**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of Resident Identifier (RI) #215's medical record, the facility's investigation file, the (Name) AMBULANCE Patient Care Report and a complaint submitted the Alabama State Survey Agency, the facility failed to honor the wishes of RI #215, a resident with Full Code status. Code status describes what type of intervention a health care facility would conduct should a resident stop breathing and/or their heart stop beating. Full Code status means when a resident stops breathing and/or their heart stops beating, staff are to activate the emergency response system and initiate Cardiopulmonary Resuscitation (CPR) in an attempt to revive the resident. During the 11:00 PM to 7:00 AM shift that began on [DATE], Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) entered RI #215's room and found the resident unresponsive. EI #4 informed EI #3, the Registered Nurse (RN), who was certified in CPR. EI #3 assessed the resident and found RI #215 did not have a pulse or respiration. After the assessment, EI #3 left the resident's room to activate the emergency response system. EI #3 did not return to the resident's room to initiate CPR. According to the (Name) AMBULANCE Patient Care Report, CPR was not being performed when they arrived. This deficient practice placed RI #215, one of 21 sampled residents, in immediate jeopardy of serious injury, harm, or death. On [DATE] at 4:15 PM, the Administrator and Director of Nursing were notified of the findings of immediate jeopardy in the area of Resident Rights, F 578. Findings include: On [DATE] at 12:21 PM, the facility submitted to the Alabama State Survey Agency an allegation of neglect. According to the report, Employee Identifier (EI) #3, a Registered Nurse (RN) failed to perform Cardiopulmonary Resuscitation (CPR) on RI #215, a resident with Full Code status, who was found unresponsive on [DATE] at 5:45 AM. A typed statement on facility letterhead dated [DATE] signed by EI #2, the Director of Nursing (DON) documented Orchard Rehabilitation & Healthcare Center's Procedure for Identifying Residents Code Status In each resident's chart there is a form labeled; Resident Information Sheet. A Do Not Resuscitate (DNR) sticker is placed on this form indicating to the clinical staff that the resident has a DNR order and no CPR is warranted in the event the resident is found with no pulse, no respirations, no heartbeat or unconsciousness. Otherwise, the resident is a Full Code and CPR should be initiated. The nurses may but, is not required to write the Resident Information Sheet the words Full code which indicates CPR is to be provided if indicated. RI #215 was admitted to the facility on [DATE], with an admitting diagnosis of Dementia with Behavioral Disturbance. RI #215's undated RESIDENT INFORMATION SHEETS indicated the resident was a Full Code. The facility's 5-Day Investigation for (RI #215) dated [DATE], documented . On [DATE] around 5:45am, (EI #3), RN was informed by (EI #4), CNA that the resident was unresponsive and wasn't breathing. According to the nurse's notes after (EI #3) assessed the resident and found no pulse, no rise or fall in chest. Then, (EI #3) called the ambulance and informed them of resident's status. At 5:50 a.m., the ambulance arrived at the facility, EKG (electrocardiogram) strip obtained, indicating no signs of life . On [DATE], approximately 9:30a.m., the director of nursing (DON) audited the resident's medical record and upon reviewing the nurse's notes regarding the occurrences of events involving resident's expiration. During the audit, the initiation of CPR was not documented in the notes . around 10:30 a.m. DON asked her (EI #3) if CPR was performed on resident and nurse stated, No, I forgot . The facility substantiated that CPR was not performed by (EI #3), RN. On [DATE] at 11:20 AM, a telephone interview was conducted with EI #3, the RN who was notified that RI #215 was found unresponsive. EI #3 was asked, what did the American Heart Association CPR guidelines instruct staff to do when a person was found unresponsive. EI #3 said staff should check the pulse, check to see if the resident is breathing and initiate CPR. EI #3 was asked, what actions she took when she was informed RI #215 was unresponsive. EI #3 said she went into RI #215's room, checked the resident's pulse and looked to see if RI #215 was breathing. EI #3 said, RI #215's skin was cool to touch. After assessing RI #215, EI #3 left the resident's room to call the ambulance. EI #3 was asked if she had called a code or initiated CPR on RI #215. EI #3 said, no. When asked why she did not initiate CPR or call a code, EI #3 replied she panicked and forgot. When asked what RI #215's code status was, EI #3 stated she thought RI #215 was a Full Code. EI #3 explained that she had RI #215's medical record when she called the ambulance, but she did not check it to see what RI #215's code status was. EI #3 stated she did not think to check the resident's code status. When asked why not, EI #3 stated she panicked and forgot. In a follow-up telephone interview on [DATE] at 3:53 PM, EI #3 was asked what the harm was in failing to initiate CPR on RI #215, a resident withe Full Code status. EI #3 replied, the resident's wishes were not followed. RI #215's Departmental Notes, written by EI #3 and dated [DATE] 8:53 AM, documented: . 