cms_GA: 2968

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
2968 PRUITTHEALTH - FITZGERALD 115617 185 BOWEN'S MILL HIGHWAY FITZGERALD GA 31750 2019-07-03 600 J 1 0 KWBX11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record review, review of written statements, review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property and review of the police report, it was determined that the facility failed to ensure that one of 14 residents (R#7) was free from sexual abuse, and the facility failed to provide protection for one of 14 residents (R#7) causing continued fear after an allegation of sexual abuse was made on 6/8/19. The facility census was 69 residents. On (MONTH) 25, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services (DHS), Acting Assistant Director of Health Services (AADHS), the newly hired Assistant Director of Health Services (ADHS), and the Regional Vice President (VP) were informed of the Immediate Jeopardy on (MONTH) 25, 2019 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 8, 2019. The Immediate Jeopardy continued through (MONTH) 27, 2019 and was removed on (MONTH) 28, 2019. The facility implemented a Removal Plan related to the Immediate Jeopardy on 6/27/19. The Immediate Jeopardy is outlined as follows: On (MONTH) 8, 2019 Resident (R) #6, a cognitively intact male, was observed by two Certified Nursing Assistants (CNA) in R#7's (a cognitively impaired female) room with his hand under R#7's covers, and was kissing the resident on her face. Per staff interviews, review of written statements and review of the police report, R#7 was fearful, crying and complained of pain to her perineal area. The two CNA's immediately reported the incident to two Licensed Practical Nurses (LPN). However, the LPN's failed to immediately report the incident to Administration which lead to a failure to protect R#7 resulting in R#6 re-entering her room again on (MONTH) 9, 2019 which caused R#7 continued fear. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). A Removal Plan was received on (MONTH) 26, 2019 related to 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600) and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607). Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans was implemented therefore, the immediacy of the deficient practice was removed on (MONTH) 28, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of ensuring that staff and residents are educated on the facility's abuse policy and know what abuse is, when to report abuse, and how to report abuse. This oversight process included the analysis of the facility staffs' conformance with the facility's abuse policies and procedures governing the timely and accurate reporting of abuse and implementing interventions in their abuse policy. In-service materials and records were reviewed. Observations and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility policies and procedures regarding what is abuse and when and how to report abuse. Findings include: A review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the definition of sexual abuse is non-consensual sexual contact of any type with a patient. A review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property documented the following procedure: Any allegation, suspicious, or identified occurrence involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. Record review revealed that R#6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment, dated 5/15/19, indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident was also assessed as requiring minimal assistance from staff. The resident was independent for locomotion on and off the unit and utilized a wheelchair and walker for mobility. Record review revealed that R#7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed that R#7 was assessed by the facility on the 5/4/19 MDS as having a BIMS score of six indicating that the resident was severely cognitively impaired with decision making skills and demonstrated inattention. The resident required extensive assistance of one person for bed mobility and was non-ambulatory. She was totally dependent on staff for dressing, hygiene and bathing. She was assessed as having functional limitation in range of motion of the upper extremity on one side and impairment on both sides of the lower extremities. Review of the care plans for R#7 revealed that the resident had a care plan dated 2/27/19 with a review date of 5/16/19 with the problem/need: Resident has difficulty expressing ideas or wants related to effects of disease process: mild intellectual disability and cognitive communication deficit. The approaches were to: Allow resident plenty of time to respond, speak to resident in a low, clear voice to increase chance of hearing, provide a quiet environment for resident when discussing important issues and resident can best understand simple, direct communication. There was also a care plan problem/need with a revision date of 2/27/19 for decreased ability to speak and understand due to poor cognitive ability with an approach for restorative nursing for training and skill practice for communication. During an interview with LPN BB (7 a.m.