A Connecticut nursing home was issued an emergency order by the Connecticut Department of Public Health directing immediate actions after the facility failed to respond adequately to drinking and bathing water samples testing positive for Legionella. The actions include a suspension of new admissions and remedial actions to protect the health and safety of residents.
During a recertification survey in April 2021 conducted by the Connecticut Department of Health, an investigation was initiated concerning infection control issues and physical and life safety code issues. The investigation originated from results of Legionella testing of the drinking water in October 2020, December 2020, January 2021, and March 2021. One or more of the water samples from the facility tested positive for Legionella.
During the course of the recertification survey, it was determined that violations of the Public Health Code occurred in 2020 and 2021. The violations include:
- The Licensee failed to maintain a water management plan to mitigate the risk of Legionella and other water borne pathogens;
- The Licensee failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of waterborne pathogen diseases and infections;
- The Licensee failed to dedicate a registered nurse to be responsible for the day-to-day operations of the infection control surveillance program under the direction of the infection control committee;
- The Licensee failed to restrict water use in the facility and use potable bottled water when there was a question of Legionella transmission from the water system;
- The Licensee failed to adequately respond when several monthly test results identified positive results for waterborne pathogens;
- The Licensee failed to report a case of Legionella in accordance with reporting requirements.
The Connecticut Department of Health emergency order against the facility includes:
- Prohibition of admission of new residents;
- Requirement to use bottled water and a retrospective surveillance review to identify residents with pneumonia of unknown etiology;
- Testing of all residents for Legionella;
- Environmental assessments and sampling activities;
- Establishment of a water sampling plan;
- Remediation/decontamination of possible environmental sources when identified;
- Contracting with an independent contractor with expertise in waterborne pathogens to conduct a water management review, remediation, and to repair/replace/correct identified deficiencies;
- Provision of a comprehensive plan of correction.
The Connecticut Department of Health stated that they will continue to closely monitor the situation and take further action if necessary to protect the health and safety of the residents.
In 2017 and 2018, the Centers for Medicare & Medicaid Services (CMS) directed that all skilled nursing facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. Obtain the Centers for Disease Control and Prevention’s toolkit titled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings from this link: https://www.cdc.gov/legionella/downloads/toolkit.pdf.
Issue:
Legionella outbreaks generally are linked to environmental reservoirs in large or complex water systems, which include those found in many nursing facilities. Transmission of Legionella can be aerosol generated or when an individual consumes contaminated drinking water. CMS requires that each facility establish and maintain an infection prevention and control program. CMS also expects that each nursing facility will have a policy and procedure to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building’s water system.
Discussion Points:
- Review the facility’s Infection Control Plan and the policy and procedure for water management to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water system. Revise as necessary.
- Train all staff on the facility’s Infection Control Plan and water management policy and procedures. Document that these trainings occurred, and file each signed document in each employee’s education file.
- Periodically audit to ensure that water samples are taken to test for presence of Legionella and other opportunistic pathogens in the facility’s water supply. Confirm that appropriate staff know how to collect and submit samples for testing, and that staff know what to do if the water samples test positive for Legionella or any other opportunistic pathogens. Ensure that a designated registered nurse is competently serving as the facility’s Infection Preventionist.
