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.
Removal Plan
- Registered Nurse (RN) #431 notified the Medical Director, Administrator, Director of Nursing (DON) and Infection Control Physician of the Legionella case.
- Administrator, DON, Assistant Director of Nursing (ADON) and Human Resources instructed staff to avoid unflushed/restricted water and to use alternative (bottled or approved) water and ice.
- Administrator, Maintenance Director #368 and Dietary Director #317 implemented bottled water for all drinking and cooking.
- Use of ice machines, showers, whirlpool tub, hoppers were restricted on the Aspen unit and on the Birch, Dogwood, Crabapple units only bed baths with provided wipes were permitted as use of showers was restricted.
- Administrator, DON, ADON and Human Resources provided staff education to RNs, Licensed Practical Nurses (LPN), certified nursing assistants (CNA), Housekeepers, Activity staff, Respiratory Therapists (RT), and agency staff. The education included the Centers for Disease Control Legionella signs and symptoms, transmission, surveillance/detection, and the facility's water management program. For any staff not on the schedule due to leave or other reasons, education would be provided prior to start of next shift.
- DON and Registered Nurse (RN) #350 assessed all current residents for signs/symptoms of legionella infection (cough with phlegm, chest pain, fever, chills, and shortness of breath).
- Water was delivered to the facility by commercial provider.
- Bags of ice were delivered by commercial provider.
- Use of ice machine, sinks, showers, whirlpool tub, and hoppers were restricted on the remaining units of Birch, Crabapple, Dogwood and Somerset.
- A phone call was held with the local health department and Ohio Department of Health Bureau of Environmental and Radiation Protection for guidance on legionella mitigation and testing.
- Portable handwashing sinks were delivered and stationed on Aspen unit.
- Signage was posted by VPCS #806, RDCS #803, the DON, ADON and Respiratory Therapy Director instructing staff to avoid unflushed/restricted water and to use alternative (bottled/approved) water.
- ServPro performed professional attic cleaning on the Aspen unit including debris removal, HEPA vacuuming, antimicrobial treatment, stain/odor blocking sealant application, air/surface testing, removal of wet insulation, ceiling repair below the attic and vent pipe repair within the Aspen unit Hallway/Attic area between rooms 503, 508, 502, 509, 510 and 501.
- A phone call meeting was held with a legionella consultant to review the facility water management plan.
- Portable handwashing stations were delivered and stationed throughout the facility.
- Maintenance Supervisor (MS) #368 installed legionella prevention filters on the Aspen unit (in the shower room, medication room and rooms 501, 502, 503, 504, 505, 506, 507, 509, 510, 515, 516, 517, 518 and 519).
- Regional Director of Operation completed Somerset unit water flush which included full flushing of all pipes, bathrooms, sinks, hoppers and dialysis den. Documentation was submitted to the Administrator.
- An Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the Medical Director, VPCS, RDO, RDCS, Administrator, DON, MDS, Housekeeping, MS #368, Human Resources, RN #431 and the ADON for QAPI tracking including weekly flushing compliance, audit outcomes, symptom surveillance, environmental concerns, legionella water management program review and risk assessment analysis review.
- MS #368 installed additional legionella prevention filters to two hand sinks in dialysis, one hand sink in the therapy gym, one hand sink in the first floor public rest room, one hand sink in laundry and six sinks in the kitchen, one sink in the Birch, Dogwood, Crabapple medication rooms, one sink in the first floor dining room, one sink in the Dogwood shower room and the Crabapple room sinks in rooms 710, 716 and 718.
- RDO re-educated MS #368 on weekly flushing, documentation rules, proper procedures (15 minutes run time, full toilet flush/hopper flush) and reporting/escalation steps.
- RDO contacted an additional Legionella Consultant #901 for mitigation support.
- Legionella Consultant #901 performed water testing of samples collected across Aspen, Birch, Crabapple, Dogwood and Somerset units.
- The facility implemented a plan for clinical monitoring by the DON/ADON or designee to review resident documentation weekly for four weeks for symptoms such as temperature, pulse, respirations, blood pressure, oxygen level, lung sounds, cough and phlegm, chest pain, fever/chills, shortness of breath.
- The facility implemented a plan for environmental monitoring by the Administrator or designee to review flushing logs weekly for four weeks and monthly thereafter.
- The facility implemented a plan for enhanced surveillance by the DON/ADON to include enhanced respiratory illness monitoring and immediate reporting of suspected cases.
- The facility implemented a plan for the water management program to be on-going and include daily monitoring of temperature, disinfectant levels, flushing logs, legionella filters for placement and function twice a day and monthly Water Management Plan meetings until investigation closed.
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