**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received immediate basic life-saving support, including cardiopulmonary resuscitation (CPR, any medical intervention used to restart a person's heartbeat and breathing after one or both have stopped), as per the resident's representative wishes and not by the Physician Orders for Life Sustaining Treatment (POLST - is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) form the Social Services Director (SSD) asked Resident 1 to sign on [DATE] despite Resident 1 being confused, unable to make decisions, and having Family Member 2 (FM 2) as the resident's representative. The POLST indicated do no attempt resuscitation (DNR) and comfort focused treatment (refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort). As a result, on [DATE] at 11:40 a.m., when Resident 1 had no blood pressure reading, CPR was not attempted. Resident 1 was pronounced dead on [DATE], at 11:46 a.m. Because of the seriousness related to Resident 1's signing a POLST when impaired and against the Resident 1's representative wishes and not providing the necessary care and treatments, on [DATE], at 4:48 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) under the 42 Code of Regulation (CRF) §483.24 Quality of Life (F678) with the scope and severity of J (isolated) in the presence of the facility's Administrator, Company's lead DSD, Company's Chief Nursing Officer, and the Director of Nursing (DON). On [DATE], at 6:32 p.m., after the facility provided an acceptable IJ Removal Plan (interventions to correct the deficient practice), while onsite, the team confirmed the implementation of the immediate corrective actions through observation, interview, and record review. The SSA removed the IJ situation in the presence of the Administrator and the DON on [DATE], at 6:45 p.m. The IJ Removal Plan included the following summarized actions: a. On [DATE], the facility's Medical Director (FMD) was notified of the complaint visit and that an intent to cite was issued to the facility. b. On [DATE], the FMD was notified of the IJ situation. The DON, DSD, Lead DSD or designee completed a chart audit on every resident and compared the advance directives, including POLST/Advance Directive to the physician order for accuracy as well as resident's capacity to make decision. Six residents had the POLST signed by family member and not the responsible party. 1l residents with the capacity had the POLST signed by responsible party. The facility reached out to the responsible parties or spoke with residents respectively on [DATE]. c. Residents with change of condition for the past 24 hours were audited to ensure that responsible party and primary physicians were notified as indicated and that medical emergency response were implemented were indicated. d. On [DATE], the Resource Nurse Consultant provided one on one (ASS) on how to complete the POLST focusing on a resident's mental capacity to understand and make decision. Residents must be competent (have the mental capacity) to make medical decision. The SSD and ASS were inserviced on the facility's policy and procedures (P&P) and on notifying a resident's family member regarding any resident's POLST status whether Full Code, No Code or Comfort-Focused Treatment or Selective Treatment. e. The Resource Nurse Consultant and Lead DSD re-educated licensed nurses on the facility's P&P regarding the immediate notification of the attending physicians when a residents develops a significant change of condition (COC - a significant change) and how to complete the POLST/ Advance Directive focusing on a resident's mental capacity to understand and make decisions. A resident's family member must be notified of any resident's POLST status. f. By [DATE], the Resource Nurse Consultant and Lead DSD educated licensed nurses on the facility's P&P for medical emergency response including transfer to a General Acute Care Hospital respecting residents' wishes. g. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented on [DATE]. The DON or a designee to monitor for code status, resident's capacity to make decisions, COC timely notification of responsible party and primary physician and medical emergency response including transfer to a general acute care hospital (GACH) compliance for at least five resident's chart during their scheduled care conference meeting starting on [DATE]. h. The Medical Records Director (MRD) or designee to audit new admissions (residents) and to compare the resident's POLST, advance directives with resident's capacity to make decisions to the physician orders for accuracy. The audit trends will be reported and reviewed at the monthly QAA Committee meeting for three months or until substantial compliance is sustained. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on [DATE] with diagnoses including Alzheimer dementia (A progressive disease that destroys memory and other important mental functions), diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]), chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should), and gastroenteritis (intestinal infection that includes symptoms such as watery diarrhea, stomach cramps, nausea or vomiting), and dysphagia (difficulty or abnormality of swallowing) oropharyngeal phase (characterized by difficulty initiating a swallow - occurring in the mouth and/or the throat). The admission Record indicated FM 2 was Resident 1's representative. A review of Resident 1's Standard admission Agreement, dated [DATE], indicated that on [DATE], FM 2 electronically signed the standard admission agreement as the legal representative for Resident 1. The standard admission agreement further indicated, The resident consents to routine nursing care ., as well as emergency care that is required. A review of Resident 1's POLST prepared on [DATE] indicated: - Section A Cardiopulmonary Resuscitation (CPR): Do not attempt resuscitation/DNR (allow natural death). - Section B Medical intervention: Comfort focused treatment - Section C Artificially Administered Nutrition: No artificially means of nutrition including feeding tubes (flexible tubes inserted in the nose or through the stomach for nutrition, medication, and hydration). - Section D Information and Signatures: discussed with patient (patient has capacity); Patient has no advance directives (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury). Resident 1 signed with a date of [DATE] overwritten on the date of [DATE]. However, the physician signed on [DATE]. The signature box indicated, I am aware that this form is voluntary. By signing this form, the person legally recognized acknowledges that this form regarding resuscitative measures is consistent with the known desires of. and with the best interest of. the individual who is the subject of this form. