**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility document and policy review, the facility failed to implement a system that allowed staff to quickly and accurately identify code status (describes the type of interventions to be provided when an individual is found without a pulse or not breathing) in the event of an emergency and failed to honor the advance directive of 1 (Resident #32) of 4 sampled residents reviewed for advance directives. Specifically, on [DATE], staff initiated cardiopulmonary resuscitation (CPR) when Resident #32 was found unresponsive, despite the resident having a signed physician's order for life sustaining treatment (POLST) and an advance directive on file that indicated the resident elected do not resuscitate (DNR) in the event they were found not breathing or without a pulse. Resident #32 received CPR at the facility, endured painful resuscitation procedures, sustained injuries, was hospitalized , and expired in the hospital the following day. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.24(a)(3) (Quality of Care) at a scope and severity of J. The IJ began on [DATE] when Resident #32 received CPR from staff, dishonoring the resident's advance directive and physician-signed POLST form that specified DNR, resulting in injuries sustained during CPR procedures, hospitalization, and prolonged death until [DATE]. The Administrator and Director of Nursing (DON) were notified of the IJ and provided a copy of the IJ template on [DATE] at 6:43 PM. A removal plan was requested. The Removal Plan was accepted by the state survey agency on [DATE] at 8:49 PM. The IJ was removed on [DATE] at 4:03 PM, after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F678 remained at the lower scope and severity of G, actual harm. Findings included: A review of a facility policy titled, Advance Directives, revised in [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy. The policy indicated, 9. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The policy further indicated, 14. In accordance with current OBRA [Omnibus Budget Reconciliation Act] definitions and guidelines governing advance directives, our facility has defined advanced [sic] directives as preferences regarding treatment options and include, but are not limited to: a. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated, e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used, and h. Life-Sustaining Treatment - treatment that, based on reasonable medical judgement, sustains an individual's life and without it the individual will die. This includes medications and interventions that are considered life-sustaining, but not those that are considered palliative or comfort measures. A review of a facility policy titled, Do Not Resuscitate Order, revised in [DATE], revealed, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Policy Interpretation and Implementation 1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record, 3. In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include: a. Physician Orders for Life-Sustaining Treatment (POLST). The policy further specified, 5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. a. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. b. Both witnesses must have heard the request, and both individuals must document such information on the physician's order sheet. c. The Attending physician must be informed of the resident's request to cease the DNR order. A review of Resident #32's admission Record revealed the facility admitted the resident on [DATE] and most recently readmitted the resident on [DATE] with diagnoses that included unspecified symptoms and signs involving cognitive functions following a cerebral infarction (stroke), type two diabetes mellitus, essential hypertension, hyperlipidemia (high cholesterol), and unspecified severe protein-calorie malnutrition. The section of the admission Record for Advance Directive information was blank. A review of a POLST form, dated [DATE] and signed by a physician and Resident #32, revealed that at the time of admission, Resident #32's POLST specified, If patient has no pulse and is not breathing, Attempt Resuscitation/CPR. The Form also included, the following guidance, Reviewing POLST: It is recommended that POLST be reviewed periodically. Review is recommended when: -The patient is transferred from one care setting or care level to another, or -There is substantial change in patient's health status, or -The patient's treatment preferences change. Modifying and voiding POLST: -A patient with capacity can, at any time, request alternative treatment or revoke a POLST by any means that indicates intent to revoke it. It is recommended that revocation be documented by drawing a line through Sections A through D, writing VOID in large letters, and signing and dating this line. -A legally recognized decision maker may request to modify orders, in collaboration with the physician/NP [nurse practitioner]/PA [physician's assistant], based on the known desires of the patient, or, if unknown, the patient's best interests. A review of Resident #32's California Advance Health Care Directive, dated [DATE], notarized and signed by the resident and the resident's power of attorney (POA), indicated a Choice NOT To Prolong Life: