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Nursing surveillance and immediate jeopardy in Veteran Health Administration community living centers unannounced
Mary Ellen Dellefield1, Caroline B Madrigal2, Catherine Verkaaik1
1Department of Nursing and Patient Care Services, VA San Diego Healthcare System, San Diego, CA.
Background:
The VA Community Living Center (CLC) Unannounced Survey Program aims to assess standards of care set by the government to protect residents.
Purpose:
To describe patterns of practice failures in nursing surveillance causing or having potential to cause immediate jeopardy, as defined by the Centers for Medicare and Medicaid Services.
Methods:
Using CLC survey data consisting of 200 statements of deficiency (SODs) for 2018 to 2019, we collected a SOD sample (n = 20) of immediate jeopardy events. They were described using descriptive statistics and discourse content analysis.
Findings:
We identified clinical events, their duration, work shift, and nursing skill mix for each SOD. Most to least common themes about failures in nursing surveillance were acquisition/transfer of information; decision-making; and early recognition of problems.
Discussion:
Our analysis of nursing surveillance failures in CLC immediate jeopardy SODs provides insight into opportunities for registered nurses and the nursing skill mix to reduce avoidable harms.
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