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated Resident 1 had moderately impaired cognition (a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 1 required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of the Physician's Order for Resident 1, dated [DATE], indicated DNR and comfort focused treatment. A review of the Physician's Order for Resident 1 dated [DATE], indicated to give intravenous fluid (IVF - administer into a vein) Dextrose (sugar) 5% with Sodium Chloride (salt) 0.9% solution (D5w/NS) at 50 milliliters (ml - unit of measurement) per hour (ml/hr) every shift for poor oral intake for five days. A review of Resident 1's nursing Progress Notes, dated [DATE] and timed at 8 a.m., indicated Resident 1 was in sleeping state, able to arouse, receiving IVF, and Resident 1's grandkids were at bedside. There was no documentation the licensed nurse called Resident 1's attending physician about the resident being in a sleeping state (asleep). A review of Resident 1's nursing Progress Notes, dated [DATE] and timed at 10:45 a.m., indicated Resident 1 was sleeping, able to open eyes, answer yes / no questions, and did not eat her breakfast. At 11 a.m., Resident 1 was noted with labored (difficult) breathing, her Oxygen (O2) Sat was 85%. Resident 1 was administered oxygen (O2) at 2 liters per minute (2L/min) through a nasal cannula (device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils). At 11:30 a.m., Resident 1's O2 Sat increased to 92%, the resident was still in a lethargic state (condition that involves deep and lasting drowsiness from which the person can be aroused only with difficulty), with a weak pulse, the heart rate was 67 beats per minute (bpm, normal rate 60-100 bpm), the breathing rate was 16 breath per minute (normal range 16 to 20 breaths/min), the blood pressure was 85/60 millimeters of mercury (mmHg - unit of measurement [normal blood pressure less than 120/80 mmHg), the body temp 97.8 degrees Fahrenheit (°F, normal range 97°F to 99°F), and the O2 Sat was 82%. FM 2 arrived and requested to transfer Resident 1 to hospital. Called 911 (telephone number for emergencies to request emergency medical services [EMS, paramedics - are healthcare professionals who respond to emergency calls for medical help outside of a hospital]) and came. At 11:40 a.m., the paramedics were unable to obtain Resident 1's blood pressure. At 11:52 a.m. unable to check apical pulse (taken in the left center of the chest, just below the nipple) and the resident was not breathing. Family at bedside. At 12 p.m., the paramedics called the police who arrived at 12:30 p.m. The police called and spoke to Resident 1's attending physician. Family called the mortuary and cleaned Resident 1's body. At 2:40 p.m., the mortuary picked up Resident 1's body. A review of Resident 1's SSD notes dated [DATE], a late entry for [DATE], indicated SSD communicated with FM 2 on [DATE] during a care conference and SSD informed FM 2 that Resident 1 clearly did not want to be full code (do CPR). SSD explained that if CPR was checked on the POLST, then a resident would receive full treatment, with the option of intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe) and advance respiratory interventions. FM 2 stated he would speak with Resident 1 and would get back to SSD. On [DATE], at 9:30 a.m., during a telephone interview, FM 1 stated that on [DATE], at 10:56 a.m., she was at Resident 1's bedside since earlier in the day. FM 1 stated Licensed Vocational Nurse 2 (LVN 2) checked on Resident 1 and told FM 1 that Resident 1 did not look well. LVN 2 checked Resident 1's vital signs (include blood pressure, heart and respiratory rate, body temperature). LVN 2 placed Resident 1 on oxygen and the bed in Trendelenburg position (the patient lays flat on the back on a 15-30-degree incline with the feet elevated above the head). LVN 2 told FM 1 to call the rest of family members. FM 1 stated FM 2 arrived at the facility at 11:25 a.m. and asked the nurses if they had called 911 and Registered Nurse 2 (RN 2) provided FM 2 with Resident 1's POLST and asked FM 2 if he still wanted RN 2 to call 911. FM1 stated FM 2 questioned RN 2 about the validity of Resident 1's POLST document because FM 2 was Resident 1's legal representative. FM 1 stated FM 2 told RN 2 to call 911. FM 1 stated that when paramedics arrived, the paramedics told FM 2 that Resident 1 was pulseless (no heart beat) and unresponsive (not reacting when touched, spoken to, etc.) and asked if FM 2 wanted them to initiate CPR and FM 2 said no. FM 1 stated that FM 1, FM 2, and other family members visited Resident 1 every day and the staff did not inform any of them that Resident 1 had signed a POLST and was a DNR with comfort focused care. On [DATE], at 12:55 p.m., during an interview with RN 1 and concurrent review of Resident 1's POLST, RN 1 stated she was familiar with the care of Resident 1 and was aware the family was very involved in Resident 1's care, visited and checked on Resident 1 every day. RN 1 stated Resident 1 was deemed by the attending physician as unable to make decisions and could not sign a POLST (date not provided). On [DATE], at 1:25 p.m., during an interview, the SSD stated that on [DATE] the facility