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Based on observation, interview and record review the hospital failed to develop a system for identifying, reporting, investigating, and controlling infections of patients by failure to maintain a sanitary water supply system to avoid sources and transmission of infections. At the time of the survey, eight patients and two visitors had tested positive for Legionella since occupancy of the new hospital building on 04/28/19. (A0749). The hospital has admitted approximately 1200 patients since obtaining occupancy. The active census was 154.

Based on observation, interview and record review the hospital failed to develop a system for identifying, reporting, investigating, and controlling infections of patients by failure to maintain a sanitary water supply system to avoid sources and transmission of infections. At the time of the survey, eight patients and two visitors had tested positive for Legionella since occupancy of the new hospital building on 04/28/19. The active census was 154.

Findings include:

According to the Centers for Disease Control and Prevention (CDC), hospital water management programs identify hazardous conditions and steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. The species of the genus Legionella are gram negative, non-spore forming bacteria that can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella occurs naturally in a fresh water environments however, can become a health concern when it grows and spreads in human-made building water systems. Keeping Legionella out of the water systems in buildings is key to preventing infection.

Review of the facility's water management plan titled "Executive Summary", dated 06/01/19, revealed the plan failed to adequately identify hazardous conditions and take steps to minimize the growth and transmission of waterborne pathogens. The facility did not have an active program for the prevention, control, and investigation of infections and communicable diseases that was adequate to reduce the risk of Legionella entering and spreading in its building water systems. The facility's water management plan was also inconsistent with the CDC toolkit related to prevention of Legionella, which sets forth the industry standards for reducing the risk of Legionella growth in building water systems.

The facility's water management plan failed to identify the risk of Legionella on its flow diagram. The flow diagram was not used to evaluate where hazardous conditions may occur and/or where there was a risk for Legionella growth, nor did it determine where control measures should be applied to control hazardous conditions. The CDC tool kit included information on how to "identify areas where Legionella could grow and spread, including areas where medical procedures may expose patients to water droplets, such as hydrotherapy and areas where patients are more vulnerable to infection, such as bone marrow transplant units, oncology floors, or intensive care units," but the facility did not identify these areas in its water management plan. Nor did the plan include or identify the risk areas of the cooling tower and the decorative waterfall at the facility. The plan lacked information for the procedures, corrective actions and time frames for a response that would be followed by the water management team if control measures or control limits established in the plan were not met for the building water systems, the cooling tower or the decorative waterfall.

Review of the facility's document titled "Infection Prevention and Control Mount Carmel Health System Fiscal Year 2019 Annual Plan approved by Mount Carmel Quality Committee of the Board on 04/17/19, documented the following: "The Mount Carmel IPC Department oversees the prevention of infection across all ministries and their affiliated services within Mount Carmel Health System (MCHS). MCHS consists of four acute care ministries (hospitals): Mount Carmel East, Mount Carmel West, Mount Carmel St. Ann's, and Mount Carmel New Albany." The Mount Carmel Grove City hospital was not identified in this document.

Staff D stated in an interview on 06/03/19 at 11:32 A.M. there was a delay in opening the facility due to construction projects. The facility obtained the occupancy permit and began admitting patients on 04/28/19. Although prior water testing was completed, the facility was unable to provide evidence the water supply system was monitored and bacteriological testing was completed prior to admitting patients.

During interview on 06/03/19 at 3:00 P.M., Staff D stated they did not have any control measures/monitoring logs for temperature, pH or chlorine residual for the hospital building. They
stated they had not started monitoring yet because the building was new.

Review of the hospital's water analysis reports revealed the hospital water system for floors one through six was sanitized between 02/05/19 and 02/20/19. On 04/11/19, the seventh floor water
system was sanitized. On 04/28/19, the hospital opened to the public for business. There was no
evidence the water system had been monitored for bacterial growth between 02/20/19 and 04/28/19.

Review of the following medical records and laboratory results confirmed the following patient's urine antigen test was positive for Legionella:

1. Patient #1 was at the hospital as an inpatient from 05/08/19-05/16/19. The patient had a positive Legionella culture on 05/17/19.

2. Patient #2 was at the hospital as an inpatient from 05/14/19 to 05/15/19. The patient had a positive Legionella culture on 05/26/19.

3. Patient #3 was at the hospital as an inpatient from 05/13/19 to 05/15/19. The patient had a positive Legionella culture on 05/25/19.

4. Patient #4 was at the hospital as an inpatient from 04/29/19 to 05/07/19. The patient had a positive Legionella culture on 05/14/19.

5. Patient #5 was at the hospital as an inpatient from 05/18/19 through 05/20/19. The patient had a positive Legionella culture on 05/29/19.

6. Patient #6 was at the hospital as an inpatient from 05/14/19 through 05/19/19. The patient had a positive Legionella culture on 05/30/19.

7. Patient #7 was at the hospital as an inpatient from 05/28/19 through 06/02/19. The patient had a positive Legionella culture on 05/31/19. Patient #7 expired 06/02/19 due to an undetermined cause.

8. Patient #8 had visited the hospital the week of 05/20/19. Patient #8 had a positive Legionella culture on 05/31/19.

9. Patient #9 was an outside contractor from another state working in the hospital the week of 4/28/19. Patient #9 tested positive for Legionella on 05/12/19.

10. Patient #10 was at the hospital as an inpatient from 05/18/19 to 05/21/19. The patient had a positive Legionella culture on 06/02/19.