Licking Memorial Hospital

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 32088 Based on interview, record review, policy review, Centers for Disease Control (CDC) guidelines, and water sampling results, the failed to ensure the water supply was free from Legionella. See A750.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 32088 Based on record review, interview and policy review, the hospital failed to ensure falls and fall interventions were documented in the medical record. This affected three (Patients #3, #4 and #5) of three medical records reviewed for falls. The census was 133. Findings include: 1. Record review revealed Patient #3 arrived to the emergency department (ED) via squad on 02/06/25, complaining of feeling weak after missing the past four dialysis appointments due to having no transportation. A Morse Fall Risk Assessment was completed on 02/06/25 at 10:00 AM which assessed Patient #3 at high risk for falls. Review of the electronic medical record (EMR) revealed no fall risk interventions were implemented. Review of the progress notes revealed the medical doctor noted on 02/06/25 at 11:29 AM that Patient #3 was hemodynamically stable but was being admitted and to arrange for dialysis. There was no mention of a fall in the ED notes. On 02/26/25, Patient #3 returned to the hospital complaining of pain, stating, “I’m hurting all over because I had a recent fall in the ED 20 days ago.” The patient reported missing dialysis as well. In the ED the patient was assessed and treated for a non-ST segment elevation myocardial infarction (NSTEMI). She was assessed at high risk for falls. Patient #3 reported limited movement to her lower extremities and tenderness to her right hip, so the doctor ordered an X-ray of the right femur which resulted within normal limits. Review of a Post Fall Huddle Worksheet dated 02/06/25 at 1:40 PM revealed Staff M documented Staff N, a Patient Care Assistant (PCA), was assisting Patient #3 to bedside and the patient’s legs gave out. Patient #3 was lowered to the floor by the PCA. Staff M documented she was notified of the incident immediately by Staff N. Staff M stated she found the patient sitting on her bottom in room 8 and the patient told her that her legs gave out and she was lowered to the ground. Staff M noted there was no sitter at bedside and stated the patient required the assistance of one person for transfers. Staff M noted the patient had an abrasion to her left knee, she notified a physician of the fall and treated the knee. Staff M noted the patient declined notification of the fall to her family and Staff M raised her level of assistance from one to two people required. There were no notations in the medical record of what fall risk interventions were implemented prior to the fall and after the fall except that her level of assistance was raised from one person to two. 2. Record review revealed Patient #4 arrived to the ED on 02/06/25 at 9:59 AM via squad complaining of falling and hitting their head on ice. A Morse Fall Risk Assessment was completed on 02/06/25 and Patient #4 was assessed at low risk for falls. Review of the EMR revealed no fall risk interventions were implemented. 3. Record review revealed Patient #5 arrived to the ED on 02/06/25 at 10:10 AM via squad complaining of falling and hitting their head on ice. A Morse Fall Risk Assessment was completed on 02/06/25 and Patient #5 was assessed at low risk for falls. Review of the EMR revealed no fall risk interventions were implemented. During an interview on 04/09/25 at 10:30 AM with Staff C, the Emergency Department Director stated all patients are assessed for falls during triage and fall interventions would be implemented immediately. He stated they use the Morse Fall risk assessment tool. Staff C said if a fall occurs, the patient will be assessed, the doctor will be notified and an incident report will be completed. Based off the assessment, new interventions and any areas of concern would be addressed. He stated nurses would also make a note of the fall in the medical record. He stated all falls in the hospital are reviewed monthly and Staff D (ED Manager) was on the Falls Audit Team. During an interview 04/09/25 at 10:31 AM, Staff D stated all patients are assessed for falls during triage and fall interventions would be implemented immediately. He stated they use the Morse Fall risk assessment tool. Staff D said if a fall occurs, the patient will be assessed, the doctor will be notified and an incident report will be completed. Based off the assessment, new interventions and any areas of concern would be addressed. He stated nurses would also make a note of the fall in the medical record. He stated all falls in the hospital are reviewed monthly and any concerns identified are immediately addressed. During interview on 04/10/25 at 10:20 AM, Staff C stated Staff M and Staff N were educated after this incident. He stated Staff M was educated to document any fall interventions and a brief synopsis about the fall in the medical record. Staff C stated Staff M thought she should document falls on the Post Fall Huddle form and not the actual medical record. Staff C stated the PCA, Staff N was educated to review fall risks for patients prior to getting them up. Staff C verified that none of the ED medical records reviewed had fall interventions documented. He stated there is no place to document fall interventions in the ED in Epic. He verified that the hospital has no way of documenting or looking back to see what fall risk interventions were implemented for ED patients. Review of the hospital policy titled “Patient Fall Safety Initiatives LMH Emergency Department” stated a nurse will assess each patient for fall risk upon presentation to the ED. For low risk patients 3 or more of the standard fall prevention interventions must be implemented and documented under the fall risk assessment template. Standard interventions include a yellow arm band, yellow blanket, cot in low position, both side rails raised, assure the floor is free of fall/trip hazards, call light in reach, phone in reach, remind the patient to call for help and give the patient or family a prevent a fall care gram. For high risk patients all of the standard fall precautions must be implemented in addition to two or more of the high risk fall prevention interventions. High risk fall interventions include: family/friend at bedside with patient, sitter at bedside, yellow dome light illuminated above door to signify the patient is a high fall risk and yellow “fall risk” sign on the door. If a patient falls a post fall huddle form will be completed and the nurse will need to complete a new fall risk assessment and update interventions. The nurse will then document the patient appearance and condition at time of discovery, patient response to the event, evidence of injury, location of the fall, physician notification and any action taken after the fall.