In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes Maryland. 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. Maryland’s State Agency has not been busy in 2025 citing IJs – there were only a handful of IJ citations in 2025 so far, and all were isolated deficiencies.
Top Areas of Noncompliance
The IJ deficiencies in 2025 in Maryland include:
- F689 – Free of Accident Hazards/Supervision/Devices
- F600 – Free from Abuse & Neglect
- F760 – Residents are Free of Significant Med Errors
Compliance Insights
While an IJ citation related to a significant medication error was reviewed in a prior The State of IJs – 2025, it is worthwhile to take a look at this IJ citation, because the error exemplifies what can happen if a nurse responsible for medication administration fails to adhere to basic medication administration practices. A Certified Med Tech, an LPN and an RN are expected to adhere to the same basic medication administration standards of practice regarding safety and effective care when administering medications based on their scope of practice.
This error involves a serious mistake an agency RN made on his first day at the nursing home where this medication error occurred. On interview the RN indicated that they were “heavily distracted” during the medication pass and did not follow the “5 rights.” The RN had stopped performing treatments to administer medication, which is probably a good indication that they may have been running late completing all of their assigned duties. The RN also indicated during the investigation that he was moving too fast and made an honest mistake. The resident involved in this citation had been admitted to the nursing home a few weeks prior to this med error occurring and there was a plan for the resident to be discharged home. The resident expired less than 12 hours after the wrong medication was administered.
The resident had a diagnosis of narcolepsy and was ordered medication for this condition which started with “M-E-T-H-” and was a 20 mg. dose. The RN responsible for the error looked at the MAR and assumed that the medication was Methadone and the nurse administered a dose in a liquid form – the correct medication to administer was a tablet. About an hour later the RN realized their mistake and reported it to the RN Supervisor who provided instructions on actions to take related to MD notification, etc. The RN required assistance to complete the notification as it was their first day working in the facility. The RN stated he had assessed the resident prior to reporting the error to the supervisor and the resident was stable. The RN contacted the third-party physician provider service to notify them of the error.
- During the video call, the nurse could not provide the CRNP with the resident’s name, date of birth or dose of Methadone administered.
- The RN could also not locate the discarded Methadone bottle, but showed the CRNP a sealed unused container, which was noted as having 100 mg. in the bottle.
- The CRNP reviewed a Methadone overdose and withdrawal sign/symptoms and questioned the RN if the facility had Narcan on hand (which it did). At this point during the call, the RN stated the resident was stable, in no distress and that they were not going to administer Narcan because the resident had no symptoms of overdose.
- The CRNP requested to see and talk to the resident bedside but was unable to as the RN told the CRNP that the resident “did not want to be bothered.”
- The CRNP gave instructions to monitor the resident and notify the medical provider if there were any changes. The resident was not sent to the hospital at that time because the CRNP did not think it was necessary based on the RN’s report.
- It was also noted in this citation that the CRNP did not have access to the clinical record as the software was not compatible.
Let’s look at what went wrong from solely a medication perspective:
Wrong patient
The Methadone was in the med cart, and it was for a resident who was never admitted to the facility – How does that happen?
Wrong medication
Instead of a medication for narcolepsy, a medication used for narcotic drug addiction was administered – The RN did not read the label and compare it to order.
Wrong dose
There was no way to validate how much Methadone was administered as the RN did not measure how much liquid was administered.
The citation does not indicate what the time of administration for the correct medication was, but it wasn’t the cause of this error.
While it did not contribute to the actual error, the CRNP did not call the facility back to check on the resident, did not speak with the attending physician and did not speak to the oncoming CRNP regarding the call from the facility regarding the error. Decisions were made based on the RN stating that the resident was stable and not symptomatic.
You have to wonder what information regarding this med error was shared with the oncoming staff at the facility and the ongoing monitoring that should have been provided following a serious medication error – especially since the dosage administered was not known.
For those of you who don’t know, the expansion of the “5 Rights of Medication Administration” was expanded in 2025 to the “10 Rights.” Following the “rights” consistently will help to minimize errors, improve patient safety and contribute to quality of care – all so very important to healthcare providers. The breach in practice identified in this citation should be an incentive to all providers to monitor your staff’s practices and conduct periodic competency assessments for medication administration as one of your facility’s standards of practice.
The Best Way to Handle an IJ? Prevent It.
Our 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.
