Q: We recently heard of a facility receiving an “immediate jeopardy” because their beds and stretchers had not had annual preventative maintenance. This is part of our Equipment Management plan and we are in the process of double checking to ensure we are indeed following our defined process; however, we are curious as to whether the “immediate jeopardy” citing is possible for this deficiency.
A: The concept of what qualifies for an Immediate Jeopardy (IJ) is somewhat subjective. CMS has a document called “Appendix Q – Guidelines for Determining Immediate Jeopardy” (available by Googling that document) that identifies certain issues and triggers for IJ. Essentially, CMS identifies an IJ situation as “A situation in which the 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.” The Guideline continues to provide situations and examples whereby an IJ may occur, but this list is only a guide and is not conclusive. The lack of PM on beds is not included on the list. You ask if citing a lack of PMs on beds as an IJ is possible, and the answer is yes… but only if the surveyor has reason to believe that the lack of PMs is has caused or likely will cause serious injury to the patient. Is it possible? Yes. But I don’t see this as probable. The concept of “A situation in which the 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” is very subjective. What may be an IJ to one surveyor, may not be an IJ to another. Until your question, I’ve never heard of an IJ situation for a lack of PMs on beds.