In the previous post we started talking about Immediate Jeopardy. There are some triggers which, when seen, should clue the hospital and nursing home surveyor or survey team into looking further to see if there is an IJ situation. Although CMS doesn’t consider the triggers to be all inclusive, they are a good starting point. CMS has placed the issues and triggers into a chart for the surveyors. I have copied that chart here for your perusal. The chart and other information can be found in the SOMAppendix Q.




A. Failure to protect from abuse.

1. Serious injuries such as head trauma or fractures;

2. Non-consensual sexual interactions; e.g., sexual harassment, sexual coercion or sexual assault;

3. Unexplained serious injuries that have not been investigated;

4. Staff striking or roughly handling an individual;

5. Staff yelling, swearing, gesturing or calling an individual derogatory names;

6. Bruises around the breast or genital area; or Suspicious injuries; e.g., black eyes, rope marks, cigarette burns, unexplained bruising.

B. Failure to Prevent Neglect

1. Lack of timely assessment of individuals after injury;

2. Lack of supervision for individual with known special needs;

3. Failure to carry out doctor’s orders;

4. Repeated occurrences such as falls which place the individual at risk of harm without intervention;

5. Access to chemical and physical hazards by individuals who are at risk;

6. Access to hot water of sufficient temperature to cause tissue injury;

7. Non-functioning call system without compensatory measures;

8. Unsupervised smoking by an individual with a known safety risk;

9. Lack of supervision of cognitively impaired individuals with known elopement risk;

10. Failure to adequately monitor individuals with known severe self-injurious behavior;

11. Failure to adequately monitor and intervene for serious medical/surgical conditions;

12. Use of chemical/physical restraints without adequate monitoring;

13. Lack of security to prevent abduction of infants;

14. Improper feeding/positioning of individual with known aspiration risk; or

15. Inadequate supervision to prevent physical altercations.

C. Failure to protect from psychological harm

1. Application of chemical/physical restraints without clinical indications;

2. Presence of behaviors by staff such as threatening or demeaning, resulting in displays of fear, unwillingness to communicate, and recent or sudden changes in behavior by individuals; or

3. Lack of intervention to prevent individuals from creating an environment of fear.

D. Failure to protect from undue adverse medication consequences and/or failure to provide medications as prescribed.

1. Administration of medication to an individual with a known history of allergic reaction to that medication;

2. Lack of monitoring and identification of potential serious drug interaction, side effects, and adverse reactions;

3. Administration of contraindicated medications;

4. Pattern of repeated medication errors without intervention;

5. Lack of diabetic monitoring resulting or likely to result in serious hypoglycemic or hyperglycemic reaction; or

6. Lack of timely and appropriate monitoring required for drug titration.

E. Failure to provide adequate nutrition and hydration to support and maintain health.

1. Food supply inadequate to meet the nutritional needs of the individual;

2. Failure to provide adequate nutrition and hydration resulting in malnutrition; e.g., severe weight loss, abnormal laboratory values;

3. Withholding nutrition and hydration without advance directive; or

4. Lack of potable water supply.

F. Failure to protect from widespread nosocomial infections; e.g., failure to practice standard precautions, failure to maintain sterile techniques during invasive procedures and/or failure to identify and treat nosocomial infections.

1. Pervasive improper handling of body fluids or substances from an individual with an infectious disease;

2. High number of infections or contagious diseases without appropriate reporting, intervention and care;

3. Pattern of ineffective infection control precautions; or

4. High number of nosocomial infections caused by cross contamination from staff and/or equipment/supplies.

G. Failure to correctly identify individuals.

1. Blood products given to wrong individual;

2. Surgical procedure/treatment performed on wrong individual or wrong body part;

3. Administration of medication or treatments to wrong individual; or

4. Discharge of an infant to the wrong individual.

H. Failure to safely administer blood products and safely monitor organ transplantation.

1. Wrong blood type transfused;

2. Improper storage of blood products;

3. High number of serious blood reactions;

4. Incorrect cross match and utilization of blood products or transplantation organs; or

5. Lack of monitoring for reactions during transfusions.

I. Failure to provide safety from fire, smoke and environment hazards and/or failure to educate staff in handling emergency situations.

1. Nonfunctioning or lack of emergency equipment and/or power source;

2. Smoking in high risk areas;

3. Incidents such as electrical shock, fires;

4. Ungrounded/unsafe electrical equipment;

5. Widespread lack of knowledge of emergency procedures by staff;

6. Widespread infestation by insects/rodents;

7. Lack of functioning ventilation, heating or cooling system placing individuals at risk;

8. Use of non-approved space heaters, such as kerosene, electrical, in resident or patient areas;

9. Improper handling/disposal of hazardous materials, chemicals and waste;

10. Locking exit doors in a manner that does not comply with NFPA 101;

11. Obstructed hallways and exits preventing egress;

12. Lack of maintenance of fire or life safety systems; or

13. Unsafe dietary practices resulting in high potential for food borne illnesses.

J. Failure to provide initial medical screening, stabilization of emergency medical conditions and safe transfer for individuals and women in active labor seeking emergency treatment (Emergency Medical Treatment and Active Labor Act).