- 7 p.m. shift) on 6/18/19 at 4:08 p.m., revealed that on Saturday, 6/8/19, after 7:00 p.m., a CNA came and reported to LPN AA that R#6 was kissing R#7 on her face and that he had his hand under the covers. LPN BB stated she and the other nurse, LPN AA, went down to R#7's room and asked R#6 to leave. LPN BB stated that R#6 got mad and called them racists. Further interview with LPN BB revealed that on 6/9/19 around shift change she was walking by R#7's room and her eyes met R#7's eyes. LPN BB stated that R#7 looked fearful. LPN BB stated that she saw that R#6 was in the room talking to R#7's roommate and then R#6 went over to R#7's bed. LPN BB stated that R#7 continued to have a fearful look on her face. LPN BB stated she went into the room and asked R#7 if she wanted R#6 in her room, and R#7 responded, no. LPN BB stated she then asked R#6 to leave, and that R#6 got mad and left. Continued interview with LPN BB revealed that on 6/9/19 she told the Acting Assistant Director of Health Services (AADHS) that R#6 had been in R#7's room twice and that R#7 was fearful. After that, CNA DD told the AADHS what occurred on 6/8/19, when they saw R#6 in R#7's room kissing her on the face with his hand under the covers. LPN BB stated that the AADHS said Oh my God, that has to be reported. During an interview with Certified Nursing Assistant (CNA) CC on 6/18/19 at 5:05 p.m., she stated on Saturday evening, 6/8/19, she and CNA DD were passing out snacks and saw R#6 in R#7's room with his hand under the covers, whispering to the resident and kissing her on the face. She stated she went and reported it to LPN AA and went down to the room with another CN[NAME] LPN AA asked R#6 to leave the room. CNA CC stated R#6 got mad and called them racists. CNA CC stated that on 6/9/19, she talked to the police when they came to the facility. During an interview with CNA DD on 6/18/19 at 5:15 p.m., revealed that on 6/8/19, around 7:30 p.m., she and CNA CC were passing out snacks when they passed by R#7's room they saw R#6 in the room with his hand under the covers and he was kissing R#7 on the face. CNA DD stated after they went and reported this incident to LPN AA, they (CNA CC, CNA DD, LPN AA, and LPN BB) went back down to R#7's room. CNA DD stated that after R#6 was asked to leave, R#7 said she was scared, pointed to her privates and started crying. CNA DD stated that the next day, on 6/9/19, she had just clocked in when LPN BB stated she had just run R#6 out of R#7's room again. Further interview with CNA DD revealed that she was not told to keep an eye out for R#6 until after 6/9/19, when the Acting Assistant Director of Health Services (AADHS) told them to. During a telephone interview with LPN AA (7 p.m.-a.m. shift) on 6/19/19 at 11:35 a.m., revealed that LPN AA stated that she was taking report with the day shift nurse on 6/8/19, around 8:00 p.m., when the CNA's (CNA CC and CNA DD) came to her and said R#6 had his hands under R#7's covers. When LPN AA and LPN BB went to R#7's room she (LPN AA) asked R#6 to leave the room. LPN AA stated that R#7 told her that he touched her, but she did not specify where. LPN AA stated she examined R#7 and noticed her brief was on tight and there was no redness or swelling. LPN AA also stated that R#6 was in R#7's room morning, noon, and night but that she had never witnessed any behaviors prior to the 6/8/19 incident. LPN AA stated she did not report this to anyone because she thought the residents were boyfriend and girlfriend. Further interview with LPN AA revealed that the next night, on 6/9/19, when she came on duty LPN BB told her that R#6 had been in R#7's room again and that she (LPN BB) made him leave. Continued interview with LPN AA revealed that on 6/9/19, as they (LPN AA and LPN BB) were talking, the AADHS walked up and heard their conversation. LPN AA stated the AADHS called the Administrator who came out to the facility that night around 7:30 p.m. LPN AA stated the police also came out to the facility that night. Review of the written statement from the AADHS provided to the police department on 6/9/19 documented the following: R#7 informed this writer that a male resident, R#6, touched in private area while in her room last night. R#7 states I asked him to stop and he was kissing me on my face, saying don't be scared, I am not going to hurt you. R#7 states that she started to cry, and he told her he would give her some chips, actually she said he used the term pay her with some chips. Not to cry or be scared. R#6 complains of hurting in her privates. She (R#7) states, I am scared of him, he said he would be back in the weekend again. R#7 reported incident to two staff members on the night of Saturday, (MONTH) 8, 2019. Staff members walked into the room during said incident. A police report dated 6/9/19 documented the following: On 6/9/19 at 1951 hours (military time for 7:51 p.m.) 911 dispatched officers to (facility) in reference to a possible sexual assault. The AADHS walked with me (officer) to R#7's room where I asked her some questions about what had happened. I spoke softly and slowly to R#7 as I asked her questions. I asked if she could tell me what