HospitalInspections.org

Based on record review, review of email correspondences, and staff interview it was determined the hospital failed to ensure infection control interventions were timely implemented after notification of a presumptive case of hospital acquired Legionella. This had the potential to affect all patients who receive care at the hospital. The census was 370.

Findings include:

Review of an email dated 10/09/25 at 1:44 P.M. from the Cincinnati Health Department (CHD) Director of Environmental Health X to the hospital revealed they were writing informing of a presumptive case of Legionnaires' where the patient was at the hospital prior to symptom onset on 09/13/25. They were directing the hospital to follow the Centers for Disease Control (CDC) guidelines, complete a full investigation, and complete a call with the CHD. In addition, they directed the hospital to consult a Legionella consultant, implement water use restrictions using point of use filters that were to be installed within two to three days, communicate the water restrictions to staff and patients, conduct a new risk assessment, create a Legionella sampling plan following the CDC guidelines, implement any identified corrections, collect a second set of samples 72 hours after the first, and revise their Water Management Program based on the Ohio Department of Health (ODH) and local health district recommendations. The Cincinnati Health Department (CHD) Director of Environmental Health X offered to set up a call with them and ODH for 10/10/25 or 10/13/25. The CHD Director of Environmental X also requested the hospital send in items prior to the call to include: the most recent version of the facility's water management program, and environmental Legionella samples obtained in the past year, a floor plan of the facility to include the water loops, temperature and chlorine monitoring logs, maintenance monitoring logs of the secondary disinfection system if available and maintenance and monitoring logs for any additional water features. Another email from the CHD Director of Environmental Health X on 10/13/25 at 9:58 A.M. to Staff B revealed the CHD was to set up a call to "get things moving." In addition, the email stated the facility should have already began working on implementing water use restrictions using point of use filters and directed the hospital to begin sending the items requested. On 10/15/25 Staff A replied to the CHD that he/she did believe further Legionella investigation and remediation was required because he/she was skeptical SP #1 had Legionella pneumonia. Staff A noted the patient experienced improvement prior to the Legionella treatment being administered. Staff A stated he/she had concerns with the accuracy of their assay in regard to the urine antigen test they use. Staff A noted that the hospital has not had any additional Legionella pneumophilia cases that would meet the case definition for healthcare associated Legionnaires' disease. On 10/22/25 at 12:14 P.M. the CHD Director of Environmental Health X emailed the hospital stating that after reviewing some of the materials it was noted the hospital had experienced recurring detections of multiple Legionella serogroups, particularly in the West Tower. He/she noted that several exceeded the one Colony Forming Unit per milliliter (CFU/mL) threshold so he/she instructed them to consult with their water management expert about the installation of a secondary disinfection system. On 10/23/25 and 10/27/25 the CHD Director of Environmental Health X emailed again requesting a reply from his/her previous inquiries about whether filters have been installed and if so, where. On 10/27/25 at 12:59 P.M. Staff B replied that the hospital had began installing the filters on oncology and transplant patients and they were in the process of notifying patients, staff and providers of what they were doing.

Interview on 10/29/25 at 10:30 A.M. with the Chief Medical Officer, Staff C revealed the hospital had spoke with the local and state health departments in response to the Legionella concerns. He/She stated the hospital did not agree with SP #1's diagnosis of healthcare associated Legionnaires' disease and they were unaware of the team member becoming sick until Friday (10/24/25). He/She stated water testing for Legionella is completed continuously and for the past year they have had good results. As of 10/28/25 they have started applying filters to the water fixtures, re-sampled the water and the water signage is up.

