Inadequate Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement an adequate water management program, which is essential for preventing the growth and spread of Legionella bacteria, a serious health risk in healthcare settings. The facility's water management program was found to be incomplete and not aligned with the current ASHRAE guidelines. Specifically, the program did not include a detailed description or flow diagrams of the building's water systems, which are necessary to identify potential areas where Legionella could grow and spread. Additionally, the program lacked control measures and monitoring procedures to ensure the effectiveness of the water management plan. During interviews, the Maintenance Director mentioned that the facility conducted Legionella testing and risk assessments, and monitored water temperatures in resident rooms weekly. However, the Director of Nursing acknowledged the absence of a formal water management plan and expressed an expectation to follow CDC guidance. The deficiency was identified through observations, staff interviews, and a review of relevant guidelines and facility documents, highlighting the potential risk of Legionella exposure to residents.