Incomplete Water Management Risk Assessment for Legionella
Penalty
Summary
The facility failed to maintain a sufficient water management program based on an accurate risk assessment, as required for infection prevention and control. Review of the Legionnaire's Risk Assessment document revealed it was undated, unsigned, and did not include the facility's name. During an interview, both the Administrator and the Environmental Services Director confirmed that the risk assessment lacked a date, signature, and facility identification, and neither could verify when the assessment was completed or by whom. Additionally, the facility's policy required a risk assessment to identify areas where Legionella and other waterborne pathogens could grow and spread, but the documentation did not meet these requirements. The census at the time was 14 residents, and this deficiency had the potential to affect all residents.