Failure to Implement Effective Legionella Prevention and Water Management
Penalty
Summary
The facility failed to maintain an effective water management and legionella prevention plan, and did not implement recommended mitigation strategies to prevent the potential spread of Legionella pneumonia. A resident with multiple comorbidities, including stroke, diabetes, and cardiac arrhythmia, was treated for pneumonia at the facility and subsequently hospitalized, where laboratory results confirmed a diagnosis of Legionella pneumonia. The facility's policy required assessment, prevention, monitoring, and control of legionella risks, but the water management plan lacked clear instructions for out-of-range measures and did not include comprehensive monitoring or chemical testing, despite the use of city water. Following the positive legionella result, the facility notified the local and state health departments and collected water samples for testing. However, the facility did not restrict water usage or install point-of-use filters as recommended by the local health department. Observations confirmed that the affected resident's bathroom and shower room, which were shared with a roommate, remained in full use without any filtration devices installed. Staff interviews verified that no water restrictions or filtration measures were implemented, and the facility's water management plan was acknowledged as insufficient by both facility leadership and the local health department. Maintenance staff reported conducting weekly water temperature checks and periodic chlorine testing, but there was inconsistent documentation and follow-up when chlorine levels were outside the recommended range. The facility's legionella prevention plan was found to be lacking in basic elements such as routine visual inspections, chemical testing, and clear protocols for responding to abnormal findings. The local health department indicated that the facility's plan was not thorough and recommended consultation to improve their water management practices.