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 32088 Based on record review, interview, policy review, email review, Centers for Disease Control and Prevention (CDC) guidelines, and water sampling results, the hospital failed to ensure the water supply was free from Legionella. This affected two (Patients #1 and #2) of two medical records reviewed for possible cases of lab confirmed health care associated Legionella but had the potential to affect anyone receiving services at the hospital. The census was 133. Finding include: Review of Patient #1’s medical record revealed the patient presented to the Emergency Department (ED) on 01/19/25 in cardiac arrest. The patient had recently been seen at the hospital on 12/17/24 and on 01/06/25 through 01/09/25 for chronic obstructive pulmonary disease (COPD) exacerbation. She came back to the ED on 01/10/25, after being discharged on 01/09/25, stating her breathing was worse, however she left the ED against medical advice (AMA). She called Emergency Medical Services (EMS) on 01/18/25 for “worsening in breathing,” but when they arrived she did not go to the hospital. On 01/19/25 she called EMS for breathing issues and this time they gave her a DuoNeb, put her on a bi-pap and took her to the ED. She arrived to the ED unresponsive with emesis on her face and mouth. The patient was tested and resulted positive for Legionella on 01/19/25. The patient was in cardiac arrest upon arrival in the ED and life saving efforts were started. Despite the life saving efforts the patient was intubated and eventually expired on 01/24/25. The discharge diagnoses included Legionella, left lower lobe pneumonia, influenza, acute on chronic hypercapnic respiratory failure, septic shock, COPD and respiratory syncytial virus (RSV). During the 12/18/24 visit the patient was in ED Room 20 and then transferred to the medical surgical unit Room 448 B1. During the 01/06/25 visit the patient was in ED Room 16 and then transferred to the medical surgical unit Room 433. On the 01/10/25 visit the patient was in ED Room 2. For the 01/19/25 visit she was in ED Trauma Room 1 and transferred to intensive care unit (ICU) bed 209. Review of Patient #2’s medical record revealed the patient presented to the ED on 12/23/24, after coming from his primary care provider, complaining of chest pressure for the past three days with lightheadedness and neck pain the previous night. A chest X-ray was done and showed no pneumonia. The patient was told to follow up with his vascular physician and to come back if needed. On 12/25/24 Patient #2 presented to the ED complaining of chills, cough, low grade fever, headache and feeling like his temples were swollen. The physician ordered pain medicine, nausea medicine and steroids. No new X-ray was ordered as his lung sounds were clear and the X-ray on 12/23/24 showed no disease process. The patient again presented to the ED on 12/28/24 complaining of fever and right sided facial pain. This time they completed a workup and noted the patient had pneumonia, but the patient and his wife requested to be transferred to another hospital. The hospital staff arranged the transfer, the transfer consent was signed and the patient went to another hospital. The patient tested positive for Legionella at another hospital on 12/29/24. Interview on 01/30/25 at 9:24 PM with the Infection Prevention Manager, Staff H, and Vice President (VP) of Lab and Oncology, Staff I, who manages Infection Prevention, revealed they have had recent positive cases of Legionella. Staff H stated they have to submit any positive Legionella cases to the local health department, Licking County Health Department (LCHD). Staff H stated she submits the information for positive Legionella cases to the local health department and then she completes an investigation to see if the onset of the disease started in the hospital or outside. Staff H stated she can safely say the onset of Legionella was from outside of the hospital if the patients are testing positive within the first 24 hours of presenting to the hospital. Staff H stated there were no employees who tested positive for Legionella at the hospital. However, they did have an employee, Patient #2, who works in a building separate from the hospital who tested positive at another hospital. During an interview on 01/30/25 at 9:45 AM, the Plant Operations Manager, Staff A, stated the water is tested throughout the hospital at different times. The water-cooling towers are tested three times a day and the water features are tested three times a week. Staff A stated they use bromine to treat the water inside and chlorine to treat exterior water sources. Staff A stated they do not use chlorine inside because of the odor. Staff A stated the hospital uses chlorine and non-chlorine scale control and stated the chlorinators kill the biofilm. Staff A stated they do not and have not tested the water for Legionella. During an interview via phone on 02/04/25 at 10:26 AM the Ohio Department of Health Epidemiologist revealed the hospital has had two confirmed cases of Legionella within one month, one patient (Patient #1) and one employee (Patient #2). Patient #2 works 0.2 miles away from the main hospital but stated his job routinely