**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, Resident Identifier (RI) #264's medical record, FUNDAMENTALS OF NURSING NINTH EDITION, the facility's PROTOCOL FOR EMERGENT CARE, the facility policy titled Cardio Pulmonary Resuscitation (CPR), and a facility reported incident received by the Alabama State Survey Agency, the facility failed to honor the end-of-life wishes of RI #264, a resident with an Advanced Directive to withhold resuscitative measures in the event of cardiopulmonary cessation and an active physician's order for DNR (Do Not Resuscitate) code status. The DNR order directed staff to not initiate CPR when the resident stopped breathing and/or their heart stopped beating. During the evening shift on [DATE], RI #264 was found unresponsive with no pulse or respirations. Licensed Practical Nurse (LPN) #3 did not check RI #264's code status in accordance with the facility's protocol before she initiated CPR. As a result of initiating CPR and activating emergency medical services (EMS), facility staff performed chest compressions and EMS staff continued chest compressions with LUCAS Devise (a mechanical chest compression device), performed endotracheal intubation, performed decompression of RI #264's right lung, and obtained intravenous (IV) and intraosseous (IO) access during the attempt to resuscitate RI #264. This deficient practice placed RI #264, one of three sampled residents reviewed for advance directives and code status, in immediate jeopardy, as the failure of facility staff to honor a resident's end-of-life wishes was likely to cause serious injury, serious harm, serious impairment, or death. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.10 Resident Rights at a scope and severity of J. On [DATE] at 5:15 PM, the Administrator and Regional Administrator were provided a copy of the immediate jeopardy template and notified of the findings at the immediate jeopardy level in the area of Resident Rights at F578-Request/Refuse/Discontinue Treatment/Formulate Advance Directives. The IJ began on [DATE] and continued until [DATE] when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past non-compliance was cited. Findings include: FUNDAMENTALS OF NURSING NINTH EDITION, with a copyright date of 2017, Chapter 23, titled Legal Implications in Nursing Practice, page 305, documented: . Advance Directives include living wills, health care proxies, and durable powers of attorney for health care .They are based on values of informed consent, patient autonomy over end-of-life decisions, truth telling, and control over the dying process . Health care providers perform CPR when needed unless there is a DNR order . The facility's policy titled Cardio Pulmonary Resuscitation (CPR), with an effective date of [DATE], documented: . PURPOSE: To circulate blood containing oxygen to vital organs pending the arrival of emergency medical services (EMS) to a resident/guest who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with the resident/guest(s) advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order . A review of the facility's undated PROTOCOL FOR EMERGENT CARE, documented: If A Resident/Guest Is Found To Be Unresponsive To Verbal and Physical Stimuli, You Must Initiate The Following Protocol For Emergent Care: . A staff member should access E-chart (electronic health record) immediately and verify the identification of the resident/guest . and if there is an order for DNR . Have a nurse notify Physician of change in condition and whether resident/guest has a current DNR order . RI #264 was admitted to the facility on [DATE], with diagnoses of Venous Insufficiency, Hypertensive Heart Disease and Chronic Kidney Disease. RI #264's Alabama Portable Physician Do Not Attempt Resuscitation Order, No/CPR/Allow Natural Death, signed by RI #264's designated health care proxy on [DATE], documented: . I, the undersigned, am the health care proxy . designated by the patient/resident to make decisions regarding the providing, withholding, or withdrawal of life-sustaining treatment for the patient/resident. I hereby direct that resuscitative measures be withheld from the patient/resident in the event of cardiopulmonary cessation . Review of RI #264's February 2023 PHYSICIAN ORDERS, revealed an order dated [DATE] for . Status . DNR . On [DATE] at 4:33 PM, the Alabama State Survey Agency received a Facility Reported Incident (FRI) which indicated staff found RI #264 unresponsive on [DATE] at 10:15 PM. The FRI report documented Narrative summary of the incident: Life-saving measures were provided to RI #264 .The guest did expire. Afterwards, the family alerted the nurse to the fact that RI #264 had a DNR order in place . Action(s) taken by the facility in response to the incident . It does appear that there was a DNR order in place and that life-saving measures were provided . The EMS run report, dated [DATE], indicated the facility contacted EMS on [DATE] at 9:37 PM. EMS arrived to RI #264 at 9:46 PM. The Narrative Section documented the following: . Dispatched on a call for CARDIAC ARREST . Control advised that CPR was in progress .The patient was apneic and being ventilated with a BVM (Bag Valve Mask) . EMS crews immediately took over CPR efforts and placed a [NAME] Device on the patient which provided compressions . A 18 G (gauge) IV (intravenous) was placed in the Right AC (antecubital) and the patient was intubated with 7.0 endotracheal tube and ventilated with a BVM . Paramedic . decompressed his/her right lung . blood came out of the decompression needle . Treatment included IV, IO access, ALS (Advanced Life Support) assessment, Vitals monitoring, endotracheal intubation, 5x EPI (epinephrine) 1:10,000, sodium bicarbonate, calcium chloride, 750 ml (milliliters) of normal saline bolus, The patient was treated using the AHA (American Heart Association) ACLS (Advanced