5 rarest immediate jeopardy triggers

In 10 years, there were 40 CMS citations that were given out only once.

Becker's compiled CMS deficiency citations for hospitals from 2014 to 2024. Of 352 categories of citations given in 10 years, 40 were handed out only once. Find the most common citations here.

Here are trends in the rarest citations:

Patient care

Deficiencies in patient care is one of the most common citations for immediate jeopardy, but some of the rarer deficiencies were:

  • Adequate personnel to formulate treatment plans
  • After-hours access to drugs
  • Care of patients-practitioners
  • Delivery of services
  • Designated requester
  • Receiving an inappropriate transfer



Inappropriate record keeping was a common trend among the rarest citations. These included:

  • Coding and indexing of medical records
  • Complete neurological exam recorded at time of admission
  • Content of record: consultative records
  • Evaluation notes onset of illness/circumstances of admission
  • Frequency of progress notes
  • Identification data includes patient's legal status
  • Institutional plan and budget
  • Nuclear medicine records
  • Orders for radiology services
  • Physician request for a discharge plan
  • Progress notes recorded by nurse
  • Progress notes recorded by others involved in treatment
  • Psychiatric evaluation includes medical history

Patient experience

Some of the infrequent citations related to patient experience:

  • Admission, transfer and discharge rights
  • Discretion and sensitivity
  • Discharge planning evaluation
  • Determinations of medical necessity
  • Extended stay review
  • Informed family
  • Patient rights: confidentiality of records
  • Patient rights: restraint or seclusion


Medical team

Medical team issues accounted for seven of the least cited reasons for immediate jeopardy.

  • Medical staff qualifications
  • Num/qual of MD/DO adequate to provide psychiatric services
  • Process for prompt resolution of grievances
  • Psychiatric evaluation completed within 60 hours of admission
  • Social services
  • Supervision of emergency services
  • Scope and frequency of review



Only two citations were written in 10 years for radioactive materials storage and disposal, and equipment and supplies.

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