Nursing surveillance and immediate jeopardy in Veteran Health Administration community living centers unannounced survey program 2018 to 2019.

Abstract 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.