The families of two residents who contacted Legionnaires’ disease at a Connecticut nursing home over the past two years have filed lawsuits for failing to meet water safety standards designed to protect residents from Legionella bacteria.
One of the residents died in July 2019, while the other one died in April 2021. Health inspectors visited the nursing facility on April 5, 2021, the day after the resident left the nursing home with Legionnaires’ disease. The health inspectors concluded that the nursing home did not develop or implement necessary safety measures and did not report repeated positive tests for the bacteria or confirmed cases of the disease to the state. The health inspectors issued an emergency order closing the facility to new patients until it addressed its water safety issues. Additionally, the nursing home was ordered to begin remediating the bacterial contamination within a matter of days while the facility was switched to bottled or filtered water.
In the summer of 2019, there were at least two confirmed cases of Legionnaires’ disease at the Connecticut nursing home. Public health officials have said that they were working with the Connecticut nursing home to implement federal safety guidelines designed to prevent bacterial growth in nursing home water systems. In spring 2021, during a recertification survey, inspectors discovered that the water quality problems had continued for months at the facility and sent inspectors to review the nursing home again.
Inspectors found that the Connecticut nursing home had conducted Legionella testing of the drinking water at the facility four times from the end of October 2020 to mid-March 2021 and that on one or more of those dates, the water tested positive for legionella, but the facility did not report the findings to the state.
The public health commissioner also cited the facility with as many as nine different public health regulation violations for failing to develop a worthy water management plan, provide staff and training for such a plan, or respond appropriately to the results of the tests they did conduct.
Presently the Connecticut nursing home does not have a Medicare rating due to a history of serious quality issues. The nursing home is subject to more frequent inspections, escalating penalties, and potential termination from Medicare and Medicaid as part of its Special Focus Facility (SFF) designation.
Compliance Perspective
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 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 ensure that it is designed to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building’s 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 the employee’s education file.
- Periodically audit to ensure that water samples are obtained according to infection control standards and sent for testing for the presence of Legionella and other opportunistic pathogens in the facility’s water supply. Confirm that appropriate staff know how to collect and submit samples, 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.