conducted interdisciplinary team (IDT - a group of health care professionals from various disciplines who work together on the care of the resident) care conference and she (SSD) informed FM 2 about the POLST Resident 1 signed. FM 2 stated he wanted CPR done for Resident 1 and he would discuss the signed POLST with Resident 1 and get back to SSD, but FM 2 did not get back to her (SSD). On [DATE], at 3:10 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 did not have the mental capacity to make decisions or consent to a POLST. On [DATE], at 10:34am, during an interview, RN 2 stated she was the supervisor on [DATE], when Resident 1 experienced a change of condition and subsequently died. RN 2 stated Resident 1 has a signed POLST for DNR and comfort measures and that was the reason they did not call the physician or paramedics. RN 2 stated that when the paramedics arrived, Resident 1 had no heartbeats and was not breathing. Paramedics asked FM 2, if he wanted the paramedics to initiate CPR but FM 2 declined. On [DATE], at 11:30 a.m., during an interview, LVN 2 stated that on [DATE], when she returned from her break at 10:59 a.m., she went to check Resident 1's blood sugar Resident 1 responded sluggishly to her compared to how Resident 1 was at 8 a.m. when LVN 2 last spoke to Resident 1. LVN 2 stated Resident 1's blood sugar was 441 milligrams per deciliters (mg/dl), and she administered Resident 1 a dose of 12 units of insulin (medication to decrease the blood sugar) as ordered and notified RN 2. LVN 2 stated when FM 2 arrived at the facility and yelled out loudly, why is no one doing anything? Did you call 911? On [DATE], at 10 a.m., during an interview, the SSD stated she and the assistant SS (ASS) interviewed Resident 1 regarding the POLST. The SSD stated the ASS spoke Resident 1's native language and also interpreted for the SSD. The SSD stated that during Resident 1's assessment interview, Resident 1 was able to state her name. The SSD stated Resident 1 said had a weak heart and knew that she was in a hospital but could not know which hospital. The SSD stated that based on Resident 1's response, she determined Resident 1 was capable of understanding and making decisions and SSD had Resident 1 sign the POLST. The SSD stated Resident 1 agreed to a DNR status with comfort measures only (refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort). The SSD stated she did not review Resident 1's medical record to check if Resident 1 had the capacity to understand and make decisions. On [DATE], at 10:30 a.m., during an interview, the DON stated Resident 1 expired unexpectedly in the facility and paramedics pronounced (declared) Resident 1 dead on [DATE], at 11:46 a.m. On [DATE], at 11:15 a.m., during an interview, FM 2 stated on [DATE], the facility conducted an IDT meeting with him and discussed Resident 1's treatment plan, care plan plans and goals. FM 2 stated during the IDT meeting he expressed his desired goal for Resident 1 to eat more, get stronger, and return to the Assisted living Facility (AFL, housing and services for people who need some help with daily care) the resident lived before going to the hospital. FM 2 stated FM 1 called him on [DATE], at 11 a.m., to inform him Resident 2 did not look well and the nurses were asking for him (FM 2) to come to the facility. FM 2 stated he arrived at the facility at about 11:25 a.m. and asked the nurses if they had called 911 and RN 2 gave him Resident 1's POLST form. FM 2 stated RN 2 refused to answer when he questioned the validity of the POLST why no one had discussed Resident 1's POLST with him as the resident's legal representative and he was the signatory of all the other documents pertaining to Resident 1's admission to the facility. FM 2 stated when the paramedics arrived, Resident 1 was already dead and that is the reason he declined when paramedics asked him if he wanted them to initiate CPR. On [DATE], at 3:47 p.m., during an interview, the facility's Medical Director (FMD) stated a medical assessment is required to determine a resident's capability to understand and make decisions. The FMD stated it was important to involve the resident's family members in the care of the resident. The FMD stated if medical interventions have been attempted and a resident does not respond positively to the treatment/interventions, the resident should be transferred to a hospital for further evaluation and diagnostic tests to rule out any medical problems. A review of the paramedics Patient Care Report dated [DATE], indicated dispatch was notified at 11:30 a.m., paramedics arrived at Resident 1's bedside at 11:46 a.m., to find an [AGE] year-old female on bed supine (face up) unresponsive, apneic (not breathing), pale, pupils dilated (when the black/dark center of the eyes are larger than normal), non-responsive, pulseless, asystole (no heartbeat) on monitor. A review of facility's policy and procedures (P&P) titled, Informed Consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) dated [DATE] indicated, it is the responsibility of the healthcare professional who proposes any medical interventions or treatment that requires informed consent to provide information to the resident/resident representative regarding the resident's condition and circumstances that are pertinent to a decision to accept or refuse the proposed intervention or treatment. A review of the facility's P&P titled, Residents' Rights Regarding Treatment and Advanced Directives dated [DATE] indicated, In the event the resident is unable to formulate an Advance Directive (AD) due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and education to the resident representative. A review of facility's P&P titled, Residents' Rights Regarding Treatment and advanced Directives, dated [DATE], indicated, Policy Explanation and Compliance Guidelines: 1. a. In the event the resident is unable to formulate an Advance Directive (AD) due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and education to the resident representative.