Tennessee Department of Health Bureau of Health Licensure

Tennessee Department of Health Bureau of Health Licensure and Regulations Division of Health Care Facilities Educational Training for Nursing Homes 2008 1

Appendix Q Guidelines for Determining Immediate Jeopardy 2

PREAMABLE FOR APPENDIX Q CONCERNS That the health and safety for individuals in crisis situations at risk are: • • • Accurately identified Thoroughly investigated Resolved as quickly as possible 3

PREAMABLE FOR APPENDIX Q CONCERNS Standardization definition for all provider types except CLIA the definitions for: • • • Immediate Jeopardy Abuse Neglect 4

PREAMABLE FOR APPENDIX Q l In the interest to eliminate abuse and neglect to all beneficiaries surveyors are cautioned: – When abuse or neglect has been identified that a thorough investigation must be conducted to determine if Immediate Jeopardy exists. FOR MORE INFO. . . See Appendix Q Preamble 5

DEFINITIONS l IMMEDIATE JEOPARDY: – A situation in which a provider’s noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. FOR MORE INFO. . . See: 42 CFR Part 489. 3 6

DEFINITIONS l Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. FOR MORE INFO. . . See: 42 CFR Part 488. 301 7

DEFINITIONS l Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. FOR MORE INFO. . . See: 42 CFR Part 488. 301 8

GOAL OF SURVEY PROCESS l To insure the provisions of quality care to all individuals receiving care or services from a certified Medicare/Medicaid entity. The identification and removal of Immediate Jeopardy, either psychological or physical, are essential to prevent serious harm, injury, impairment, or death for individuals 9

PRINCIPLES Only one individual needs to be at risk. Identification of Immediate Jeopardy for one individual will prevent risk to other individuals in similar situations. l Serious harm, injury, impairment does Not have to occur before considering Immediate Jeopardy. The high potential for these outcomes to occur in the very near future also constitutes Immediate Jeopardy. 10 l

PRINCIPLES Serious harm can result from both abuse and neglect. l Psychological harm is as serious as physical harm. l When it is established by investigation that a resident was harmed by a cognitively impaired individual due to the entity’s failure to provide care and services to avoid physical harm, mental anguish, or mental illness, this should be considered neglect. l 11

PRINCIPLES Any time a team cites abuse or neglect, Immediate Jeopardy will be considered. l Upon recognizing a situation which may constitute Immediate Jeopardy, the investigation will continue until Immediate Jeopardy is confirmed or ruled out. l The serious harm, injury, impairment or death may have occurred in the past, may be occurring at present, or may be likely to occur in the very near future. 12 l

PRINCIPLES l After determining that the harm or potential for harm meets the definition of immediate jeopardy the survey team will consider the following points concerning entity compliance. – The entity either created a situation or allowed a situation to continue which resulted in serious harm or a potential for serious harm, injury, impairment or death to an individual. – The entity had an opportunity to implement corrective or preventive measures. 13

IMMEDIATE JEOPARDY TRIGGERS Table found in appendix Q that lists issues with associated triggers. This guide includes situations that most likely create jeopardy to an individual’s psychological and/or physical health and safety. l Triggers assist the surveyor in considering Immediate Jeopardy. l Harm does not have to occur before considering immediate Jeopardy. Survey teams will consider both potential and actual harm when reviewing the triggers. l 14

IMMEDIATE JEOPARDY TRIGGERS l Failure to protect from abuse FOR MORE INFO. . . See Triggers Appendix Q 1. Head trauma or fractures l 2. Non-consensual sexual interactions l 3. Unexplained serious injuries not investigated l 4. Staff striking, yelling, swearing or gesturing derogatory names. l 15

IMMEDIATE JEOPARDY TRIGGERS l Failure to protect from neglect. l l FOR MORE INFO. . . See Triggers Appendix Q l 1. Lack of timely assessment past injury. 2. Lack of supervision with known needs. 3. Repeated occurrences e. g. , falls. 4. Failure to carry out physician orders. 5. Access to chemical and physical hazards by individuals at risk 16

IMMEDIATE JEOPARDY TRIGGERS l Failure to protect from neglect. l l l FOR MORE INFO. . . See Triggers Appendix Q l 6. Non-functioning call system. 7. Unsupervised smoking by an individual with a known safety risk. 8. Lack of supervision of cognitively impaired individuals with know elopement risk. 9. Use of chemical/physical restraints without adequate 17 monitoring.

