HospitalInspections.org

Based on interview and record review, it was determined that the hospital did not ensure that there was an infection control surveillance program that included specific measures for prevention, early detection, control, education, and investigation of infections and communicable diseases specific to Legionella.

Findings include:

On 8/27/19, surveyors reviewed the hospital water plan for prevention of Legionella. The water plan included the Legionella limits in the hospital water and the recommendation action to be taken when the levels were outside the acceptable range of colony forming units (CFU) of Legionella per Millimeter.

The following action levels were documented for domestic water:

"A. 10 or less CFUs ; acceptable control No remedial action required.
B. More than 10 CFUs and up to 100; Prompt flush and retest. Then "online" biocide treatment of the system if necessary.
C. More than 100 CFUs; Immediate "off-Line cleaning and biocide treatment. Take prompt steps to prevent employee exposure."

A review of the Legionella test results of water samples taken from 10 different areas of the hospital was completed. Six of the 10 areas tested positive for Legionella. The positive levels were located in the following areas:

a. Surgery Center ice machine - 25 CFUs.
b. Patient room 106 patient sink - 30, 15 CFUs
c. Patient room 110 patient shower - 105, 10 CFUs
d. Patient room 115 patient sink - 21 CFUs.
e. Patient room 115 patient shower - 415 CFUs
f. Nursing desk sink in the nursery, hand sprayer - 15 CFUs.

The ice machine, patient room 106 sink, patient room 115 patient sink and the nursing desk sink in the nursery all met the criteria for a level B remediation.

Patient room 110 patient shower and patient room 115 patient shower met the criteria for a level C remediation.

No documentation was provided by the hospital to indicate that the remediation had been completed in the areas that had tested positive.

On 8/27/19, at approximately 3:00 PM, an interview was conducted with the infection control coordinator (ICC). The ICC stated that as soon as they received the results of the water tests the hospital closed patient rooms 106, 110 and 115. The ICC stated that they replaced the faucets and shower heads in the patient rooms. The ICC stated that they were just waiting for the test results of the water sample they sent on 8/12/19.

At approximately 3:30 PM, the hospital facilities manager and the corporate facilities consultant were interviewed. The corporate facilities consultant stated that the hospital sent a water sample from the cooling tower and were waiting for results from that test prior to retesting the affected areas and to decide what further action to take.

A review of the patient census was completed during the interviews. Patient 18 was a current patient in room 110. Patient 18 was admitted to the room on 8/22/19. The ICC was asked about placing a patient back into the rooms prior to retesting the water. The ICC stated that she had asked the corporate environmental hygienist, who was the person over the water management program. if it was safe to put patients back into the room. The ICC stated she thought it could be safe since they replaced the faucets in the patient rooms.

On 7/27/19, at approximately 3:40 PM, the ICC provided a copy of an email dated 8/12/19 from the corporate environmental hygienist. The email noted the following action items:

aa. Replace the shower head in room 115.
bb. Replace the sink faucet in room 110.
cc. Review ice machine cleaning procedures.
dd. Evaluate whether carbon filters are needed.
ee. Consider sanitation methods for the ice machine water line.
ff. Balance hot water loops with a target 120 F (Fahrenheit) temperature.
gg. Regular PM (preventative maintenance) for water temperature measurements at outlets (Did not discuss)
hh. Trace out the water tank and water heater. Document.
ii. Send tank Legionella sample today and it should return approximately 2 weeks.
jj. Prepare for a hot water flush to be done after the tank ample returns and water loop temperatures are addressed
Evaluate capability
150 F at 30 minutes contact time.

No documentation was provided to indicate that the above items had been completed. The ICC provided the work orders for the faucet and shower fixtures to be changed. This was completed on 8/15/19.

No documentation was provided to indicate that the patients rooms had been deemed safe for patient occupancy prior to remediation of the water system.