Failure to Implement Comprehensive Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to provide evidence of a comprehensive Water Management Program (WMP) necessary to prevent the spread of Legionella and other waterborne pathogens in the building water systems. During interviews and document reviews, it was found that the facility did not conduct a risk assessment to identify areas where Legionella and other pathogens could grow and spread. The WMP lacked a detailed description of the building water system, did not specify testing protocols, and omitted acceptable ranges for control measures. The documentation provided was a basic outline and did not include required elements such as a specific risk assessment, a detailed water system diagram, or a building description. A resident with multiple comorbidities, including chronic anemia, urinary retention, chronic kidney disease, and asthma, was admitted to the facility for rehabilitation after a hospital stay for septic shock. The resident later tested positive for Legionella antigen during a subsequent hospitalization for septic shock secondary to acute cystitis and pneumonia. The facility received notification of the positive Legionella case but was unable to provide documentation of a completed risk assessment or a comprehensive WMP at the time of the survey. The infection preventionist confirmed that the risk assessment was started only after the notification of the positive case and had not been completed. Further interviews revealed that the facility manager was unaware of when the current water system diagram was developed and confirmed that no risk assessment had been conducted as part of the WMP. Measures in place, such as water heater temperature logs and ice machine maintenance, lacked documentation of acceptable parameters and specific procedures. The facility relied on annual municipal water quality reports, which were not included in the current plan. The documentation and policies provided did not reflect a coordinated WMP consistent with CDC and ASHRAE standards, and there was a lack of documentation of program activities.