**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy and procedure review the facility failed to ensure the residents rights were honored by failing to provide an opportunity to formulate advance directives. Resident #1's advance directive for Do Not Resuscitate (DNR) was not honored by the facility when they failed to obtain clarification of code status during the admission process, per facility policy. This failure resulted in the resident experiencing serious psychosocial harm by not honoring the resident's wishes for a natural, dignified death. Successful Cardiopulmonary Resuscitation (CPR) may result in major physical trauma including broken ribs, lung bruising, damage to the airway and internal organs, and internal bleeding. Along with the physical trauma, residents who receive CPR may have to deal with serious long-term consequences like possible brain damage from oxygen deprivation. Findings include: Review of Resident #1's admission Record documented an admission date of [DATE] with the following diagnoses: enterocolitis due to Clostridium difficile, unspecified kidney failure, unspecified urinary retention, unspecified dementia (unspecified severity without behavioral disturbances psychotic disturbance mood disturbance and anxiety), and Alzheimer's disease. Review of the form titled Medical Certification for Medicaid Long Term Care Services and Patient Transfer [Also known as Form 3008] dated [DATE], reads, Section H: Advance Care Planning: Do Not Resuscitate (DNR) was not checked yes or no, left blank. Review of the form titled admission readmission Nursing Evaluation dated [DATE], at 18:17 (6:17 PM) authored by Staff A, Licensed Practical Nurse (LPN) reads, Section VIII: Baseline Care plan: Section B. Social Service Advanced Directives. Code Status/Advanced Directives 1. Does the resident have advance directives b. Full Code (wants CPR) was documented. 2. Advanced Directives reviewed with Resident/Representative: a. Yes was documented. Review of the document titled Consent To Treat dated [DATE], no time, reads: Telephone consent per [Resident representative's name] was signed by Staff A, LPN and Staff C, Registered Nurse (RN). Review of the document titled Informed Consent for Pneumococcal Vaccine for Resident #1 dated [DATE], no time documented, reads: Per [Resident representative's name] and was signed by Staff A and Staff C. Review of the document titled Informed Consent for Resident Influenza Immunization for Resident #1 with no date or time reads, Per [Resident representative's name] and was signed by Staff A and Staff C. Review of the document titled COVID-19 [Coronavirus 2019) Vaccination/Booster for Resident #1 dated [DATE] no time reads, Per [Resident representative's name] and was signed by Staff A and Staff C. Review of Resident #1's progress notes documented no social services notes within the medical record. Review of Resident #1's electronic medical record [emr] documented the form titled Internal Medicine progress note dated [DATE], scanned in date [into emr] [DATE], reads, Assessment: septic shock due to urinary tract infection Proteus mirabilis on urine culture, right lower lobe pneumonia, history of hypertension, history of coronary artery disease, history of TIA (Transient Ischemic Attack), acute chronic CKD (kidney disease), acute pulmonary insufficiency, improving, advanced age, dementia. Plan: continue with PO (by mouth) antibiotics as per infectious disease, CM (case management) to coordinate SNF (skilled nursing facility), replace magnesium as per protocol, daily labs, PT (physical therapy)/OT (occupational therapy)/DVT (deep vein thrombosis)/GI (gastrointestinal) prophylaxis as appropriate, home medications as appropriate, further pending patients' clinical course and recommendations by consultant's plan of care discussed with patient family at bedside all questions answered. Code Status documented as DNR. Review of the handwritten document titled Code Blue Response worksheet dated [DATE] at 11:46 AM reads: Resident Name: [Resident #1's name], Date: [DATE], Time 11:46 AM, Location of code: Resident #1's room, Nurse in charge of code: [Staff name], Code status verified by: [Staff Name], EMS (Emergency Medical Services)/911 notified (time): 11:47 AM, EMS arrival time: 11:51 AM. MD (Medical Doctor) or ARNP (Advanced Registered Nurse Practitioner) [sic] present: No, Crash cart present: yes, Pulse present: No, Breathing: No, Chest compressions initiated: yes, Time: 11:47 AM by Whom [Staff Name], Rescue breathing initiated: Yes, Ambu mask: checked Time: 11:47 AM Vital signs, heart rate 0, BP (blood pressure) 0, respiratory rate 0, SPO2 (oxygen saturation) 77%, blood sugar unable to read, Number of CPR cycles completed: 5, Resuscitation terminated at 12:08 PM, paramedics took over at 11:52 AM. Regain pulse: No, Regain breathing: No, Conscious: No, Transferred to: not applicable, will transfer to