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Based on Generator Log review, observation, and interview, it was determined two of three generators serving the facility were supplied with maintenance-free batteries. Battery cells cannot be inspected on maintenance-free batteries, which assure batteries are capable of starting the generator if normal power is lost. Maintenance-free batteries are not allowed on Type 1 Essential Electrical Systems per NFPA 110, Section 3-5.4.5. The failed practice had the potential to affect all patients, staff, and visitors in the areas served by the generators with the maintenance-free batteries, which included the Medical/Surgical Unit, Critical Care Unit, Emergency Department, Laundry, Information Systems, Dietary Department, Medical Records Department, and the Maintenance Department. The census on 02/15/11 was 28 patients. The findings follow:

A. Review of the "Generator Test Log " on 02/15/11 at 1145 revealed Generator #3 and Generator #4 were supplied with maintenance-free batteries. The battery section on the log forms for these generators revealed " maintenance-free " batteries were used on the generators and there was no place to indicate the battery cell readings on the form.
B. In an interview on 02/15/11 at 1330 the Maintenance Director verified Generator #3 and Generator #4 were supplied with maintenance-free batteries.
C. Maintenance free batteries were observed on Generator #3 and Generator #4 while touring the facility with the Maintenance Director on 02/17/11 at 0930.

Based on observation and interview it was determined the facility did not perform monthly testing of five out of five Line Isolation Monitors in the facility as required by NFPA 99, Section 3-3.3.4.2. Monthly testing of the Line Isolation Monitors ensures proper operation of the devices, which are utilized to prevent electric shock in the areas they serve. The failed practice had the potential to affect all surgical patients and intensive care patients, and staff and visitors in the Surgery Department and the Intensive Care Unit. On 02/15/11 the Surgery Department had seven patients and the Intensive Care Unit had five patients. The findings follow:

A. On a tour of the Operating Suite with Director of Surgery on 02/16/11 at 0900, Line Isolation Monitors were observed in Operating Room #1 and Operating Room #2.
B. On a tour of the facility with the Maintenance Director on 02/17/11 at 1300 Line Isolation Monitors were observed in Critical Care Unit Rooms #1, #2, and #3.
C. In an interview on 02/17/11 at 1330, the Maintenance Director stated that while the Line Isolation Monitors were tested periodically, he could not verify they were tested monthly because the testing was not documented and was not available for review.
D. This was a recurring deficienciy that was previously cited on the standard survey conducted on 11/20/08.

Based on Generator Log review, observation, and interview, it was determined two of three generators serving the facility were supplied with maintenance-free batteries. Battery cells cannot be inspected on maintenance-free batteries, which assure batteries are capable of starting the generator if normal power is lost. Maintenance-free batteries are not allowed on Type 1 Essential Electrical Systems per NFPA 110, Section 3-5.4.5. The failed practice had the potential to affect all patients, staff, and visitors in the areas served by the generators with the maintenance-free batteries, which included the Medical/Surgical Unit, Critical Care Unit, Emergency Department, Laundry, Information Systems, Dietary Department, Medical Records Department, and the Maintenance Department. The census on 02/15/11 was 28 patients. The findings follow:

A. Review of the "Generator Test Log " on 02/15/11 at 1145 revealed Generator #3 and Generator #4 were supplied with maintenance-free batteries. The battery section on the log forms for these generators revealed " maintenance-free " batteries were used on the generators and there was no place to indicate the battery cell readings on the form.
B. In an interview on 02/15/11 at 1330 the Maintenance Director verified Generator #3 and Generator #4 were supplied with maintenance-free batteries.
C. Maintenance free batteries were observed on Generator #3 and Generator #4 while touring the facility with the Maintenance Director on 02/17/11 at 0930.

Based on observation and interview it was determined the facility did not perform monthly testing of five out of five Line Isolation Monitors in the facility as required by NFPA 99, Section 3-3.3.4.2. Monthly testing of the Line Isolation Monitors ensures proper operation of the devices, which are utilized to prevent electric shock in the areas they serve. The failed practice had the potential to affect all surgical patients and intensive care patients, and staff and visitors in the Surgery Department and the Intensive Care Unit. On 02/15/11 the Surgery Department had seven patients and the Intensive Care Unit had five patients. The findings follow:

A. On a tour of the Operating Suite with Director of Surgery on 02/16/11 at 0900, Line Isolation Monitors were observed in Operating Room #1 and Operating Room #2.
B. On a tour of the facility with the Maintenance Director on 02/17/11 at 1300 Line Isolation Monitors were observed in Critical Care Unit Rooms #1, #2, and #3.
C. In an interview on 02/17/11 at 1330, the Maintenance Director stated that while the Line Isolation Monitors were tested periodically, he could not verify they were tested monthly because the testing was not documented and was not available for review.
D. This was a recurring deficienciy that was previously cited on the standard survey conducted on 11/20/08.