I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits. On [DATE] at 3:50 PM, a review of Station #2 and Station #3's POLST book, revealed a more recent copy of a POLST form for Resident #32, dated [DATE] and signed by a physician and Resident #32's POA. Resident #32's [DATE] POLST indicated, If patient has no pulse and is not breathing, Do Not Attempt Resuscitation/DNR. (Allow Natural Death). A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. Section S of the MDS, related to POLST and code status, was not completed. A review of Resident #32's comprehensive Care Plan revealed there were no Focus areas or interventions related to the resident's end of life wishes. There was, however, a Focus area, initiated on [DATE], that indicated the resident required transfer to an acute care setting due to being unresponsive, and the resident's condition was unable to be managed in the facility. An intervention directed staff to send a copy of the resident's code status/POLST to the acute care facility. A review of Resident #32's Order Summary Report, listing active orders as of [DATE], revealed an order dated [DATE] for DNR. A review of Resident #32's Progress Notes revealed the following entries: - a Change of Condition note, dated [DATE] at 1:51 PM that indicated Resident #32 yelled Help at 1:20 PM. Per the note, a registered nurse (RN) went in right away and found the resident unresponsive, and a Full code was confirmed and a Code Blue was paged overhead. The note further indicated no respirations or heartrate were found. According to the note, CPR was initiated, the resident's blood sugar was checked, suctioning was performed, and the physician was notified. Per the note, at 1:24 PM, a pulse was felt, but the resident remained unresponsive, and after ongoing CPR, at 1:27 PM, staff were unable to obtain a pulse, respiratory rate, or blood pressure. Intravenous (IV) fluids were given, and paramedics arrived at 1:32 PM and took over CPR. The note indicated that at 1:38 PM, 18 minutes after calling the code, the nurse notified Resident #32's POA, and the POA agreed to Full code CPR. The paramedics and fire department continued CPR and transported Resident #32 to a local hospital at 1:57 PM; and - a Nurse's Note documented by Registered Nurse (RN) #9, dated [DATE] at 2:31 PM, that indicated at 1:20 PM, the resident called out for help, and RN #9 responded and found the resident on the bed with their eyes open and breathing, but unresponsive. Per the note, the resident's pulse was initially 75 beats per minute and their oxygen saturation was 100 percent (%), but the resident suddenly stopped breathing and had no pulse. The note further indicated a code blue was initiated, 911 was called, and CPR was initiated. A review of Resident #32's hospital record revealed an HPI [History of Present Illness]- General Illness note, dated [DATE] at 2:38 PM, that indicated Resident #32 was found unresponsive and pulseless, and CPR was initiated. Per the note, emergency medical services (EMS) reported that upon arrival at the skilled nursing facility, Resident #32 was found to be in ventricular fibrillation (VFib) arrest (when the lower heart chambers contract in a very rapid and uncontrolled manner, resulting in no blood pumped to the rest of the body). The note indicated CPR was performed for around 25 minutes, in conjunction with four rounds of epinephrine and four rounds of shock. The note indicated that on [DATE] at 3:50 PM, upon a Physical Exam, Resident #32 was intubated, pulseless, and on a vent, bilateral breath sounds present. The note further indicated, On arrival [to the hospital], patient lost pulses so CPR was restarted. Patient was intermittently going into Vtach [ventricular tachycardia], therefore patient given one more round of shock. The note also detailed conversations with Resident #32's POA regarding the resident's end of life wishes. The note indicated Resident #32's POA reported to the hospital that the resident told them many times that they wanted to be DNR, but the paperwork was not completed, and the current paperwork reflected the resident was a full code. Per the note, the POA requested the hospital place the resident on hospice care with no further workup or treatment at this time and wants to focus on comfort care. On [DATE] at 9:21 AM, a phone call was placed to Resident #32's POA. A voicemail was left, but no return call was received. A review of computed tomography (CT) results, performed in the hospital on [DATE], revealed the IMPRESSION included, 5. Acute, nondisplaced fracture of right anterolateral 2nd rib. Acute, mildly displaced fractures of the right anterior 2nd-5th ribs at the costochondral junction. 