happened. She could not carry on a conversation, so I had to ask direct questions to get a response. She made the following statements. I love him, Told him to leave me alone, He was going to pay me back for the chips, He said he loved me, Told him to stop and he didn't stop, He was going to see me this weekend, I told him to stop touching me this morning, He didn't stop touching me, He was touching me with his hands and He was touching in the private. I then spoke with CNA's DD and CC. Both stated they were giving out snacks when they saw resident #6 standing by R#7's bed kissing her face while his hands were under the cover rubbing her. They stated they got nurse AA to come to the room and she told him to leave so they could check on the resident and he got upset. I then spoke with nurse BB and she stated she was walking by R#7's room around 6:00 p.m. this day 6/9/19 and saw R#6 in R#7's room. She stated she stood in the hallway and watched R#6 as he spoke with R#7's roommate about the Lord and gave her a honeybun. She stated R#6 started to talk to R#7 and she had a scared look on her face. She stated she asked her if she wanted the man in the room and she shook her head no. She stated she then asked R#6 to leave the room. Record review revealed that on 6/9/19, there was a physician's order to send R#7 to the emergency room for evaluation and treatment. Review of the Emergency Documentation dated 6/9/19, documented in the physical exam, a visual inspection of the patient's skin reveals no evidence of redness, skin tearing, bruising or abrasions on her head, neck, chest, abdomen, thighs, legs or perineal region. There was no blood or any type of discharge in the patient's diaper. There is no evidence that we see of any type of injury or forced trauma on this patient. I do not see any physical findings at this time that lead me to believe that the patient has been harmed in any way. Interview on 6/19/19 at 11:05 a.m., with the Acting Assistant Director of Health Services (AADHS) confirmed that she first became aware of the physical contact between R#6 and R#7, that had occurred on 6/8/19, and 6/9/19, after R#6 had re-entered R#7's room on 6/9/19. The AADHS stated that she was working the day shift, on Sunday (6/9/19), on the North hall and overhead a conversation at the nursing station between LPN AA and LPN BB and CNA CC and that she asked them what was going on. When they told her, about the incident that occurred on 6/8/19 and 6/9/19, the AADHS made them aware that the incident should have been reported right away. The AADHS stated that she would not have considered that R#6 and R#7 were having a relationship because R#7 could not consent to a sexual relationship. The AADHS stated that LPN AA should have known that the sexual contact initiated by R#6 was not consensual contact. Although the two LPN's (AA and BB) removed R#6 from R#7's room on 6/8/19, they failed to immediately notify the Administrator. The staff's failure to report this incident resulted in a failure to provide protection for R#7 which resulted in R#6 re-entering R#7's room again on 6/9/19 causing R#7 continued fear. The facility implemented the following interventions to remove the Immediate Jeopardy: 1. Resident #6 was put on one-on-one supervision until he was transferred to another facility on 6/11/19. Resident #6 will not be returning to the facility. On 6/9/19 both LPN's were suspended. LPN #1 (AA) was subsequently terminated for not timely reporting incident. LPN #2 (BB) received education on abuse and timely reporting by the DHS before returning to work on 6/17/19. Resident #7 had a Quarterly Minimum Data Set (MDS) Assessment on 5/4/19 with a Brief Interview for Mental Status (BIMS) score of 6. Resident #7 was assessed by the DHS on 6/9/19 regarding her emotional and physical well-being and sent to the ER for emergency evaluation as well. Resident #7 has been assessed daily for her emotional/behavioral health by the DHS since 6/9/19 and has been added to the Behavior Management Program on 6/10/19. Resident #7 is also scheduled for a behavioral health services check with outside Psychiatrist on 7/10/19. 2. All residents have the potential to be affected. The ADHS, DHS, and Social Worker has completed abuse interviews with cognitive residents that have a BIMS score between 10-15 to rule out any other abuse allegations. Questions included has staff, a resident, or anyone else here abused you and have you seen any resident here being abused? Residents with a BIMS score lower than a 10 will receive a body audit and assessed for any behavioral changes. All interviews and body audits were completed between 6:00 p.m. and 11:00 p.m. on 6/25/19. An interview was conducted with forty-three residents and the remaining twenty-two residents received a body audit for a total of 65 residents in house. No adverse findings were found. 