takes him into the hospital main building. Patient #2 reported working in the ED on 12/11/24, in the basement on 12/16/24, in an unspecified location at the main hospital on 12/18/24, and in the cafeteria on 12/20/24. Patient #2 denied all other high-risk exposures. Patient #2 had an illness onset of 12/22/24. He developed pneumonia and was hospitalized. His Legionella urine antigen test came back as positive on 12/29/24. The second case, Patient #1, had an illness onset of 01/09/25. Patient #1 was hospitalized with pneumonia and was urine antigen positive on 01/19/25. She died on 01/24/25. This case had been to the hospital a couple times within the last month for respiratory issues such as respiratory failure, shortness of breath, and COPD exacerbation. She had been admitted to the hospital on the following dates: 12/18/24 to 12/19/24; 01/06/25 through 01/09/25; and a single visit on 01/19/25. Patient #1 did use Bilevel positive airway pressure (BiPAP) during the visits on 12/17/24, 01/06/25, and 01/19/25. She was also at the hospital for one hour on 01/10/25 before deciding to leave AMA. The Ohio Department of Health Epidemiologist stated two possible cases or one presumptive case in a year constitutes an outbreak and further investigation is needed. The hospital has had two possible cases within one month. The hospital had been working for over a week to get water plans and the Bureau of Infectious Disease (BID) was waiting for the hospital to send the requested information to them. The hospital needed to identify what rooms the patients were in to see if they were on the same water loop. If so, it is likely they were infected at the hospital. To determine where a person contracted Legionella from can be hard to prove but the evidence would be strong if they test the water. The epidemiologist stated if they have a possible outbreak, they should be testing the water. She stated both Patient #1 and Patient #2 were in the ED during their incubation period in December 2024. These cases are possibles and two possibles within the same year constitutes an outbreak. The Ohio Department of Health Epidemiologist stated the hospital needed to test their water and submit the results. She stated BID submitted a request to the hospital for additional information, but the hospital had yet to reply. During an interview on 02/04/25 at 11:29 AM, Staff H and Staff I confirmed they received a request for additional information from BID a few days ago, but they thought they did not have to send the information because Ohio Department of Health (ODH) Bureau of Survey and Certification (BOSC) was in the building requesting some of the same documents. Staff H verified no Legionella water testing had been completed and stated she was instructed by Staff I not to test unless asked to do so. Staff H stated she was aware Patient #1 and Patient #2 were in the ED around the same times during their incubation period, but stated Patient #2 was only there for a few hours working on a stroke cart. He was not working with any water so she did not think that was a possible case of healthcare associated Legionella. Staff H verified it was possible Patient #2 used the bathroom and/or washed his hands while he was working in the ED. Staff H also verified Patient #2 could have been in the hospital to get food from the cafeteria at any time. Staff H stated Patient #1 was identified as a possible case of healthcare associated Legionella but LCHD said the case was closed out and nothing further was required. Staff I stated the hospital does not do specific testing for Legionella; they do ongoing bacteria testing. Staff I stated they notify the health department of any positive Legionella cases then they go by the health department prompts on what to do next. Staff I stated in 2023 ODH asked for a Legionella Environmental Assessment Form (LEAF) and it was completed. The LEAF is a tool used to identify the risk factors in a facility and determine interventions to help control the risk of Legionnaire’s disease. Review of an email sent by ODH Environmental Specialist (EPS) #100 from the Bureau of Environmental Health & Radiation Protection to Staff B on 02/10/25 at 11:33 AM revealed after EPS #100 reviewed the hospital’s initial Legionella investigation/ remediation plan he informed the hospital, Staff B, the Bureau of Environmental Health and Radiation Protection has determined the material previously submitted by the hospital fit the ODH criteria for a limited Legionellosis investigation. He informed Staff B Ohio’s hospital licensing rules require routine sampling for Legionella. He stated it was an ODH standard to ask for sampling at a healthcare facility whenever there was a Legionellosis disease case with exposure as an inpatient during their incubation period. EPS #100 asked the hospital to collect samples from all hot water distribution loops and other water features following the guidance in the hospital licensing rules and since this is also an investigation the following adjustments were noted: samples should be 1 liter (L) following CDC guidance for Legionella investigation sampling samples should include all fixtures in the case room. EPS #100 wrote the facility should send a map of sampling locations to himself and the LCHD for approval prior to collecting samples and encouraged the hospital to ask any questions. During an interview on 02/25/25 at 9:39 AM, Staff A and the Vice President of Engineering, Staff L, stated the hospital had been working with BID and ODH EPS #100 from the Bureau of Environmental Health & Radiation Protection. He stated they first came up with a plan on where in the water system they should test for Legionella. Then they worked with Staff H to decide what rooms to test. They worked with Chem-Aqua and BID to fine tune the identified Legionella testing sites. Staff L stated on 02/19/25 10 water samples and six swab samples were taken. The results were expected to be back within one week, so they should be in any day now. Staff L stated after the hospital receives the results the department leadership, to include