CMS Part IV : Acting to Avoid Immediate Jeopardy

How are CMS Immediate Jeopardy Investigations Conducted? 

Whether your CMS surveyor is concerned with a failure to protect or prevent harm for a served individual or not, they are always on the lookout for potential abuse or neglect. Circumstances that identify triggers must be investigated to assure there is no risk of harm to individuals under the entity’s care.  All surveyors are expected to be familiar with the seven key components of an entity’s systematic approach to prevent abuse and neglect.  These components are:  screening, training, prevention, identification, investigation, protection and reporting response.

As triggers are identified, surveyors investigate who, what, when, where and why. The investigation is designed to be an impartial, objective process and includes observation, interviews, record review, and the preservation of physical evidence as appropriate to the matter.   The survey team leader or state agency is notified of the concern and investigative efforts are coordinated to gather evidence to confirm or rule out the IJ.

  • Who – who was involved in the IJ situation: staff, individuals receiving care, others in the entity?
  • What – what harm has occurred, is occurring or is likely to occur?
  • When – when did the situation first occur?
  • Where – where did the potential / actual harm occur? Is it an isolated incident or entity wide?
  • Why – why did the potential/ actual harm occur?

Surveyors must validate each of these areas as they conduct their investigation. Let’s look at an example.  A resident is admitted following a hospitalization for psychiatric care.  The individual has a history of impaired cognition and judgment, impulsiveness and exiting behavior.  The record indicates documented behavior of the individual standing near the door waiting for it to open and then sneaking out very fast.  The surveyor recognizes 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 interviews staff and learns that the individual has tried to exit 25-40 times per shift and observes the resident has been successful 5 times in the last 30 minutes. The surveyor learns that the locking mechanism on the door is broken, the resident knows how to operate the key pads and that the patient requires 1:1 and is not safe on this unit. The surveyor also reviews facility investigations and found that none were conducted for this patient. The resident exits one more time and escapes to the busy street near the entity.  The resident is found and brought back to the hospital with a bloody lip.

How do you think the surveyor’s investigation turned out for this entity?  What is the decision process for Immediate Jeopardy?  How are decisions made and what is the outcome for this entity?  Download the CMS Investigation IJ Tool to learn their process. Tune in next month for Part V – CMS Immediate Jeopardy Series:  What is the Decision Process for Immediate Jeopardy?

Please contact C&A at 707-573-4535 if we can help make your survey an easier process.

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