HospitalInspections.org

Based on observation, testing, and interview, the provider failed to maintain a remote alarm in a continuously occupied location for one of one locations (Onan generator annunciator at the nurses' station). Findings include:

1. Observation and testing at 10:15 a.m. on 8/7/18 revealed the Onan generator annunciator was mounted in the patient wing nurses' station. When tested by the maintenance technician the annunciator failed to show trouble with the generator being offline. The generator was first tested by taking the non-running generator offline. Testing of the electrical supply to the annunciator revealed the device was provided with electrical power. Record review of the generator log book revealed the 250 kW diesel Onan generator would carry a load when tested monthly.

Interview with the maintenance technician at the time of the observation confirmed those findings.

This deficiency has the potential to affect 100% of the occupants of the building.

Based on record review and interview, the provider:
*failed to run the emergency generator under load each month for thirty minutes with a minimum five minute cool down time for eight of the prior twelve months (September 2017 through July 2018),
*failed to record battery specific gravity testing, and
*failed to provide the percent of nameplate value during load runs. Findings include:

1. Record review of the generator log book revealed eight of the prior twelve months (September 2017 through July 2018) generator load runs documented were less than the required length of run and cool down times (0.5 hours which is 30 minutes plus the required cool down time of at least 5 minutes, which would indicate at least 0.6 hours) as listed below:

*8/17/17, ok (power outage).
*9/21/17, 8:15 a.m. to 8:30 a.m. (fifteen minutes).
*10/26/17, 8:40 a.m. to 9:00 a.m. (twenty minutes).
*11/30/17, 9:45 a.m. to 10:15 a.m. (thirty minutes).
*12/27/17, ok.
*1/25/18, 9:40 a.m. to 9:55 a.m. (fifteen minutes).
*2/21/18, 8:25 a.m. to 8:40 a.m. (fifteen minutes).
*3/29/18, 1:00 p.m. to 1:20 p.m. (twenty minutes).
*4/19/18, 9:30 a.m. to 9:45 a.m. (fifteen minutes).
*5/24/18, 8:15 a.m. to 8:30 a.m. (fifteen minutes).
*6/28/18, ok.
*7/25/18, ok.

2. Review of the generator log book revealed eight of the prior twelve months (September 2017 through July 2018) did not have documentation of weekly testing of the generator batteries' specific gravity.

3. Review of the generator log book for the 250 kW diesel Onan generator revealed twelve of the prior twelve months (August 2017 through July 2018) load runs documented did not indicate the percent of nameplate value the generator was carrying while under load. A load run of thirty percent (or higher) of nameplate value must be carried each month by the generator or load banking would be required. There was no documentation that any load banking had been performed.

4. Interview with the maintenance technician at 3:30 p.m. on 8/7/18 confirmed those findings.

This deficiency has the potential to affect 100% of the occupants of the building.