Failure to Monitor Water Heater Temperatures per Infection Control Policy
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as required by policy and national standards. Specifically, the facility did not monitor or document the temperature of the water heater (WH) or hot water storage tank (HWT) as outlined in their Water Management Program. The program required that water heater and storage tank outlet temperatures be maintained at or above 140 degrees Fahrenheit to prevent the growth of Legionella and other waterborne pathogens. Interviews with the Maintenance Director and Maintenance Tech revealed that while there was a work order in the maintenance management system to check water temperatures monthly, no records or logs of temperature readings could be found. The new Maintenance Director confirmed that there was no documented monitoring of the WH or HWT temperatures. Further, the Nursing Home Administrator acknowledged that a previous maintenance director had implemented a robust plan for temperature testing, but no documentation could be produced to verify ongoing monitoring or compliance with the facility's water management protocols. The lack of documented temperature monitoring meant the facility could not demonstrate that control measures were being followed to minimize the risk of Legionella and other pathogens, as required by their infection prevention and control policy and national guidelines. This deficiency had the potential to affect all 48 residents residing in the facility.