Inadequate Legionella Water Management Program
Penalty
Summary
The facility failed to develop and implement an adequate Legionnaires Water Management Program (LWMP) as part of its infection prevention and control program. Record review showed that the LWMP, last revised in June 2020, lacked essential procedures for using control measures to prevent the introduction and spread of Legionella in the building's water system. The policy did not specify control limits or parameters, did not include monitoring procedures or documented environmental testing protocols for Legionella, and did not establish acceptable control limits for the measures being monitored. Additionally, there were no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case in the facility. During an interview with facility leadership, including the Administrator, DON, Corporate Nurse, Corporate Maintenance Director, and the Infection Control Preventionist, it was revealed that they were unaware of the inadequacies in the LWMP. They did not know that the plan lacked procedures for control measures, acceptable control limits and parameters, monitoring procedures, testing protocols, or established interventions for non-compliance or cases of legionellosis. These failures had the potential to affect all residents in the facility.