CMS Surveyors are trained to identify certain triggers for potential or actual harm to individuals. These triggers are grouped as circumstances where an entity has failed to protect from physical or psychological harm, abuse or neglect. When circumstances present that raise a surveyor’s concern, an investigation must be performed to confirm or rule out Immediate Jeopardy (IJ). Remember, harm does not have to occur when identifying IJ. Either potential or actual harm to one or more individuals can invoke IJ.
When a surveyor is investigating “Failure to protect from abuse”, the surveyor may be reviewing a patient record and see references to a serious injury such as head trauma or fractures. Perhaps unexplained injuries are noted, such as bruises around the breast, black eyes, rope marks or cigarette burns. The surveyor may observe staff yelling or swearing at an individual or see staff striking or handling a person roughly.
Be aware of the following triggers that may result in Immediate Jeopardy:
- Failure to protect from abuse, such as unexplained injuries
- Failure to prevent neglect, such as lack of assessment or supervision
- Failure to protect from psychological harm, consider restraints, threatening or demeaning behaviors
- Failure to protect from undue adverse medication consequences and/or failure to provide medication as prescribed, such as administering a medication to a patient with known history of allergic reaction to it
- Failure to provide adequate hydration to support and maintain health, such as malnutrition, lack of potable water
- Failure to protect from widespread nosocomial infections, for example failure to practice standard precautions, maintain sterile technique during procedures, or identify and treat infections, such as improper handling of blood and body fluids
- Failure to correctly identify individuals, such as wrong surgery performed on wrong individual
- Failure to safely administer blood products and safely monitor organ transplantation, such as wrong blood transfused or lack of monitoring for blood transfusions
- Failure to provide safety from fire, smoke and environmental hazards and/or educate staff in handling emergency situations, such as lack or emergency equipment or obstructed corridors preventing egress
- Failure to provide initial medical screening, stabilization of emergency medical conditions and safe transfer for individuals and women in active labor seeking emergency treatment (EMTALA), such as individuals turned away from ER without proper medical screening
For more details here is a list of CMS Immediate Jeopardy Triggers.
For a complete list of Immediate Jeopardy Triggers, refer to: CMS State Operations Manual, Appendix Q – Guidelines for Determining Immediate Jeopardy, Rev.102, Issued: 02-14-14.
Learn more next month in Part IV – CMS Immediate Jeopardy Series: How are CMS Immediate Jeopardy Investigations Conducted?