Failure to Implement Comprehensive Water Management Program for Legionella
Penalty
Summary
The facility failed to follow its water management program for Legionella, affecting all 88 residents. The Maintenance Director reported that he flushes water in empty resident rooms and soiled utility rooms, documenting these tasks in an electronic system. However, the Administrator confirmed that the facility's water management plan does not include flushing as a control measure, nor does it identify specific building water systems requiring control measures or assess the level of risk in those areas. The plan also lacks a diagram showing how water is distributed throughout the facility, only including a diagram of water flow out of the building. Additionally, the plan was already in place before the current Maintenance Director started and he did not participate in its development. A resident previously tested positive for Legionella pneumonia, prompting water testing that returned negative results. The facility has an eyewash station in the laundry room, which the Maintenance Director checks for functionality, and another station is planned for the kitchen. The Water Management Program document does not identify building water systems needing Legionella control measures or assess the risk of hazardous conditions in those systems, and it lacks a comprehensive diagram of the facility's water system. These omissions indicate the facility did not fully implement or document required elements of its infection prevention and control program related to water management.