HospitalInspections.org

Based on review of CDC guidelines, observation and staff interviews, the CAH (Critical Access Hospital) failed to prevent and control the transmission of potential infections related to Legionella as evidenced by lack of a system to assess and promote water safety to prevent the growth of Coliform spore bacteria that promotes Legionella growth which can cause respiratory infection known as Legionnaire's Disease. This failed practice had the potential to affect all CAH patients. The facility had 76 inpatient admissions and 52 swing bed admissions for fiscal year 2023.

Findings are:

A. Review of CDC (Centers for Disease Control and Prevention: Legionella) (Last Reviewed March 25, 2021) stated the "Seven key elements of a Legionella water management program are to:
-Establish a water management program team;
-Describe the building water systems using text and flow diagrams;
-Burden of Waterborne Disease;
-Identify areas where Legionella could grow and spread;
-Decide where control measures should be applied and how to monitor them;
-Establish ways to intervene when control limits are not met;
-Make sure the program is running as designed (verification) and is effective (validation); and
-Document and communicate all the activities.

B. Tour of the hospital with the Facility Service Manager (5/7/2024 from 11:12 AM - 11:32 AM) revealed a lack of any weekly flushing of fixtures, sinks and showers.


C. Interview with the Facility Service Manager (5/9/2024 at 9:34 AM) confirmed that the facility did not have a weekly flushing program , lacked a facility water schematic, lacked applied and identified control measures, and interventions when the control measures are not met. The Facility Service Manager stated "the only monitoring completed was water temperatures and oxidant residual (chlorine)."


D. Interview with the CEO (Chief Executive Officer) (5/9/2024 at 9:14 AM) confirmed that the facility did not have a weekly flushing program , lacked a facility water schematic, lacked applied and identified control measures, and interventions when the control measures are not met. The CEO stated "they will follow up and get a Legionella plan in place and will include infection control/safety committee in developing the plan."