545AM Called to room by CNA. Resident lying in bed with eyes slightly open and mouth open with yellowish colored substance noted on gown and sheet. Unable to obtain pulse, no rise or fall of chest noted. (Name) Ambulance called and informed of resident status. 550 AM . (Name) Ambulance in facility, EKG strip ran, no sign of life noted. (Name) Ambulance exited building @ (at) 6AM . The (Name) AMBULANCE Patient Care Report indicated on [DATE] at 5:37 AM, EMS received an emergency call that RI #215 was found unresponsive in bed. According to the report, EMS arrived on scene at 5:45 AM and to the resident at 5:53 AM. The report further indicated . Arrived to find pt (patient) unresponsive in bed. Eyes dry pupils fixed and dialated (dilated), pulseless and apnic (apneic). Skin cool to touch color normal. No JVD (Jugular Vein Distention) or edema. Asystole times 3 leads pacing spikes. Rigor starting to set in. No CPR being performed . No ACLS (Advanced Cardiac Life Support) pronounced at 0600 . In an interview on [DATE] at 9:50 AM, EI #1, the Administrator, was asked what should be done when a resident was found unresponsive. EI #1 said, CPR should be initiated. When asked if the facility's protocol was followed when RI #215 was found unresponsive on [DATE], EI #1 said no. EI #1 was asked, what should EI #3, the RN, have done when she was informed RI #215 was unresponsive, EI #1 said, EI #3 should have started CPR. When asked what the harm was in failing to provide CPR to RI #215, a resident with Full Code status, EI #1 said the resident's wishes were not followed. Contained within the facility's investigation was a document titled . ACTION PLAN TOOL . DATE: [DATE] PROBLEM IDENTIFIED: CPR not initiated ACTION PLAN Discussion in Interdisciplinary morning meeting regarding facility's current procedure to perform CPR, if indicated, providing the resident is not a DNR status. A DNR sticker is found on the Resident Information Sheet to alert the nurse of a DNR status. Discussion was if facility needed to add another sticker that says Full Code to all charts that are not a DNR. Plan at this time is not to change the current procedure for identifying a resident's code status. However, there is a QAPI opportunity to train & re-educate all nurses on proper procedure on when to perform CPR. Training in progress since [DATE], regarding when to perform CPR . COMPLETION DATE [DATE] DATE COMPLETION FINALIZED [DATE]. ****************************** On [DATE] at 2:15 PM the facility submitted an acceptable Allegation of Credible Compliance (AOCC), which documented: . F578=IJ 1. On [DATE], RI#215 was admitted to the facility with a full code status. 2. On [DATE], RN did not perform Cardio Pulmonary Resuscitation (CPR) on RI#215 after she accessed the resident and found that the resident was unresponsive. 3. On [DATE], RN received 1:1 training by the DON on performing CPR on a resident who is found unresponsive or no signs of life. The residents code status should be determined and the code status is followed according to the resident's Advance Directive. If the resident is a full code, the nurse should perform CPR. A resident is a full code unless, there is a Do not resuscitate (DNR) sticker in front of the chart on the Patient Information sheet. A DNR sticker on the chart means that CPR is not warranted. All RNs received training on performing CPR by the DON on [DATE] which included: if a resident is found unresponsive or no sign of life the resident code status should be determined and code status is followed according to their Advance Directive. The nurse should perform CPR on a resident who is a full code. A resident is a full code unless, there is a Do not resuscitate (DNR) sticker in front of the chart on the Patient Information sheet. A DNR sticker on the chart means CPR is not warranted. 4. On [DATE], DON reviewed all residents' current charts to ensure the code is status clearly indicated for quick access by staff. 5. On [DATE], all charts were reviewed and found code status accurate. 