Failure to Assess and Report Legionella Risk in Facility Water System
Penalty
Summary
The facility failed to adequately assess, identify, and involve the local public health department regarding the adequacy of its water management plan to prevent the growth of Legionella or other waterborne pathogens. Despite positive Legionella test results in the facility's water system since 2023, there was no documentation of a comprehensive risk assessment or notification to the local health authority. The Infection Preventionist and Director of Nursing were aware of the positive results and monitored residents for respiratory symptoms, but could not provide documentation of risk assessments or confirm timely notification to public health authorities. The Administrator stated that the facility followed recommendations from an outside water management company, which included water flushing, but did not pursue further action or report findings to the health department due to the absence of confirmed resident cases of Legionella disease. Observations revealed that residents continued to use water from faucets in dining rooms and medication storage rooms for drinking, mouthwash, and showers, even in areas where Legionella had been detected. Staff, including CNAs, LPNs, and RNs, confirmed that water for drinking and medication administration was obtained from these sources. Although filters were reportedly provided for certain rooms and residents were instructed not to drink from sinks, there was no documentation that bottled water was supplied, and water coolers were filled from the same faucets with positive Legionella results. Laboratory results documented multiple positive Legionella findings in various rooms, with colony-forming units per milliliter (CFU/mL) ranging from 0.5 to 30. The facility's policies indicated a commitment to preventing water-borne contaminants, but there were gaps in implementation, including missed testing periods and lack of documentation for risk assessments and mitigation steps. The Medical Director was aware of the positive results but did not consider them harmful and relied on the water management team for guidance.