Attachment S_Scope and Severity Matrix.pdf

Scope and Severity Rating Descriptions (Scope and severity rating descriptions A-L are described below.

Ratings are listed in order from least serious to most serious ratings.)

Ratings with Potential for Minimal Harm

A Isolated/Potential for minimal harm – Least serious rating and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor impact on the resident(s).

B Pattern/Potential for minimal harm – Least serious deficiency but affects more than a limited number of residents, staff or occurrences. This deficiency has the potential for causing no more than minor negative impact on the resident(s) and was not found to be throughout the facility.

C Widespread/Potential for minimal harm – Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all of the residents but has the potential for causing no more than a minor negative impact on the resident(s).

Ratings with Minimal Harm or Potential for Actual Harm

D Isolated/Minimal harm or potential for actual harm – This is a less serious (but not the lowest level) deficiency and is isolated to the fewest number of residents, staff or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential to negatively affect the resident’s ability to achieve his/her highest functional status.

E Pattern/Minimal harm or potential for actual harm – This is a less serious (but not the lowest level) deficiency and affects more than a limited number of residents, staff or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident’s ability to achieve his/her highest functional status.

This deficiency was not found to be throughout the facility.

F Widespread/Minimal harm or potential for actual harm – This is a less serious (but not the lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all of the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident’s ability to achieve his/her highest functional status.

Ratings with Actual Harm

G Isolated/Actual harm – This is a more serious deficiency but is isolated to the fewest number of residents, staff or occurrences. This deficiency results in a negative outcome that has negatively affected the resident’s ability to achieve his/her highest functional status.

H Pattern/Actual harm – This is a more serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident’s ability to achieve his/her highest functional status. This deficiency was not found to be throughout the facility.

I Widespread/Actual harm – This is a more serious deficiency that was found to be widespread throughout the facility and/or has the potential to affect a large portion or all of the residents. This deficiency results in a negative outcome that has negatively affected the residents’ ability to achieve his/her highest functional status.

Ratings with Immediate Jeopardy

J Isolated Immediate Jeopardy – This is the most serious deficiency although it is isolated to the fewest number of residents, staff or occurrences.

This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

K Pattern/Immediate Jeopardy - This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout the facility.

L Widespread/Immediate Jeopardy - This is the most serious deficiency and was found to be widespread throughout the facility and/or has the potential to affect a large portion or all of the residents. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

Definitions of Scope

Isolated: When one or a very limited number of residents are affected and/or one or a very limited number of staff are involved, and/or the situation has occurred occasionally or in a very limited number of locations.

Pattern: When more than a very limited number of residents are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same practice. The effect of the deficient practice is not found to be pervasive throughout the nursing home.

Widespread: When the problem(s) causing the deficiency is pervasive in the nursing home and/or represents a systemic failure that affected or has the potential to affect a large portion or all of the facility’s residents.

Scope and Severity Grid

Immediate Jeopardy to the resident’s health and safety Level 4 J K L Actual Harm that is not immediate jeopardy Level 3 G H I No Actual Harm, with potential for more than minimal harm Level 2 D E F No Actual Harm, with potential for minimal harm Level 1 A B C

Isolated Pattern Widespread