IMMEDIATE JEOPARDY TRIGGERS l Failure to protect from neglect. FOR MORE INFO. . . See Triggers Appendix Q 10. Failure to adequately monitor and intervene for serious medical/surgical conditions. l 11. Improper feeding/positioning of individual with known risk for aspiration. l 12. Inadequate supervision to prevent physical altercations. l 18

IMMEDIATE JEOPARDY TRIGGERS l Failure to protect from psychological harm. l PLEASE SEE TRIGGERS IN APPENDIX Q FOR ADDITIONAL LISTS THAT ARE NOT ALL INCLUSIVE FOR MORE INFO. . . See Triggers Appendix Q 19

Locating Appendix Q http: //cms. hhs. gov/manuals/Downloads som 107 ap_q_immedjeopardy. pdf 20

Ao. C VS Po. C l Corrections 21

Plan of Correction A plan of correction (POC) is an allegation of substantial compliance with program requirements. (Regulatory reference: SOM, 7304 D – Acceptable Plan of Correction) 22

Ao. C vs Po. C Allegation of compliance (Ao. C) to remove the immediacy of jeopardy l When IJ is identified, required to submit Ao. C to remove immediacy & Po. C for all other deficiencies (SOM, 7308) l Acceptable plan of correction (Po. C) required to determine substantial compliance l 23

Cases of Immediate Jeopardy l Facility must submit an allegation of removal of the IJ (Ao. C) l CMS & State Survey Agency (SSA) will request an Ao. C & Po. C l CMS & SSA review the Ao. C to determine if acceptable l Ao. C must include: - date the IJ was removed - sufficient detail to demonstrate that the IJ has been addressed 24

Cases of Non-Immediate Jeopardy l Po. C required for deficiencies cited higher than level 1 {A, B, or C} l Po. C must be submitted within 10 calendar days of receipt of SOD l Failure to submit an acceptable Po. C will delay revisits l Accepted by SSA 25

Po. C is Considered Acceptable Only When… l l l Corrective action for residents affected are stated Identifying potential for others affected is indicated Systemic changes are implemented Monitoring to sustain compliance is detailed Implementing dates are provided Possible roadblocks are avoided 26

Corrective Action for Residents Affected l l l Corrective action Steps taken Specific interventions Completion dates Individual(s) implementing 27

Identify Potential for Others Affected l Factors to consider in other residents that have the potential to be affected by the same deficient practice – Specific population potentially affected – Review the deficient practice – Scope and severity of the tag – Specific system 28

Measures for Systemic Changes l Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur – not just the immediate issue – broaden the view to a systemic problem l Policies and/or procedures l How and where issues fit into the system 29

Measures for Systemic Changes (continued) l In-service – – – programs Date implemented Who attended Date initiated Staff not in the building New employees Agency personnel 30

Monitoring to Sustain Compliance Outline plans to monitor l Indicate individual(s) responsible for monitoring – how this will be reviewed l – frequency that new implementation is reevaluated Develop a plan with detail l Integrate into quality assurance system l 31

Implementation Dates l Include corrective action completion dates – must be acceptable to the SSA l If the Po. C is acceptable, the SSA will notify the facility l Facilities are ultimately responsible for their own compliance 32

Roadblocks l l l Denial Brevity Repetition Generalizations In-Services 33

Denial l Po. C is not the forum for disputing deficient practice – will postpone corrective actions needed for implementation AND MAY RESULT IN TERMINATION OF YOUR PROVIDER AGREEMENT FOR MEDICARE AND MEDICAID 34

Brevity l Information to indicate who, where, when, how & what of corrective action is critical l Detail is necessary l Ensure sustaining substantial compliance 35

Repetition l Make certain the corrective action has removed the deficient practice l Identify specifics for each tag cited l Copy and paste 36

Generalizations l Committee, Team, Frequent, Often, Random l Identify information Explain who, when, what and how of corrective actions l Do not cross reference l 37

In-Services Include: l l l l content who presented the information target audience dates initiated how addressed for staff not present include new hires/agency personnel evaluate/monitor for comprehension & implementation 38

Identify Systemic Problems l Human l Mechanical l Corporate 39

Human l Education l Burnout l Agency personnel 40

Mechanical l l l Environment Equipment Natural disasters Implementing manufacturer’s recommendations Monitoring Maintenance 41

Corporate l Philosophy l Support l Involvement 42

Road to Compliance l For IJ: accepted Ao. C (by CMS & SSA) revisit for removal of IJ submit Po. C (followed by acceptance) revisit to determine compliance l For non-IJ: accepted Po. C (by surveying entity) revisit to determine compliance 43

Citation Trends 44

F-224 Staff Treatment of Residents Based on observation, record review and interviews, it was determined that the facility failed to investigate Resident to Resident altercations in order to prevent and protect Residents from reoccurrence. The facility failed to identify, correct and intervene in situations which abuse of Residents is more likely to occur for 9 Residents (#5, #11, #22, #24, #25, #29, #38, #50) of 51 Residents sampled, placing all Residents in the facility in Immediate Jeopardy. FOR MORE INFO. . . See CFR 483. 13(c) 45