6. On [DATE], the RN who failed to perform CPR was placed on suspension for 5 days and then placed on administrative leave [DATE]. RN has not worked between the suspension and the administrative leave. 7. On [DATE], the RN that failed to perform CPR was reported to the Alabama Board of Nursing. 8. On [DATE], an inservice was conducted for all licensed staff on 7-3 shift, 3-11 shift and 11-7 shift prior to the beginning of their shift. The training included, performing CPR on full code residents who are found unresponsive or no sign of life. The resident's code status should be determined and the code status followed according to their Advance Directive. The nurse should perform CPR on a resident who is a full code. A resident is a full code unless, there is a Do not resuscitate (DNR) sticker in front of the chart on the Patient Information sheet. A DNR sticker on the chart means CPR is not warranted. This training was conducted by the DON. 9. On [DATE], all licensed staff have received training on when to perform CPR when a resident found unresponsive or no sign of life. The resident code status should be determine and code status followed according to their advance directive. The nurse should perform CPR on a resident who is a full code. A resident is a full code unless there is a Do not resuscitate (DNR) sticker in front of the chart on the Patient Information sheet. A DNR sticker on the chart means CPR is not warranted. New hired licensed staff will receive CPR training during orientation. ************************ After reviewing the facility's information provided in their AOCC and verifying the immediate actions had been implemented, the scope/severity level of F 578 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. This deficiency was cited as a result of an investigation of complaint/report number AL00035599.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of Resident Identifier (RI) #215's medical record, the facility's policy with a subject of Advance Directives and Refusal of Treatment, the HIGHLIGHTS of the 2015 American Heart Association Guidelines Update for CPR (Cardiopulmonary Resuscitation) and ECC (Emergency Cardiovascular Care), the (Name) AMBULANCE Patient Care Report and a complaint submitted the Alabama State Survey Agency, Employee Identifier (EI) #3, a Registered Nurse (RN) failed to perform CPR on RI #215, a resident with Full Code status, who was found unresponsive, without a pulse or respiration, on [DATE]. Code status describes what type of intervention a health care facility would conduct should a resident stop breathing and/or their heart stops beating. Full Code status means when a resident stops breathing and/or their heart stops beating, staff are to activate the emergency response system and initiate CPR in an attempt to revive the resident. During the 11:00 PM to 7:00 AM shift that began on [DATE], EI #4, a Certified Nursing Assistant (CNA) entered RI #215's room and found the resident unresponsive. EI #4 informed EI #3, the RN, who was certified in CPR. EI #3 assessed the resident and found RI #215 did not have a pulse or respiration. After the assessment, EI #3 left the resident's room to activate the emergency response system. EI #3 did not return to the resident's room to initiate CPR. According to the (Name) AMBULANCE Patient Care Report, CPR was not being performed when they arrived. This deficient practice placed RI #215, one of 21 sampled residents, in immediate jeopardy of serious injury, harm, or death. On [DATE] at 4:15 PM, the Administrator and Director of Nursing were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality Life, F 678. Findings include: On [DATE] at 12:21 PM, the facility submitted to the Alabama State Survey Agency an allegation of neglect. According to the report, Employee Identifier (EI) #3, a Registered Nurse (RN) failed to perform Cardiopulmonary Resuscitation (CPR) on RI #215, a resident with Full Code status, who was found unresponsive on [DATE] at 5:45 AM. The facility's undated BALL HEALTH CARE SERVICES INC. ADMINISTRATIVE POLICY with a subject of Advance Directives and Refusal of Treatment documented: . STANDARD: . Prior to the arrival of EMS, Cardiopulmonary resuscitation (CPR) will be initiated for residents when cardiac arrest occurs, for residents who have requested CPR in their advanced directives, for residents who do not have a valid DNR order . The American Heart Association's HIGHLIGHTS of the 2015 American Heart Association Guidelines Update for CPR and ECC with a copyright date of 2015 documented . Summary of High-Quality CPR Components for BLS (Basic Life Support) Providers . Check for responsiveness No breathing or only gasping (ie, no normal breathing) No definite pulse felt within 10 seconds . If you are alone with no mobile phone, leave the victim to activate the emergency response