Failure to Implement Effective Infection Control and Water Management Program
Penalty
Summary
The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria. The deficiency was identified after a resident, who was bedbound, ventilator-dependent, and had not left the facility for over two weeks, became unresponsive and was hospitalized with septic shock and pneumonia. The resident subsequently tested positive for legionella pneumophila antigen and died in the hospital. Review of the facility's water management documentation revealed significant gaps, including the absence of updated control measures for areas affected by flooding and closure, lack of detailed plumbing schematics, and insufficient documentation of water system maintenance, flushing, and monitoring. There was no evidence that the water management plan had been revised to address changes in the physical plant, such as the closure of the Somerset unit after flooding, nor was there a written description of how water was supplied, heated, stored, or circulated throughout the building. Observations and interviews further revealed that water stagnation and potential sources of contamination were not adequately addressed. For example, the Somerset unit, which had been closed after flooding, still had water running to certain areas, and there were no logs or documentation to confirm that water lines were being flushed to prevent stagnation. In addition, the attic area above the affected resident's room showed signs of mold, water damage, a decomposed animal carcass, and leaking pipes, all of which were verified by maintenance staff. These environmental conditions, combined with the lack of clear signage and communication to staff regarding water restrictions and infection control measures, contributed to the risk of legionella exposure. The facility's infection control practices were also found lacking in other areas. For instance, a respiratory therapist was observed providing suctioning and tracheostomy care to a resident in contact isolation for Clostridium difficile infection without wearing appropriate personal protective equipment. This failure to adhere to standard infection control protocols had the potential to affect multiple residents on the same unit. Overall, the facility's inaction and insufficient oversight in both water management and general infection control practices led to the identified deficiencies.