infectious disease, the contracted water treatment company (Chem-Aqua), and possibly BID will discuss the next steps. Staff L stated their next moves depended on the testing results. Review of an email dated 03/18/25 at 3:39 PM from Staff B to EPS #100 revealed on 12/30/2024 the hospital was notified an employee, Patient #2, tested positive for Legionella at a Columbus hospital. Licking Memorial Hospital (LMH) Infection Prevention identified the employee was treated in the ED on 12/23/2024, 12/25/2024, and 12/28/2024 as a patient. On 12/23/24 he was noted to be symptomatic for an unspecified viral upper respiratory infection. His subsequent visits were similar with fever, headache, and mild shortness of breath. Upon request the patient transferred to a tertiary facility in Columbus for an additional workup. There he tested positive for Legionellosis. Because he was symptomatic during his first ED visit LMH Infection Prevention determined his exposure/incubation period ranged from approximately 12/9/24 through 12/23/24. He was interviewed to ascertain potential exposure sources within the hospital. As an employee he routinely works from home and is in the office two days per week. His primary work site is in an off-campus building and not located inside the hospital. However, he sometimes provides services inside the hospital. Patient #2 reported he worked in the hospital for approximately two hours during his incubation/exposure period. He worked in the ED on 12/11/24 setting up a piece of telecommunications equipment/hardware. During this two-hour period he was in ED Trauma Room 2. The only water source in this room is a handwashing sink. Patient #2 reported to the LCHD he uses an in-home Continuous Positive Airway Pressure (CPAP) machine. He reported he was not compliant with routinely disinfecting his equipment. As a result the LCHD determined Patient 2’s exposure was non-hospital acquired. Patient #1 was admitted to LMH for four days between 01/06/25 and 01/09/25. She also presented to the LMH ED on 01/10/25 and again on 01/19/25. Patient #1 tested positive for Legionella on 01/19/25 and was admitted. Staff B noted for Patient #1’s 01/06/25 - 01/09/25 admission she was in Room 433. Room 433’s water sources are a handwashing sink and a toilet. Because of the patient’s medical status the patient did not use the centralized shower room where water droplets could have been aerosolized. This patient was noted to regularly use a CPAP machine at home. The LCHD determined this patient’s case was non-hospital acquired. Although LMH agreed this patient’s exposure was likely her CPAP machine, she was designated as a possible healthcare-associated case because of her four day inpatient stay beginning on 01/06/25. LMH’s Legionella procedure requires water testing when an additional healthcare-associated transmission is found after the intensive surveillance is initiated. Therefore, water is tested only if there are more than one definite/presumption or more than two possible healthcare-associated infections within the specified time frame. Because the threshold was not exceeded, LMH did not test its water in January of 2025. However, as requested by BID, LMH tested all of the locations designated in its water testing plan that was submitted to and approved by ODH on 02/18/2025. He stated the hospital sampled and tested water in ten locations. Of those ten samples, positive results above 1.0 Colony-Forming Units per milliliter (CFU/mL) were identified in six areas. Four of the locations were identified with Legionella erythra. In the CDC’s Legionella Control Toolkit, this species and serogroup is not listed on the CDC’s type of Legionella associated with Legionnaires Disease. Two of the locations were identified with Legionella anisa (blue-white). This species and serogroup is listed by the CDC as less associated with Legionnaires disease. The sink in Room 433, where Patient #1 was admitted, tested positive for Legionella erythra. When the initial report was received from the 02/19/25 samples immediate remediation steps were taken. Over a period of two days the hospital gradually increased the potable hot water temperatures in the building and flushed the system within its capabilities. Testing was repeated on 03/06/25 for previously positive locations. Those results were received on 03/14/25 and showed improvement. The hospital’s next steps were to develop a formal partnership with ChemAqua to facilitate an updated review of the existing Water Management Plan (WMP), coordinate with ChemAqua to identify any potential gaps or opportunities to improve the existing WMP/policy, continue intensive surveillance for new Legionella-positive cases for the remaining 60-day monitoring period, and if additional cases are identified, follow existing hospital policy regarding internal investigations and any necessary additional water testing, and conduct ongoing water testing as specified in OAC 3701-22-07. During an interview on 03/27/25, ODH EPS #100 from the Bureau of Environmental Health & Radiation Protection stated the hospital has not been following their recommendations. He stated they were concerned LMH has not provided a sufficient sampling set and has not taken the necessary steps to reduce potential transmission at their facility. LMH recently submitted their sample results for two sets collected at their request in the last month. They requested a sampling plan prior to collection, which the facility submitted on 02/14/25. They informed the facility the sampling plan was not approved and needed a more even distribution of samples. The facility did not submit a revised plan and collected samples following their initial strategy on 02/19/25. Samples included the following locations: the cold water main (one sample) which was negative, the cooling tower (one sample) which was negative, the water wall (one sample) which was negative, the Plant Operations sink (one sample) which was positive, the 4th floor ice machine (one sample) which was negative, and the 4th floor sinks and showers (five samples) which were