Failure to Enforce Legionella Water Management Program and Document Required Activities
Penalty
Summary
The facility failed to enforce its Legionella Water Management Program (LWMP) as required by its own policy. The LWMP included a checklist of inspection items, frequencies, and documentation requirements, but there was little to no evidence that these activities were performed or recorded prior to notification from the local health department. The Maintenance Director confirmed that while some activities may have been conducted, there was no documentation to support ongoing compliance with the LWMP until after the facility was alerted to possible Legionella contamination. The LWMP itself was found to be adequate for the facility type, but it had not been periodically reviewed, and some of its documentation was not specific to the facility. The deficiency came to light during a complaint investigation after two residents who had been admitted with complex respiratory and cardiac conditions tested positive for Legionella following their transfer to acute care facilities. One resident experienced a significant drop in oxygen saturation and required emergency transfer, while the other was treated for a persistent cough and tested positive for Legionella antigen. The source of the Legionella could not be conclusively determined, but the facility's lack of documented implementation of its water management plan was evident. Interviews with facility leadership, including the Administrator, Maintenance Director, and DON, revealed that the LWMP had not been reviewed or updated except in response to the notification of possible Legionella cases. Water testing and mitigation activities were only documented after the facility was informed of the potential contamination. Prior to this, there was no evidence of regular monitoring, system flushing, or other control measures as outlined in the LWMP.