Failure to Implement Water Management Program for Infection Control
Penalty
Summary
The facility failed to develop and implement an effective water management program as part of its infection prevention and control program, specifically to prevent the growth of opportunistic waterborne pathogens such as Legionella. The facility's policy required an interdisciplinary water management team, a detailed diagram of the water system, identification of risk areas and situations, and documentation of control measures. However, interviews revealed that the Maintenance Director was not performing or documenting water testing for Legionella, did not have a diagram or list of at-risk areas, and was unfamiliar with the facility's plumbing. The Director of Nursing believed the water management plan was overseen by administration, while the current Administrator stated the program was discontinued after the removal of a water fountain. The previous interim Administrator confirmed that the facility previously had a water management program, which was not maintained after certain water features were removed. At the time of the survey, the facility census was 89 residents, all of whom were potentially affected by the lack of an effective water management program. There was no evidence of ongoing monitoring or documentation to identify or control sources of waterborne bacteria, and key staff members were unclear about their roles and responsibilities regarding the water management program. The absence of a current, implemented program and lack of staff knowledge and documentation directly led to the deficiency cited by surveyors.