In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Ohio. 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
The most frequently cited IJ deficiency so far in 2025 in Ohio is F600 Free from Abuse and Neglect. There are variety of other tags that are being cited in Ohio that mimic topics that have cropped up in other States’ IJ trends such as F678 Cardio-Pulmonary Resuscitation and F880 Infection Prevention and Control.
Compliance Insights
Today we are traveling down the list of Ftags to F760 Residents Are Free of Significant Med Errors to provide our readers with insight into what can go wrong with faulty systems. We are going to touch on two (2) IJs that were both cited with a “J” S/S, as well as another “J” S/S cited at F684 Quality of Care.
IJ Citation Example – F760 S/S: J
Example #1 exemplifies that failure to follow basic good practices related to medication administration can lead to a potentially very serious negative outcome for a resident. It all started with an LPN applying a new 50 mcg Fentanyl patch after the LPN was not able to locate or remove the resident’s previously administered Fentanyl patch. This nurse also did not report the missing patch until after the resident overdosed and did not complete a head-to-toe assessment to locate the previous patch before applying a new one. The Nurse Practitioner ordered a hospital transfer due to the resident’s reported marked change in condition.
EMS arrived and assessed the resident and found — guess what– two (2) Fentanyl patches and needed to administer Narcan. EMS removed the second patch. The diagnosis was accidental overdose — the resident could have died.
The State Agency conducted a thorough investigation and identified a number of concerns, including the facility’s lack of a system for accurate monitoring for Fentanyl patch placement and not initiating an immediate incident investigation when the patch was missing. It was obvious that licensed nurses needed reeducation on the management of Fentanyl patches from A to Z and the policy and procedures related to Use of Fentanyl patches needed review and revision by the Medical Director, Pharmacist and Director of Nurse. I am hoping you all can emphatically say that your system is comprehensive, including having two (2) nurses sign for removal and destruction of the used patch.
IJ Citation Example – F760 S/S: J
Example #2’s IJ situation involved two (2) residents. For Resident #1, the staff did not reorder the resident’s antiseizure medication per policy.
The resident missed two (2) doses of their Vimpat on the same day and began to experience seizure activity requiring a transfer to the hospital – the resident was medicated, intubated and ultimately life flighted to another hospital and was admitted to Neuro ICU “due to the significant Medication Error.”
Everyone reading this should reeducate and ensure that all licensed nurses responsible for medication administration or have oversight of the nurses understand the necessity for having all ordered medications available for administration and the nurse’s responsibility to reorder medication as per policy and that is usually a specified number of days before the supply runs out. Any agency staff working in your building should also know your protocols.
And, while it was not identified at IJ level as per the SOD, Resident #2 was also included in the citation as they did not receive the Fentanyl patch order by their physician to manage their pain. Just an FYI, if you haven’t figured it out, a State Agency’s investigation is comprehensive and includes a number of residents so if you don’t have good medication management systems, issues are going to be identified.
IJ Citation Example – F684 S/S: J
The deficiency citation at F684 is so very straightforward in highlighting licensed nurses understanding their responsibility to report a change in a resident’s condition in a timely manner to the medical practitioner and the medical practitioner’s responsibility to address the change in condition, which in this case was a marked decline with multi-faceted symptoms.
- The resident was assessed with multiple changes including tachycardia, shortness of breath, fatigue and increased weakness.
- The resident was seen by the NP, who addressed the tachycardia, but not the overall decline in condition.
- The resident continued to decline and was sent to the hospital. The admitting diagnoses included metabolic encephalopathy, pneumonia, UTI, sepsis and altered mental status. The resident passed away at the hospital.
The SOD addresses the concerns identified by OT/PT staff (increased weakness and fatigue) related to the resident’s decline, and the lack of assessment notes by nursing as well as indications that changes in the resident may not have been reported timely to the medical practitioner. The end result of the State Agency’s investigation was that the facility failed to ensure changes in the resident’s condition were identified timely and that there was a lack of comprehensive and individualized interventions implemented. Certain interventions were implemented such as a 4 Plex swab (results were negative), SpO2 testing, etc., but no comprehensive “interdisciplinary evaluation or assessment” of why care needs had increased since admission or evidence that discharge plan needs were being addressed.
This is another education moment for your clinical staff. Communication between disciplines is crucial as is communication with the medical staff so that appropriate follow-up and assessment is completed for identified changes.
If everything is not addressed, go back and follow-up again, update/revise the plan of care, document comprehensive, meaningful progress notes, listen and observe your resident and don’t discount even those small changes and the need to report them to the medical practitioner.
You may not be able to prevent changes from evolving into a significant change in condition, but you will have been providing quality care as circumstances changed that is validated in your documentation.
Stay Survey-Ready with CMS Compliance Group
Avoiding citations starts with strong systems. Our nursing home mock surveys, policy reviews, and staff training help nursing homes identify risks before surveyors do.
Call (631) 692-4422 or visit cmscompliancegroup.com to schedule a consultation.
