Failure to Implement Water Management and Infection Control Measures for Legionella
Penalty
Summary
The facility failed to implement effective infection control measures related to its water management program and reporting of Legionella infection. The maintenance supervisor was unable to provide evidence of a comprehensive water management plan beyond daily water temperature logs, and there was no documentation of monitoring or control measures for water quality or disinfectant levels. The infection preventionist nurse confirmed that the facility did not have a customized water management policy and was not monitoring all necessary control measures and limits as recommended by CDC guidelines. The facility's policy required a water management program with annual review, but there was no evidence of such review or updates since 2017. A resident was admitted and later readmitted with multiple diagnoses, including pneumonia and sepsis. The resident was diagnosed with Legionella pneumonia at a general acute care hospital, but this information was not identified or acted upon by facility staff upon readmission. The registered nurse supervisor and director of nursing both acknowledged that the resident's medical records were not thoroughly reviewed, resulting in a delay in recognizing the Legionella infection. The infection preventionist nurse was only made aware of the positive Legionella result after notification from a public health nurse, rather than through internal review or communication from the hospital. The facility also failed to report the confirmed case of Legionella infection to the California Department of Public Health as an unusual occurrence within the required 24-hour timeframe. Review of facility policies indicated that such events should be reported promptly, but staff were unaware of the infection until notified by public health authorities. Additionally, there was no documentation in the facility's quality assurance and performance improvement records to show that infection control and water management policies were reviewed or updated annually, as required by facility policy.