Failure to Document and Respond to Legionella Notification
Penalty
Summary
The facility failed to provide documented evidence of actions taken and follow-up after being notified that a discharged resident tested positive for Legionella at a hospital. The resident, who had diagnoses including cerebral edema, urinary tract infection, E. Coli, and required supplemental oxygen, was transferred to the hospital due to altered mental status and shortness of breath. Hospital testing confirmed a positive Legionella PCR result from a nasopharyngeal swab. The Infection Preventionist (IP) Nurse received a phone call from the hospital informing them of the positive result but did not document the conversation or ask for critical details such as the date of the positive test or whether the resident was symptomatic. After receiving the notification, the IP Nurse relayed the information to the DON and ADON and inquired about the last time the facility's water system was tested for Legionella, which was in February with negative results. The IP Nurse was told by the Maintenance Director that further testing would not be conducted due to the previous negative result. No further investigation, water testing, or resident tracking was initiated. The IP Nurse acknowledged that the conversation with the hospital should have been documented and that additional information should have been gathered to determine if the infection was healthcare-associated. Other staff, including the ADON, Clinical Resource, and Maintenance Director, confirmed that the information about the positive Legionella case was shared verbally but not documented or acted upon according to infection surveillance protocols. The Administrator was not made aware of the hospital's notification, and the facility did not report the case to the Health District as required. The facility's policy required ongoing surveillance and appropriate interventions for significant infections, but these steps were not followed in this instance.