to staff on duty 06-22-2010 and it was determined that the remote annunciator panel first alarmed on 06-22-2010 at 9:00 PM. The Engineering Manager was unaware of the remote annunciator panel for the emergency generator showing a trouble light until the Life safety Code survey on 06-23-2010.


Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer ' s recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

6-4.2*
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:
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 .The date and time of day for required testing shall be decided by the owner, based on facility operations.

6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.