Failure to Monitor for Legionella in Facility Water System
Penalty
Summary
The facility failed to monitor for legionella in its water system, as required by its Infection Prevention and Control Program policy. The policy indicated that a water management program was established, with control measures and testing protocols in place, and designated the Maintenance Director as the leader of the program. However, interviews revealed that maintenance technicians had not received training on water borne pathogens and were not instructed to monitor for legionella. The Maintenance Director was unaware of areas at risk for legionella development and confirmed that no monitoring had been performed for legionella or other water borne pathogens. Additionally, the LPN-Resident Care Manager/Infection Preventionist acknowledged understanding that legionella could develop in areas of standing water but had not participated in identifying at-risk areas or monitoring for legionella. No specific residents or their medical conditions were mentioned in the report.