CMS Immediate Jeopardy: Part V

What is the Decision Process for Immediate Jeopardy?

Last month we reviewed a case example about a resident who was cognitively impaired in a psychiatric entity and demonstrated ongoing exit behaviors.  The resident was able to elope multiple times. The surveyor recognized this as a trigger for failure to prevent neglect due to lack of supervision for a cognitively impaired individual with known elopement risk.  The surveyor began the investigation and learned that this had occurred multiple times, no facility investigation had been performed and actions had not been instituted to protect the individual from harm associated with this behavior.

The surveyor has gather information from multiple sources, including observations, record review, interview with staff, review of facility investigations, observations of physical plant and so on.  The surveyor now refers to their decision grid to arrive at an appropriate conclusion.  The surveyor must respond to the following questions to confirm or rule out Immediate Jeopardy (IJ).

  • Has actual harm occurred?
  • Does the actual harm that occurred meet the definition of Immediate Jeopardy?
  • Is there a likelihood of potential serious harm?
  • Does the potential harm meet the definition of Immediate Jeopardy?
  • Is the harm likely to recur in the very near future, if immediate action is not taken?
  • Did the facility have knowledge of the situation? If so when did they first become aware?
  • Did they thoroughly investigate the circumstances?
  • Did they implement corrective actions?
  • Does this meet the definition of Immediate Jeopardy?
  • Which is the most appropriate tag to define the failed practice?

As the surveyor reviews their decision process, it becomes clear that the entity knew of the resident’s behaviors, did not take appropriate action to protect the resident, did not investigate or implement corrective measures.  In addition, there was a likelihood that this would recur in the near future and that potential serious harm could occur.

The surveyor proceeds with a decision of Immediate Jeopardy and identifies the most appropriate regulation(s) that applies to the situation.  The state agency is notified and proceeds with termination procedures per the state operations manual.

Learn how to address Immediate Jeopardy situations in Part VI: How to Address an Immediate Jeopardy Decision?

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