Interview on 10/29/25 at 11:43 A.M. with Staff B revealed the hospital follows the CDC guidelines in regards to Legionella. He/She stated the nurses look in the electronic system called, Surveillance every morning and at different times throughout the day for reportable's to include Legionnaires' disease. Staff B stated the electronic system automatically sends over the positive test results from the lab to the health department. He/She stated the health department would contact the hospital if they determine that a positive case is hospital acquired. If a positive result is indicated, staff would notify water management and discuss the case with the Infectious Disease physician, Staff A. She stated they would look further to see what symptoms the patient arrived with, whether the patient was in the hospital and if so when within 14 days prior to symptom onset. They'd also ask if they use a home Continuous Positive Airway Pressure (CPAP). He/She stated the hospital does not call patients to question them regarding the positive Legionella test once they are discharged that is the health departments jurisdiction. He/She stated the hospital did not agree that SP #1's case was hospital acquired so they did not begin implementing/submitting the health department requested items right away. He/She stated the health department missed the fact that the patient used his/her home CPAP machine at the hospital and verified that SP #1 tested positive three times (09/16/25, 09/17/25 and 10/03/25) using the same urine antigen tests that the hospital currently uses. Staff B stated Staff A determined SP #1 did not have Legionnaires' disease because despite the positive tests, the patient got better with no Legionella treatment. He/she verified there was a delay in the health department request for installation of the water filters and sampling because the hospital did not feel it was hospital acquired Legionella. However the hospital was installing the filters now and would be finished within the next few days. He/She stated she is not sure what the CDC expert decided from the 10/24/25 call related to SP #1 but he/she verified that during the call they were initially informed that a hospital employee, Staff D tested positive for Legionnaires' disease. He/She stated Staff D is an Environmental Specialist (EVS), and part of his job is to instruct new staff and flush water around the hospital. He/She stated Staff D worked 9/30/25 through 10/03/25, 10/06/25 through 10/10/25 and 10/13/25 through 10/17/25 and was everywhere in the hospital. He/She stated the employee has not returned back to work and was still hospitalized. He/She stated now Environmental Services staff are required to wear masks when flushing and they have provided some direction to Plant Operations staff in regards to focusing on obtaining water samples from floors three, four and seven where SP #1 was located during the admission.

Interview on 10/29/25 at 2:05 P.M. with the Cincinnati Health Department (CHD) Director of Environmental Health X revealed the initial case (SP #1) identified on 09/2025 was confirmed by three positive tests and the patient met the case definition for Legionnaires' disease. The hospital argued different issues to include that something was wrong with the tests but the argument did not stand. The hospital requested the case be reviewed at a higher level so on 10/24/25 the CHD, the ODH and the CDC were on a call with the hospital to discuss SP #1's case. The CDC agreed with the health department. During the call on 10/24/25, they were notified that a hospital employee tested positive for Legionnaires' disease. The Director of Environmental Health notified the hospital on 10/09/25 of the presumptive healthcare associated case of Legionnaires' and what was required of the hospital. He/She stated the hospital was to install filters within three days of notification, however the hospital just started installing them a couple of days ago. He/She stated they expected the filters to be on and water restrictions were just implemented on Friday (10/24/25).

Interview on 10/30/25 at 9:32 A.M. with Assistant Nurse Manager, Staff F during SP #1's medical record review revealed SP #1 is frequent on his/her unit and stated the patient was currently in the hospital after being directed by his cardiologist to go during a visit. He/She stated the patient was a seen frequently at the hospital. Staff F stated SP #1 was on his/her unit for most of his stay starting 08/28/25 and comes often. Staff F stated that when a patient uses a home CPAP or Bilevel Positive Airway Pressure (BiPAP) machine respiratory staff have them sign a form and look over the machine. Staff then documented in the notes. Staff F verified there was no signed home BiPAP consent form and stated the nurse documented the patient had a home issued device the first two entries within two hours a part and every entry after, to include the respiratory therapist notes the patient was using a hospital issued device. Staff F stated the hospital encourages patients to use the hospital machines because they are usually better. Staff F verified the 10/28/25 urine antigen test had not resulted for SP #1 and stated SP #1 could keep having positive Legionella urine antigen tests because it may be colonized versus active. Staff F verified that there was no sputum sample obtained to verify whether the patient had an active infection for either of the three positive tests.

Interview on 10/30/25 at 12:42 P.M. with the ODH Environmental Specialist Y revealed the hospital was first notified by the local health department on 10/09/25 that SP #1's case was determined presumptive healthcare associated Legionnaires' disease and informed of the CDC guidelines for hospitals to complete a full investigation. He/She stated, "Epidemiology is how we classify Legionella. The first case (SP #1) was presumptive and we treat one presumptive or two possible's the same." The hospital was instructed to send in various documents to include the water management plan, past Legionella water sampling results, a floor plan and current Legionella water sampling plans, for review to ensure they sample all of the possible areas of contamination based off of where the patient stayed. He/She stated the hospital was to install point of use filters within two to three days of notification and implement water-use restrictions. He/She stated the hospital argued that SP #1 was not positive for Legionnaires' disease and wanted a second opinion. They set up a call on 10/24/25 to discuss SP #1's case with the local health department, the hospital, a CDC representative and during the meeting another positive Legionnaires' case in connection to the hospital was confirmed. It was a hospital employee who tested positive after presenting to an outside hospital. As of 10/30/25 they have not received the water sampling plans.

