HospitalInspections.org

Based on facility documentation and policy review and staff interview it was determined the facility failed to ensure the temperature of the water reached the minimum temperature required by the hospital's policy for the prevention, maintenance and remediation procedures for Legionella. This could affect all patients admitted to the hospital. The current census at the time of the survey was 261.

Findings include:

A review of the hospital's policy for the "Prevention, Maintenance and Remediation procedures for Legionella" was completed on 08/10/11. The policy directed the maintenance personnel to disinfect the domestic hot water system on a quarterly basis. This is to be done by raising the water supply temperature to achieve a minimum return temperature of 160 degrees. This procedure is to be conducted at night beginning at 10:00 PM and announced in advance to prevent scalding. The first quarter disinfecting procedure took place on 03/29/11. The temperature of the water was not recorded on the daily boiler room log for 9:00 PM, 10:00 PM or 11:00 PM on 03/29/11. Interview with the Vice President of Operations on 08/10/11 at 2:00 PM confirmed there was no documented evidence of the water temperatures at the times the disinfection of the water system.