HospitalInspections.org

Based on record review and interview the facility did not ensure that the emergency generator was being inspected weekly in accordance with NFPA 110. Failure to inspect the generator on a weekly basis could result in the generator not starting or functioning properly in the event of a power outage. The facility had a census of six patients on the day of survey. This deficiency affected all patients, staff and visitors present on the day of the survey.

Findings include:

During record review on October 15, 2012 at 1:35 PM, the facility was unable to provide documented weekly inspections for the previous twelve month period. When questioned about the weekly inspections the Director of Facilities stated that he was unaware of the weekly inspection requirements.

Actual NFPA Standard:

NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition.
6-3.4
A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

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.