system and get the AED (Automatic External Defibrillator) before beginning CPR Otherwise, send someone and begin CPR immediately . RI #215 was admitted to the facility on [DATE], with an admitting diagnosis of Dementia with Behavioral Disturbance. RI #215's undated RESIDENT INFORMATION SHEETS indicated the resident was a Full Code. The facility's 5-Day Investigation for (RI #215) dated [DATE], documented . On [DATE] around 5:45am, (EI #3), RN was informed by (EI #4), CNA that the resident was unresponsive and wasn't breathing. According to the nurse's notes after (EI #3) assessed the resident and found no pulse, no rise or fall in chest. Then, (EI #3) called the ambulance and informed them of resident's status. At 5:50 a.m., the ambulance arrived at the facility, EKG (electrocardiogram) strip obtained, indicating no signs of life . On [DATE], approximately 9:30a.m., the director of nursing (DON) audited the resident's medical record and upon reviewing the nurse's notes regarding the occurrences of events involving resident's expiration. During the audit, the initiation of CPR was not documented in the notes . around 10:30 a.m. DON asked her (EI #3) if CPR was performed on resident and nurse stated, No, I forgot . The facility substantiated that CPR was not performed by (EI #3), RN. On [DATE] at 11:05 AM, a telephone interview was conducted with EI #4, the CNA assigned to care for RI #215 during the 11:00 PM to 7:00 AM shift, beginning on [DATE]. EI #4 stated she was unsure of the time, but it was during her last rounds, she discovered RI #215 was unresponsive. When asked what she did, EI #4 stated she left the room to inform the Charge Nurse, EI #3. After notifying the Charge Nurse, EI #4 stated she and the Charge Nurse went to RI #215's room. According to EI #4, EI #3 assessed the resident. After assessing the resident, EI #3 left the resident's room and went to the nurses' station. EI #4 stated she was unsure what the Charge Nurse, EI #3, did at the nurses' station. Then EI #4 stated she noticed the paramedics came to the facility and hooked RI #215 up to a machine. When asked what RI #215's code status was, EI #4 said she did not know. When asked if a code was called, EI #4 said no. On [DATE] at 11:20 AM, a telephone interview was conducted with EI #3, the RN who was notified that RI #215 was found unresponsive. EI #3 acknowledged she was CPR certified. EI #3 was asked, what did the American Heart Association CPR guidelines instruct staff to do when a person was found unresponsive. EI #3 said staff should check the pulse, check to see if the resident is breathing and initiate CPR. EI #3 was asked, what actions she took when she was informed RI #215 was unresponsive. EI #3 said she went into RI #215's room, checked the resident's pulse and looked to see if RI #215 was breathing. EI #3 said, RI #215's skin was cool to touch. After assessing RI #215, EI #3 left the resident's room to call the ambulance. EI #3 was asked if she had called a code or initiated CPR on RI #215. EI #3 said, no. When asked why she did not initiate CPR or call a code, EI #3 replied she panicked and forgot. When asked what RI #215's code status was, EI #3 stated she thought RI #215 was a Full Code. EI #3 explained that she had RI #215's medical record when she called the ambulance, but she did not check it to see what RI #215's code status was. EI #3 stated she did not think to check the resident's code status. When asked why not, EI #3 stated she panicked and forgot. In a follow-up telephone interview on [DATE] at 3:53 PM, EI #3 was asked did she have a cell phone or any other communication device to call for assistance. EI #3 replied she had a cell phone. When asked if she used her cell phone to call the ambulance/Emergency Medical Service (EMS), EI #3 said no, she used the telephone at the nurses' station. EI #3 was asked what she did after she called EMS. EI #3 replied she was in panic mode. She did not know if she went back in RI #215's room or if she went into the office. EI #3 stated she knew she went in the office and made a copy of RI #215's face sheet for EMS. RI #215's Departmental Notes, written by EI #3 and dated [DATE] 8:53 AM, documented: . 545AM Called to room by CNA. Resident lying in bed with eyes slightly open and mouth open with yellowish colored substance noted on gown and sheet. Unable to obtain pulse, no rise or fall of chest noted. (Name) Ambulance called and informed of resident status. 