Failure to Implement Effective Water Management and Infection Control for Legionella
Penalty
Summary
The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria in the water supply. Despite receiving water test results indicating elevated and increasing levels of legionella, the facility did not re-evaluate or update its water management risk assessment or plan, nor did it provide effective interventions to mitigate the risk. The facility also did not ensure that residents were prevented from accessing or using water from areas where legionella could be present, as evidenced by residents continuing to use sinks and showers in affected areas without appropriate filters or signage restricting use. The facility's water management risk assessment was outdated and lacked critical components such as summaries, acceptable control levels, and response procedures for positive legionella findings. Maintenance activities were inconsistently documented, with no evidence of routine maintenance or cleaning of showers, whirlpools, or flushing of water in unoccupied rooms as required. Water testing was limited to a single location, and when results showed a significant increase in legionella levels, there was no documented investigation or intervention. Staff interviews confirmed a lack of awareness of the severity of the test results, and there was no evidence that residents were assessed for symptoms of Legionnaires' Disease during the period of elevated risk, including those with respiratory symptoms or hospitalizations. Residents, including those with high-risk conditions such as tracheostomies, ventilator dependence, and those receiving dialysis, continued to use water sources that were potentially contaminated. Interviews with residents confirmed ongoing use of sinks and showers in areas where legionella was present, and staff confirmed that there were no effective restrictions or visual cues to prevent such use. The facility's infection surveillance system was also found to be ineffective, as it failed to track infections and monitor trends, and appropriate infection control techniques were not followed during wound care for at least one resident.
Removal Plan
- An all-staff in-service was completed on risks, signs and symptoms and interventions for legionella by the DON and IP Nurse #302.
- Water to each sink in all facility rooms was shut off to prevent accidental use by residents and staff. Gallon jugs of purified water were put in place to wash hands with dates and names on each.
- The DON/designee would audit employee call-offs weekly, monitoring for any symptoms related to legionella illness. Any concerns would be immediately reported to the Administrator and addressed by the Quality Assessment Performance Improvement (QAPI) committee as necessary.
- The facility contracted with PT enterprises to assist with the water management plan. PT enterprises took twelve water samples (four swabs and eight additional 250 ml potable water samples).
- Point of use filters for all water sources in the facility were ordered.
- The DON brought in hot and cold-water dispensers for use on the second and third floors. This water was provided for residents' use for any residents who did not want to drink bottled water and staff were responsible for bringing the water to residents. Additional bottled water was supplied to the fourth floor.
- The DON educated the weekend staff and agency staff working on-site on not using the room sinks or shower on the second floor, as well as signs and symptoms of legionella.
- A Legionella assessment data collection form was created in point click care (PCC), which included a set of vital signs, a review of potential symptoms of legionella, a place for a narrative, and a yes or no question as to whether or not the resident experienced more than three symptoms beyond their baseline.
- All nurses would be educated on this form. Any nurse not educated would not be allowed to work the floor until the education was completed. Nurses would complete this assessment on resident admission and with resident change of respiratory condition.
- New legionella filters were received and placed on the main floor bathroom sink, therapy room sink, room [ROOM NUMBER] sink faucet, shower heads on the second, third and forth floors, at the nursing station sinks on the second, third and forth floors and on the dialysis center sinks by Maintenance Manager #322.
- Legionella tests for six residents who were transferred from the facility for signs and symptoms of respiratory distress were completed.
- A contracted plumbing company ([NAME] Plumbing) came to the facility to evaluate appropriate adapters to fit on the sink filters. They also evaluated sanitation. The water remained off to the room sinks at this time.
- The DON/designee completed resident assessments (legionella assessment data collection form) for all facility residents. The resident assessments would continue to be conducted weekly by the DON/designee and/or Infection Preventionist. Any concerns would be immediately reported to the Administrator and Medical Director for follow-up.
- The facility Water Management Committee, including the Administrator, DON, IP #302, Maintenance Manager #322, Housekeeping/Laundry Supervisor, RT Director and Dietary Manager met to further discuss the facility's Water management -Legionella plan.
- The facility QAPI committee met to review any updates to the water management plan and complete audits.
- The facility new water management protocols included: a.) Each faucet and shower head aerator would be cleaned with an approved scale and lime build-up cleaner semi-annually to ensure proper water flow quarterly. b.) The hot water boilers would be set at 140 or greater. Facility staff would record the temperature of each hot water device weekly and adjust immediately if less than 140. To ensure compliance to policy, staff would retest the following day to confirm appropriate temperature. c.) Hot water holding tanks would be set at a minimum of 140 to inhibit the growth of Legionella and other opportunistic pathogens. Facility staff would record the temperature weekly and adjust immediately if less than 140 to ensure compliance. d.) Regular cleaning and changing of filters would be done per manufacturers' recommendations. The facility would remove scale and clean using approved cleaning agents semi-annually and changing the filters every six months or per manufacturer recommendations. Maintenance Manager #322 would audit monthly to ensure compliance and audits will be reviewed in QAPI meetings. e.) Weekly flushing of water would be added to housekeepers assignments which would consist of flushing for three minutes each faucet and showers also flush all toilets at least once every week. The supervisor would review documentation weekly to ensure compliance. Audits would be reviewed, and the facility would determine where the failure occurs during QAPI meetings. f.) If the facility experiences one or more positive cases of legionellosis, the facility would conduct semi-annual testing to determine if the water management plan (WMP) was effective in controlling legionella and the Maintenance Manager #322 will follow up with the vendor to determine failure to conduct and correct this. g.) For any positive legionella in the water, the facility would contact PT enterprises, to conduct testing on water samples, provide alternate water sources for bathing and patient care, inspect all faucets for built-up scaling and cleaning with appropriate cleaner and replace all filters on incoming water sources. h.) Legionella filters would be changed per manufacturers' recommendations.
- The facility received ordered parts which were being installed with a plan to have all installation of parts/filters completed.