CMS Manual System - Louisiana Department of Health and Hospitals

If immediate jeopardy has been ruled out based upon the evidence, then evaluate whether
actual harm that is not immediate jeopardy exists at Severity Level 3 or the potential for
more than minimal harm at Level 2 exists.
Severity Level 3 Considerations: Actual Harm that is not Immediate
Jeopardy
Level 3 indicates noncompliance that results in actual harm that is not immediate
jeopardy. The negative outcome can include, but may not be limited to clinical
compromise, decline, or the resident‘s inability to maintain and/or reach his/her highest
practicable level of well-being.
Examples of avoidable actual resident outcomes that demonstrate severity at Level 3 may
include, but are not limited to:
Significant unplanned weight change and impaired wound healing (not
attributable to an underlying medical condition) due to the facility‘s failure to
revise and/or implement the care plan to address the resident‘s impaired
ability to feed him/herself;
Loss of weight from declining food and fluid intake due to the facility‘s
failure to assess and address the resident‘s use of medications that affect
appetite and food intake;
Unplanned weight change and declining food and/or fluid intake due to the
facility‘s failure to assess the relative benefits and risks of restricting or
downgrading diet and food consistency or to obtain or accommodate resident
preferences in accepting related risks;
Decline in function related to poor food/fluid intake due to the facility‘s
failure to accommodate documented resident food dislikes and provide
appropriate substitutes or
A resident with known celiac disease (damage to the small intestine related to
gluten allergy) develops persistent gastrointestinal symptoms including weight
loss, chronic diarrhea, and vomiting, due to the facility's failure to provide a
gluten-free diet (i.e., one free of wheat, barley, and rye products) as prescribed
by the physician.
NOTE: If Severity Level 3 (actual harm that is not immediate jeopardy) has been ruled
out based upon the evidence, then evaluate as to whether Severity Level 2 (no
actual harm with the potential for more than minimal harm) exists.