Failure to Implement Legionella Prevention and Control Measures
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding Legionella prevention and response. After a resident, who had been admitted since November 2024, was transferred to the hospital with acute respiratory failure and subsequently tested positive for Legionella, the facility did not conduct required testing or remediation of its water system as outlined in its Water Management Plan. Staff interviews confirmed that neither the water system nor equipment where Legionella could proliferate were tested following the confirmed case, despite the facility's policy and CDC guidance requiring such actions after a healthcare-associated Legionnaires' disease diagnosis. Additionally, the facility did not document the results of control measures as required by its Water Management Plan. The maintenance supervisor acknowledged that water heater temperatures were checked but not logged, and there was no documentation to show which portable air conditioning units had been cleaned. The facility's water management plan also did not identify humidifiers as a risk for waterborne pathogens, and routine Legionella monitoring was not performed, contrary to the plan's requirements for outbreak investigation and control. Furthermore, a humidifier was found in the affected resident's room, which was against the facility's own procedures for Legionnaires' disease prevention. Staff were unaware of the prohibition on humidifiers until after the resident's hospitalization. Although a water sample from the humidifier was collected, it was not tested. These failures in following established policies and procedures exposed the facility's residents to the potential spread and growth of Legionella.