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Based on observation, staff interviews, review of the water sample testing reports, review of the facility infection control log, review of the facility policy and procedures, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure the infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection (A0750).

Based on observation, staff interviews, review of the water sample testing reports, review of the facility infection control log, review of the facility policy and procedures, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure the infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection for two of 16 patients reviewed (Patient #11 and #12). This could affect all patients receiving services from the facility. The facility census was eight.

Findings include:

Review of facility water laboratory sample results received on 09/27/23 revealed the facility had high levels of Legionella bacteria in the water sample. The test revealed acceptable levels of less than 0.1cfu (colonized forming units)/ml (milliliters) were safe and presented little to no danger from Legionella bacteria. Test less than 0.1cfu/ml conditions may allow legionella growth and action is recommended. If 10-100cfu/ml legionella growth appears to be poorly controlled, action is recommended. Acceptable methods of remediation of portable water systems include the use of high temperatures and/or elevated chlorine levels in the system water. Re-testing to validate step after remediation of a positive result is always recommended.

Review of the facility water sample results revealed 16 of the 33 areas tested were positive for Legionella. Results from the water sample test noted a level of 0.01 cfu/ml from the sink in Room 322, 12 cfu/ml from the sink in Room 320, 9.02 cfu/ml from the sink in Room 300, 0.3 cfu/ml from the sink in Room 303, 22 cfu/ml from the sink in room 305, 12 cfu/ml from the sink in room 309, 0.2 cfu/ml from the shower wand in room 311, 0.4 cfu/ml from the sink in room 316, 4.5 cfu/ml from the sink in room 318, 41 cfu/ml in the intensive care bay three, 3.2 cfu/ml in room 201, 1.2 cfu/ml in a patient and nurses' sink in the basement, 1.5 cfu/ml in a patient and nurses' sink in the basement, 52 cfu/ml in the emergency room bay 11 sink, 21 cfu/ml in the emergency room bay 3 sink, and 12 cfu/ml in the emergency room bay 7 sink. There was no evidence the cooling tower was checked.

There was no documentation that the local or state health department was notified of the facility's positive Legionella bacteria results.

Interview on 11/22/23 at 9:50 A.M. with Staff A revealed the facility had a positive legionella test in September 2023. She reported the facility had done everything they possibly could to fix the issue, and they were waiting to be retested on 11/28/23. She reported the facility hired a new water management company in September 2023, but she was not sure why.

Interview on 11/22/23 at 10:05 A.M. with Staff B reported she was unaware of any issues with the facility's water systems.

Interview on 11/22/23 at 11:35 A.M. with Staff D and Staff E revealed the facility did have another water management company in place until September 2023. They reported the old company used an ionizer system and the facility measured copper and silver levels in the water daily and that was to take care of legionella. Staff E reported he went to clean out a boiler in September 2023 and there was an enormous amount of sludge inside and the company gave him no guidance or chemicals he requested. The facility then hired a new water management company and they suggested to start fresh and to get a baseline as to where the facility stood with legionella before implementing their plan. The test was completed on 09/27/23. The water management company recommended the facility install an iclor system which will chlorinate the water. Staff E also reported that to get the proper plumbing into place for the iclor machines the facility had to hire plumbers, and they began installing those on 09/29/23. He confirmed they completed the job, and the water management company had the iclor machines installed by 10/12/23. He reported the lines were constantly flushing the systems adding chlorine to the lines. He also reported the facility had ordered all the filters for the faucets and they would be installed by 11/26/23. Both Staff D and E confirmed no test had been done of the facility's only water-cooling tower and that all water came from the city in the same place and then branched off into four areas to service the building.

Interview on 11/22/23 at 2:01 P.M. with Staff F revealed surgeries were performed as scheduled with no changes to the process.

Interview on 11/28/23 at 8:29 A.M. with Staff A revealed that the water management system representative informed the facility that the filters in the faucets were unnecessary and the iclor system was handling the problem of legionella in the water and the filters would do nothing. She confirmed all filters were installed on 11/25/23 and 11/26/23. She also confirmed the facility was retesting the water today, but the results were still not available.

