**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of a facility policy titled Cardiopulmonary Resuscitation (CPR), the Emergency Medical Services (EMS) run report, and the American Heart Association (AHA) Adult Basic Life Support (ABLS) Algorithm for Health Care Providers, the facility failed to ensure CPR response was provided in accordance with facility policy and in accordance with the AHA ABLS Algorithm for Health Care Providers for Resident Identifier (RI) #58 on [DATE], when Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA), found RI #58 unresponsive and alerted the Licensed Practical Nurse (LPN), EI #3, around 9:59 PM. EI #3, the LPN, without knowing RI #58's code status, said he began chest compressions and continued, without providing rescue breaths, until about 10:14 PM, when he stopped to go find out RI #58's code status and to make phone calls to the resident's representative and the Director of Nursing (DON). EI #3 failed to call out for assistance from other staff who were in the building, including EI #5, Registered Nurse (RN)/House Supervisor, who was on duty at the time of the occurrence. EI #3 further failed to call EMS until 10:44 PM, approximately 45 minutes after RI #58 was found unresponsive. No code was ever announced and the facility crash cart was not utilized. EMS arrived at the facility at 10:52 PM. RI #58 was pronounced deceased on [DATE] at 11:12 PM after EMS interventions. This deficient practice placed RI #58, one of three sampled residents reviewed for the provision of CPR, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On [DATE] at 6:49 PM, EI #1, the facility Administrator; EI #2, the DON; EI #14, the [NAME] President of Clinical Operations; and EI #15, the Director of Operations were given a copy of the Immediate Jeopardy (IJ) template and notified of the findings of substandard quality of care at the IJ level in the area of Quality of Life, at F678-Cardio-Pulmonary Resuscitation (CPR). Findings include: On [DATE] the State Survey Agency received a third-party complaint involving concerns with inconsistencies in the timeline of events related to RI #58's death. Per the complainant, there was a delay in contacting EMS after RI #58 was found unresponsive on [DATE]. A facility policy titled, Cardiopulmonary Resuscitation (CPR), last revised [DATE], documented: Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Policy Explanation and Compliance Guidelines: 1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR a. Verify scene safety b. Check for responsiveness c. Call out for staff assistance d. Call 9-1-1 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order . The American Heart Association (AHA) Adult Basic Life Support (ABLS) Algorithm for Health Care Providers, dated 2020, documents the following sequence of response should be initiated in the event Health Care Providers respond to a person in need of CPR and EMS: . Verify scene safety. Check for responsiveness. Shout for nearby help. Activate emergency response system via mobile device (if appropriate). Get . emergency equipment (or send someone to do so). Look for no breathing or only gasping and check pulse (simultaneously). No breathing or only gasping, pulse not felt . By this time in all scenarios, emergency response system or backup is activated . and emergency equipment are retrieved or someone is retrieving them. Start CPR Perform cycles of 30 compressions and 2 breaths . Check . (for a pulse if no AED). Resume CPR immediately . Continue until ALS (advanced life support) providers take over or victim starts to move. RI #58 was admitted to the facility on [DATE] and had diagnoses to include: Congestive Heart Failure, Dementia, Stage 3 Chronic Kidney Disease, Peripheral Vascular Disease, Coronary Artery Disease, and Physical Debility. RI #58's admission RECORD documented the following: . ADVANCE DIRECTIVE Code Status: Full Code . RI #58's undated OAK TRACE RESIDENT CARE GUIDE and December Medication Administration Record (MAR) also documented RI #58's code status was Full Code. RI #58's Progress Notes contained the following entries: -On [DATE] at 10:38 PM EI #3, the LPN, documented that RI #58 expired around 10:15 PM, and the facility physician, DON, resident representative, and 911 were called. - A Late Entry note dated [DATE] at 3:51 AM was made by EI #2, the DON. This note documented that the nurse was called to RI #58's room by a CNA who stated RI #58 did not look good. Further, the note indicated the nurse (EI #3) entered RI #58's room at approximately 9:50 PM and found RI #58 unresponsive with no