Navigating Common Immediate Jeopardy Citations in Nursing Homes and Assisted Living Facilities: A Partnership for Success
by Chris Blomquist, RN, BSN, QCP, Regional Director of Skilled Nursing - MN
As nursing home administrators and directors of nursing, we share the responsibility of providing a safe and healthy environment for our residents. Despite our best efforts, our facilities may sometimes face immediate jeopardy citations, which indicate situations where residents are at risk for serious harm or even death. Understanding the CMS definition of Immediate Jeopardy is essential to our efforts to prevent these situations.
CMS Definition of Immediate Jeopardy
Immediate Jeopardy (IJ) is a term used by the Centers for Medicare & Medicaid Services (CMS) to describe a situation in which a provider's noncompliance with CMS requirements has caused or is likely to cause serious injury, harm, impairment, or death to a resident. CMS surveyors use the Core Guidelines in the State Operations Manual Appendix Q to determine and cite Immediate Jeopardy (see link below). Recognizing and addressing IJ situations promptly is crucial in ensuring the safety and well-being of our residents.
Common IJ citations being issued in 2023
Free from Accident Hazards, Adequate Supervision, and Safe Devices (F689): This issue may arise when residents are not properly supervised or when equipment is misused, resulting in accidents and injuries. For example, a resident might be transferred incorrectly using a full-body mechanical lift, causing the lift to tip over and the resident to sustain injuries.
Advance Directives (F578): Miscommunication or lack of proper documentation for life-sustaining treatment preferences can lead to potentially life-threatening situations. In one instance, a resident's Provider Orders for Life-Sustaining Treatment (POLST) identified the resident as having an active do-not-resuscitate (DNR) order, but the physician orders indicated the resident should receive CPR.
Investigate, Prevent, Correct Alleged Abuse, Neglect, Exploitation, or Mistreatment (F610): Failing to report, investigate, and address accusations of abuse or neglect can place residents at immediate risk. In one case, a facility failed to report and investigate a resident's report of rough handling by a Certified Nursing Assistant (CNA) and later received an additional accusation of sexual abuse from the resident about the CNA.
Mitigating Risk
To reduce the likelihood of immediate jeopardy citations, we must prioritize staff training, implement robust policies and procedures, maintain accurate documentation, and conduct regular audits to ensure compliance. Recognizing sentinel events and near misses as opportunities to review and update policies and using them as triggers for additional audits and investigations, can significantly improve overall resident safety. Fostering open communication between staff members, residents, and their families is also crucial in providing high-quality care.
At Advanced Health Institute, we are dedicated to helping nursing homes and assisted living facilities provide the highest level of care for their residents. Our team of experts can assist in identifying potential risks, implementing best practices, and ensuring regulatory compliance. By partnering together we can audit our records, review policies, develop plans of correction together, and review and assist with writing and investigating vulnerable adult reports. Let's not wait for an immediate jeopardy citation to address these critical issues. Through collaboration with Advanced Health Institute, we can safeguard the well-being of our residents and maintain the highest standards of care.