Part VI – CMS Immediate Jeopardy Series

How to Address an Immediate Jeopardy Decision?  

The survey team leader wants to address an Immediate Jeopardy situation with your leadership.  The surveyor verbally presents the circumstances of the situation, the investigation performed and the decision process.  The specific details, including the individuals at risk is provided before leaving the entity.  What should you do?  Immediately remove the risk!

To take appropriate actions to remove the risk, you may need to perform your own investigation to assure you know what the situation is, how isolated or widespread. Using the example of the cognitively impaired resident in the psychiatric facility who has ongoing exit behaviors, think in terms of how to remove the risk for this and other individuals.  Recall that this behavior was known to staff and 1:1 was suggested.  The lock was not secure, and the resident knew how to access the keypad – address the lock and keypad issue. The entity had not investigated the issue. The facility was not secure, and the resident was able to exit the building to a busy street, can this be addressed to prevent exit, secure the premises, monitor individuals activity?

Think not only of how to protect this individual but all individuals who may be affected by these circumstances.  Address the who, what, when, where and why questions. Investigate the resident’s behavior.  Is it known?  Can it be addressed? Was exit behavior addressed in the care plan? Were actions carried out? Is the plan effective? How many other residents are at risk?

What happened?  How did the resident elope? What was the resident’s physical, emotional, mental status prior to elopement? What supervision was provided? Was outside medical treatment needed? What did ER reports conclude regarding resident’s condition?  When was the resident last seen?

When the resident was able to elope, how long before the facility was aware and acted? When was the resident found and who found the resident?  Was the outside temperature or weather a factor? Was injury present?

Where the resident was located, were elopement precautions in place? How did the resident exit the facility?  What hazards are near the facility?  And why did this happen?  Was the care plan followed? Were locks working?  Alarms working? Staff present?  Staff properly trained to manage exit behaviors? Was the patient supervised? Were there other contributing factors that should be considered?


To protect the resident, take immediate action.  For example, protect the patient by initiating 1:1 now.  Convene the team to review the plan of care and assure the appropriate modifications are made to protect from harm. Plan for appropriate placement to protect the resident until locks and keypads are addressed.  Address the physical environment issues to secure the unit and keep residents safe until you can address all investigative items contributing to the situation.  Your ability to understand the surveyor’s issue and take immediate action to remove the risk are critical to the removal of Immediate Jeopardy.  It is too your advantage to address as many contributing factors as possible while the surveyor is still onsite.  Only onsite confirmation of corrective actions justifies a determination to remove Immediate Jeopardy.   If corrective actions are instituted before the end of the survey, the IJ is still reported but it includes the surveyor reviewed actions that were taken to ameliorate the risk.  When questions arise about Immediate Jeopardy and CMS, contact us and we’ll assist you with the necessary actions to get your organization back on track.

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