pulse, so CPR was started, 911 was called, and EMS arrived and pronounced RI #58 deceased around 10:15 PM. - Another Late Entry note dated [DATE] at 1:28 PM was made by EI #3, LPN. This note indicated RI #58 was found unresponsive on [DATE], CPR was performed with no positive response, 911 was called and the local EMS team responded and performed CPR until around 11:00 PM, when they gave the official call for expiration (time of death). RI #58's Patient Care Record (run report) from the Local EMS response team documented the following: . Chief Complaint: cardiac arrest Duration: 50 minutes . Narrative Pt. (patient) lying supine (lying on back) in bed on arrival Pt was last known alive at 2130 (9:30 PM) according to nursing home staff . NH (nursing home) staff states patient is a full code . Cardiac Arrest: Yes, Prior to EMS Arrival Estimated time of Arrest: (greater than) 20 Minutes Est (estimated) Time Collapse to 911 (the approximate time from nursing staff finding resident unresponsive until the time 911 was called) : 35 Minutes . Est Time Collapse to CPR (the approximate time from nursing staff finding the resident unresponsive until the time CPR was initiated): 50 Minutes . CPR Initiated by: EMS Time 1st CPR: 22:54 (10:54 PM) [DATE] Incident Times . Call Received 22:44:44 (10:44 PM) At Patient 22:54:00 (10:54 PM) . This run report did not indicate facility staff were performing CPR upon EMS arrival. Further, the report documented an in-field pronouncement of time of death as [DATE] at 11:12 PM. On [DATE] at 5:54 PM an interview was conducted with EI #3, the LPN/Charge Nurse, assigned to RI #58 on [DATE] on the 3 PM-11 PM shift. EI #3 was asked about the incident on [DATE] when RI #58 was found unresponsive. EI #3 said, RI #58's vital signs were taken by EI #4, the CNA, prior to medication pass and they were within normal limits. EI #3 said, when he initially tried to administer RI #58's medications, RI #58 refused. EI #3 went back within approximately 30 minutes and RI #58 accepted them just before 9:29 PM. EI #3 said EI #4, the CNA, came to him about twenty to thirty minutes later (9:49 PM to 9:59 PM) when he was at the nurse's station charting vital signs to tell him RI #58 did not look good. EI #3 said he got up, and they went down to the resident's room. EI #3 said RI #58's head of the bed was elevated about 30-45 degrees and RI #58 was sitting face-forward, eyes closed, with a small drop of foam at the right corner of his/her mouth. EI #3 said he immediately checked for respirations, then a carotid, apical and wrist pulse and there was nothing on all four. EI #3 claimed at that point, he told the CNA, EI #4, to go call 911 as he started CPR. EI #3 said EI #4 then left the room while he did chest compressions. He indicated he did sets of 30 chest compressions, with no rescue breaths. EI #3 further stated he did not call a code. EI #3 said while doing the compressions, he could not remember if RI #58 was a full code or DNR, so he stopped CPR to go to the nurse's desk to check. EI #3 said RI #58 was listed as a full code. EI #3 indicated while he was at the desk he made calls to 911, RI #58's family, and the DON. When asked why no other nursing staff were involved in the resuscitation efforts for RI #58, EI #3 said he just went with what he needed to do, rather than for him to go look for people that he may or may not have found. When asked what he meant by people he may or may not have found, EI #3 said they could have been on lunch, outside, or the intercom may not have worked. EI #3 was asked when the crash cart was brought to the room. EI #3 answered, it was not taken to the room. EI #3 was asked where the backboard was. EI #3 answered, it was on the crash cart. EI #3 was asked why it was not utilized. EI #3 said, because he was by himself. When asked what other nurses and CNAs were on duty at the time of the incident, EI #3 said he did not know. EI #3 was asked why he did not use the call light to get assistance. EI #3 said, he did not think of it. EI #3 alleged he returned to RI #58's room after making his phone calls and continued CPR until EMS arrived and took over. On [DATE] at 10:09 AM a follow-up interview was conducted with EI #3. EI #3 was asked what the CPR guidelines were from the American Heart Association. EI #3 said check to see if they are breathing, check for a pulse, check for any obstruction (in the airway), call their names, shake them or rub their chest, if no response, start CPR, call for assistance, and call 911. EI #3 was asked when no one else came, why he did not yell out for help. EI #3 