Review of the medical record for Patient #11 revealed she had an outpatient event on 10/18/23 where she was in the facility for cardiopulmonary rehabilitation. She was then admitted to the facility on 11/03/23 and discharged on 11/07/23. She came to the emergency with complaints of shortness of breath. She was found to have pneumonia due to an unspecified organism. She was tested for influenza A and B, and COVID 19 on 11/03/23 with negative results.

Review of the medical record for Patient #12 revealed he was admitted to the hospital on 09/16/23 and discharged on 09/18/23 after being treated for a fall. He was then readmitted to the hospital on 10/30/23 and discharged on 11/02/23. His chief complaint was shortness of breath and respiratory distress. Patient #12 was found to have pneumonia due to an unspecified organism. He was tested for Influenza A and B, and COVID 19 with negative results. Patient #12 was then again readmitted to the hospital on 11/09/23 and transferred to a higher level of care hospital on 11/10/23. He was admitted with shortness of breath and found to have large bilateral pleural effusions. He was tested again for influenza A and B, and COVID 19 with negative results.

Review of undated facility legionella monitoring logs revealed the only dates on each sheet were one through thirty and one through thirty-one. It stated the number of patients in the facility and if their diagnosis had worsened. No other information was listed.

Interview on 11/28/23 at 9:30 A.M. with Staff C revealed the facility did notify her of the positive legionella in the facility. She reported the water management company and Facilities Director were coming up with solutions to fix the problem. Staff C reported she changed none of the nursing processes during this time, but she monitored patients for signs and symptoms. Staff C also reported none of the positive areas were shut from water until the iclor machines and filters were installed because no patient was drinking water from those areas. She reported that just turning on the faucets and letting the water run would not transmit legionella. Staff C also reported that she did not have any written criteria for how she came up with how to monitor patients. She reported that she just looked at the CDC website and used information from there. She reported she was only checking active patients who were admitted and reported she did not look at readmissions or patients who had used the facility for outpatient treatments. Staff C confirmed Patient #11 and #12 were not tested for Legionnaires' disease even though their pneumonia was caused from an unknown organism, and they had multiple trips to the hospital.

Review of the CDC's Legionnaires' Disease publication (dated 06/06/17) revealed the following:

-Legionnaires' disease is a serious, and often deadly, lung infection (pneumonia). People usually get it by breathing in water droplets containing Legionella germs. People can also get it if contaminated water accidentally goes into the lungs while drinking. Many people being treated in health care facilities including long-term care facilities and hospitals, have conditions that put them at greater risk of getting sick and dying from Legionaries' disease. Legionella grows best in buildings with large water systems that are not managed effectively.

-76% of people got Legionnaires' disease from a health care facility in 76% of locations reporting exposures. One in four dies from getting Legionnaires' disease from a health care facility.

-Health Care Facilities may put people at risk for Legionnaires' disease when they do not have an effective water management program. These limit germ growth by keeping hot water temperature high enough, making sure disinfectants amounts are right, keeping water flowing (preventing stagnation), operating, and maintaining equipment to prevent slime (biofilm), organic debris, and corrosion. Monitoring factors external to buildings, such as construction, water main breaks, and changes in municipal water quality.

-Contaminated water droplets can be spread by showerhead and sink faucets, jetted therapy baths, cooling units, ice machines, cooling towers, and water features.

-Some people are at higher risk including adults 50 years and older, current, or former smokers, and people with weakened immune systems or chronic disease.

-Health Care providers can test for Legionnaires' disease in people with health care-associated pneumonia, especially those with severe pneumonia or in facilities where other Legionnaires' disease cases have been identified or Legionella has been found in the water source. Health Care Facilities should report Legionella to the local public health authorities quickly and work with them to investigate and prevent additional infection.

Review of the facility policy titled, Legionella Surveillance, effective and approved November 2023, revealed an updated policy to reflect the changes made remove Legionella from the system. It also stated heightened surveillance and environmental sampling, including increased suspicion for Legionella cases and increased frequency of testing above the facility's usual testing protocols.

This deficiency represents non-compliance investigated under Substantial Allegation OH00148468.