Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement and maintain an effective Legionella water management program as required by its infection prevention and control policy. During interviews, the maintenance staff was unable to explain current procedures for preventing Legionella growth and admitted to not knowing what actions were necessary for the program. The maintenance staff also reported that no hot water system temperatures had been taken since June 2024, following the departure of the previous administrator who was responsible for the Legionella program. Although the maintenance staff occasionally ran water down the drains, there was no documentation of these actions, and he incorrectly believed that city testing for Legionella was sufficient. A review of the facility's Legionella Prevention Policy and Procedure indicated the importance of maintaining building water systems to prevent Legionella growth, specifically mentioning systems such as hot tubs, hot water tanks, large plumbing systems, cooling towers, and decorative fountains. The Director of Nursing confirmed that the maintenance staff was unaware of the required water testing or other necessary steps for Legionella prevention, and only recently obtained information on what should be included in the facility's Legionella policy.