positives. EPS #100 noted every sink and shower the hospital tested had detections and the only patient rooms they sampled were on the fourth floor. According to BID some of the potential exposures for both cases may have occurred in the ED on the first floor. EPS #100 stated “Regardless, to get a clear picture of water system’s health, sampling throughout the facility is necessary.” Detections were for Legionella anisa and/or Legionella erythra. Follow-up samples were collected on 03/06/25 but only included the previous positives as sampling locations for six samples total. ODH guidance provided at the start of the investigation stated “Collect a set of samples at the same locations as the previous set.” All four floor locations were positive again and above 1 CFU/mL. The plant operations sink was negative. Despite both cases being linked to the ED on the first floor the area was never sampled. ODH guidance also states samples should be evenly distributed and include each floor and each case room fixture. It is unknown at this time if the facility implemented water-use restrictions or installed point-of-use filters throughout the facility. EPS #100 intends to request additional information to clarify the water restrictions and the use of filters. They are also requesting additional sampling be completed at the facility. LMH still maintains the transmission of Legionnaires’ Disease through their water supply is unlikely. BID and the Bureau of Environmental Health & Radiation Protection does not agree with this conclusion, as there are still areas of the hospital that have gone largely untested, and the results they have provided demonstrate the facility has water conditions conducive to Legionella growth. During an interview on 04/09/25 at 10:00 AM, Staff B stated the hospital submitted it’s original water sampling plan to ODH EPS #100 from the Bureau of Environmental Health & Radiation Protection. Staff B stated EPS #100 said the water testing plan was fine. He stated of the ten areas tested, six came back positive for Legionella growth. They increased the water temperatures, however he could not speak to the specific temperatures, and retested the water. He stated there were still positives, but the amount of Legionella was less than before. He stated there were some communication issues with the hospital and EPS #100 in regards to sampling the water. He stated EPS #100 sent an email on 04/04/25 at 4:27 PM stating “I noted that the samples on other floors requested on 02/18 were not included from my understanding after discussions with our epidemiology staff, the ED was visited by both cases so that should have been included as first-floor samples. We were also concerned that locations that were negative in the first set were excluded from the second. For further sampling, we ask that another sampling plan is included. Has LMH conducted any system-wide remediation in response to the positives?” Staff B stated he forwarded the email to the department leaders at the time of receipt. He stated they were going to be getting together to discuss and submit another Water Sampling Plan to include the ED by this end of the week. He stated Staff L is working with Chem-Aqua to look at their existing Water Management Plan to “Beef it up” but they quoted $12,000.00. The hospital feels that is too much to pay for reviewing and making recommendations on their current plan, so they are currently negotiating prices. He stated additional testing was done on 04/01/25 and the hospital was waiting on the results. During an interview on 04/09/25 at 1:26 PM Staff A and Staff L stated they have sampled the water three times and each time they only tested the locations positive in the previous test. They stated if an area was negative on any of the testing results they did not retest those areas. They stated they did not test the ED and they were not able to test the patient room where Patient #1 was housed on the fourth floor because there was a patient in that room with “Something going on” and they did not want to test with a patient in the room. They stated they tested the room directly next to the room Patient #1 stayed in because they run off the same plumbing. Staff A and Staff L stated after the first set of results they increased their hot water temperatures from 112 degrees Fahrenheit (F) to 119-120 degrees F and flushed the water on the fourth floor. They stated each time they tested the amount of Legionella lessened or it was not detected. He stated the area of Room 448 patient sink increased from the second set of results, but it still was not as high as the first set of results. Review of the hospital’s water sampling results revealed the hospital contracted with Chem-Aqua for water sampling and the samples were sent to The Legion Experts Special Pathogens Laboratory in Pittsburgh, PA. The hospital conducted three water samples on the following dates 02/20/25, 03/07/25 and 04/02/25. The 02/20/25 samples were taken from the plant operations sink, main, Room 400.5 patient shower, Room 490.5’s ice machine, Supply Room 445, patient Room 448, patient Room 449, patient Room 433, the water wall and water tower critical control point (CCP). These results were obtained on 03/04/25 and revealed the Plant Operations sink was positive for Legionella erythra with 1.5 CFU/mL concentration, the patient’s shower Room 400.5 was positive for Legionella erythra with a 10 CFU/mL concentration, Supply Room 445 was positive for Legionella anisa and erythra with a 20 CFU/mL concentration, patient Room 448 was positive for Legionella erythra with a 10 CFU/mL concentration, patient Room 449 was positive for Legionella anisa with a 20 CFU/mL concentration and Room 433 was positive for Legionella erythra with a 2.0 CFU/mL concentration. The results of the 03/07/25 testing dated 03/14/25 revealed the Plant Operations sink was not detected, the patient’s shower Room 400.5 was positive for Legionella erythra with a 1.5 CFU/mL concentration, Supply Room 445 was positive for Legionella erythra with a 1.5 CFU/mL concentration, patient Room 448 was