said he thought the CNA was getting help. EI #3 was asked why he did not redirect the CNA to call for help. EI #3 said it did not occur to him, because he was continuing CPR. EI #3 said after everything was over, EI #4, the CNA, told him she never heard him tell her to get help or call 911. On [DATE] at 9:39 AM another follow-up interview was conducted with EI #3 regarding discrepancies on the timeline of events on [DATE]. EI #3 was asked what was done between approximately 9:50 PM and 10:50 PM (during this event on [DATE]). EI #3 said he did not just stand around, that he did CPR and called 911, the resident's family and the DON. When asked about the call placed to 911, EI #3 said he told them they had an unresponsive resident, gave them the room number and the facility's address. EI #3 further claimed he was unable to contact 911 from his personal cell phone he had with him because he did not have 911 capabilities on it, so he called from the facility's phone at the desk. EI #3 was asked if he followed the proper protocol for CPR for an unresponsive resident. EI #3 admitted he did not call for additional help. When asked at what point he contacted 911, EI #3 said around 10:15 PM. EI #3 was asked why he did not give other CPR certified nurses in the building the opportunity to assist him with efforts to revive RI #58. EI #3 answered, he was nervous and he was working with what he had on his own. EI #3 was asked why he did not instruct EI #4 to call a code, and he said he guessed it slipped his mind. EI #3 was asked what training he had received that indicated he should pause CPR for a nonresponsive resident to call the DON, EMS and the family. EI #3 said, there was not any that dictated that. EI #3 was asked how could that affect the outcome for the resident. EI #3 said, it could result in being unable to revive the person. EI #3 was asked if calling 911, getting the crash cart and assisting with the CPR would be some things another staff member could have done, if he had called for help. EI #3 acknowledged the AHA guidelines instructed to call for assistance, but said everything was happening so fast it slipped his mind. EI #3 was again asked what he did between 10:14 PM when he made his phone calls and when EMS arrived, and he stated he was in the room with RI #58 providing CPR. EI #3 was then asked how he could have documented a nurses note at 10:38 PM if he was performing chest compressions. EI #3 said, he just did not know. EI #3 was asked if other people were in the facility, why he would not have called for assistance. EI #3 again said he was very nervous. EI #3 was asked, when he found RI #58 without respirations or a pulse at 9:59 PM, why the EMS run report documented they were not called until 10:44 PM. EI #3 said he did not recall; it was all from memory. On [DATE] at 3:41 PM, during a phone interview with the Captain of the local EMS response team, the Captain confirmed the call to 911 was received from EI #3 at Oak Trace Care and Rehabilitation Center on [DATE] at 10:44 PM, as listed on the run report (referenced above). He also confirmed no other calls came in from the facility on this date. An interview was conducted on [DATE] at 3:36 PM with EI #4, the CNA assigned to care for RI #58 on [DATE] on the 3PM-11PM shift. EI #4 was asked what she could tell the surveyor about the night RI #58 was found unresponsive. EI #4 said after finishing rounds, she went to check in on RI #58 around 10:00 PM and found that he/she did not look to be breathing, so she notified EI #3, her Charge Nurse. EI #4 said she then went back down to RI #58's room with EI #3, who shook RI #58's arm and called the resident's name a couple of times. EI #4 also reported that EI #3 checked for a pulse and did not find one. EI #4 said at that point, she left the room because she smelled feces. When asked what EI #3 did for RI #58, EI #3 said she did not know because she left the room to get supplies to clean up the bowel movement. EI #4 was asked if she ever witnessed EI #3 performing CPR. EI #4 said, she did not witness him performing CPR. EI #4 said the next time she saw EI #3, he was standing behind EMS while they performed CPR for RI #58. On [DATE] at 8:14 PM EI #5, the Registered Nurse (RN)/House Supervisor on [DATE] on the 3P-11P evening shift, was asked about RI #58 being found unresponsive on [DATE]. EI #5 said RI #58 expired that night. EI #5 said she never heard a code called, and when she found out about it, EMS was already there and RI #58 was expired. When asked how she would ordinarily hear a code called, EI #5 said over the