6. Acute, displaced fractures of the left anterior 3rd-6th ribs. 7. Suspected acute nondisplaced sternal fracture. Findings are most likely due to chest compressions. A review of a hospital Multidisciplinary Team Note, dated [DATE] at 4:14 PM, revealed, Patient extubated at 1614 [4:14 PM]. Patient subsequently went agonal and asystole on the monitor. Per the note, asystole and no pulse were verified by two nurses, and a physician was notified. Resident #32's time of death was [DATE] at 4:25 PM. A review of Resident #32's deceased Discharge Summary, dated [DATE] at 4:42 PM, revealed, Preliminary cause of death included VFib cardiac arrest status post ROSC [return of spontaneous circulation] and Acute hypoxic respiratory failure status post intubation on mechanical ventilation. During an interview on [DATE] at 8:35 AM, RN #9 stated she was the nurse that performed CPR on Resident #32. She stated she was sitting at the nurse's station and heard the resident call for help. When she went to the room, the resident's eyes were open, but the resident did not respond. According to RN #9, Licensed Vocational Nurse (LVN) #5 and MDS Nurse #2 were at the nurse's station at the time. RN #9 said she told LVN #5 to call a code blue. Per RN #9, MDS Nurse #2 looked in the POLST book at the nurse's station and could not find Resident #32's POLST, so she used the POLST that was scanned into the resident's electronic health record (EHR), which indicated Resident #32 was a full code. RN #9 stated the paramedics arrived and were given a copy of the POLST printed off the computer that indicated the resident was a full code. RN #9 could not recall the date on the POLST form they pulled from the computer and subsequently provided to the paramedics, but she confirmed the document indicated Resident #32 was to be a full code. During an interview on [DATE] at 12:53 PM, LVN #5 stated she was at the nurse's station and heard Resident #32 scream for help. Per LVN #5, RN #9 went to check on the resident and told LVN #5 to call a code blue and to check the resident's POLST. RN #9 said when she and MDS Nurse #2 located a POLST that indicated full code, CPR was initiated and 911 was contacted. LVN #5 stated she was the one that called Resident #32's POA and informed them facility staff were performing chest compressions, and the POA agreed to continue them. During an interview on [DATE] at 7:41 AM, MDS Nurse #2 stated she was the on-call nurse and was at the nurse's station at the time of Resident #32's code. She stated RN #9 called out for a code blue. According to MDS Nurse #2, Resident #32 had a POLST that reflected full code, so CPR was initiated. MDS Nurse #2 said a copy of the POLST reflecting full code was given to EMS, and they continued the code as the resident was leaving the facility to go to the hospital. During the interview, MDS Nurse #2 was shown a copy of Resident #32's POLST dated [DATE] that reflected the resident was to be DNR. MDS Nurse #2 said she was shocked and did not know what happened. MDS Nurse #2 then looked in the POLST book, which was present in the office at the time of the interview, and verified Resident #32's POLST form was no longer in the book. MDS Nurse #2 then walked with this surveyor to the Medical Records office to see where Resident #32's POLST form was located. During an interview on [DATE] at 8:04 AM, the Medical Records Director (MRD) stated the process for POLST forms was for the admissions department and social services to get a POLST completed and signed upon admission, if the resident did not currently have one in place. The POLST was then given to the physician for signature, and once signed, medical records uploaded the form into the resident's EHR and placed the original in the POLST book. During an interview on [DATE] at 8:08 AM, the Medical Records Assistant (MRA) stated that when a new POLST form was completed and signed, it should be placed in the POLST book, and scanned into the EHR. The MRA provided Resident #32's [DATE] POLST form indicating DNR and stated she pulled it from the POLST book that morning, [DATE], due to the resident no longer being in the facility. During an interview on [DATE] at 7:36 AM, the Director of Nursing (DON) reviewed Resident #32's EHR and said the POLST completed in 2016 (reflecting full code) was the only one available. The surveyor then showed the DON a copy of the [DATE] POLST reflecting the resident had elected DNR and informed her the copy was located in the POLST book at the nurse's station on [DATE]. The DON said that when a POLST form was completed and signed, medical records staff should scan a copy into the EHR and place the form in the POLST book. The DON further stated that a code status order should be transcribed into the EHR so that it would be listed in the EHR in the same area resident allergies were listed. She indicated this allowed for ease of access to that pertinent information. The DON said that if there were residents who did not have a POLST available, then evidently the staff were not following through with the process correctly. A review of Resident #32's EHR revealed no code status was reflected in the area where the resident's allergies were listed, as the DON indicated it should be. During a subsequent interview on [DATE] at 10:26 AM, the DON stated the breakdown in the process for Resident #32's code was that the facility was converting from paper charts to all EHR over the prior weekend. According to the DON, Resident #32's chart was one that still had documents that needed to be scanned. She further stated the resident's POLST dated [DATE] must have been in the resident's old chart and a copy was not placed in the POLST book by medical records staff when it was signed three years ago. The DON said the previous POLST from 2016 that reflected full code was in the POLST book at the time of Resident #32's code. Per the DON, Resident #32's paper chart was disassembled over