**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, the facility's policy and procedure for Emergency Care/CPR (Cardio-pulmonary resuscitation), facility reports, and interviews with staff, the facility failed to act in accordance with the resident's Advance Directives in accordance with his Full Code status (the desire to be resuscitated in the event his heart or breathing stopped) after finding him unresponsive with no respirations. This affected one (Resident #1) of four residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's Full Code status deprived him of potentially lifesaving measures and likely contributed to his death. Immediate Jeopardy at a scope of J (isolated) was identified at 11:30 a.m. on [DATE]. On [DATE] at 5:20 a.m., the Immediate Jeopardy began. On [DATE] at 4:30 p.m., the Interim Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective [DATE]. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: Cross reference F678 A closed electronic record review conducted for Resident #1 found he was admitted from the hospital on [DATE]. An AHCA form 5000-3008 (a Medicaid eligibility determination form completed by hospitals upon patient discharge to a nursing home), dated [DATE], revealed that Resident #1 had no Advanced Directives and no Do Not Resuscitate Order (DNRO) upon discharge. His diagnoses included fracture of the right shoulder and pelvis following a motor vehicle accident, hypertension (high blood pressure) and anxiety. Resident #1 had an admission Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], revealing an admission from an acute-care hospital. He had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 points, indicating intact cognition. Active discharge planning was occurring for him to return to the community. A Death in Facility MDS assessment, dated [DATE], revealed that Resident #1 was discharged from the facility on [DATE]. His discharge status was deceased . The baseline care plan, dated [DATE], indicated Resident #1 had a physician's order for Cardio-Pulmonary Resuscitation (CPR). Further record review confirmed a physician's order for FULL CODE dated [DATE]. (Photographic evidence obtained) The Physician's Assistant - Certified (PA-C) saw Resident #1 for an initial visit on [DATE] and noted he was doing well. He was seen again on [DATE] and was last seen on [DATE] for follow-up for anxiety and discharge planning. The PA-C noted Resident #1 was feeling okay but reported anxiety. Resident #1 was noted as wanting to go home, and Social Services (SS) was working on his discharge. An electronic Progress Note authored by the Activities Aide on [DATE] noted Resident #1 was alert and oriented with the ability to make his needs known. Resident #1 is FULL CODE. (Photographic evidence obtained) A Social Services (SS) Progress Note, dated [DATE], indicated Resident #1 was consulted about his discharge plans and found he intended to return home. Resident #1 stated he could take care of himself at home. (Photographic evidence obtained) An electronic progress note authored by Licensed Practical Nurse (LPN) A on [DATE] at 6:28 AM, revealed that at approximately 5:20 AM, Certified Nursing Assistant (CNA) B came to another resident's room to report Resident #1 appeared to be having a seizure. CNA B said she had already reported this to Registered Nurse (RN) C. While LPN A was in the other resident's room, RN C went to that room to ask which resident was having the seizure. LPN A ran to Resident #1's room and observed the resident pale/yellow in color. When she called his name and touched his hand, he was unresponsive. LPN A did a sternal rub and Resident #1 began to gasp for air. She went to get oxygen while CNA B continued to keep the resident responding. A non-rebreather mask (a device that helps provide oxygen in an emergency) was used for oxygen delivery. RN C called 911 and LPN A and CNA B attempted to keep the resident responding. Resident #1 would only gasp one breath at a time periodically and was pursed-lip breathing. At approximately 5:30 AM, the resident no longer gasped for air and had no pulse. The ambulance arrived shortly thereafter and pronounced his death at 5:41 AM. There was no indication in the note that Resident #1's code status was checked or that chest compressions and/or other life-saving techniques were initiated when the resident stopped breathing. (Photographic evidence obtained) The Discharge summary, dated [DATE], noted Resident #1's Advanced Directives were marked Other Directive, Full Code. (Photographic evidence obtained) A review of the facility's Emergency Care (CPR) Policy and Procedure (undated) revealed: Policy: The facility will identify each resident's choice for treatment and care, help the resident to develop Advanced Directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics, decision-making policies and procedures, and Florida State law. In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's Advanced Directives. Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest or respiratory arrest in accordance with the resident's Advance Directives or DNR order. In the absence of a DNR order or for those residents who do not have a valid DNR order, CPR must begin. Procedure: 1. At the time of admission, the facility will request copies of the resident's completed Advance Directives if any . 2. The resident/legal representative will be made aware that the resident has the right not to have CPR performed in the event of cardiac emergency. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative . 3. A DNR or full code order should be entered and signed by the physician in [the electronic medical record system] and code status displayed on the resident's PCC header below their photo . 4. Code status will be noted on the monthly POS (physician's order sheet) and verified as accurate as part of the monthly POS review. 5. Should a resident experience cardiac emergency, staff will refer to the presence of a yellow form signed by the resident and physician to determine if CPR should be performed. 6. Advance Directives will be reviewed at least quarterly with the resident or legal representative by Social Services staff . 7. Any changes in DNR status will be communicated to care-giving staff and noted in the medical record immediately upon MD approval. 8. Staff will be educated regarding the Emergency Care (CPR) policy during orientation and at least annually thereafter. (Photographic evidence obtained) Further review of the facility records revealed that LPN A's written statement (undated), revealed that on [DATE] at 5:20 AM, the CNA informed her that Resident #1 may be having a seizure. The CNA stated she had informed the other nurse who was not far from Resident #1's room. When LPN A got to Resident #1's room, he was unresponsive to touch and his name. He gasped upon application of a sternal rub and oxygen was applied on high with a non-rebreather mask. The other nurse stayed at the nursing station and called 911 until EMS (Emergency Medical Services) arrived. Per EMS, 0541 (5:41 AM) was the time of death. (Photographic evidence obtained) An undated, written statement made by RN C, revealed that after being notified by the CNA and entering Resident #1's room, he was breathing irregularly. RN C tried to vigorously arouse him and ran to call 911. She returned to the resident's room where his nurse and CNA (LPN A and CNA B) were, and was notified that Resident #1 had expired. (Photographic evidence obtained) An interview was conducted with the Regional Director of Clinical Services (RDCS) on [DATE] at 3:11 PM. She explained that Resident #1 had been admitted on [DATE] for rehabilitation following a motor vehicle crash. He had multiple fractures. On [DATE] at around 5:20 AM, CNA B reported that Resident #1 began shaking during routine personal care. LPN A and RN C responded and found Resident #1 breathing, but otherwise unresponsive to a sternal rub. When Resident #1 ceased to breathe, no CPR was initiated, and he was pronounced deceased by paramedics at 5:41 AM. Resident #1's code status was Full Code. When LPN A was interviewed, she did not know why she did not start CPR. In a statement provided by RN C, she reported that Resident #1 presented with irregular breathing. She called 911 and LPN A was sent to the resident's room. 911 stated EMS was dispatched immediately. When RN C returned to the room, LPN A notified her that Resident #1 was no longer breathing and had expired. The RDCS confirmed that Resident #1's code status was not checked at any time during the event. In response to the event, all employed nurses' CPR certifications were checked and verified. Anyone who did not have a current, valid certificatin was not permitted to work until they did. A required training notification was sent to all staff on [DATE] and training began at 8:30 AM that same morning. Both LPN A and RN C were trained, but then suspended pending the outcome of the investigation, which started immediately. Code Blue drills were initiated daily on each shift. Training in CPR, Abuse and Neglect, and Code Blue drills was completed by [DATE] for all nurses but one, who would receive the training prior to returning to work. Agency nurses had to complete the education, and new staff would be provided this education during orientation. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted [DATE] to review the facility's response and plan of correction and a Performance Improvement Plan (PIP) was developed. The committee reviewed the Emergency Procedures policy and procedure, as well as new hire orientation and annual training. Residents who expired in the facility in the last 30 days were reviewed for code status and Advance Directives with no concerns identified. CNA B was interviewed via telephone on [DATE] at 10:30 AM. She explained that when she went to provide care to Resident #1 the morning of the event, he had a seizure. She ran, reported this to RN C, then went to get LPN A. When she and RN C went to Resident #1's room, he was mouth breathing. RN C asked, Where is LPN A? This is her patient! LPN A arrived and did sternal rubs as Resident #1 began mouth breathing less frequently. LPN A ran to get oxygen, instructed RN C to call 911, and told CNA B to keep doing sternal rubs and shaking/tapping Resident #1's shoulder. After initially gasping for air rapidly, Resident #1's breaths slowed to about one gasp every 10 seconds. LPN A asked, Where is RN A, she should be doing CPR. LPN A continued to shake the resident but then said, I can't get any readings on him. He is gone. She took the oxygen off and left the room. Maybe a minute later, the paramedics arrived and said he was dead. She did not know why LPN A did not do CPR since the process is that the nurse will call the code and start CPR. The code status is supposed to be checked immediately when finding a resident unresponsive. CNA B was trained in CPR at that time and the code status was in the resident's chart. She thought LPN A knew Resident #1's code status because she had him all night. She has since received all the training in abuse and neglect, Emergency Procedures and CPR and has participated in two Code Blue drills, which were being conducted often. On [DATE] at 11:35 AM, RN C was interviewed and explained that she was not assigned to Resident #1 the morning of the event. Toward the end of the shift, as she was finishing up morning medications (she did not recall the time), the assigned CNA (CNA B) approached her and said Resident #1 was not doing well. She went to Resident #1's room while CNA B went to get Resident #1's assigned nurse, LPN A. Resident #1 had a pulse but his breathing was labored. She walked out of the room to call rescue and as she was going out, LPN A and CNA B walked in. After calling 911, she was headed back to the resident's room but was called by a staff member in the other unit, and was told rescue was at the door and did not know where to go. RN C walked to the entrance to direct the rescue team then walked with rescue to the resident room. LPN A reported at that time that Resident #1 had stopped breathing. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the survey team as follows: A Performance Improvement Plan (PIP) was developed and initiated on [DATE] to provide immediate correction and attaining/maintaining regulatory compliance. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Interdisciplinary Team and Medical Director on [DATE]. Action steps taken included 1) Unit Managers verified the code status for each resident to ensure the paper and electronic medical record (EMRs) matched. A new binder was created to include residents who had elected a Do Not Resuscitate (DNR) order for easy access. The DNR form would be filed under the Documents tab in the EMR and in the hard (paper) chart, 2) Mock code blue drills were initiated on [DATE] at approximately 8:15 AM and will continue daily for one week, then move to weekly for 30 days, then monthly to ensure staff are trained to perform in the event of an actual emergency, 3) RN C and LPN A were suspended pending an investigation, 4) Staff in-service trainings were initiated on [DATE] related to emergency procedures and the facility policy. The in-services will be mandatory for all clinical staff and will be ongoing until all staff have been trained, 5) Employee files were checked for CPR Certifications on [DATE] and a documentation roster will be maintained. All facility nurses files were audited, 6) The Staff Development Coordinator and Human Resources Director reviewed new employee Orientation Checklist/Annual Checklists for clinical staff were reviewed, 7) All residents who expired in the facility the last three months were evaluated to ascertain and identify the cause of death and opportunities for improvement. A Root Cause Analysis was conducted and found the facility failed to call CODE BLUE or start CPR resulting in death. The Nurse did not initiate CPR per the resident's wishes and per the facility policy and procedure. The code status was present in the medical record. In-Service training on Advanced Directives, Emergency Procedures, Abuse/Neglect and Code Blue Drills commenced [DATE] at 8:30 AM and as of [DATE], twenty-four (24) out of twenty-five (25) facility nurses had been trained. The remaining nurse would not be permitted to return to work until she received the training. Mock Code Blue drills commenced [DATE] and were conducted daily on each shift through [DATE] and were now being conducted daily. Nurses' personnel files were audited on [DATE] with 100% of employed nurses CPR certification verified. LPN A and RN C were terminated on [DATE] as a result of the investigation. The Board of Nursing and law enforcement were notified. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, the facility's policy and procedure for Emergency Care/CPR (Cardio-pulmonary resuscitation), facility reports and staff interviews, the facility failed to provide CPR prior to the arrival of Emergency Medical Services (EMS) personnel and in accordance with the resident's physician's order and Advance Directives when an unresponsive resident stopped breathing. This affected one (Resident #1) of four residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's Full Code status (the desire to be resuscitated in the event that his heart or breathing stopped), deprived him of potentially lifesaving measures and likely contributed to his death. Immediate Jeopardy at a scope of J (isolated) was identified at 11:30 a.m. on [DATE]. On [DATE] at 5:20 a.m., the Immediate Jeopardy began. On [DATE] at 4:30 p.m., the Interim Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective [DATE]. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: Cross reference F578 A closed electronic record review conducted for Resident #1, found he was admitted to the facility from the hospital on [DATE] with diagnoses including fracture of the right shoulder and pelvis following a motor vehicle accident. An AHCA form 5000-3008 (a Medicaid eligibility determination form completed by hospitals upon patient discharge to a nursing home), dated [DATE], revealed that Resident #1 had no Advanced Directives and no Do Not Resuscitate Order (DNRO) upon his discharge. Resident #1 had a physician's order dated [DATE] for FULL CODE. (Photographic evidence obtained) The admission Minimum Data Set (MDS) assessment, dated [DATE], revealed that Resident #1 was admitted from the hospital and had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 points, indicating intact cognition. Active discharge planning was occurring for Resident #1 to return to the community. The Death in Facility MDS assessment, dated [DATE], revealed Resident #1 was discharged from the facility on [DATE]. His discharge status was deceased . The baseline care plan, dated [DATE], noted Resident #1 had a physician's order for Cardio-Pulmonary Resuscitation (CPR). (Photographic evidence obtained) The Physician's Assistant - Certified (PA-C) saw Resident #1 for an initial visit on [DATE] and noted he was doing well. He was seen again on [DATE] and was last seen on [DATE] for follow-up for anxiety and discharge planning. The PA-C noted Resident #1 was feeling okay but reported anxiety. Resident #1 was noted as wanting to go home, and Social Services (SS) was working on his discharge. The Activities Aide authored an electronic progress note on [DATE] and reported that Resident #1 was alert, oriented, and able to make his needs known. His code status was FULL CODE. A Social Services (SS) Progress Note, dated [DATE], indicated Resident #1 was consulted about his discharge plans and found he intended to return home. Resident #1 stated he could take care of himself at home. (Photographic evidence obtained) On [DATE] at 6:28 AM, Licensed Practical Nurse (LPN) A authored an electronic progress note reporting that at approximately 5:20 AM, Certified Nursing Assistant (CNA) B came to report that Resident #1 appeared to be having a seizure. CNA B had already reported this to the Registered Nurse (RN). When LPN A went to Resident #1's room, she observed that he was pale/yellow in color. When she called his name and touched his hand, he was unresponsive. LPN A did a sternal rub, and Resident #1 began to gasp for air. She went to get oxygen while CNA B continued to keep the resident responding. A non-rebreather mask (a device that helps provide oxygen in an emergency) was used for oxygen delivery. RN C called 911 and LPN A and CNA B attempted to keep the resident responding. Resident #1 was gasping periodically and was pursed-lip breathing. At approximately 5:30 AM, the resident no longer gasped for air and had no pulse. The ambulance arrived shortly thereafter and pronounced his death at 5:41 AM. (Photographic evidence obtained) There was no indication in the progress note that the nurses checked Resident #1's code status or that chest compressions and/or other life-saving techniques were initiated when the resident stopped breathing. The Discharge summary, dated [DATE], noted that Resident #1's Advanced Directives were marked Other Directive, Full Code. (Photographic evidence obtained) A review of the facility's Emergency Care (CPR) Policy and Procedure (undated) revealed: Policy: The facility will identify each resident's choice for treatment and care, help the resident to develop Advanced Directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics, decision-making policies and procedures, and Florida State law. In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's Advanced Directives. Prior to the arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest or respiratory arrest in accordance with the resident's Advance Directives or DNR order. In the absence of a DNR order or for those residents who do not have a valid DNR order, CPR must begin. Procedure: 1. At the time of admission, the facility will request copies of the resident's completed Advance Directives if any . 