In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Illinois 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 Areas of Noncompliance
There have been a lot of IJ deficiencies cited in Illinois this year and a number of these citations are associated with F600 Free from Abuse & Neglect and F689 Free from Accident Hazards/Supervision/Devices. We are going to take a look at a few of them from a “heads-up” perspective of issues to be alert for and also peek at the findings of a complaint survey for a facility that resulted in three (3) citations – F700 Bedrails (“K” scope and severity, F684 Quality of Care and F698 Dialysis (each a “J” scope and severity).
F600 Free from Abuse and Neglect
Let’s start with what is happening with abuse in Illinois.
- A facility failed to implement a plan to prevent resident physical abuse for a resident who was exhibiting increased agitation and aggression while residing on the Dementia Unit – sound familiar? The result was another resident had a trash can shoved in their face and sustained “bleeding lacerations”. Needless to say, the resident had multiple risk factors identified at the time of admission, but the preventative care was not comprehensive.
- Another facility was cited with two (2) F600 IJs in the same month – one (1) at a “K” and one (1) at a “J” scope and severity. The “K” citation involved both sexual and mental abuse from staff and other residents.
Regarding the issues cited at the facility mentioned in the second bullet, a lot of things went wrong. There were issues with a male resident with a history of a Class 4 felony sexually assaulting a female resident and this case was going to trial. The staff did not follow the plan of care for the male resident, who also physically assaulted another male resident. The female resident, who was sexually abused by the male resident a year earlier, and also recently by a male staff member actually signed herself out AMA because she did not feel safe in the facility. Law enforcement was involved, and the male resident was discharged to the hospital and did not return. However, the care plan was not fully developed or followed to prevent additional abuse by a high-risk resident or to protect other residents.
Don’t Forget
There should be evidence of care plan review/ revision and evidence that protective interventions have been developed and implemented to prevent recurrence and protect other residents. Don’t forget that even though two residents may have been involved in an event, others could also be at risk.
The second IJ cited at a “J” scope and severity centered on mental abuse. The outcomes for these residents were not good – one resident reported being “fearful” of another resident and self-isolating due to threats from the resident who was making the resident feel fearful. The citation included that another resident was threatened by the same resident and suffered from “mental anguish” due to threats to physically harm and kill him. The citation detailed the threats to both residents and noted that the resident who was verbalizing the threats had a history of verbally aggressive behavior to others, had a criminal history of attempted armed violence, as well as information that the resident used alcohol and drugs. Yes, it is quite a history, and he also disobeyed facility rules related to leaving the facility when his community pass privileges were revoked. The police had been summoned to the facility multiple times. A discharge plan was finally implemented, and a court order was obtained to discharge the resident in 10 days. Hopefully the facility’s plan included improving resident background checks to ensure the safety of all resident by implementing appropriate interventions.
F689 Accidents/ Supervision/ Devices
IJ citations related to the risk for burns are cited in many states. One (1) “L” scope and severity citation that was reviewed for Illinois was regarding a resident sustaining a burn from the radiator in her room when she fell against the wall mounted radiator in her room – the resident sustained a burn to her foot. The other circumstances documented in this deficiency are regarding the facility failing to monitor the temperature of hot beverages being served and another resident sustained multiple full thickness burns after spilling hot tea in her lap . . . doesn’t this one sound familiar?
Needless to say, the facility did a lot of work to address the heater-related burn including weekly temperature checks of the radiator’s thermal surface and keeping beds and chairs away from the radiators. A comprehensive plan was developed and implemented to secure kitchen equipment and prevent residents being served beverages not at an optimal temperature.
Going in a totally other direction, there was an IJ citation with a scope/severity of “J” for three (3) residents with known histories of substance abuse being able to obtain illicit drugs. All three residents were reviewed for opioid use as part of this complaint survey. All events occurred in the facility as none of them had out on pass privileges.
- One resident received Narcan at the facility and was sent to the ER for evaluation and treatment.
- Another resident was sent to the ER for evaluation and treatment and experienced another suspected opioid overdose a few weeks later requiring Narcan.
- The 3rd resident was sent to the ER for evaluation of seizure activity and required intubation a used syringe was found at his bedside.
Four (4) days after the IJ was cited, an abatement plan was submitted and it was not until the 5th submission of a plan was it accepted – a week after the IJ was identified. A facility needs comprehensive policies and procedures for substance use disorders and a well-educated staff to address the needs of those residents who have a history of drug use. Obviously, appropriate preventative care plans should also have been in place.
Today’s post is a good reminder for all healthcare providers: Don’t admit residents who have concerns that you’re not equipped to handle. You’re setting staff – and the facility – up for failure. Train and educate your staff.
F700 Bedrails
Lastly, we are going to review the results of a complaint investigation that resulted in three (3) deficiencies for another facility. The first deficiency at F700 Bedrails relates to a resident’s death by positional asphyxiation – their head and neck were between the bed rail and the mattress, and the rest of his body was on the floor. The deficiency indicates that no alternatives to rails were attempted and point to information in the medical record that indicate bed rails may not have been needed. The facility indicated that the resident was possibly down for 45 minutes or more.
Remember these principles for side rail use:
- Attempt alternatives before using a bed rail
- Assess and monitor the resident’s risk of injury/entrapment prior to installation as well as their ability to benefit from the use of a bed rail – can the resident actually use the rail for the reason/s you are documenting
- Ensure the bed rail has appropriate dimensions and installation follows manufacturer’s recommendation – what kind of PMP is your Maintenance staff doing
- Is consent obtained following education on risk/benefits
- Is there a care plan in place for use of the bed rails, periodic attempts at reduction, etc.
F689 Dialysis
A totally different area was reviewed during this same complaint survey, and this area was F698 Dialysis. In this instance, a resident being treated with peritoneal dialysis experienced severe shortness of breath and was transferred to the hospital. They required mechanical ventilation for respiratory failure to prevent “imminent deterioration” and further organ dysfunction from hypoxia and hypercarbia. Findings included:
- All staff not familiar with the manual filling of the dialysis machine and overfilling
- Current orders not being available
- A licensed nurse not checking orders because the resident was not her patient and the nurse was only instructing the LVN how to hook-up the manual dialysate tubing.
We can all understand the serious nature and scope and severity of this deficiency.
F684 Quality of Care
Rounding out this trifecta is a F684 Quality of Care “J” level citation. The facility failed to seek emergency care for a diabetic resident who was experiencing elevated blood sugar level. The levels were too high for accurate readings on the facility’s glucose monitoring device. The resident was being given multiple doses of insulin, there was no timely notification of the physician and when a physician called back, the staff nurse was not sure of the physician’s name and did not write down the order. Staff initiated CPR on the resident who was a DNR – no one checked the orders prior to the initiation of resuscitation. Agency nurses acknowledged no training on the facility’s policies and procedures. The entire deficiency easily highlights that licensed staff caring for the resident were not familiar with managing a resident with diabetes and multiple comorbidities, yet alone not being familiar with the facility residents or its policies.
Turn Survey Outcomes Into a Compliance Comeback
Whether you’ve received a citation or just want to improve, our team helps nursing homes rebuild stronger systems and prevent repeat deficiencies.
Let’s talk. Call (631) 692-4422 or visit cmscompliancegroup.com.