funeral home once family arrives. Review of the nursing progress note dated [DATE] at 1308 (1:08 PM) authored by Staff D, LPN reads, resident was observed unresponsive, chart was checked confirmed to be FULL CODE. paged code blue and 911 was called CPR was started at 11:47. AED (automatic external defibrillator) was applied. No shock advised. Continued CPR until EMS arrived and took over at 1152. Family was called, paramedics continued CPR until 1208 and he was then pronounced dead. family was still on phone and was updated about passing. MD aware and received order to release body to funeral home, [Funeral Home's Name] was called and arrived to pick up body at 1445 (2:45 PM), family was with patient upon release. During an interview on [DATE] at 9:10 AM the Administrator stated, I am aware of this [incident with Resident #1], we did a report, immediate and 5 day. The information we had to work with was not clear on the 3008. I can't tell you why this occurred. We did complete an RCA (Root Cause Analysis) and PIP (Performance Improvement Plan) to make certain this would not happen again. We have fully implemented this plan. During a telephone interview on [DATE] at 10:00 AM, Resident #1's representative stated, I explained that he was a DNR when they called to let us know he was coding. He was a DNR at the hospital. No one called me or asked me about his code status. They did not call me the day he got there or any other time about whether he was a DNR. We came in to see him and no one asked us. I was very upset that they did this. He did not want CPR done. I don't really understand how this happened. They should have either gotten this from the hospital or asked me. They did not have any discussion about whether he was a DNR. I learned about this when the Director of Nursing called and told me that they were doing CPR, that's when I told them, he was a DNR. It was very distressing. He was a [AGE] year-old man, and they probably did more harm than good when they did that. I was called by the nurse that night he went there and asked for a consent to treat and about immunizations for the flu and pneumonia. So, I really can't understand why they didn't ask about that [advance directives]. During an interview on [DATE] at 10:45 AM, the Director of Nursing (DON) stated, I found out that the resident [Resident #1] had a DNR when I called his [resident representative] when he was coding and that was when she told me that he was a DNR. We did realize that there was a progress note scanned into the system that stated DNR after we began to investigate this. The nurses, I guess, went by the 3008 which checked no advanced directives and DNR was not checked yes or no. I was aware that they documented on the admission that he was a full code and that was discussed with him or his family. No call was made to verify his wishes and he was not able to make that decision. Social services did not call and discuss advance directives with the family, they should have. Our policy is that on admission we obtain advance directives, and we did not do this. I think that the Social Service Director usually does advanced directives with the MDS (Minimum Data Set) [coordinator] on day 5. That is too long to wait for that to be done, it should be done on the day of admission. We should be doing them on admission. I did see the physician progress note that stated he was a DNR that was scanned into the system before he arrived. It was available for anyone to review. The nurses and the Social Services Director do have access to that scanned document. We did a QAPI (Quality Assurance Performance Improvement) on that same day and identified that we had opportunities to have determined what his and his representative's wishes were for advanced directives. The nurse did not call and verify the code status on admission when the 3008 was incorrect. I don't know if the nurse actually got report from the hospital. Our Social Service Director did not see the resident after admission, they did not address advanced directives with his representative. During an interview on [DATE] at 3:30 PM, the Medical Director stated, I was aware that [Resident #1's Name] was coded, and I understand that was not his representative's wishes. I do think that we should have determined his wishes for resuscitation prior to his death and we did identify that the information provided by the hospital was incomplete and we really should have called and verified with his family whether or not he was a full code based on the inaccurate documentation. During an interview on [DATE] at 3:45 PM, Staff A, LPN stated, I did not get report from the hospital on this patient [Resident #1]. I looked at the 3008 and it did not indicate DNR or the code status. The DNR was not filled in at all, so I just looked at [it] as he was a full code. I did not call and ask his representative, his family if he was a DNR or