Failure to Conduct Comprehensive Risk Assessment for Legionella in Facility Water System
Penalty
Summary
The facility failed to conduct a thorough risk assessment to determine why opportunistic waterborne Legionella continued to grow and spread in the facility's water system. Despite ongoing positive Legionella test results in multiple rooms since 2023, the facility's actions were limited to periodic flushing, temperature monitoring, and the installation of water filters in affected rooms. Documentation revealed that only three rooms were retested in April, instead of the five recommended by the consultant, and there was no evidence of regular meetings to discuss results or perform comprehensive risk assessments. The Director of Plant Operations acknowledged that the expansion tank had insufficient air pressure, which could contribute to Legionella growth, and that cleaning of the mixing valve was performed without documentation. Interviews with facility staff indicated a lack of clarity and consistency in following the water management plan and consultant recommendations. The administrator was unsure why only three rooms were retested and admitted that positive findings were not reported to the local health authority, as no residents had tested positive for Legionella disease. There was also no documentation that residents' families were notified of the ongoing Legionella issue. The facility experienced a gap in water testing during a change in testing companies, and the water management company had only recommended flushing, with no further interventions until a plumber was called for mechanical inspection after two years of positive results. Water temperature logs showed variable temperatures in the affected rooms, with some readings within the range that supports Legionella growth. Laboratory results documented persistent low to high levels of Legionella in several rooms, with the highest recorded at 30 CFU/mL. The facility's policy stated a commitment to prevention and control of water-borne contaminants, but the lack of comprehensive risk assessment, incomplete testing, and insufficient documentation contributed to the ongoing deficiency affecting all residents in the facility.