550 AM . (Name) Ambulance in facility, EKG strip ran, no sign of life noted. (Name) Ambulance exited building @ (at) 6AM . The (Name) AMBULANCE Patient Care Report indicated on [DATE] at 5:37 AM, EMS received an emergency call that RI #215 was found unresponsive in bed. According to the report, EMS arrived on scene at 5:45 AM and to the resident at 5:53 AM. The report further indicated . Arrived to find pt (patient) unresponsive in bed. Eyes dry pupils fixed and dialated (dilated), pulseless and apnic (apneic). Skin cool to touch color normal. No JVD (Jugular Vein Distention) or edema. Asystole times 3 leads pacing spikes. Rigor starting to set in. No CPR being performed . No ACLS (Advanced Cardiac Life Support) pronounced at 0600 . On [DATE] at 10:04 AM, an interview was conducted with EI #2, the Director of Nursing (DON). When asked what RI #215's code status was, EI #2 replied the resident was Full Code. When asked if a code was called when RI #215 was found unresponsive, EI #2 said no, not according to the nurse's note. When asked was CPR initiated when RI #215 was found unresponsive, EI #2 said no. When asked was the facility's policy followed and correct actions taken when RI #215 was found unresponsive, EI #2 said no. In a follow-up interview on [DATE] at 3:31 PM, EI #2 was asked what steps staff should take when a resident is found unresponsive. EI #2 said, assess the resident, and check the resident's chart to see if the resident is a Full Code. If a Full Code, initiate CPR. When asked if CPR was initiated on RI #215, EI #2 said no. In an interview on [DATE] at 9:50 AM, EI #1, the Administrator, was asked what should be done when a resident was found unresponsive. EI #1 said, CPR should be initiated. When asked if the facility's protocol was followed when RI #215 was found unresponsive on [DATE], EI #1 said no. EI #1 was asked, what should EI #3, the RN, have done when she was informed RI #215 was unresponsive, EI #1 said, EI #3 should have started CPR. Contained within the facility's investigation was a document titled . ACTION PLAN TOOL . DATE: [DATE] PROBLEM IDENTIFIED: CPR not initiated ACTION PLAN Discussion in Interdisciplinary morning meeting regarding facility's current procedure to perform CPR, if indicated, providing the resident is not a DNR status. A DNR sticker is found on the Resident Information Sheet to alert the nurse of a DNR status. Discussion was if facility needed to add another sticker that says Full Code to all charts that are not a DNR. Plan at this time is not to change the current procedure for identifying a resident's code status. However, there is a QAPI opportunity to train & re-educate all nurses on proper procedure on when to perform CPR. Training in progress since [DATE], regarding when to perform CPR . COMPLETION DATE [DATE] DATE COMPLETION FINALIZED [DATE]. *************************** On [DATE] at 2:15 PM, the facility submitted an acceptable Allegation of Credible Compliance (AOCC), which documented: F678=IJ 1. On [DATE], RI #215 was admitted to the facility with a full code status. 2. On [DATE], RI#215 was found unresponsive by the RN and CPR was not initiated. 3. On [DATE], the RN was educated and then reeducated on [DATE] on performing CPR on residents that are full code. The code status is located in the front of the medical records on the Patient Information sheet. Education provided by the DON. 4. On [DATE], all other RNs were educated on when to performing CPR on a resident who are full code status. The code status is located in the front of the medical records on the Patient Information sheet. Education provided by the DON. 5. On [DATE], the DON implemented a weekly monitoring tool titled Deaths Facility to identify if CPR was performed on residents who were full code. 6. On [DATE], all other licensed staff was educated on performing on full code. The code status is located in the front of the medical records on the Patient Information sheet. The education was provided by the DON. 7. On [DATE], the DON reviewed all resident records using the facility census to determine which residents were full code and those who were DNR and that the code status was clearly identified in the medical records. 8. On [DATE], 3/11 and 11/7 were in-serviced prior to the beginning of the shift on Neglect and goods and service to care for the resident including CPR. All licensed staff will be in serviced by [DATE] by the DON or Designee. All other licensed nursing will be in serviced prior to the beginning of their shifts. Based on a review of the facility's in-service record, as of [DATE], nine of nine Registered Nurses and 10 of 11 Licensed Practical Nurses had been in-serviced on Performing CPR on residents. *************************** After reviewing the facility's information provided in their AOCC and verifying the immediate actions had been implemented, the scope/severity level of F 678 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. This deficiency was cited as a result of the investigation of complaint/report number AL00035599.