In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Nebraska. 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.
IJ Noncompliance
There have been only six (6) IJ situations in Nebraska so far in 2025 – five (5) had a scope and severity of “J” with one (1) additional deficiency cited at a “K” level for F584 related to temperatures in the facility. We are not going there today because we are going to take a look at a F755 Pharmacy Services/Procedures/Pharmacist/Records citation.
While you read the review of this F755 citation addressing a medication error, you should be thinking could this happen in my facility for such an extensive period of time? Then … lurking in the back of your mind should be the question — are our communication and follow-up systems solid? Are they being followed?
F755 Pharmacy Services/Procedures/Pharmacist/Records S/S: J
This case involved a resident with multiple commodities and who required an anticonvulsant to treat seizures. The resident’s orders included Dilantin oral suspension 125 mg.5 ml – give 8 ml via peg-tube two times a day as well as an order for Phenytoin oral tablet chewable 50 mg – give 3.5 tab via peg-tube every 12 hours PRN – if we run out of liquid Dilantin. During review of the medication administration record (MAR) for the month of March 2026, the following information was highlighted –
- Refer to a nurses note on two days for the 4PM dose
- The following two days had entries noting the medication for the 8AM and 4PM doses was not available
- Not the next day, but on the following day, the 4PM dose was documented as drug not available
- Skip a day again and the 8AM dose was documented as drug not available
This was coupled with the review indicating no documentation related to the administration of the ordered PRN Phenytoin being used when the liquid Dilantin was not available. The MAR review also had entries that indicating “unknown” for administration and one entry regarding the Phenytoin documented as “effective.”
- Skipping to the next month, there are entries indicating a charting omission for an 8AM dose, and a noon dose on two back-to-back dates, which doesn’t appear consistent with the order. The citation states “ MAR further revealed no documentation that Phenytoin was administered” that month – meaning the Phenytoin had not been administered on days the Dilantin liquid was not available for administration.
- There was a single entry during the first month, shortly after the initial missed doses, that a communication as well as a call was placed to the pharmacy regarding the refill of the Dilantin liquid. The citation noted that the medication was backordered and should be delivered tomorrow.
- Early in the second month, the resident was sent to the hospital due to a seizure.
The surveyor investigation identified that there was only one communication with the physician that was days after the initial missed doses and the directive was Phenytoin should be used when Dilantin was not available.
The interviews with the appropriate administration staff members took place, as did a review of the pertinent policies and procedures for Local Pharmacy Medication Ordering and Medication: Administration including Scheduling and Medication Aides, which addressed medication errors and completion of associated medication error reports. The DON also shared the facility’s Nurse Shift Change Checklist which addressed the nurse’s responsibility to verify that all medications had been administered on either the clinical dashboard or EMAR. This citation demonstrates more than one system failure.
Compliance Insights
- There is administrative responsibility to ensure that staff know facility policies and procedures related to all aspects of medications from ordering, procurement, and all the way to administration.
- Reeducate staff responsible for medication administration on protocol to follow when a medication is not available, including prompt follow-up with the provider pharmacy and notification of the physician that a medication is not available. The physician cannot make adjustments to the medication regimen if they do not know the status of availability of an ordered medication.
- Use your QA process to periodically audit to assess compliance with established procedures and initiate corrective actions before the State Agency comes knocking at your door.
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.
