Legionella bacteria commonly grow in stagnant water. In the 12 months ending in March of last year there were a total of 173 positive samples at three of the facilities. Image: Joseph Thomas Photography/Shutterstock.com
An inspector general review of four VA facilities has identified failures to comply with the department’s policies for preventing and detecting possible presence of the bacteria that causes Legionnaire’s Disease, saying its presence “could put veterans and employees at risk of illness and death” at the facilities auditors visited.
The report, which could have wider implications across the VA system, said that is a special concern at the VA because seven tenths of its patients are age 50 or above. That is one of the high-risk categories for that potentially fatal form of pneumonia, which is transmitted by breathing in water droplets containing it, for example when drinking from a water fountain or taking a shower.
It closely follows one by the IG’s office at the GSA warning of risks from Legionella bacteria in buildings owned or leased by that agency government-wide.
The latest report notes that the VA has standards for prevention and control of the bacteria, which most commonly grow in stagnant water; those policies including water safety testing, validation, remediation and reporting practices. However, it found compliance issues in the four facilities reviewed, in Salem, Va.; Brooklyn, N.Y.; Pittsburgh; and Dublin, Ga.
None of the four “consistently complied with water collection sample requirements,” it said. Staff “were either not aware of the directive requirements or did not realize that they did not complete all samples required” and two were not following procedures such as ensuring that samples were taken without first flushing the tap.
It said that in the 12 months ending in March of last year there were a total of 173 positive Legionella samples at three of the facilities, but they completed only a tenth of the required follow-up tests after taking remedial steps such as regular flushing of water systems. Presence of the bacteria remained “persistent” at the Salem facility despite such steps, it added.
Further, it said that “facility leaders responsible for notifying clinical staff of Legionella detection in routine water samples did not communicate positive test results to staff to ensure clinical awareness for diagnostic testing” and that higher leaders “did not receive complete water safety test results needed to perform effective prevention oversight.”
VA management agreed with the IG’s recommendations to address its findings.
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