intercom or someone hollers out for help. When asked who assisted with the resuscitation efforts for RI #58, EI #5 stated nobody but EI #3. EI #5 said, the House Supervisor's responsibility when a full code resident becomes unresponsive is to assist with the code, get the crash cart, start chest compressions, get the ambu-bag, call 911, and assist in the efforts to revive the resident. EI #5 said, that was why they needed to announce the code because they need all the help they can get. EI #5 said, EI #3 should have hollered and someone would have heard him. EI #5 further stated no one can perform a code by themselves. An interview was conducted on [DATE] at 10:56 AM with EI #2, the DON. EI #2 was asked what process was followed the night RI #58 coded. EI #2 answered, she did not know what steps were taken, she just asked if they did CPR. EI #2 then showed the surveyor EI #3's name and phone number on caller ID of a voicemail he left her on [DATE] at 10:14 PM. EI #2 was asked the purpose of the AHA guidelines referenced in the facility's CPR policy. EI #2 said these were guidelines on how to respond in situations in which CPR is necessary or a resident is unresponsive. EI #2 was asked which of those steps were followed for RI #58. She said EI #3 told her he called 911 and that was all that she was aware of. EI #2 reported EI #3 was involved in the resuscitation efforts on [DATE] for RI #58. EI #2 said all the nurses and CNA should have been involved as support. EI #2 said EI #3 and EI #4 did not notify anyone. EI #2 was asked who called for help, and she said no one. EI #2 was asked who should have called for help, and she said the nurse. EI #2 was asked how should the nurse have called a code. She said he could have hollered out, paged over the intercom or sent someone to do it. EI #2 was unsure why EI #3 never called a code to alert the other staff in the building. On [DATE] at 10:38 AM a follow-up interview was conducted with EI #2, the DON. EI #2 reported EI #3 called 911 around 10:45 PM and they arrived at 10:52 PM. When EI #2 was asked what time EI #3 started CPR, she responded he did not give her a time that he started CPR, but he told her that RI #58 was dead at approximately 10:15 PM when he called her. This deficient practice was cited as a result of the investigation of complaint/report number AL00043033. ***************************************************************************** On [DATE] at 4:52 PM, the facility submitted the following acceptable Removal Plan addressing F678: Removal Plan 678 On [DATE], an audit was performed by the Director of Nursing on 2 crash carts to ensure and are complete with an Ambu bag. Crash carts are fully stocked, and accessible to all staff. On [DATE], education was provided to the Administrator, Director of Nursing, by the Corporate Consultant, Regional Director of Operations, regarding emergency procedures, code blue drill, crash cart locations and cardio-pulmonary resuscitation. Education provided: How to do a code blue drill - simulation of a resident in need of cardiopulmonary resuscitation Where the crash carts are located and what belongs on the crash carts Who needs to be part of the code blue drills - all team members Drills will be completed on a Quarterly basis - this is a plan, not policy The Director of Nursing did a return demonstration of cardiopulmonary resuscitation. Cardiopulmonary Resuscitation policy was reviewed. Where the code status is found in PCC on the resident dashboard and on the resident face sheet This information will be disseminated through the mock codes to all team members On [DATE] the Director of Nursing, corporate nurse, and Director of Operations performed a mock code at 7:17pm to assess the staff response. Team members 17 (LPN- 3, RN- 2, CNA- 3, Other- 9)-responded to the code blue drill and received a copy of the Cardiopulmonary Resuscitation policy and were trained on the Cardiopulmonary Resuscitation policy, and crash cart location by the Director of Nursing. Education Provided: How to do compressions How to use Ambu bag Where to find crash carts Where to find code status in PCC on the resident dashboard Where on the face sheet the code status is found How to call for help - yell for help When to call 911 - call nurse if nurse not available call 911 yourself On [DATE] the Director of Nursing performed a mock code drill at 6:00 am to assess the staff response. Team members 7 (LPN- 0, RN-1, CNA- 4, Other-2) responded to the code blue drill and received a copy of the Cardiopulmonary Resuscitation policy and were trained on the