3. All staff were in-serviced by the DHS and Clinical Competency Coordinator (CCC) on abuse, types of abuse, timely abuse reporting, who to report abuse to and when to report abuse; including state agency contact information, resident protection (one-on-one supervision). Scenarios were also provided to staff on abuse identification of abuse indicators with non-cognitive resident to observe for fearfulness, anger, stress, defensiveness, anxiety, worrying, or fear of being alone with staff. In-service education was initiated on 6/25/19 at 7:30 p.m. until 11:00 p.m. and completed 6/26/19 between 9:00 a.m. and 11:00 a.m. 5 of 5 RN's, 12 of 12 LPN's, 21 of 21 CNAs, 8 of 8 housekeeping, 7 of 7 administrative, 6 of 6 dietary, 4 of 4 therapy, and 1 of 1 maintenance 100% of staff have competed in-service on 6/26/19. 4. Newly hired staff will be in-serviced on abuse on the first day of hire during orientation and annually by the CCC. 5. The CCC and/or Social Worker will interview 5 residents a week for 6 weeks on abuse questions and for cognitively impaired residents the DHS and/or ADHS will complete the Weekly Head to Toe Assessment. The CCC will report any adverse findings to the administrator immediately. The Administrator will report adverse findings to the state agencies and the DHS or ADHS will report adverse findings to the physician. The CCC and/or Social Worker will also interview 5 staff members per week for 6 weeks, Monday through Friday on both shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m., on questions about abuse and abuse scenarios. The abuse scenarios will include cognitively impaired residents to observe for fearfulness, anger, stress, defensiveness, anxiety, worrying or fear of being alone with staff. Any adverse findings will be reported to the Administrator immediately for proper reporting to state agency. 6. The immediate jeopardy was communicated with the Senior Nurse Consultant, Area Vice President, Sr. Vice President of Clinical Services, and COO of Community Services on 6/25/19. An ad hoc meeting was held with the medical director, the administrator, DHS, ADHS, Licensed Practical Nurse, senior nurse consultant, area vice president, restorative nurse and certified nursing assistant on 6/27/19 to discuss the immediate jeopardy finding and the allegation of credible compliance. 7. The Administrator will take all findings to the QAPI committee for action as needed monthly beginning 06/26/19 x 3 months. All immediate corrective actions will be completed by 6/27/19. The State Agency Validated the following to remove the Immediate Jeopardy: 1. Record review revealed a Physician order for [REDACTED]. A Physician order dated 6/11/19 for R#6 that documented may transfer to DCH via 1013; Res (Resident) medically stable for transport. Review of a Nurses Note dated 6/11/19 at 2:00 p.m., documented Res transported to psych in-patient facility via 1013 . Record review of a One on One Monitoring form dated 6/9/19 at 8 p.m. revealed the following instructions documented: Staff member is to closely monitor res. If he leaves his room for any reason. Day 1 Sunday Res. Placed on 1:1 monitoring at 8 p.m. d/t (due to) alleged sexual assault. Immediately following incident, resident returned to his room and was monitored by CN[NAME] Night 1 Sun (Sunday): Stayed in bed all night did not leave his room. Day 2 Mon (Monday) 6-10 - Walked in hall for short time, returned to bed and didn't come out of room. Monitored him while out of bed. Night 2 Mon 6-10 Charge nurse monitored resident and was given instruction to observe if resident left room for any reason. I served as Charge Nurse (CN) and he did not leave his room. Day 3 Tuesday 6/11/19 Watched until discharged , walked only in room and returned to bed. Behavioral Symptom Screening Form for R#7 dated 6/9/19, 6/12/19, 6/19/19, 6/26/19, documented the following: Resident was the victim of an alleged sexual assault from another male resident. Resident appeared frightful and scared. Review of the list of residents that had a Brief Interview for Mental Stability (BIMS) of 10 or Greater revealed a list of 43 Residents with BIMS greater than 10. Census list dated 6/25/19 revealed that 43 residents are marked as being interviewed and that 22 residents are documented as having skin assessments. Forty-three resident interviews revealed no adverse findings were noted. Twenty-two skin assessments were completed. Review of the 22 skin assessments revealed that there were not any adverse findings noted. Record review of the Census list documents for each resident document that one on one education was provided to the resident and documented that letter was mailed to the responsible party and the date letter was mailed. 2. Record review revealed that Body Audit forms were completed for each of the 22 residents without any adverse findings noted. Further review revealed 43 Resident interviews regarding Abuse. Specific questions included: Has staff, a resident, or anyone else here abused you? Have you seen any resident here being abused? Each form documents that each of the 43 residents received education on how to report suspected abuse/neglect. There were no negative findings of abuse noted. Each form documented that education was provided regarding the facility abuse policy. Each form documented that education was provided regarding the facility abuse policy. 