positive for Legionella anisa with a 1.0 CFU/mL concentration, patient Room 449 was positive for Legionella anisa and erythra with a 1.5 CFU/mL concentration and Room 433 was positive for Legionella erythra with a 1.0 CFU/mL concentration. The results on 04/09/25 for the 04/02/25 samples revealed the patient’s shower Room 400.5 was not detected, Supply Room sink 445 was positive for Legionella anisa with a 1.0 CFU/mL concentration, patient Room 448 was positive for Legionella erythra with a 3.0 CFU/mL concentration, patient Room 449 was positive for Legionella erythra with a 0.5 CFU/mL concentration and Room 433 was positive for Legionella erythra with a 0.5 CFU/mL concentration. Review of the hospital policy titled “Surveillance for Healthcare-Associated Legion and Aspergillus Infections” revealed all positive laboratory test results for Legionella are reported to Infection Control. Tests included are culture, urine antigen, and serology. Physicians are encouraged to test for Legionella when ordering cultures for possible nosocomial pneumonia. Each positive case is reviewed to determine whether it was or could have been healthcare associated. When a single case of lab confirmed definite health care-associated Legionnaires’ disease is identified or two or more cases of lab confirmed, possible health care-associated Legionnaires’ disease occurs within six months of each other, infection prevention will begin intensive prospective surveillance for additional cases. Intensive surveillance will continue for at least two months. If evidence of continued healthcare associated transmission is found, an environmental investigation will be undertaken to determine the source. Water samples from potential sources of aerolized water will be tested following CDC approved methods. All Legionella isolates from patients and the environment will be saved and subtyped. As soon as the source is identified, the water distribution system involved will be decontaminated by procedures outlined in Plant Operations Policy. If the source is not identified, then the surveillance will continue for two months. A decision will be made by the Infection Prevention Committee at that time whether to proceed with decontamination of the hospital water distribution system. Review of the hospital policy titled “Outbreak Investigations,” effective 05/15/24, revealed at the time that an outbreak, or a cluster, of a specific infection is suspected, the Infection Control Committee will be responsible for evaluating the evidence and for instituting appropriate control measures to limit the exposure to patients, employees and the public. As soon as any member of the hospital detects a rise in endemic infection rates or suspects an outbreak situation, the Infection Preventionist will be notified. The Infection Preventionist will conduct an initial investigation of the evidence to determine the likelihood that an excess of cases has occurred and to determine if a potential problem exists. Through a review of lab reports, medical records, and interviews with staff and/or patients, the Infection Preventionist will verify the diagnosis of the reported cases, evaluate the severity of the problem to determine whether the health department must be notified immediately, conduct a retrospective review of lab reports, surveillance records and clinical records to identify other cases and to develop a line-listing of cases that characterizes the cases by the person, place and time. The Infection Preventionist will present the data to the Infection Control Committee and Executive Administration and a decision will be made to start a basic investigation or a full-scale study. A basic investigation consists of the initial investigation (line listing) plus a search of the literature to verify the existence of an outbreak and to identify the most likely casual factor. From there the hospital will implement control measures that have been shown to be effective in the past. Ongoing surveillance will be done to confirm that the control measures were effective. A full-scale study is warranted if the outbreak involves a disease or condition which causes considerable morbidity or mortality (Legionnaire’s), the necessary control measures are not readily apparent or if a commercial product or medical device is involved. In addition to steps taken during a basic investigation, the full-scale study will include identifying and verifying the diagnosis of new cases, developing a case definition, formulating a tentative hypothesis about the likely reservoir, source, and mode of transmission, testing the hypothesis, instituting control measures and communicating the findings. The policy notes, some diseases warrant investigation immediately because of the potential of potential outbreaks. Legionnaires’ Disease is listed and notes one definite case of nosocomial pneumonia or two suspected cases within six months as warranting immediate investigation. Review of the hospital policy titled “Reporting and Recording of Communicable Diseases,” effective 12/16/24, revealed a working relationship between the hospital and local public health departments is necessary for rapid identification of an epidemic problem in the community. Class B diseases (Legionella) will be reported by the end of the next business day after the existence of a case, suspected case or a positive laboratory result is known followed by the reporting in the Ohio Disease Reporting System (ODRS). The Infection Prevention Department is responsible for entering the positive lab findings in ODRS. The monthly statistics of these diseases are included in the Infection Control Report. Review of the hospital’s policy titled “Water Systems Management-ASHRAE 188,” effective 01/22/25, revealed the purpose of American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 188 is to establish minimum Legionellosis risk management requirements for building water systems. The presence of Legionella bacteria in building water systems is not in of itself sufficient to cause to Legionnaires’ Disease. Other necessary factors include