Interviews with the staff revealed that there are three water loops on the campus. Filters are currently being installed at all point-of-use locations throughout the entire campus. These filters began installation on Friday, October 21, 2025. The process is progressing smoothly but also depends on supply and demand. Orders have been placed to install filters across the campus and are being executed as soon as deliveries arrive. Several units have already been completed. The most critical units are where the filter installation has started. Only one room is currently under construction, and this room is not in the same area or on the same water loop as the location of the positive test patient. All water loops have a chloride system in place, which operates during the first week of each month. During this time, the water lines are also flushed in different parts of the facility. Three West is a critical area, and all faucets in this section are flushed weekly. Updates are being made to the water system to ensure areas have a fully looped water system.

Review of SP #1's medical record revealed the patient went to an outside hospital complaining of rectal bleeding and shortness of breath (sob) that started that day on 08/28/25. The patient was given packed red blood cells at the outside hospital and transferred to this hospital on 08/28/25 at 9:04 A.M. for an acute transverse colon bleed. After several attempts to find the bleed, they were able to clip the bleeding vessels to stabilize the bleed. On 08/13/25 a Computed Tomography (CT) scan revealed the patient had bilateral pleural effusions and some consolidation in the lower lobes. The doctor noted diuresis was held related to the patient not making urine. The patient had a history to include diabetes, end stage renal failure status post transplant times two, chronic kidney disease of transplanted kidney, Gastrointestinal (GI) bleed, hemodialysis status post transplant, hypertension, atrial fibrillation and pulmonary hypertension. On 09/03/25 the pulmonary doctor noted the bilateral effusions were worsening and on 09/04/25 the provider noted the patient had increased work of breathing (wob), diminished lungs sounds to the lung bases and shortness of breath with moving around. On 09/04/25 at 9:27 A.M. the pulmonary doctor added a diagnosis of acute hypoxic respiratory failure and ordered Zosyn (antibiotic medication) be discontinued and to resume chronic amoxicillin (antibiotic medication). The patient was on two Liters (L) nasal cannula (nc). On 09/08/25 the provider noted pulmonary edema and mild crackles on auscultation, the patient was now on 3L nc. The patient continued to report shortness of breath. On 09/10/25 at 9:35 P.M. the breathing treatments were increased to every four hours. On 09/11/25 at 5:13 A.M. the nurse noted the lung sounds were diminished but the cough resolved with diuresis. On 09/13/25 the patient's white blood cells elevated to 21,000 cells per microliter (uL). On 09/15/25 at 12:30 A.M. a rapid response was called for increased work of breathing and hypotension. The provider noted the patient was septic and transferred the patient to the intensive care unit. The patient was started on vancomycin and Zosyn (antibiotic medications). On 09/15/25 at 7:00 A.M. the patient was intubated related to a new onset of mental changes, cough and rhonchi and the provider added the diagnosis mild septic shock. On 09/16/25 at 10:48 A.M. the patient tested positive for Legionnaires' disease. A retest was ordered as the provider noted he/she thought it was a false positive. On 09/17/25 at 1:39 P.M. the patient tested positive for Legionnaires' disease for the second time. On 09/18/25 the provider started the patient on meropenem (broad spectrum antibiotic) and levaquin (antibiotic medication). On 09/19/25 at 5:29 P.M. the patient was removed from the ventilator and placed on oxygen at 2L via a nc. On 09/15/25 at 1:14 A.M. the patient was started on the BiPAP, it was stopped related to the patient being intubated and re-started nightly on 09/19/25. There was a note by the nurse on 09/15/25 where he/she clicked the patient was using the BiPAP from home. However, review of the respiratory therapist notes revealed the patient was using a hospital issued device. On 09/26/25 at 2:56 P.M. the patient was discharged to a skilled nursing facility.

Further review of the medical record revealed on 10/03/25 the patient was at the hospital for shortness of breath and at 3:22 P.M. the SP #1 tested positive for Legionella for a third time via the urine antigen test. The patient was provided treatment and discharged. On 10/27/25 at 10:26 A.M. SP #1 was admitted to the hospital for shortness of breath and bilateral leg edema. The patient was diagnosed with pneumonia and was being treated with broad spectrum antibiotics. On 10/28/25 the patient was tested for Legionella and the results the patient is a current patient during the investigation.