the prior weekend, and on Monday, [DATE], medical records staff placed the POLST from 2021 that indicated DNR into the POLST book at the nurse's station, which is why the surveyor was able to view it on Tuesday, [DATE]. The DON confirmed that for the past three years, Resident #32 desired to be DNR, but a copy of their prior POLST reflecting full code was in the POLST book instead. During an interview on [DATE] at 9:58 AM, the Administrator stated he understood there were two issues that needed addressed: the POLST process was broken, and the CPR event with Resident #32. The Administrator said at the time of the code, Resident #32's [DATE] POLST that showed the resident was a full code was the one available to staff. The Administrator further stated the resident's current POLST, dated [DATE], that reflected the resident's DNR status was located in a physical chart in medical records in the back of the facility, not readily accessible to staff during the code. The Administrator said the POLST should not have been located in the physical chart because the facility no longer used physical charts and indicated the form should have been in the POLST book instead. The Administrator stated that when staff were looking for a code status, they should first look in the EHR, and secondarily or simultaneously look in the POLST book to identify a resident's code status. During an interview on [DATE] at 1:26 PM, the DON stated her expectations for the POLST and advance directives process was that upon admission the staff would ask the resident or their responsible party what their wishes were. A POLST should then be completed and signed, and a copy scanned into the EHR. The DON said a nurse would then input the code status order into the EHR. The DON said she wanted her end of life wishes to be respected and her decisions to be followed, and she wanted that for others as well. The DON said the failure to honor a resident's advance directive or POLST was not only not honoring their wishes but also a life and death decision. During an interview on [DATE] at 2:17 PM, the Administrator stated he expected staff to implement residents' advance directives and POLSTs in the event of an emergency. He stated he expected staff to be able to locate the POLST and to understand the importance of checking them in the event of an emergency. The Administrator further stated it was important to honor a resident's advance directive because it was their wishes and a resident's right. During an interview on [DATE] at 10:37 AM, the Medical Director stated he expected staff to complete POLSTs and advanced directives thoroughly, obtain the appropriate signatures, and to always honor and follow each resident's wishes. On [DATE] at 8:49 PM, a Removal Plan was submitted by the facility and accepted by the state survey agency. It read as follows: 1. Medical Records on [DATE] will conduct a facility wide audit to determine if all residents have the code status uploaded into the electronic health records of the resident's chart. 2. A list of Residents that are identified by Medical Records as to not having a POLST will be given to Social Services, Case Manager, and Director of Nursing. Social Services will inquire if the residents want to complete a POLST form with the resident's corresponding facility Physician. Residents that refuse to sign a POLST will be considered full code unless their advance directive says otherwise. This will be completed on [DATE]. 3. Medical Records staff will remove the POLST binder from the nursing station and Medical Records will provide each Resident with a physical chart containing the face sheet, the signed POLST, and the personal inventory of the resident. This will be completed on [DATE]. 4. The Director of Nursing (DON) and designee conducted an in-service to Licensed Nurses and Department Heads during their shift on [DATE] and [DATE]. The in-service was about the location of the code status of the resident which is made available on the resident's physical chart as well as on the scanned documents of the resident's electronic health record. Every nurse will be in-serviced in person or through a phone call on [DATE]. DON will check off each nurse to ensure completion. Twenty-Eight licensed vocational nurses (LVNs) and seven registered nurses (RNs) will be in-serviced prior to working their shift. 5. DON and Administrator conducted an in-service with Medical Records Staff on [DATE] on the importance of uploading signed POLST forms in the resident's electronic health record within 72 hours of admission and providing each Resident with a physical chart containing the face sheet, the signed POLST, and the personal inventory of the resident. 6. The DON conducted an in-service with the interdisciplinary team (IDT) on [DATE]. After a care conference with the resident or the responsible party, and when the POLST is confirmed, the IDT will verify if the POLST is available in the resident's electronic health record and will notify Medical Records Staff accordingly. Care conferences are completed within 14 days of admitting to the facility, quarterly, annually, and when there is a significant change of condition. 