F-223 ABUSE Based on observation, interview and record review, it was determined the facility failed to thoroughly investigate incidents of Resident to Resident altercations, failed to report injuries of unknown origin and Resident to Resident altercations to the State Agency for 10 Residents (#5, #11, #22, #24, #25, #29, #38, #46, &#50 ) of the 51 sampled Residents. This facility failure resulted in placing all Residents in the facility in Immediate Jeopardy. FOR MORE INFO. . . See CFR 483. 13(c) 46

F-309 Highest Practicable Well being (Quality of Care) l Based on medical record review, observation, and interview, the facility failed to follow physician's orders for two (#17, #2) of twelve residents receiving Coumadin therapy. The facility's failure to ensure physician orders were followed placed resident #17 in Immediate Jeopardy. 47

F 332 483. 25(m)(1) MEDICATION ERRORS l Based on review of the "Nursing 2006 Drug Handbook 26 th Edition", review of "Common Insulins: Pharmacokinetics, Compatibility, and Properties" from the American Society of Consultant Pharmacists, medical record review, observations and interviews, it was determined the facility failed to ensure 48

l 6 of 8 (Nurse #1, 2, 3, 5, 6 and 7) nurses on 4 of 4 (Halls 100, 200, 300 and 400) resident hallways and on 3 of 3 (Days, Evenings and Nights) shifts nurses administered medications without a medication error rate less than 5 percent (%). A total of 9 errors were observed out of 43 opportunities for error, resulting in a medication error rate of 20. 93%. Failure of 5 of 8 (Nurses #1, 3, 5, 6 and 7) to calculate sliding scale insulin doses correctly, or timely administration of fast acting insulin before meals for 6 of 9 (Residents #5, 8, 14, 15, 21 and 25) residents observed receiving sliding scale insulin during the medication administration pass on 4 of 4 (Halls 100, 200, 300 and 400) resident hallways and 3 of 3 (Days, Evenings and Nights) shifts resulted in Immediate Jeopardy in insulin administration. These residents were receiving insulin administration by subcutaneous injection by insulin syringe. 49

. Based on review the Pharmacy Consultant Services Agreement, review of drug regimen reviews, medical record review, observations and interviews, it was determined the facility failed to ensure that residents were free of medication errors including significant medication errors. Re-certification orders for the "calculation based scales" (dosages) of sliding scale insulin were not accurately transcribed. The nursing staff failed to accurately calculate and administer "calculation based scales" (dosages) of sliding scale insulin in accordance with physician orders. The nursing staff also failed to consistently round up or down after the resultant dosage calculation for the insulin was obtained. Administration and Pharmacy demonstrated no knowledge of the existing inconsistencies and errors in the administration of the "calculation based scale“ dosages of sliding scale insulin and did not provide in-services for the calculation of the “calculation based scale" dosages of sliding scale insulin. 50

F 323 483. 25(h) ACCIDENTS AND SUPERVISION l Based on review of facility policy, observation and medical record review, it was determined the facility failed to provide a safe environment by not ensuring a defined process for the safe use and secure storage of razors after a resident with a history of aggressive behaviors threatened to use a razor against others on two secure units. The failure of the facility to provide a defined process for safe use and secure storage of razors for cognitively impaired residents, resulted in a Serious and Immediate Threat to the health and safety of all the residents on the secure units. 51

K-072 Fire drills l Based on observations, review of local fire department response to fire alarms, review of resident council minute reports, staff interviews and resident interviews regarding their perception of the staff during emergency evacuation it was determined the facility staff on 1 of 3 floors of the facility (the second floor) were not familiar with procedures to exit the building incase of an emergency and/or fire as evidenced by three staff members who did not know the code for the key pad to open the locked exit door to the outside stairwell on the second floor. The failure of the staff to know the code to open the locked exit door placed the residents on the second floor in a serious and immediate threat to their health and safety if an evacuation was needed through the locked door to the 52 stairwell.

K 038 Exit access is readily available at all times l At approximately 9: 15 AM, inspection of the exit doors located on the second floor revealed the doors were locked and the staff were unable to unlock the doors. Only one staff member had the keys and was not present on the floor. NFPA 101, 19. 2. 2. 2. 4 53

Top Immediate Jeopardy Citations for 4 th Quarter 2007 1. 2. 3. 4. 5. Notification of Changes……… F 157 Social Services…………………F 250 Comprehensive Assessments. F 272 Comprehensive Care Plans…. . F 280 Accidents……………. . F- 54

Top Immediate Jeopardy Citations for 4 th Quarter 2007 6. Special Needs………………. . . F-328 7. Administration………………. . . F-490 8. Notice of Rights and Services. F-156 9. Staff Treatment of Residents………F-224 10. Quality of Care……………. . F-309 55

QUESTIONS l All questions will be recorded with answers sent to all nursing homes in Tennessee. 56

Thank You Health Care Facilities Offices MTRO: (615) 650 -7100: Nashville ETRO: (865) 588 -5656: Knoxville WTRO: (731) 423 -6454: Jackson Central Office number: Nashville (615) 741 -7221 57