environmental conditions that promote the growth of Legionella, a means of transporting the bacteria to people in the building, and exposure of susceptible people to colonized water that is inhaled or aspirated into the lungs. Legionella can grow in parts of the building that are continually wet and certain devices can spread contaminated water droplets via aerosolization. Legionella bacteria grows best within a temperature range of 77 degrees F to 108 degrees F. A water temperature of 120 degrees F does not kill the Legion bacteria. A hot water temperature of 140 degrees F for 32 minutes kills Legionella. A hot water temperature of 140 degrees F is recommended and the disinfection range is 158-176 degrees F. The Ohio Department of Health regulates hot water for human use to a maximum temperature of 120 degrees F. The Licking Memorial Hospital Engineering department will follow the requirements within the “Compliance” section of ASHRAE 188. General requirements listed included developing a team, developing a list of buildings, completing a building survey, obtaining water system diagrams, developing principles of the Water Management Program, analysis of building water systems, determining control locations, determining control limits, implementing monitoring, establishing corrective actions when control parameters are outside of the established limits, confirm program implementation and establish documentation, and maintain records appropriate to these principles. Further review of the policy revealed the hospitals team will consist of the VP of Financial Services, the Assistant VP of Engineering Services, all engineering service managers, the Director of Safety, the Director of Infection Prevention and Environmental Services Management. The locations in the plan included Licking Memorial Hospital. Building surveys were conducted for each location. The Licking Memorial Hospital building survey revealed the building is eight stories, 419,000 square feet, and the potable water supply is from a municipal water source in the city of Newark. The building uses three open-circuit cooling towers with five chillers for building cooling and the water is treated and tested per Licking Memorial Hospital Plant Operations Policy 01830 0031. The building has two boilers which provide steam for multiple uses including sterilizers, laundry, dishwasher, building heating and humidification. All water used in the boiler system is fed from the potable municipal source and is treated and tested per Licking Memorial Hospital Plant Operations Policy 01830 0031. The sole source for the potable water system is supplied from the city of Newark, which is a municipal Environmental Protection Agency (EPA) certified water source. Three hot water tanks utilize steam heat exchangers to supply heated potable water throughout the original building. The Pavilion uses insta-heat to heat potable water so there are no storage tanks in this part of the building. All heated potable water uses a return loop to eliminate dead ends. There are multiple showers in the building for patients and staff. Aerators are removed from the faucets in areas likely to not be in use for extended amounts of time. This building does have patients stay overnight. This building does have four ornamental water features and the water treatment for these features are outlined in policy 01830 0031. This location does treat patients with chemotherapy, compromised immune systems and provide respiratory therapy services. The building survey risk summary revealed the physical size of the building required larger sized and higher complexity mechanical systems to support it. There are five safety showers in the building that are flushed weekly. There are 50 showers in the building that are for a mix of patients and employees and it is recommended they be flushed with warm water a full minute before use. All ice machines have internal ultraviolet lighting to kill bacteria. In the history of this building there has never been an incident that has led to testing for Legionella. The hospital listed its risk level as medium. Further review of the hospital’s Water Management Policy revealed risk summary program implementation is the responsibility of the Director of Engineering and other engineering management personnel as needed. The policy stated the purpose of the policy is not to test specifically for Legionella, but the results of the tests can be an indication of bacteria concentrations that would trigger the necessity of an outside vendor conducting a test for Legionella bacterium. In the event a culture test for Legionella is necessary, an outside vendor will be utilized to collect samples and submit them to a qualified testing lab. If cases of Legionella occur the hospital shall take immediate steps to clean and disinfect the system. All documentation will be retained by the Plant Operations Manager for 10 years. Review of the hospital policy titled “Water Testing Procedures,” effective 12/19/23, revealed the purpose of the program is to ensure the water used in the boilers, condensers, cooling towers and water features meets defined standards of various parameters. In the boilers, the water is treated to prevent scale, corrosion and fouling in the water. In the condensers and cooling towers the water is treated to prevent scale, corrosion, fouling and microbiological growths in the condenser water. Proper biological control minimizes the spread of diseases such as Legionella. Boiler water will be tested every eight hours at 12:00 AM, 8:00 AM and 4:00 PM. Dayshift will test daily for hardness, total dissolved solids (tds), sulfur trioxide (SO3), alkalinity, phosphonate and potential of hydrogen (pH). The results will be recorded in the boiler Water Test Log and Operators Desk Log and the engineer, or their assistant, will make any needed adjustments. The cooling tower water tests will be completed when the cooling towers are in operation. Free chlorine in the main cooling tower and the CCP cooling tower will be tested at 12:00 AM, 8:00 AM and 4:00 PM and the results will be