2. The resident/legal representative will be made aware that the resident has the right not to have CPR performed in the event of a cardiac emergency. Should the resident or legal representative request to not have CPR performed in the event of a cardiac emergency, the facility will provide a yellow DO NOT RESUSCITATE form and explain the terms to the resident or legal representative . 3. A DNR or full code order should be entered and signed by the physician in [the electronic medical record system] and code status displayed on the resident's PCC header below their photo . 4. Code status will be noted on the monthly POS (physician's order sheet) and verified as accurate as part of the monthly POS review. 5. Should a resident experience a cardiac emergency, staff will refer to the presence of a yellow form signed by the resident and physician to determine if CPR should be performed. 6. Advance Directives will be reviewed at least quarterly with the resident or legal representative by Social Services staff . 7. Any changes in DNR status will be communicated to care-giving staff and noted in the medical record immediately upon MD approval. 8. Staff will be educated regarding the Emergency Care (CPR) policy during orientation and at least annually thereafter. (Photographic evidence obtained) A written statement given by LPN A (undated), noted that on [DATE] at 5:20 AM, the CNA informed her that Resident #1 may be having a seizure. The CNA stated she had informed the other nurse, who was not far from Resident #1's room. When LPN A got to Resident #1's room, he was unresponsive to touch and his name. He gasped for air upon application of a sternal rub, and oxygen was applied on high with a non-rebreather mask. The other nurse stayed at the station and called 911 until EMS (Emergency Medical Services) arrived. Per EMS, 0541 (5:41 AM) was the time of death. (Photographic evidence obtained) A written statement made by RN C (undated), revealed that after being notified by the CNA and entering Resident #1's room, he was breathing irregularly. RN C tried to vigorously arouse him and ran to call 911. She returned to the resident's room where his nurse and CNA (LPN A and CNA B) were, and was notified that Resident #1 had expired. (Photographic evidence obtained) An interview was conducted with the Regional Director of Clinical Services (RDCS) on [DATE] at 3:11 PM. She explained that Resident #1 had been admitted on [DATE] for rehabilitation following a motor vehicle crash. He had multiple fractures. On [DATE] at around 5:20 AM, CNA B reported that Resident #1 began shaking during routine personal care. LPN A and RN C responded and found Resident #1 breathing, but otherwise unresponsive to a sternal rub. When Resident #1 ceased to breathe, no CPR was initiated, and he was pronounced deceased by paramedics at 5:41 AM. Resident #1's code status was Full Code. When LPN A was interviewed, she did not know why she did not start CPR. In a statement provided by RN C, she reported that Resident #1 presented with irregular breathing. She called 911 and LPN A was sent to the resident's room. 911 stated EMS were dispatched immediately. When RN C returned to the room, LPN A notified her that Resident #1 was no longer breathing and had expired. The RDCS confirmed that Resident #1's code status was not checked at any time during the event. In response to the event, all employed nurses CPR certification was checked and verified. Any who did not have it were not allowed to work until they did. A required training notification was sent to all staff on [DATE], and training began at 8:30 AM that same morning. Both LPN A and RN C were trained, but then suspended pending the outcome of the investigation, which started immediately. Code Blue drills were initiated daily on each shift. Training in CPR, Abuse and Neglect and Code Blue drills was completed by [DATE] for all nurses but one, who would receive the training prior to returning to work. Agency nurses had to complete the education and new staff were provided this education during orientation. