The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Tennessee

In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Tennessee. 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.

Key Areas of Noncompliance

Today we are exploring two (2) IJ citations both given a “J” scope/severity related to quality-of-care issues that are not so uncommon. Both of these deficiencies were cited during complaint surveys.

F600 Free from Abuse and Neglect

A facility was cited at F600 related to its failure to ensure residents were free from neglect due to the facility not providing sufficient licensed nursing staff to “perform assessments and administer morning medications” for a sample of six (6) residents. The circumstances became IJ territory when one of the sampled residents had a change in condition and there was no nurse in that area to assess the resident. The resident’s spouse reached out to 911 and the resident was taken to the ER based on information provided by the spouse, assessed by Emergency Department staff and was admitted.

Another resident did not have their morning blood glucose check completed and did not receive their physician ordered medications to control the resident’s diabetes that same morning. Mid-evening this resident had an extremely high blood glucose level of over 400 mg/dl. While at the hospital, the Case Manager Director received a message (not evident from whom) asking if an APS (Adult Protective Services) or an Ombudsman referral needed to be made due to neglect at the nursing home related to the patient not receiving their morning med when no nurse was available. When contacted by the Case Manager, the Administrator shared that a nurse called in when scheduled for work. The nurse not showing up for work resulted in a “late starting” work around to provide the unit with nurse coverage.

• The on-call nurse was requested to report for work after 12PM by the Staffing Coordinator, who was not alerted of the need for the on-call nurse earlier in the day and the nurse did not arrive until 1:45PM.
• The nurse who was to “cover” the unit was involved with a resident who was actively dying on their assigned unit.
• The DON, on interview, admitted she did not follow-up with the Staffing Coordinator regarding the on-call nurse. Medical staff were advised on all medications, Accucheck, and blood glucose levels that were missed that morning, medications administered late, etc. with appropriate orders being implemented when indicated.
  

We all recognize the importance of administering medications as per physician orders and the heightened need for time compliance for certain medications such as insulins, seizure medications, antibiotics and anticoagulants – all of which were identified as being missed that morning. This is an unusual – but appropriate – application of the Abuse regulation related to citing F600 for neglect, when we tend to see such issues cited at F760 – Residents Are Free of Significant Med Errors. It certainly broadens your point of view and provides insight into what can happen related to insufficient nursing staff being available and contingency plans not being monitored for timely implementation.

F697 Pain Management

Since we are on a roll with medications today, let’s review what happened at another facility’s deficiency at F697 Pain Management another high-risk area for deficiencies. This deficiency was cited at a “J” scope/severity and is centered on the facility’s pain management for two (2) residents being inconsistent with professional standards of practice.

Unfortunately, one of the situations is more common than we might like to think. The fresh post-op resident for an amputation did not receive adequate pain management for their level of pain. The citation indicates that there were orders in place for moderate and mild pain, but does not address severe pain, but one can assume such an order was in place. The issue revolved around the resident not receiving the ordered medication for pain reported at a moderate level on multiple occasions that would have required administration of Hydrocodone. The resident was medicated with Ibuprofen 800mg, which was available and ordered for mild pain. The fly in this ointment is appropriate development, implementation  and follow-up was not completed by the Nursing staff related to pain management. In fact, the pharmacy reported that they never received an order for Hydrocodone and use of the supply in the E-kit was tied to the pharmacy having an order for use of this drug.

As you can imagine, the DON and Medical Director were interviewed and the Medical Director shared that they would expect the staff to follow up on why the medication was not available and the lack of pain management probably contributed to the resident’s agitation which resulted in the resident having an unwitnessed fall from bed. This fall resulted in a subarachnoid hemorrhage and a periorbital fracture.

The second resident also sustained a fracture from a fall from their bed, but the resident did not show signs/symptoms of pain post-fall or report pain at that time.  The post-fall evaluation indicates prn pain medication provided; this was not validated when the medication administration record (MAR) was reviewed. Hours later there was evidence of pain; a stat x-ray was ordered and completed. The x-ray was not obtained timely, but results did show an acute periprosthetic fracture and the resident was sent to the hospital. There was no evidence that pain medication was administered.

Compliance Insights

It is worth the effort for every Director of Nursing to review the facility’s Nurse Staffing Plan to ensure that the replacement plan for callouts is comprehensive and responsible staff understand timely implementation of the plan.  What pops out in the deficiency discussed is the breakdown in communication. Don’t let such a situation occur in your facility.

Where to begin with pain management? At the beginning – review your Pain Management Policy from beginning to end to ensure that it is comprehensive and includes actions to take when medication is not available. Then educate, educate, educate and monitor ongoing compliance.

Received an IJ Citation? We’re Your First Call