1. Individuals turned away from ER without medical screening exam;

2. Women with contractions not medically screened for status of labor;

3. Absence of ER and OB medical screening records;

4. Failure to stabilize emergency medical condition; or

5. Failure to appropriately transfer an individual with an unstabilized emergency medical condition.


When determining if there is a finding of IJ, the nursing home and hospital surveyor or survey team must look for the components of IJ.

The first component of IJ is Harm, which is divided into actual and potential. To determine which one it is the nursing home and hospital surveyor or survey team asks the following questions:

  • ActualWas harm an outcome? Does the harm meet the definition of IJ? In other words, has the facility’s failure to comply with the requirements actually caused serious injury, harm, impairment, or death?
  • PotentialIs potential harm likely to occur? Does the potential harm meet the definition of Immediate Jeopardy? In other words, is the facility’s failure to comply with the requirements likely to cause serious injury, harm, impairment, or death to an individual?

The second component of IJ is Immediacy. The investigator looks to see if the harm or potential harm is likely to occur in the very near future to this particular person or to others in the facility, if immediate action is not taken.

The third component of IJ is Culpability. Here the surveyor or the survey team is looking to answer the following questions:

  1. Did the facility know about the situation? If so when did the facility first become aware?
  2. Should the facility have known about the situation?
  3. Did the facility thoroughly investigate the circumstances?
  4. Did the facility implement corrective measures?
  5. Has the facility re-evaluated the measures to ensure the situation was corrected?

The nursing home and hospital surveyor or survey team considers the facility’s response to any harm or potential harm that meets the definition of IJ. Just because the facilty’s staff  say they did not know about a particular issue or situation does not excuse that facility from knowing about and preventing IJ. The survey team or surveyor uses his or her experience and knowledge to determine if the circumstances could have been predicted. The nursing home and hospital surveyor or survey team should continue to investigate enough information has been gathered in order to evaluate any prior indications or warnings regarding the jeopardy situation and the facility’s response. The crisis situations in which a facility did not have any prior indications or warnings, and could not have predicted a potential serious harm, are very rare.

So what happens if a facility is found in Immediate Jeopardy? Do they get closed down? No, not immediately. The facility is given a period of time in which to correct the deficiency. CMS works with the state survey agency and tells them each next step to follow. There are many opportunities for the facility to correct situation, but when necessary, CMS will initiate termination from participation, meaning the facility will not be eligible to receive federal monies for the care of patients/residents.

Be safe and be informed!


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2 Responses to “Nursing Home And Hospital Surveyors Look For Immediate Jeopardy – Part 2”

  1. Judith Robinson Says:

    I would like to know where I might purchase a copy of the surveyors guidelines for nursing homes and hospitals. I need state guidlines(CA) and federal guidelines.
    Thank you for your anticipated help.
    Judith RobinsonRN, CLNC

  2. admin Says:

    Hi Judith,

    The Surveyors Guidelines are available free from the CMS site. There are only federal guidelines for the surveys. When surveying for state issues, the state surveyors in California Use Title 22. There are no “guidelines” for Title 22. The surveyors just use the regulations. You will find a link to the CMS guidelines on my post called “Where oh where does a nursing home and hospital surveyor find the regulations?” at

    The California Title 22 is found online as well. It is more difficult to navigate, but you get the hang of it very quickly. Go to: and click on “Title 22” in the list. You will get another list. Click on the plus sign beside “Division 5 Licensing and Certification of …..”. Then you next will need to click on the plus sign beside the chapter that corresponds to the type of facility you want to look at. You will then see links to each individual section of the regulations for that facility type. Click on the link and you will see the text for that regulation. Use your back arrow to go back to look at the text for another regulation.

    You can also buy both of these items. The California Title 22 is available from

    The State Operations Manual (SOM) can also be bought from a commercial supplier. Which supplier will often depend on which part of the SOM you want. For instance you can buy just the portion for Long Term Care from I’m not sure you can buy the entire SOM from a commercial place (it is huge!), but you can certainly print it out for yourself, or any portion thereof from the link in the blog at

    Thanks for asking. And if you wish to share a story, or write a guest blog regarding some of your experiences related to reviewing records for attorneys, please feel free to e-mail me. I would love to have my readers learn about issues from your perspective.


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