In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Iowa. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes.
Top Area of Noncompliance
The most frequently cited IJ deficiency in 2025 in Iowa is F689 – Accidents.
All the IJs cited were a Scope/Severity of “J” with one (1) “K” citation. If you have been reading any of our prior IJ spotlight citations, you know that burns sustained related to the heat generated by heating units will always be a concern and a burn situation was the cause of the “K” citation.
However, today, we are going to explore an IJ situation at F692 Nutrition/Hydration Status Maintenance related to two residents experiencing severe weight loss.
Compliance Insights
All facilities monitor their Quality Measures related to weight loss, so how did a 12.6% and a 13.1% weight loss in 180 days occur not just for one but for two residents?
A review of the 2567’s content makes it clear that both residents had clinical, as well as behavior concerns, that the facility staff did not consistently address when identified. Areas of concern such as providing supervision during meals for a resident, who was known to have a better intake when supervised, having a system in place for obtaining and documenting weights as per the plan of care, and needing an improved communication system between the RD, the Dietary Manager, the Director of Nursing and the Medical staff were needed.
The list of “failures” noted the following:
- Failed to implement a care plan for actual weight loss
- Failed to complete weekly weights as ordered
- Failed to revise/increase interventions after initiation of a house supplement did not result in the resident maintaining/gaining weight
- Failed to obtain and implement a physician order for nutritional supplements
- Failed to notify the responsible physician of the weight loss
While not noted in the 2567, there also appears that an at risk for weight loss care plan was not initiated based on individual risk factors.
All of the failures are not listed here, but it is easy to identify multiple system failures that resulted in a significant negative outcome for two residents, and poor communication appears to be a major one. Poor communication certainly was a factor regarding the RD, who only visited the facility every two weeks. Such a schedule would make communication crucial in sharing information with the dietitian for their input and guidance related to the nutritional plan of care when their onsite guidance is limited.
Obviously, obtaining and documenting residents’ weights/reweights are a standard of practice in a nursing home and a comprehensive policy and procedure needs to be developed, maintained and monitored. There should never be issues such as the weight monitoring sheet not being located or entries that should be in the medical record not completed. These types of system failures have the potential to preclude the clinical team from promptly identifying a weight loss that needs follow-up in a timely manner. You know that there is a concern when the responsible RD is not sure if the weight policy is “set in stone.” If a facility does not have a sound weight policy, how does it develop an appropriate plan of action to prevent or address weight loss when weights are not being consistently obtained and documented?
To compound the clinical situation for one of the residents in this citation, they developed a bowel complication and were hospitalized for dehydration further complicating their clinical status. What happens when dehydration occurs? A review to determine if adequate fluids are being provided, what are the orders, what is documented on intake records, where is the risk for dehydration care plan, etc. Needless to say, this type of deficiency could happen anywhere if you do not have a clinical team communicating with each other, following the individual plan of care, and changing the plan when a weight loss is initially identified.
The Best Way to Handle an IJ? Prevent It.
CMSCG consultants help nursing homes strengthen their compliance infrastructure with targeted mock surveys, staff education, and system reviews.
Reach out today at (631) 692-4422 or info@cmscg.net.