full code. He was confused and not able to tell me, so I should have called them and asked. I just don't have a good enough reason why I didn't. I did get verbal consent to treat, flu, pneumonia, and COVID-19 consents over the telephone from his [representative]. I don't know if it was overly busy that evening. I don't know why I did that. I did document that I called the representative on the admission form, but I did not do that for the advance directives. I should not have documented that. During an interview on [DATE] at 4:10 PM, Staff C, RN stated, I did witness the consents for [Staff A's name] on 11/13 if I signed them. I do not recall her asking about advanced directives when we did that. I did not complete his admission that evening and did not know whether or not he was a full code. I can't remember what time that call was. During an interview on [DATE] at 3:15 PM Admissions Director stated, I did speak with [Resident #1's representative] and review the admission packet with her. I will usually let the residents or families know about the physician services, payor sources, and any copays. I review if the resident has a POA [Power of Attorney], she indicated that she did, and I requested the paperwork be provided to us. I did review the Advance Directives portion with her. She did tell me that he was a DNR, and I explained that I needed the form, the yellow DNR form and that she needed to provide the Social Services Director and the nurses with this information. I can't recall what date exactly that I spoke to her, but I know that the date she electronically signed it was different then the date I actually spoke to her. She told me that she would get in touch with social services to address the DNR, at least I think she did. I did not reach out to his nurse or to the social service department or Social Service Director. I really should have. I really can't say why I didn't follow up, there really is no excuse for this. I don't generally get advanced directives signed, that is the responsibility of the Social Service Director, but I really should have completed this. I should have followed up with social services after our discussion. It was simply a lack of communication all the way around. During a telephone interview on [DATE] at 5:05 PM Resident #1's representative stated, I did speak with the admissions person about the admission package, that I needed to sign it electronically. They did talk to me about his advanced directives. I did tell them that he was a DNR, and she told me that I needed to bring in the yellow form I had and talk to the nurses and social services about this. That's why I thought they knew he was a DNR. Review of the policy and procedure titled, Advanced Directives Code Status, last revision date of 1/2023 reads, Standard: It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate orders in accordance with State and Federal regulations. Guideline: Admission/readmission: Code Status verified upon admission with resident/representative by admitting nurse. Nurse reviews code status with the resident/representative and confirms decision with the attending physician (MD). DNR: Admitting nurse must review with resident/representative with a witness present (preferably another nurse or social services). Review of the policy and procedure titled, Admissions Policies, last reviewed [DATE], reads: Policy Interpretation and Implementation. 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. 3. The objectives of our admission policies are to: d. Review with the resident, and/or his/her representative (sponsor), the facility's policies and procedures relating to resident rights, resident care, financial obligations, visiting hours, etc. The Immediate Jeopardy was verified as removed on [DATE] and substantial compliance was confirmed on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of the immediacy to prevent the likelihood of serious psychosocial harm and/or possible serious injury when the facility provided evidence of the actions taken to remove the immediacy to include conducting a root cause analysis, assessment of all current residents for the formulation of advanced directives, training of licensed staff in the admission process for obtaining advanced directives and the advanced directives policy and procedure encompassing aspects such as the Do Not Resuscitate (DNR) process for new admissions, readmissions, cases of existing DNR, changes to DNR status, and revocation of DNR. It also covered the importance of reviewing the admission packet for any advanced directive, the protocol for situations where a resident is unable to make decisions (including contacting the responsible party to confirm code status), and the correct procedure for obtaining a physician's order for advanced directives as evidenced by the following: On [DATE], an Ad Hoc [when necessary or needed] QAPI meeting was held with 15 