In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Connecticut. 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
- F880 Infection Prevention & Control
These IJs focused on the facilities’ failure to ensure their water management plans were followed related to Legionella. One facility was cited for failure to report a positive Legionella water sample to the State Agency at all, and another was cited for failure to submit the positive sample timely. You can understand how those circumstances led to both facilities being cited at a scope/severity of “L” – widespread.
- F689 Free of Accident Hazards/ Supervision/ Devices
Connecticut, not unlike many other states we have reviewed so far, has several F689 citations which are related to wandering and elopement, high-risk areas where providers can easily become vulnerable due to the need to maintain complex systems. For example, one nursing home ended up in IJ after an alarm door was triggered and staff could not locate a cognitively impaired resident with a history of wandering and pulling on doors. The resident was found in a stairwell – which staff neglected to check after the code was called to locate the resident – with his wheelchair upside down next to him. The resident sustained injuries and was transferred to the hospital with several fractures and a diagnosis of acute cystitis. One staff member thought the resident was off the unit at an activity and another checked the hallway doors but did not check the stairwell where there was not only a door off the unit, but a second door which led down the stairwell to another floor. That door was not permitted to be locked or alarmed per the fire code. Ultimately, the resident opened both doors and ended up at the bottom of the stairs.
There’s a handful of other Ftags which were cited at an IJ level so far this year, including F742 Treatment/Svc for Mental/Psychosocial Concerns.
Compliance Insights
Behavioral health concerns, especially in a facility where there typically aren’t these types of events, can lead to a negative outcome – not only for the resident, but for the facility. Thankfully, in the citation we are going to dig into today, there was no negative outcome for the resident, and instead the facility was put into immediate jeopardy for its lack of appropriate actions for a resident making suicidal statements. Let’s look at what happened when a surveyor reviewed this resident for mood/behavior during a recertification survey.
F742 S/S: J (Isolated)
The facility was put into IJ when it was identified that it failed to provide appropriate treatment and services for one resident to attain the highest mental and psychosocial well-being after he expressed suicidal ideation (SI). The resident, who was severely cognitively impaired and diagnosed with anxiety disorder, was reviewed as part of the survey process. The resident had been transferred to the ER for combative behavior towards staff and threatening to kill them or physically harm them. The resident was cleared and returned the same day – not an uncommon scenario for a nursing home resident. The resident’s mood/behavior care plan wasn’t reviewed and updated until a month later and included common care plan library/generic interventions for mood and behavior.
A month later, documentation was observed that the resident had requested a rope to hang himself three times to an aide. The progress note indicated that the provider was notified, and the resident would continue to be monitored. There was no indication that the resident representative was notified. Ultimately, nothing happened to the resident, but when the surveyors got involved, things went downhill for the facility.
- The surveyor interviewed the Social Worker who had no idea that the resident had expressed SI a week earlier – until the surveyor notified her. The Social Worker also stated that the IDT did not have meetings and communicated with her via a log. The Social Worker was able to state the actions she would have taken if she had been notified – all of which were appropriate – but she didn’t since she wasn’t aware.
- The ADNS was not aware of the resident’s SI until the surveyor notified her. She was unable to identify nursing interventions which were implemented or the type of monitoring implemented for the resident to keep him safe. No documentation indicating that the resident has been assessed for being a danger to self or others could be provided.
- The surveyor observed the resident multiple times in his bed with a corded call bell clipped to the bed linen. The call bell cord was 8-10 feet in length. The ADNS was notified by the surveyor that the call bell was in the resident’s room on multiple observations.
It’s easy to guess what happens next, given that core members of the IDT weren’t aware of the resident’s statements and no action had been taken by the facility other than a secure text message to the physician with a reply to monitor the resident. During further interviews, staff were really not able to verbalize the facility’s SI protocol, including the Administrator. During the interview with the Administrator, it was identified that the resident had still not been assessed by a qualified clinician and the resident’s corded call bell remained in place.
Here’s what providers need to consider to avoid citations in this area.
Communication is Key
- It doesn’t matter if a resident is severely cognitively impaired or staff don’t think the statements are serious – you need to treat it as such. Alert the appropriate individuals, have a team meeting and do what you need to in order to assess the resident and his/her danger to harm self or others.
It’s a bad look for the facility’s Administrator to not know a resident had expressed SI until a surveyor brings it up . . . especially after the surveyor had been interviewing other staff members during the survey. It’s definitely not a good look for a physician to have been notified about an expression of SI but not ensure that the resident was evaluated or transferred to the ER for evaluation if needed. Ensure you have good system in place to get everyone on the same page and take immediate action.
- When the nurse notified the physician, the physician didn’t give specific monitoring orders and stated that the facility should have monitored the resident according to its monitoring protocols. The physician did not personally assess the resident and used information provided by the RN to provide orders. He was unaware that the resident was making persistent expressions of SI and thought it had only been one statement.
Facility staff weren’t aware of or able to verbalize the protocol, so that was going to be a problem. Second, the physician wasn’t provided with sufficient information to make a determination about next steps for the resident – including whether 1:1 monitoring would have been appropriate or if the resident should be transferred to the ER.
There’s Probably a Policy for That
When interviewed, the RN Supervisor told the surveyor that he/she hadn’t encountered a resident with SI in a long time but stated that there’s probably a policy for that. He/she could not explain the facility’s protocol for SI. The facility was able to identify a “decades old” policy which required revisions, and it was revised as part of the removal plan.
When Appendix PP of the State Operations Manual was revised and the behavioral health services regulations were added, that was the time to dust off the P&P manual – or develop an implement new policies – to address potential concerns such as these. Take a look at your policy manual Table of Contents – do you have a sufficient policy in place for a concern such as an expression of SI? Do staff know what to do and who to tell? What happens if it’s on a night or weekend? Check your protocol for potential holes and quiz your staff. In the citation discussed today, it was actually the aide who recognized there was a potential safety concern, reported what the resident said and brought the resident to the nurses’ station for monitoring and follow-up. The system broke down after that.
🚨 Concerned About Compliance? Let CMSCG Help You Stay Survey-Ready
At CMS Compliance Group, we don’t just identify problems—we help you solve them. Our interdisciplinary team has a proven track record of guiding nursing homes and other post-acute providers through the most serious compliance challenges. CMSCG consultants offer:
- Mock surveys with detailed findings across all departments
- Post-survey support and Plan of Correction development
- Ongoing quality assurance reviews to keep your systems functioning at the highest standards
Let’s make compliance your organization’s strength. Call us at (631) 692-4422 or contact our team to schedule a consultation.
