|Electrical Systems - Essential Electric System Maintenance and Testing|
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918
Based on observation and interview, the facility failed to maintain essential electrical systems for one of two emergency generators.
1. Observation on August 29, 2019, at 8:45 a.m., revealed the surveyor, maintenance director and administrator observed the strong noxious smell of the #2 outside diesel generator (located next to the outside wall of resident rooms #34 - 48), during the weekly load test of the unit.
2. Interview on August 29, 2019, at 10:45 a.m., with the resident in room #34-2 (with the help of an interpreting nurses aide), revealed the resident had concerns with the fumes that enter his room during weekly emergency generator run tests of unit #2.
3. Observation on August 29, 2019, at 12:30 p.m., revealed the surveyor measured the distance from the emergency generator exhaust to an intake within the building. The distance measured was 17 feet.
a. The American Institute of Architects, Academy of Architecture for Health, Guidelines for Design and Construction of Hospital and Health Care Facilities indicate, "fresh air intakes shall be located at least 25 feet from exhaust outlets of...combustion equipment stacks..or areas that may collect vehicular exhaust or other noxious fumes. (Prevailing winds and/or proximity to other structures may require greater clearances.)"
b. NFPA 110, 2010 edition 7.10.2, "Exhaust system installation shall be gastight to prevent exhaust gas fumes from entering inhabited rooms or buildings and terminate in such a manner that toxic fumes cannot reenter a building or structure, particularly through windows, air ventilation inlets, or the engine air-intake system.
4. Observation on August 29, 2019, at 1:00 p.m., revealed resident rooms on wing #34 - #48 lacked carbon monoxide (CO) detectors in every room to alert the facility staff of possible CO from the emergency generator #2 exhaust fumes.
Interview with the maintenance director and administrator on August 29, 2019, at 1:30 p.m., confirmed the exhaust outlet for emergency generator #2 shall be above roof level, and arranged to minimize recirculation of exhaust air into the building.
| ||Plan of Correction - To be completed: 10/23/2019|
To ensure that the fumes from the exhaust outlet for the emergency generator #2 do not permeate into the building, the following will occur:
Generator #2 exhaust outlet will be extended to above roof level.
Contractor was at facility 9/9/19 to assess generator for extension of the stack
CO2 detectors will be installed in resident rooms that may be affected by the exhaust outlet of generator #2
An audit will be completed by Maintenance Director or designee weekly for 1 month and monthly ongoing to ensure CO2 detectors are functioning properly.
Staff will be educated by Staff Educator in conjunction with Maintenance Director, no later than 9/20/19 to identify when and process for CO2 detectors when they are activated
Results of the audit will be presented at the monthly QA meeting for review