Cardiac Life Support) Algorithm. The patient was not transported and CPR efforts were discontinued .Time of death was called at 22:20 (10:20 PM) . The facility document titled Verification of Investigation documented the facility's investigation and review of the incident. According to the facility's investigation, it was discovered that a physician's order had been issued for RI #264 to be a DNR; however, LPN #3 failed to adhere to the established protocol while searching for RI #264's code status. The investigation further revealed, the nursing staff had been trained to check the laptop first for code status, and if unavailable, refer to the hard chart. The investigation documented that there was no evidence to suggest that LPN #3 followed either of these steps before initiating CPR for RI #264. On [DATE] at 3:46 PM RI #264's Health Care Proxy (HCP) and spouse, was interviewed. The HCP confirmed that RI #264 was a DNR, which was consistent with RI #264's end-of-life wishes and his/her end-of-life wishes for RI #264. The HCP said when he/she arrived at the facility he/she was informed that CPR was performed, and he/she let the facility know that CPR should not have been performed because RI #264 had DNR code status in accordance with both of their wishes. The HCP said it was hard seeing RI #264 after the resuscitation efforts, and he/she saw bruises on RI #264's chest. On [DATE] at 9:52 AM, an interview was conducted with LPN #3 who said she reported to work at approximately 7:00 PM on [DATE]. According to LPN #3, early in the shift and while administering medication, Certified Nursing Assistant (CNA) #6 informed her that RI #264 was experiencing difficulty breathing. Upon observation and assessment, LPN #3 said RI #264 had labored breathing and an O2 (oxygen) saturation of 74 percent (%). LPN #3 said RI #264 stopped breathing shortly after she responded. LPN #3 said she looked in RI #264's medical chart and did not find any document indicating that RI #264 was a DNR. LPN #3 said she assumed that RI #264 was a full code because she did not see anything in the chart. LPN #3 said she obtained the crash cart and then entered RI #264's room, assessed his/her pulse, and initiated CPR. LPN #3 stated that she continued performing chest compression until another nurse arrived and took over. LPN #3 said that EMS personnel took over the CPR upon their arrival. LPN #3 said after RI #264 was pronounced dead, the resident's family arrived at the facility. LPN #3 said RI #264's spouse had asked why RI #264 was intubated since he/she had DNR code status. Later during the interview, LPN #3 stated the facility policy directed staff to first access the E-Chart to determine a resident's code status and only resort to the physical chart if the E-Chart was unavailable. LPN #3 admitted to not following the policy when she relied on the physical chart to locate the code status. LPN #3 said disregarding a resident's advanced directives resident could cause the resident to experience pain and trauma resulting from the resuscitation, intubation, and IV administration. An interview was conducted with LPN #27 on [DATE] at 1:55 PM. LPN #27 said that she did not check the code status when she responded to the code involving RI #264 on [DATE], because she assumed it had already been done. LPN #27 said the importance of following a resident's advanced directives was to ensure their wishes regarding CPR and end-of-life care were honored. An interview was conducted with LPN #5 on [DATE] at 7:21 PM. LPN #5 said she responded to the code involving RI #264 on [DATE] after the code was announced. LPN #5 explained that the facility's policy indicated the code status was to be verified before initiating a code. LPN #5 said when she arrived at the code, she assumed that RI #264 was a full code. An interview was conducted with the Director of Nursing (DON) on [DATE] at 5:20 PM. The DON said the potential harm of failing to follow an advanced directive could result in death or pain if CPR was administered. An interview was conducted with the Administrator on [DATE] at 12:30 PM. When asked about RI #264, the administrator said CPR was performed on this resident who was a DNR. The administrator said that the nurse did not follow policy when she checked RI #264's code status which resulted in CPR being performed on a resident with a DNR. The administrator said it was important to follow a resident's advanced directive to ensure the resident's wishes were carried out. The administrator said the potential harm of not following an advanced directive would be loss of dignity and rights for the resident. This deficiency was cited as a result of complaint/report number AL00043289. ************************* The facility took immediate actions to correct the non-compliance and prevent reoccurrence by: - On [DATE] the facility identified that Licensed staff had initiated CPR on RI #264 when RI #264 had an active DNR order and began immediate actions to correct the noncompliance. - On [DATE] an investigation was initiated, the event was reported to ADPH on [DATE], two LPNs involved both received one on one education and education of all licensed staff was initiated. - Education of licensed nurses was completed on [DATE]. - On [DATE] mock codes were initiated and continued on [DATE] to include all licensed nurses. - On [DATE] a review of all DNRs in the building was completed. - On [DATE] an emergency Quality Assurance and Performance Improvement (QAPI) meeting was completed related to Emergency Protocols. Monitoring was established that the facility would continue to monitor DNR codes by providing emergent care protocol training with code drill upon hire, quarterly and as needed. ************************* After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from [DATE] to [DATE], thus immediate jeopardy past non-compliance was cited.