Failure to Communicate and Coordinate With Public Health on Legionella Investigation
Penalty
Summary
The deficiency involves the facility’s failure to effectively and timely communicate and provide information to State and local public health authorities regarding a potential Legionella exposure, as required under its infection prevention and control and water management responsibilities. The facility’s undated Water Management Policy stated that when a suspected or confirmed outbreak occurred, the Water Management Team would investigate, identify the source, assess exposure, implement control measures, notify residents or responsible parties, and notify public health authorities regarding a confirmed outbreak. However, the policy did not address how the facility would respond when a public health authority notified the facility of a possible healthcare exposure to Legionella, nor did it include provisions for timely, collaborative, and ongoing communication with public health authorities or timely development of a Legionella sampling plan based on their recommendations. Record review showed that a resident was hospitalized, then admitted to the facility for several days, and later rehospitalized for a non-respiratory injury. During the subsequent hospitalization, a Legionella urine antigen test was performed and was positive, confirming Legionnaires’ disease. The Bureau of Infectious Disease determined that any healthcare admission within 14 days prior to symptom onset was considered a potential source of exposure, and the resident’s stay at the facility fell within this window. The resident’s facility record contained no additional information related to the Legionnaires’ disease diagnosis. A timeline from State environmental health authorities documented that, after being notified of a possible healthcare-associated Legionella exposure, the local health department and State agency requested materials and a representative water sampling plan from the facility. While the facility initially provided temperature logs, past routine Legionella sampling, and a water management plan, it did not timely develop or submit the requested Legionella sampling plan. Multiple follow-up calls and emails from State and local public health authorities over several weeks went unanswered or yielded only verbal statements that a plan was being developed. The Environmental Specialist reported that the facility had not sent in a sampling plan and had stopped communication, and the local health department confirmed that communication from the facility ceased on a specific date. The Administrator acknowledged that he had not submitted the sampling plan despite being contacted by the State agency, resulting in a failure to provide timely, collaborative, and ongoing communication and information to public health authorities during the investigation of a potential Legionella exposure.
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