Failure to Monitor and Prevent Legionella in Water System
Penalty
Summary
The facility failed to ensure adequate measures were in place to monitor and prevent the presence of Legionella in the facility's water system. The facility's infection prevention and control plan, dated 11/14/24, outlined the process for detecting, preventing, and controlling healthcare-associated infections, including the testing of water for pathogens like Legionella at least quarterly. However, after receiving positive test results for Legionella rubrilucens in Linden Lane Room 27 and L. pneumophila in the Skilled Hall Med Room on 10/10/24, the facility did not conduct further testing to confirm the safety of the water system. An interview with the Maintenance/Environmental Services Director revealed that although the facility flushed the water system with 160-degree water following the positive test results, no subsequent testing was performed to ensure the effectiveness of this measure. The director confirmed that additional testing should have been conducted to verify the safety of the water for all individuals in the facility. This oversight indicates a lapse in the facility's infection prevention and control program, specifically in the monitoring and management of waterborne pathogens.
Plan Of Correction
Water was retested by the Maintenance Director on 02/14/2025. Samples were sent to Special Pathogens Lab, and results were obtained by the facility on 02/21/2025. All tests came back negative. Education was provided to the Maintenance Director regarding Legionella testing and the facility water management plan by the Nursing Home Administrator. Legionella testing will be completed as indicated in the Infection Control plan. The Nursing Home Administrator will audit to ensure Legionella testing is being completed quarterly, as indicated in the Infection Control plan. Results of these tests will be reviewed at the quarterly quality assurance meeting.