recorded in the cooling tower water test log. The chlorine pump is automatically activated at the top of each hour for ten minutes. The engineer, or assistant, will make any required adjustments. Dayshift will perform a dip slide test every Wednesday by 11:00 AM for the cooling towers and record the results in the Bacteria Log. Cooling tower parameters were listed as tds, trasar, calcium hardness, free chlorine and total bacteria dip slide. The hospital uses an outside vendor for water treatment services for all cooling towers and each month the vendor reviews operator data, collects samples, runs independent testing and makes further adjustments or recommendations. The policy notes since the cooling tower water treatment system has routine testing and constant oversight of data, it operates at a consistent level of control to prevent the likelihood of any biological outbreaks. Dayshift is required to test the water wall on Monday, Wednesday and Friday by 5:00 PM for hardness, bromine, pH, alkalinity and tds. The results will be recorded in the Water Feature Log. Control chemical will be added as needed. When the McConnell, surgery and patio fountains are in operation dayshift will test the water on Monday, Wednesday and Friday by 5:00 PM for chlorine, pH, and alkalinity and record the results in the Water Feature Log. Control chemical will be added as needed. Review of the CDC Legionella Guidance revealed healthcare-associated cases that meet clinical and laboratory criteria for confirmed or suspected Legionnaires’ disease are further classified as presumptive or possible. Presumptive is when a lab tested confirmed Legionnaires’ disease case has stayed at one or more healthcare facilities for a duration of greater than or equal to ten days of continuous stay during the 14-day exposure period. Possible is when a lab tested confirmed Legionnaires’ disease case stayed at or visited one or more healthcare facilities during any portion of the 14 days before symptom onset. CDC noted Legionellosis is an important public health problem. It is necessary for individuals with suspected illness to be reported to public health so that outbreaks of illness may be identified, and common sources remediated to prevent ongoing exposure and illness. CDC recommends a full public health outbreak investigation for the source of Legionella in a facility upon identification of a case of presumptive healthcare-associated legionnaires’ disease at any time or cases of possible healthcare-associated legionnaires’ disease within 12 months of each other. Meeting one of these criteria raises concern regarding the potential for ongoing transmission of Legionella to others. The terms “outbreak investigation” and “full investigation” are used interchangeably. The steps of an outbreak investigation are the same for a full investigation. Once public health personnel determine a full investigation is needed a series of steps should take place. The steps are to collect case information, test clinical specimens, take steps to prevent additional exposures, assess and test water sources, and ensuring the outbreak is over by water sampling and surveillance for an appropriate timeframe. The hospital should consider implementing immediate control measures if a healthcare facility’s potable water is the likely source of Legionella exposure. Examples of immediate control measures include: water restrictions to avoid creating aerosols, avoiding exposure to hydrotherapy tubs, avoiding use of water from sink/tub faucets in patient rooms, restricting showers, limit consumption of non-sterile ice from facility ice machines for anyone at risk for aspiration or who has swallowing difficulties, provide sterile water to hematopoietic stem cell or solid-organ transplant patients for tooth brushing and drinking, and using sterile water to flush their feeding tubes. Consider providing bottled water to other susceptible patients. CDC states Legionellosis grows best in temperatures between 77°F-113°F. There’s potential for Legionella growth in the absence of other Legionella controls under either of the following conditions: cold water temperatures that rise above 77°F or warm water temperatures that fall below 120°F. Maintaining a disinfectant residual throughout a system can help prevent Legionella growth. Measure the disinfectant residual to confirm its presence, noting the difference between the disinfectant residual value at the water supply and at fixtures. Slowly moving or stagnant water increases water age, which provides opportunities for Legionella growth. Increased water age also contributes to disinfectant residual loss and water temperatures favorable for Legionella, so look for faucets or fixtures that aren’t used regularly and flush them to maintain water flow. Review of the CDC guidelines for Case Definitions concerning Legionnaire’s Disease revealed the Council of State and Territorial Epidemiologists (CSTE) developed new language to help public health investigators better categorize these types of Legion cases. Confirmed and suspect are CSTE surveillance case classifications, based on type of laboratory testing and clinical presentation. Probable is a CSTE surveillance case classification, based on epidemiology linkage and clinical presentation in absence of lab testing. Presumptive and possible are healthcare exposure classifications and can apply to confirmed, suspect and probable cases. Exposure categories were presumptive healthcare associated cases and possible healthcare associated cases. Presumptive healthcare associated cases are if a patient has a continuous hospital stay of 10 days or greater during the 14 days before symptom onset. Possible healthcare associated cases are determined if a portion of the 14 days prior to symptom onset was spent in one or more healthcare facilities. CDC defines a Legionnaire’s Disease outbreak as two or more cases associated with the same possible source during a 12-month period. It applies to cases associated with travel, healthcare, potable water systems and devices that are common sources of outbreak.”