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE] to review the facility's response and plan of correction, and a Performance Improvement Plan (PIP) was developed. The committee reviewed the Emergency Procedures policy and procedure, as well as new hire orientation and annual training. Residents who expired in the facility in last 30 days were reviewed for code status and Advance Directives, with no concerns identified. CNA B was interviewed via telephone on [DATE] at 10:30 AM. She explained that when she went to provide care to Resident #1 the morning of the event, he had a seizure. She ran, reported this to RN C, then went to get LPN A. When she and RN C went to Resident #1's room, he was mouth breathing. RN C asked, Where is LPN A? This is her patient! LPN A arrived and did sternal rubs as Resident #1 began mouth breathing less frequently. LPN A ran to get oxygen, instructed RN C to call 911, and told CNA B to keep doing sternal rubs and shaking/tapping Resident #1's shoulder. After initially gasping for air rapidly, Resident #1's breaths slowed to about one gasp every 10 seconds. LPN A asked, Where is RN A, she should be doing CPR. LPN A continued to shake the resident but then said, I can't get any readings on him. He is gone. She took the oxygen off and left the room. Maybe a minute later the paramedics arrived and said he was dead. She did not know why LPN A did not do CPR since the process was that the nurse would call the code and start CPR. The code status was supposed to be checked immediately when finding a resident unresponsive. CNA B said she was trained in CPR at that time and the code status was in the resident's chart. She thought LPN A knew Resident #1's code status because she had him all night. On [DATE] at 11:35 AM, RN C was interviewed and explained that she was not assigned to Resident #1 the morning of the event. Toward the end of the shift, as she was finishing up morning medications (she did not recall the time), the assigned CNA (CNA B) approached her and said Resident #1 was not doing well. She went to Resident #1's room while CNA B went to get Resident #1's assigned nurse, LPN A. Resident #1 had a pulse but his breathing was labored. She walked out of the room to call rescue and as she was going out, LPN A and CNA B walked in. After calling 911, she was headed back to the resident's room, but was called by a staff member in the other unit and was told rescue was at the door; they did not know where to go. RN C walked to the entrance to direct the rescue team, then walked with rescue to the resident's room. LPN A reported at that time that Resident #1 had stopped breathing. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the survey team as follows: A Performance Improvement Plan (PIP) was developed and initiated on [DATE] to provide immediate correction and attaining/maintaining regulatory compliance. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Interdisciplinary Team and Medical Director on [DATE]. Action steps taken included 1) Unit Managers verified the code status for each resident to ensure the paper and electronic medical record (EMRs) matched. A new binder was created to include residents who had elected a Do Not Resuscitate (DNR) order for easy access. The DNR form would be filed under the Documents tab in the EMR and in the hard (paper) chart, 2) Mock code blue drills were initiated on [DATE] at approximately 8:15 AM and will continue daily for one week, then move to weekly for 30 days, then monthly to ensure staff are trained to perform in the event of an actual emergency, 3) RN C and LPN A were suspended pending an investigation, 4) Staff in-service trainings were initiated on [DATE] related to emergency procedures and the facility policy. The in-services will be mandatory for all clinical staff and will be ongoing until all staff have been trained, 5) Employee files were checked for CPR Certifications on [DATE] and a documentation roster will be maintained. All facility nurses files were audited, 6) The Staff Development Coordinator and Human Resources Director reviewed new employee Orientation Checklist/Annual Checklists for clinical staff were reviewed, 7) All residents who expired in the facility the last three months were evaluated to ascertain and identify the cause of death and opportunities for improvement. A Root Cause Analysis was conducted and found the facility failed to call CODE BLUE or start CPR resulting in death. The Nurse did not initiate CPR per the resident's wishes and per the facility policy and procedure. The code status was present in the medical record. In-Service training on Advanced Directives, Emergency Procedures, Abuse/Neglect, and Code Blue Drills commenced [DATE] at 8:30 AM, and as of [DATE], twenty-four (24) out of twenty-five (25) facility nurses had been trained. The remaining nurse would not be permitted to return to work until she received the training. Mock Code Blue drills commenced [DATE] and were conducted daily on each shift through [DATE] and are now being conducted daily. Nurses' personnel files were audited on [DATE] with 100% of employed nurses' CPR certification verified. LPN A and RN C were terminated on [DATE] as a result of the investigation. The Board of Nursing and law enforcement were notified. .