Tennessee: “Survey Says!”
The Department of Health continues to write a high number of Immediate Jeopardy (IJ) tags in nursing homes. It is critical that facilities become familiar with what constitutes noncompliance. If an IJ is written the impact for facilities is far reaching and can include steep fines, a hold on admissions and of course a negative impact on the 5-star rating.
Facilities will need to understand what type of situations put them at risk for an IJ. Noncompliance with federal health, safety, and/or quality regulation with evidence that a serious adverse outcome has occurred are key determining factors. An IJ can be cited if a serious adverse outcome is likely to occur. The fact that it did not occur does not minimize the outcome of an IJ.
Facilities are expected to take immediate action to correct. If State Surveyors find that immediate action was taken the citation may then be written under past non-compliance at a lower level. This is key information to know and understand. Bad things happen, it is how we manage through these situations that counts. If the facility can demonstrate an immediate response that covers what State Surveyors would be looking for if cited, it reduces the risk greatly for the facility.
Key areas for IJ are as follows:
#1 Free from Abuse and Neglect
The facility failed to provide a safe environment and ensure supervision to prevent neglect for one resident who eloped. The resident was left unsupervised at a medical appointment. The resident left the appointment and was missing for over 8 hrs. Elopement was cited several times with several facilities at an IJ level.
Residents were observed to be unclean and unkempt, had strong urine odors and soiled linens.
Strong urine odors for 6 residents, dirty meal trays from a meal the prior day, soiled linen on the floor, bare mattresses, strong lingering odors.
Failed to prevent sexual abuse of 2 residents when a male staff member inappropriately touched the residents.
#2 Care Plan Timing and Revision
Failed to revise a care plan for an unplanned weight loss and lost 41.3 lbs in 5 months.
#3 ADL Care Provided for Dependent Residents
Failed to provide proper grooming and hygiene services, assist with meals and provide showers and baths. Failed to provide incontinence care resulting in actual harm.
#4. CPR
The facility failed to ensure that there was at least one CPR certified staff member on each shift to perform CPR.
#5. Free of Accident Hazards/Supervision/Devices
Several facilities cited in this area with citations around elopement.
#6. Nutrition/Hydration Status Maintenance
Failure to prevent weight loss. Failed to implement interventions to prevent further weight loss.
#7. RN 8 hrs/7 days/wk, Full-time D.O.N.
Failed to employ an RN acting as a D.O.N. for 18 of 52 wks over 5.5 months. Failed to provide RN coverage for 4 out of 30 days.
Above are some examples that will help facilities understand what items can lead to an IJ. Note that if after 6 months a facility is not in substantial compliance CMS requires that the facility be terminated from the Medicare /Medicaid program.
All of this points to the importance of managing risk in our day-to-day operations of our facilities. It is the right thing to do for those in our care.
If you or your facility need support in understanding how to avoid the pitfalls of an IJ please feel free to reach out to Advanced Health Institute or email me directly at lfossen@ahinstitute.com
Lynn Fossen R.N.
VP of Consulting
A.H.I.