Failure to Implement Legionella Water Management and Infection Surveillance
Penalty
Summary
The facility failed to maintain and implement an effective water management plan for Legionella prevention and did not follow its own infection prevention and control program for infection surveillance. The Maintenance Director reported that while hot water heaters are emptied monthly, the kitchen's hot water heater is not emptied due to the presence of a water softener, and shower heads are only replaced when broken rather than being regularly cleaned or disinfected. The facility's water management plan outlined specific control measures such as maintaining water heater temperatures, annual cleaning, quarterly disassembly and cleaning of shower heads, and regular temperature checks and flushing of unused water outlets. However, there was no documentation to show that these control measures were being monitored, and the plan did not include interventions for when control limits were not met. The Administrator acknowledged that although a Legionella environmental assessment was completed, no further action was taken based on its findings. Additionally, the facility's Infection Preventionist, who is also the DON, stated that she had stopped using McGeer's Criteria for infection surveillance and did not utilize a standardized tool for collecting infection data. During a recent COVID-19 outbreak, the infection log did not include residents who tested positive, despite the facility's policy requiring ongoing surveillance and systematic data collection to identify and control infections. The policy emphasized the importance of surveillance in identifying communicable diseases and outbreaks, but the facility failed to follow these procedures, resulting in incomplete infection tracking and reporting.