Failure to Maintain Safe Water Temperatures and Chlorine Levels
Penalty
Summary
The facility failed to monitor and respond to abnormally low hot water temperatures, which is crucial for the prevention and management of Legionella. The Infection Prevention and Control (IPC) Nurses and the Maintenance Director were responsible for reviewing the water management program and monitoring water for Legionella. However, there was a lack of communication and awareness about any issues with the water system, as the IPC Nurse was not informed of any problems. The water management program book showed outdated testing, with the last test conducted in 2023, and the Administrator provided conflicting information about the testing dates. The facility's water testing results indicated that the chlorine levels in certain areas were significantly below the required minimum, and the hot water temperatures were not maintained at the recommended levels. The Corporate Maintenance Director acknowledged that the water temperatures were often below 110 degrees Fahrenheit, which is below the recommended range of 114-118 degrees Fahrenheit due to low chlorine levels. Despite the facility's policy to test water temperatures daily, there were many days without recorded temperatures, and the facility did not consistently test on weekends. The facility's water temperature records revealed numerous instances of temperatures below the recommended levels, with some readings even below 100 degrees Fahrenheit. Maintenance staff admitted to not taking daily temperature checks consistently and acknowledged issues with a mixing valve. The facility's failure to maintain appropriate water temperatures and chlorine levels, as well as the lack of consistent monitoring, created conditions conducive to the growth of Legionella, posing a potential risk to the residents.