Family members of a patient who died from Legionnaires’ Disease at a Wisconsin hospital have filed a wrongful death lawsuit against that hospital. The patient was originally admitted to the hospital for a bone marrow transplant in mid-October 2018 and died from Legionnaires’ Disease in January 2019.
According to the lawsuit filed December 1, 2021, in Dane County Circuit Court, the patient developed signs of pneumonia December 3, 2018, after being at the hospital from mid-October to mid-November for a bone marrow transplant to treat his leukemia. He was found to have Legionnaires’ disease, for which he was hospitalized again December 5, and yet again in late December 2018, before being transferred to hospice care and dying January 12, 2019.
The lawsuit states that the Wisconsin hospital, “negligently operated the subject premises in a manner which permitted the hazardous condition of the contaminated water supply to exist.”
The Wisconsin hospital first announced an outbreak of Legionnaires’ Disease in late November 2018. Prior to that time, there were no cases of Legionnaires’ Disease associated with the hospital in the previous 23 years. A hospital spokesperson stated that the problem was initiated when a decision was made to reduce water flow during low demand times. Reducing water flow can make water systems more vulnerable to infectious bacteria, including the Legionella bacteria that causes Legionnaires’ Disease.
In response to the problem, the hospital extensively chlorinated its water system and resumed regular water flow. Additional steps were also taken by the Wisconsin hospital to reduce potential future risk, including continuous low-level chlorination to hot potable water, contracting with a vendor for high-level chlorination and filtration in the case of immediate risk, and increased monitoring for Legionella.
In 2018, nearly 10,000 cases of Legionnaires’ Disease were report to the Centers for Disease Control and Prevention (CDC). Per the CDC, about one in every 10 people who contact the Legionella bacteria will die from Legionnaires’ Disease. The death rate is higher for those in healthcare settings such as hospitals and nursing homes.
Obtain the CDC’s toolkit for managing safe water systems at Legionella Toolkit-Version 1.1-June 24, 2021 (cdc.gov).
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 by showers, drinking fountains, water flow from faucets, and mist from decorative fountains that is contaminated with the Legionella bacteria, or can occur 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. Ensure that environmental services personnel are knowledgeable of their responsibilities in maintaining a safe water system. 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.