members present to include the Administrator, DON, Medical Director [via telephone], Infection Control & Prevention Officer, Labor Coordinator, Social Worker, Maintenance, Unit Manager Northbrook, Evening Manager, Unit Manager Southbrook, Social Services Assistant, Activities Assistant, and Certified Dietary Manager to develop a Performance Improvement Plan based on the identified Root Cause Analysis. On [DATE], Staff A, LPN, received 1on 1 education from the Director of Nursing on the policies and procedures related to advanced directives, encompassing aspects such as the Do Not Resuscitate (DNR) process for new admissions, readmissions, cases of existing DNR, changes to DNR status, and revocation of DNR. It also covered the importance of reviewing the admission packet for any advanced directive, the protocol for situations where a resident is unable to make decisions, including contacting the responsible party to confirm code status. On [DATE], the Social Services Director received 1on 1 education from the Director of Nursing on identification advanced directives, including code status upon admission and measures for appropriate follow-up to guarantee the implementation of these directives. On [DATE], the Admissions Director received 1 on 1 education from the Director of Nursing on promptly notifying the nursing staff and/or social services about any advanced directives communicated by patients or their responsible parties, either before or after admission. On [DATE], all current licensed staff, 34 of 34, received education from the Director of Nursing and the Unit Manager on the policies and procedures related to advanced directives, encompassing aspects such as the Do Not Resuscitate (DNR) process for new admissions, readmissions, cases of existing DNR, changes to DNR status, and revocation of DNR. It also covered the importance of reviewing the admission packet for any advanced directive, the protocol for situations where a resident is unable to make decisions (including contacting the responsible party to confirm code status), and the correct procedure for obtaining a physician's order for advanced directives. On [DATE], all additional staff, 91 of 91, received education from the Director of Nursing and the Unit Manager regarding the policy and procedure related to advanced directives. On [DATE], the Assistant Director of Nursing, Northbrook Unit Manager, Southbrook Unit Manager, Weekend Supervisor, Evening Supervisor, LPN MDS Coordinator and RN MDS Assessor received 1on 1 education from the Director of Nursing on the policies and procedures related to advanced directives, encompassing aspects such as the Do Not Resuscitate (DNR) process for new admissions, readmissions, cases of existing DNR, changes to DNR status, and revocation of DNR. It also covered the importance of reviewing the admission packet for any advanced directive, the protocol for situations where a resident is unable to make decisions (including contacting the responsible party to confirm code status), and the correct procedure for obtaining a physician's order for advanced directives. Review of the follow up Ad Hoc QAPI meeting conducted on [DATE], the committee reviewed the audits completed to date with 2 audits completed with no deficient practice identified. The committee reviewed staff training to date. At the time of the meeting, 107 of 125 staff had received education. No newly hired employees were onboarded between [DATE] and [DATE]. The committee discussed agency education to date, noting all 29 agency employees (25 Certified Nursing Assistants and 4 LPNs) received advanced directive education. Based on results of audits and training to date, the committee recommended continued audits of all admissions and readmissions as well as continued education until all staff had completed education. The committee also recommended ongoing new hire and agency education. Review of the follow up Ad Hoc QAPI meeting conducted on [DATE], the committee reviewed audits completed to date with 13 audits completed with no deficient practice identified. At the time of the meeting 125 of 125 staff had received education. Six newly hired employees were onboarded between [DATE] and [DATE], 6 of 6 new hires received advanced directive education. Based on results of audits and training to date, the committee recommended continued audits of all admissions and readmissions as well as continued new hire/agency education. During staff interviews on Interviews were conducted with 11 licensed nurses, 14 Certified Nursing Assistants and 5 additional ancillary staff (Physical Therapy Assistants, Occupational Assistants) the Social Services Director, and Admissions Director for verification of training provided for advanced directives and verified having received education and verbalized understanding of all aspects of the facility policies and procedures related to advanced directives.