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Based on interview, policy review, and record review, the facility failed to ensure the infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital (A749).

Based on interview, policy review, and record review, the facility failed to ensure the infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital for one of 10 patients reviewed (Patient #1). The census was 21.

Findings include:

Review of the medical record for Patient #1 revealed an admission date of 12/08/23 and a discharge date of 12/28/23. Diagnoses included acute respiratory failure with hypoxia, acute exacerbation of chronic obstructive pulmonary disease, hypertension, hyperlipidemia, type two diabetes mellitus, and pulmonary nodules. Patient #1 had a past medical history of cardiomyopathy, chronic depression, chronic obstructive pulmonary disease, diabetes mellitus type two, and lumbar radiculopathy.

Review of the history and physical dated 12/08/23 revealed Patient #1 presented to the emergency room on 11/30/23 with complaints of shortness of breath and her pulse oximetry read 86% on room air. She was then placed on a bipap and given steroids. Patient #1 tested positive for influenza A in the hospital and was sent to the long-term acute care hospital on 12/08/23 for further respiratory support and physical therapy.

Review of the discharge summary dated 12/28/23 revealed Patient #1's final diagnosis was acute respiratory failure with hypoxia. She was discharged home with home health care and in stable condition.

Review of short stay acute hospital notes dated 01/01/24 to 01/09/24 revealed Patient #1 was tested for legionella pneumonia on 01/02/24 and the results returned on 01/03/24 as positive.

Review of the infectious disease progress note dated 01/05/24 revealed Patient #1 was positive for legionella pneumonia, and they recommended seven days of Levaquin (antibiotic) after being treated with three days of Zithromax (antibiotics). The note reported that the hospital was going to notify her landlord and the long-term acute care hospital she had just discharged from was notified on 01/04/24.

Review of the pulmonologist note dated 01/05/24 revealed Patient #1 had been diagnosed with legionella pneumonia. Patient #1's landlord was going to be notified but the long-term acute care hospital that Patient #1 had recently discharged from was notified on 01/04/24.

Observation on 02/20/24 at 10:32 A.M. of the facility's water system with Staff D revealed the facility's only hot water heater was registering 120 degrees Fahrenheit. Staff D reported the facility had no water-cooling tower. Staff D also reported that the facility did not routinely test for legionella, and he had not received any notices from the facility's water supplier about issues with the water.

A further interview on 02/20/24 at 11:10 A.M. with Staff D revealed he flushed rooms that had been empty for more than seven days weekly. He also reported he checked water temperatures monthly and just recorded a vague statement. He confirmed he checked three to four of the facility's sinks in patient rooms for temperatures but did not record what rooms and what the final readings were.

Interview on 02/20/24 at 12:41 P.M. with Staff A confirmed Patient #1 showed no signs and symptoms of legionella while in the facility. She reported Patient #1 was in isolation for influenza A during her stay. Staff A also reported no other patients had shown signs and symptoms of legionella or had tested positive in her four years as the infection preventionist.

Interview on 02/20/24 at 1:25 P.M. with Staff C revealed about a month ago a physician who worked for the facility notified him that a patient who had recently been discharged from his facility was in the hospital positive for Legionnaire's disease. He stated the physician did not report to him the patient's name and informed him the local health department was also being notified. Staff C stated he was waiting to hear from the local health department.

Interview on 02/20/24 at 1:30 P.M. with Staff A revealed Staff C did inform her the physician called in and reported a patient had tested positive for legionella that was recently in the facility, but he did not provide a name because he did not have one and he informed her to wait to hear from the local health department.

Interview on 02/20/24 at 1:45 P.M. with Staff E revealed he called the facility to inform Staff C that a patient who had recently been discharged from the facility was in the hospital with legionella. Staff E identified the patient as Patient #1. Staff E confirmed he did not give a patient name to Staff C but wanted to let him know so he could start looking into things. Staff E also reported that Patient #1 did test positive for legionella at the beginning of her admission and she was being treated for legionella, but she had two negative tests after that. Staff E was unable to provide dates.

Interview on 02/20/24 at 1:55 P.M. with Staff C revealed he felt he did nothing wrong because Staff E did not give him a name to investigate. Staff C confirmed that he did not question Staff E as to a patient's name nor did he reach out to the local health board to see if any cases were reported from his facility. Staff C stated he let his infection preventionist know of the issue and wanted her to wait for the call from the local health department.

Telephone interview on 02/20/24 at 2:53 P.M. with Staff F confirmed she worked for the local health department. She reported Patient #1 was in their system as being reported positive for legionella on 01/16/24. She stated the report stated the test was completed on 01/02/24 and resulted on 01/03/24 and reported to her on 01/16/24. Staff F revealed the report stated Patient #1 had come from a private home in the county. Staff F confirmed if a patient who tested positive for legionella came from a facility the facility was notified. She confirmed the health department was not aware Patient #1 had been discharged from the facility on 12/28/23 which was within the two-week legionella incubation period.

Review of the facility policy titled, Legionella Pneumonia, revised October 2018, and reviewed April 2023, revealed Legionnaire's disease is a water borne illness with two common presentations: a serious pneumonia and influenza like illness known as Pontiac Fever. One confirmed case and two suspected cases are considered an Outbreak. Notify corporate support for outbreak. Immediate steps after corporate notification are standard precautions, notify medical staff of case or suspicion of legionella, patients being screened for pneumonia should have diagnostic testing for Legionella, no tap water used for irrigations or flushes, begin outbreak investigation, follow corporate support team directions for environmental culturing and water hygiene program implementation and health department notification.

The facility failed to follow their policy once notified of a positive case.

This deficiency represents non-compliance investigated under Substantial Allegation OH00150130.