An Infection Control Case Study That May Make You Sick!

This is a true account of what I found at one of the facilities I took over a couple of years ago.  It demonstrates that one problem can be so much bigger than any of us realize.

“A Salmonella outbreak?  How did that happen?” I asked.  (Read below to find out.)

I had recently taken over a small facility in a rural Southern town.  The facility had problems and the staff was pretty good at running off administrators and DONs.  I quickly realized which staff members had the “victim mindset” and which ones were my allstars.  After a week or so on the job, one of my allstars asked me if I could get anything done about the roaches.


Apparently, we had a pest control problem I wasn’t aware of and had been having one for quite awhile.

“They’re all over Dietary,” my employee said.

“Yes, I can,”  I replied.

So, I waited that evening until around 8:30 pm after the Dietary staff had been gone for a little while and I went to the Dietary department.  As soon as I flipped the light on, I saw a floor absolutely covered with roaches scattering about.  I don’t think I’ve ever seen that many bugs at one time.  Aaaarrrggghhh!

This was horrible!  I fired the pest control company the next day and got someone else in.  I explained that it was a priority that we got swift resolution to the roach problem.  The entire facility was treated inside and out and within a week we had our problem under control.

I thought I would have a little break from the major issues so I could focus on the operations of my facility.  That was not to be.  A few days later, we got the report that one of our residents had been diagnosed with salmonella.  Then another resident.  Then a third.  Then a fourth.

We had an OUTBREAK!

How was this possible?  What had happened?

As most people do, I initially investigated the dietary department and its food preparation techniques and sanitization thinking that someone had left raw chicken on the counter and contaminated some other food source.

I didn’t come up with anything.  We rewashed and sanitized everything in Dietary anyway.  We checked with our food distributor to find out if they were aware of any alerts on any of the food items we’d received.  Nothing.

Next, my quick review of the CDC website revealed that Salmonella can be transmitted from handling reptiles.  So, I go through the entire staff finding out who has pet snakes, turtles, and lizards at home.  It was actually pretty hilarious thinking about it now.  I tackled it just like any other investigation.  Except, instead of asking if they had knowledge of a facility incident, I’m sitting across the desk asking staff if they have a pet lizard at home.  I’m sure I left a few folks with questions about my sanity.

That was a dead-end.

Things didn’t make sense.  For one thing, the residents were scattered over the facility.  They had different nurses and different CNAs.  Another item of confusion was that two of the residents were tube-fed and didn’t even receive a pleasure tray.  They were NPO, nothing by mouth.

I had the tubefeeding formula tested.  Nothing.

What was going on?!

What was the common denominator?  How was this outbreak being spread? We were at a standstill.  My infection control nurse couldn’t find the link.  I didn’t see any obvious connection.  Back to Salmonella research.

Interestingly, I found that roaches carry diseases such as … Salmonella.  I went back to see how it was being spread because I still didn’t see a common denominator between all the residents.  We didn’t have reports of roaches in the rooms.  As I’m standing in the room of one of the tube-fed residents scanning everything in sight, I see it.  The water pitcher!  Even though this resident didn’t drink from the water pitcher, the nursing staff kept it at bedside for tube-feeding flushes.

My AHA moment!

I go to the next affected tube-fed resident’s room.  There’s the water pitcher! Every one of my affected residents had a water pitcher.  That was the only common link.

I go to the Dietary manager and ask didn’t we rewash and sanitize every bit of our dishes, silverware, and water pitchers.  Yes, we did.  But, what we didn’t do is go to the closets where the new water pitchers were kept.  Apparently, the closet had also been affected by the roach infestation and, even though a new water pitcher should be washed before going out to the floor, some had not been.

It was this group of water pitchers that carried the salmonella from the roaches straight to my residents and had caused the outbreak at the facility.

My Sherlock Holmes-like abilities of deduction had served me well!  The residents were treated, the water pitchers were sanitized (actually, I think I just threw those away and ordered more!  Better safe than sorry!), all the areas were cleaned, and we had a new pest control company that got the job done! I didn’t run into any severe survey or compliance issues related to this.  I could just see getting F-441F-469 among other f-tags at an IJ!  Luckily, I think the State had bigger issues at other facilities at the time.

So, has anything like this ever happened to you?  Did you have to play detective to figure out what was going on?  Tell us about it in the comment box below.




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