7. Medical Records Staff will conduct audits for newly admitted and readmitted residents to ensure POLST forms are uploaded in the electronic heath record of the resident's chart and available in the resident's physical chart. This will be done within 72 hours of admission. 8. Medical Records Staff will conduct twice a week audit of all the nursing stations to ensure POLST forms are uploaded in the electronic health record of the resident's chart and available in the resident's physical chart. This will be done twice a week for 3 months, and then weekly after indefinitely. 9. The Administrator notified the facility Medical Director of this recent survey findings, and he will conduct a follow up in-service with the Licensed Nurses (Twenty - Eight licensed vocational nurses (LVNs) and seven registered nurses (RNs)), on [DATE]. All AM/PM shifts will be present. The in-service will be recorded and sent to the nurses that cannot be present. This will be done by [DATE]. 10. Newly hired Licensed Nurses and IDT will be oriented by the Director of Staff Development (DSD) or designee on where to locate the Code Status of the residents which are on the electronic health record or the resident's chart and available in the resident's physical chart. This will be completed on the day of orientation. 11. The DON will conduct monthly in-services to licensed nurses for 3 months on where to locate the code status of the resident which is made available on the resident's physical chart as well as on the scanned documents of the resident's electronic health record. The POLST is located in the documents tab on the electronic health record. 12. Medical Records Director will report during monthly QA meeting the findings of the audits on POLST and Quality Assurance (QA) committee will monitor trends. This will be done for 3 months. 13. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE]. This meeting was to discuss the IJ findings and to develop a plan to get it removed. The Director of Nursing, Administrator, and Medical Records Director attended. Per the facility, all immediate corrective actions would be completed by [DATE]. Onsite Verification: The IJ was removed on [DATE] at 4:03 PM, after the survey team verified the implementation of the Removal Plan as follows: 1. Medical Records audits were reviewed for completion with spot checks done to ensure each resident had a POLST uploaded into their EHR. 2. Review of the residents identified as not having a POLST consisted of one resident, who was not able to make the decision themselves. Multiple calls were placed to their responsible party (RP) without a response. Until a signed POLST is obtained, the resident will remain a full code. Facility staff will continue to reach out to the RP. 3. Nurse's stations were checked with verification of each resident having their own chart containing their POLST, face sheet, and personal inventory. 4. The in-service conducted by the DON was reviewed for content along with the sign in sheet to ensure nurses were being in-serviced prior to their next shift if not in the building during the in-service. Nurses and Department Heads were interviewed to ensure they received the in-service and questions were asked to ensure they understood the processes. 5. Inservice Training Reports were reviewed for content. Interviews with Medical Records staff revealed an understanding of the process and their role in ensuring the POLST is available to staff for review. 6. The Inservice Training Report was reviewed and revealed the interdisciplinary team (IDT) was inserviced on the POLST process. Members of the IDT were interviewed regarding their knowledge of the process and their role in the process. 7. The audit form to be used by Medical Records for admissions going forward was reviewed for content. 8. The audit form to be used for the twice a week audit of the POLST forms was reviewed for content. 9. The Inservice Training Report for the education provided by the Medical Director was reviewed, as well as all the content of the education. Attendance signatures were reviewed. An interview was conducted with the Medical Director on [DATE] at 10:37 AM. The Medical Director confirmed he had educated staff regarding POLSTs, including completing each section thoroughly, ensuring all sections were signed, and his expectations for staff to honor POLST and advance directive wishes. The Medical Director also stated he discussed multiple scenarios with staff while providing the education, and staff interacted and asked pertinent questions. 10. The Inservice Training Report for the education provided to the DSD regarding newly hired nurses was reviewed. The material used to orient new nurses was reviewed with the DSD and an interview was completed to ensure she understood her role in the process of obtaining and honoring POLSTs and advance directives. 11. The in-service to be conducted monthly by the DON was reviewed for content, and the DON was interviewed on her role in the process of ensuring POLSTs and advance directives are honored by staff. Dates for the next three monthly in-services were supplied. 12. The Medical Records Director was interviewed on [DATE] at 8:23 AM regarding her role in the process. She was able to verbalize the process and indicated she would report audit findings during QA meetings each month. 13. The Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting's signature page was reviewed.