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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The Centers for Medicare and Medicaid (CMS) have a classification for crisis situations in which the health and safety of individual(s) are at risk. This classification is called Immediate Jeopardy (IJ).

CMS developed guidelines for surveyors of nursing homes and hospitals to use to help determine if the circumstances they are seeing pose an Immediate Jeopardy to a patient or resident’s health and safety. The guidelines assist Federal and State Survey and Certification personnel and Complaint Investigators in recognizing situations that may cause or permit Immediate Jeopardy in a nursing home or hospital as well as to almost all other certified Medicare/Medicaid entities. The surveyors can apply these principles and guidelines to all types of surveys and investigations: certifications, recertifications, revisits, and complaint investigations. The main goal of having these guidelines is to help the surveyors and investigators identify and prevent serious injury, harm, impairment, or death.

CMS has provided some definitions for the surveyors.

Immediate Jeopardy is defined as a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.

Abuse is defined as “The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.”

Neglect is defined as a “Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.”

In order to determine if there is an IJ situation, the nursing home and hospital surveyor or survey team will keep in mind that only one person needs to be at risk. They will also consider that serious harm, injury, impairment, or death does NOT have to occur before considering Immediate Jeopardy. Harm can come from both abuse and neglect and psychological harm is as serious as physical harm. The serious harm, injury, impairment or death may have occurred in the past, may be occurring at present, or may be likely to occur in the very near future as a result of the jeopardy situation. In other words, a situation that can cause any of the problems above may or may not be currently happening, but if there is a potential for it to happen, that can constitute an IJ situation. Harm does not have to occur before the surveyor or survey team can consider or call IJ.

In order to call an IJ, the nursing home and hospital surveyor or survey team must also consider if the facility either created a situation or allowed a situation to continue which resulted in serious harm or a potential for serious harm, injury, impairment or death to individuals and if the facility had an opportunity to put corrective or prevention measures in place. During the investigation the surveyor/investigator will investigate and answer the following questions: Who was involved? What harm has occurred, is occurring, or most likely will occur? When did the situation first occur? Where did the potential/actual harm occur? Is it an isolated incident or a facility-wide problem? Why did the potential/actual harm occur?

In the next post I will discuss the triggers for IJ.

Keep safe and be informed!


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So let’s say you have a problem with a facility. Perhaps you saw staff yelling at a nursing home resident. Maybe you are a nursing home resident and the staff are ignoring your requests for assistance. Perhaps you are a patient in a hospital and the staff are not doing your care right. Maybe it is your managed care insurance company who is not approving treatment you need. What do you do? You are sick, you aren’t feeling well, they (meaning the doctors and nurses) are smarter than you aren’t they? They should know what they are doing, right? So you accept it without question.. until now! You do have rights as a patient or resident of a facility. When those rights are violated, you have the right to make a complaint, to have someone look at it and see if the facility violated your rights and/or any regulations.

Every state has one or more agencies to which you can report issues and complaints for any type of facility. Since every state has its own agencies, the agency you contact in one state might not be the agency you contact in another. You can search on the Internet and you might find a phone number to call, or you might find many phone numbers to call, and none of them are the right one to help you. What can you do?

There are several resources on the Internet that can help you. They will have information to lead you to the right agency for your state.

  • One of these is The National Center on Elder Abuse (NCEA). The NCEA has a directory of all state and regional ombudsmen, state offices on aging, state licensure and certification agencies, state adult protection agencies, nursing home quality review boards, Medicaid agencies and Medicare Fraud Control Units nationwide.

  • Another source for making a complaint or reporting a hospital problem is This site, which is administered by a hospital administrator, walks you through steps you should take prior to contact any outside agencies. Many times a complaint can be handled “in house”.

  • You can also contact the Joint Commission to make a complaint against a hospital. There is a box & link towards the bottom right of the page that will lead you to the appropriate place for submitting a complaint.

Stand up, get help and watch out for yourself!


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Welcome to my world – the world of a surveyor of healthcare facilities. Here you are going to learn a great deal about nursing homes and hospitals. You are going to see things that go on behind the scenes. You are going to find out what the surveyors (investigators) look for. What kind of training do they get to do their job? How do they interpret the regulations? Where do they go to get the regulations? How can you, when you make a complaint to the state agency who oversees these facilities, make the job of the investigator more effective? You are going to learn that and so much more as you follow this blog.

You are going to learn where you can find the regulations, learn what they say, and find out how to know what they mean.

Some of you are wondering why you need to know this. It doesn’t matter what age you are, the likelihood is that at sometime you are going to end up inside a hospital, clinic, nursing home, or other health care facility. You need to be prepared, informed, and ready. In today’s world you need to watch out for yourself. In this blog you will find out why you need to watch out for yourself, and the best way to do it. You will learn what to look for, what questions to ask, and where to go to solve problems, investigate issues, or make a complaint.

There is no day that goes by that we don’t hear about something related to abuse (whether it is elder abuse, child abuse, or medical abuse). You hear on the news about medical problems such as medication errors, infections, and surgery problems. How can you protect yourself and your loved ones? How can you help inform your friends and family when you hear they are heading into a healthcare facility?

Read this blog, keep up with what is happening here, and you will be a better informed consumer, ready to take on the strange world of healthcare with a better chance of avoiding complications than those who have no preparation or knowledge of what to expect.

So WELCOME! and stay tuned for more!


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