Failure to Implement Water Management Program Leads to Legionella Infection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing and following a water management program (WMP) in accordance with industry standards and CDC guidelines. The facility's own policies required annual water program assessments with a qualified contractor, regular flushing and disinfection of water fixtures, quarterly water testing for Legionella, and documentation of HVAC preventative maintenance. However, records showed that the facility did not conduct annual assessments from 2019 through 2024, did not perform or document quarterly water testing in several required months, and failed to maintain records of regular flushing, disinfection, and HVAC maintenance as outlined in their policies. Water sample results from August 2024 revealed multiple positive findings for Legionella in various locations throughout the facility, with concentrations indicating poor control of Legionella growth. Despite these findings and recommendations from a contracted water safety company for ongoing quarterly sampling and weekly flushing of infrequently used fixtures, the facility did not provide evidence of continued mitigation steps after March 2025. Staff interviews confirmed that the water management plan was not followed, and required flushing and disinfection had not been performed as scheduled. A resident admitted in August 2025 with dementia and adjustment disorder developed a fever and was hospitalized with sepsis and pneumonia. Hospital records confirmed a positive urine test for Legionella, and the resident required an extended course of antibiotics. The failure to implement and document the required water management and infection control measures resulted in a resident contracting Legionella pneumonia, with the facility unable to demonstrate compliance with its own policies or regulatory expectations.