In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Colorado. 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
Several of the IJs at F689 are related to elopements, but there’s an added layer to the citations we’ll review – behavioral health concerns which go beyond a resident merely wandering out of the building to get some fresh air.
IJ Citation Example – F689 S/S: J
This citation was a good read because it’s about an elopement from a “totally secure building” where the entire campus had a six-foot high security fence around it with a wired overhang to discourage residents from climbing over the fence. This obviously isn’t your grandma’s nursing home. The facility specializes in behavioral health, and the entire resident population was at risk for elopement, so you think they’d have this down pat, but sometimes there’s a really determined resident involved in a scenario.
The resident, who had a known history of untreated schizophrenia, routinely displayed exit-seeking behaviors, including trying to find holes in the fence. The resident eloped from the facility in the evening and was not noticed to be absent from the facility until 16 hours later. He had spent the night at a local hospital. Review of the facility’s security cameras showed the resident unscrewing lights in the yard, poking at the fence, and going in and out of the building. He was later seen exiting the door with a packed bag and walked along the fence line until he was out of view. The facility staff checked the fence and discovered two holes in the fence. The overhang guard wire on the fence had been unscrewed and removed. It was later determined that the resident used the facility’s silverware to complete this work on the fence. He used the holes in the fence to climb up and over the fence where he had removed the overhang. He then stopped at the hospital because he was thirsty, where the staff convinced him to stay overnight. The police arrived to question the resident, who left on his own from the hospital. The facility staff found the resident and brought him back to the facility.
Now, you know that the work and planning for this didn’t occur overnight. Documentation in the SOD included observations of the resident commonly being observed walking along the fence and trying to “manipulate” it so he could get out. The resident would also acquire “objects” to help him achieve his goal of getting out of the facility through the fence.
Compliance Insights – Elopement
When surveyors issue an Immediate Jeopardy (IJ) citation, it signals that resident health and safety were placed in serious danger. In this case, the findings highlight multiple breakdowns in basic systems of care and monitoring:
- Staff admitted they had not conducted resident checks prior to the elopement, and no one could account for when the resident was last seen the prior night.
- Documentation indicated that the nurse administered 6AM supplements to a resident who was not even in the building.
- Staff failed to follow the resident’s care plan, which specifically required monitoring for exit-seeking behaviors, including observing the resident’s attempts to breach the fence.
These failures demonstrate a systemic lack of oversight and adherence to care planning, which surveyors interpret as a direct threat to resident safety. Key areas to reinforce:
- Resident supervision protocols – ensure staff are consistently conducting and documenting their checks, if needed.
- Review documentation basics – including the need to perform a task before documenting it as complete . . .. and the consequences of falsification of documentation.
- Care plan interventions – Staff need to be trained and aware of individual resident care plans, especially for residents with exit-seeking behaviors. Monitor staff compliance through audits and monitoring/oversight. In this case, there was a plan in place, but staff didn’t follow it. That’s a hard way to learn a lesson.
IJ Citation Example – F689 S/S: J
This second IJ citation provides a good reminder about staff responsibility for monitoring residents at risk for elopement. In this example, the resident was able to leave the facility unsupervised after the receptionist opened the front door for someone else and didn’t see that the resident also walked out the door. The resident was found at a homeless shelter 5 miles from the facility by his guardian. The resident returned to the facility and the facility initiated 15-minute checks.
. . . Four hours later, the resident got back out the door (!!!) after a nurse buzzed the door open and didn’t check the camera to determine who was trying to leave. The resident was gone from the facility for more than a day until a facility employee observed the resident on the side of the road. The resident was ultimately transferred to another facility with a locked unit.
Received an IJ Citation? We’re Your First Call
CMS Compliance Group helps nursing homes respond to Immediate Jeopardy citations quickly and effectively—with root cause analysis, documentation support, and recovery planning.
Contact us today at (631) 692-4422 or cmscompliancegroup.com.
