HospitalInspections.org

Standard: NFPA 101, Sect. 7.9.3 requires the emergency lighting system be tested every 30 days (for at least 30 seconds) and annually for 90 minutes. It also requires that written records of inspections and tests be maintained for inspection by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to conduct periodic testing of the emergency lighting system as required by NFPA 101. This deficient practice presents a risk that the emergency lighting system will not work in the event of smoke, fire and/or power interruption.Emergency lighting is needed in order to safely evacuate patients and could result in harm to all twelve (12) patients in the facility as identified by the "Daily Unit Census" provided by the Director of Support Services on 05/30/12 at 8:10 am. The findings are:

A. Record review of the facility's maintenance records revealed no documentation of monthly or annual testing of the emergency lighting system (battery packs).

B. On 05/30/12 at 9:10 am, during interview, the Director of Support Services stated that the emergency lighting and exit signs were tested but that he did not know that a written record was required.

C. On 05/30/12 at 3:55 pm, the Administrator, Director of Support Services and the Lead Maintenance Tech acknowledged the finding above at the exit conference.

NFPA 99:
3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1. * Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

NFPA 110:
Section 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.

NFPA 110, Chapter 6, Routine Maintenance and Operational Testing
(Requirements for Weekly, Monthly, Semi-annually, Annually, and every 2 years are explained.)




Based on record review and staff interview, the facility failed to ensure that the specific gravity of the battery cells for the emergency generator used to protect residents during times of primary power failure were being tested monthly as required in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). This deficient practice could result in the batteries' failure to provide power to start the generator in the event of a power failure, which presents a risk of potential harm to all twelve (12) patients in the facility as identified by the "Daily Unit Census" provided by the Director of Support Services on 05/30/12 at 8:10 am. The findings are:


A. Review of the monthly documents for the specific gravity testing from 05/2011-05/2012, showed a single number.

1. The facility is equipped with two (2) generators.

2. The facility's generators are equipped with two (2) batteries.

3. The monthly documentation showed a single number recorded for the specific gravity of the generator batteries. Each cell of the batteries is required to be tested and the reading for each cell number recorded every month to verify the reliability of the batteries.

B. On 05/30/12 at 10:02 am, during interview, the Director of Support Services stated he did not know the specific gravity reading for each battery cell was required.

C. On 05/30/12 at 3:45 pm, the Administrator, Director of Support Services and Lead Maintenance Assistant acknowledged the above finding at the exit conference.