3. Record review of the Inservice Education Program Summary Record dated 6/27/19 revealed that the abuse policy and procedure was reviewed. In addition, symptoms of abuse in non-cognitive residents: fearfulness, anger, stress, defensiveness, anxiety, worry or fear of being alone with person. Forty-one staff members are noted to have signed this form. Record review of the Active Employee Listing revealed that the facility has 59 active employees. Fifty-nine employees signed Inservice Education Program Attendance Record Form. Review of the Inservice Education Program Summary Record Form dated 6/25/19 through 6/26/19 revealed that education was provided regarding abuse, what is abuse, types of abuse, any suspected abuse must be reported immediately to the Administrator, no matter what time of day or what time. Abuse scenario reviews. Interview with staff on 6/28/19 revealed that staff had been educated on the components of the abuse policy, and received in-services regarding what is abuse, types of abuse, signs of symptoms of abuse for cognitively impaired residents, who to report abuse to, when to report abuse, and how to report abuse. Interviews included the following staff and residents: LPN FF ( 6/28/19 at 11:00; CNA GG- 1:41 p.m.; at 11:49 a.m. Financial Counselor HH; 12:08 p.m. Speech language Pathologist II; at 12:51 p.m. with Floor Tech JJ; at 1:10 p.m. with CNA KK and CNA LL; at 1:16 p.m. with the DON; at 1:30 p.m. with HK (QQ); at 1:34 p.m. Maintenance & Housekeeper MM; at 1:37 p.m. Laundry Aide NN; at 1:40 p.m. with PTA OO; at 1:47 p.m. LPN Unit Manager PP; at 1:40 p.m. with HK RR; at 1:50 p.m. LPN SS (7A-7P) (SS); at 2:00 p.m. with Dietary TT; at 2:30 p.m. with Dietary UU; at 4:57 p.m. with Area Vice President, Senior Nurse Consultant, the DHS, and ADHS; at 3:55 pm- CNA VV (7P-7A); 6/28/19 at 4:10 p.m. with LPN WW (7P-7A); at 4:30 p.m. with LPN XX (7P-7A); 6/28/19 at 5:00 p.m. RE. Interview on 6/28/19 at 3:05 p.m. via telephone with a family member of resident C stated the SW called him on 6/27/19 to talk about abuse and the policy. She told him they would be mailing him a copy of the policy and was to sign the form and mail it back. Interview on 6/28/19 at 4:40 p.m. with R D stated the staff gave her a copy of the abuse policy and procedure yesterday and talked to her about abuse and the policy. R D stated the staff also gave her roommate a copy. Interview on 6/28/19 at 5:00 p.m. with R [NAME] stated she had a copy of the abuse policy which was sitting on her overbed table that they brought her yesterday. 4. Record review revealed the facility had two new employees. Interview with LPN FF on 6/28/19 at 11:00 a.m. revealed that her first day was Wednesday and that she had received the following training: Abuse training - types of abuse physical, verbal, mental, sexual; right not to be abused, report, report immediately within two hours. If you see, remove abuser immediately - and contact DHS and Administrator. Check on the abused monitor for fear, anxiety, can't talk - tense, flinching. Received on the first day and every day since then. I immediately report to Administrator or DHS. Phone numbers are on bulletins. Beside Abuse policy. I know how to get abuse policy. A copy of policy is posted. Always report. Person is safe. Even if resident is confused you treat as any allegation of abuse and you report immediately. Protect resident. Separate the residents and watch perpetrator. Protection is priority. Delegate staff members. 5. Record review revealed that The Clinical Care Coordinator (CCC) and Social Worker (SW) interviewed five residents for the week of 6/27/19 regarding abuse and five additional Head to Toe assessments were completed for cognitively impaired residents. No adverse findings were noted. Further review revealed five Staff Abuse Questionnaires that included the following questions: What training have you received at this facility regarding abuse and neglect? How often is training held, what would you do if a resident becomes agitated and physically aggressive while you were providing care? Per our policy who would you report alleged abused to? List two examples of abuse, what would you do if you discovered two residents fighting? What would you do if you saw a staff member hit a resident? What would you do if the staff member you saw hit a resident was back at work the next day performing care to the residents? Do you know where the numbers are to report abuse and neglect? Can you tell me per our abuse policy, how quickly does the facility have to report alleged abuse to the state? 6. Review of the Ad hoc QAPI meeting notes revealed an Ad hoc meeting was held on 6/27/19 at 3:00 p.m. and that the following were in attendance: Physician, three LPN's, one RN, Administrator, Area Vice President, Senior Nurse Consultant, one CNA and topics discussed were ongoing complaint survey/IJ tags. Interview on 6/28/19 at 1:47 p.m. with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that an Ad hoc QAPI meeting was held 6/27/19 to discuss the findings with the Immediate Jeopardy tags. 7. Interview on 6/28/19 at 1:47 p.m. with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that the findings for the Immediate Jeopardy will be taken to the QAPI committee for action as needed. 2020-09-01