Cardiopulmonary Resuscitation policy and crash cart location by the Director of Nursing. Education Provided: How to do compressions How to use Ambu bag Where to find crash carts Where to find code status in PCC on the resident dashboard Where on the face sheet the code status is found How to call for help - yell for help When to call 911 - call nurse if nurse not available call 911 yourself On [DATE] the Director of Nursing performed a mock code drill at 9:31 am to assess the staff response. Team members 20 (LPN- 0, RN-2, CNA- 6, Other-12) responded to the code blue drill and received a copy of the Cardiopulmonary Resuscitation policy and were trained on the Cardiopulmonary Resuscitation policy and crash cart location by the Director of Nursing. Education Provided: How to do compressions How to use Ambu bag Where to find crash carts Where to find code status in PCC on the resident dashboard Where on the face sheet the code status is found How to call for help - yell for help When to call 911 - call nurse if nurse not available call 911 yourself On [DATE] the center had an independent contractor for the American Heart Association trainer on site that is training all nursing staff on American Heart Association Cardiopulmonary Resuscitation. On that date 12 nurses, 8 CNAs and 13 non-licensed staff members were either certified or re-certified in accordance with American Heart Association guidelines and requirements, to include a skills check-off and return demonstration. On [DATE] the administrator, Director of Nursing, corporate nurse, and the regional director of operations developed the Communication of Code Status policy and reviewed and adopted it and reviewed the Cardiopulmonary Resuscitation policy. On [DATE], the DON utilized the Communication of Code Status policy and provided education to 7 nurses, 11 CNA, and 30 non licensed. There are 28 total staff members, 7 - nurses, 10- CNAs and 11- non licensed that still need to be trained on the Communication of Code Status policy. [DATE] - 7 CNAs, 8 LPNs, 1 RN and 7 non-licensed staff were educated, On [DATE] - 2 CNAs, 5 LPNs, and 18 non-licensed. The intention is that this policy be in-serviced to all licensed and non-licensed staff. No staff will be allowed to work [DATE] in the facility until they have received the training on the new policy. An employee list is being used to ensure all staff are participating in mock code blue drills. To ensure all team members are trained, the schedule is being used to make sure anyone that is coming into work gets training prior to starting their shift. We are utilizing the employee list of all staff to confirm who has been trained and who not been trained. The Administrator, Director of Nursing and the staff development coordinator will be available at the start of each shift ensure this education is completed prior to staff starting their shift. No nurses will work in the center without current Americana Heart Association Cardiopulmonary Resuscitation card. and will have been trained on the facility Cardiopulmonary Resuscitation policy by the Director of Nursing. All licensed nurses have current cardiopulmonary resuscitation cards with hands on training verified by the administrator on [DATE]. Copies supplied. On [DATE] The DON identified the LPN had not followed facility policy and terminated this nurse. The Director of Nursing will perform mock code blue drill on each shift every week for 4 weeks to ensure staff are following the facility policy on cardiopulmonary resuscitation. An employee list is being used to ensure all staff are participating in mock code blue drill. To ensure all team members are trained, the schedule is being used to make sure anyone that is coming into work gets training prior to starting their shift. We are utilizing the employee list of all staff to confirm who has been trained and who not been trained. The Administrator, Director of Nursing and the staff development coordinator will be available at the start of each shift ensure this education is completed prior to staff starting their shift. An ad hoc quality assurance performance improvement meeting was held on [DATE], that included Dr., Administrator, Director of Nursing, corporate nurse, and regional director of operations. The root cause of the incident was noncompliance of one licensed practical nurse. Contents will be completed and the immediacy will be removed on [DATE]. **************************************************************** After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F678 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.