**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy and procedure the facility failed to implement policies and procedures to honor the resident's right to choose an advance directive for one resident (#1) out of three reviewed for Advance Directives. Resident #1 was found not breathing with no pulse. The nursing staff did not honor the resident's wish to have all resuscitative efforts made until approximately 2 hours after the resident was discovered. Resident #1 expired in the facility. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy which began on [DATE] with a scope and severity of J. The findings of Immediate Jeopardy were determined to be past noncompliance with a correction date of [DATE] after surveyor verification af actions implemented removed and corrected the noncompliance. Findings included: An interview was conducted on [DATE] at 10:45 a.m. with the Social Services Director (SSD) She said on admission she always checked a resident's advance directives. The SSD said if the resident had a DNR (Do Not Resuscitate Order) she verified that it was legitimate and if they had a power of attorney (POA) she verified it was legal. An interview was conducted on [DATE] at 10:50 a.m. with Staff G, LPN/Unit Manager (UM). She said every resident had a physician order in the medical record for their code status (Advance Directive choice). She said the resident's code status showed up at the top of the electronic medical record for each resident and that had to be put in separate from the order. If the electronic medical record system is down Staff G said there is a computer back up of the Medication Administration Record (MAR) they can print that had the resident's code status on the top. When asked if the facility had a DNR book or paper copy of resident code status she stated, I'm trying to think of that one .don't think we have a book. Review of a facility policy titled Advance Directives, reviewed [DATE], showed the following: Policy, The resident has the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. Procedure 1. Provide information about advance directives to resident. a. The facility provides the resident (or their legal surrogate) with the Facility Guide at the time of admission. The guide provides written information about advance directives. b. If the resident was incompetent at the time of admission but later becomes able to receive and understand the guide, the information is given to the resident. c. The resident or surrogate does not have to write an advance directive to partake of facility services or as a condition of admission. 2. The resident and/or surrogate will be questioned at the time of admission about the existence of any advance directive written prior to admission. a. Photocopy all previously written advance directives, placing the copy in the medical record. b. Return the original advance directive to the resident/surrogate. 3. Should the resident or surrogate wish to write an advance directive, as defined by law, the facility shall assist the resident or surrogate to obtain the necessary forms. a. Make copies of a newly written advance directive, placing the copy in the medical record. b. Return the original advance directive to the resident/surrogate. 4. The attending physician shall record in the medical record pertinent information related to the formulation or implementation of the advance directive. Such information includes, but is not limited to: a. Any verbal advance directive that was written in his or her presence; b. Any diagnosis that the resident has a terminal or irreversible condition; c. Specific treatment steps to be taken when the advance directive is implemented; and d. All revocations or limitations placed on the advance directive in his or her presence. 5. The attending physician must document in the medical record the discussion with the resident or surrogate regarding choices and decision of advance directives. a. Upon executing any valid Advance Directive, the designated paperwork will be placed in the resident's medical record under the Advance Directive tab. b. When responding to a call for assistance, health care professionals and emergency personnel will honor the advance directive. 6. The resident or a probate court may revoke an advance directive. a. Document in the medical record, under the advance directive tab, the date, time and place of the revocation. b. The resident will complete a new Advance Directive/Medical Treatment Decisions Form to reflect new changes. The prior advance directive form will be placed in the medical record overflow chart in the medical records department. c. Update the face sheet to reflect the revocation. 7. Upon transfer or discharge, include a copy of all executed advanced directives in the document sent to the receiving facility. 8. Licensed Nursing Staff and Social Service staff will receive annual in-service education on Advance Directives. Resident #1 Review of the resident's electronic medical record admission profile showed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia, syncope and collapse, chronic kidney disease, benign prostatic hyperplasia. Review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008, dated [DATE] showed the resident had a discharge diagnosis of pneumonia upon leaving the hospital, where he was admitted on [DATE]. Form 3008 showed the resident was discharged on antibiotics for pneumonia, on oxygen 2 liters (L) as needed, and requested Full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status. Review of Resident #1's MDS (Minimum Data Set) Assessment, completed [DATE], Section C, Cognitive Patterns, showed resident had a BIMS (Brief Interview of Mental Status) Score of 3, indicating severely impaired cognition. Review of Resident #1's medical records showed a care plan in place, dated [DATE], for Advance Directives (Full Code) with a goal of advance directives will be honored by staff. A review of Resident #1's physician orders revealed the following: -Full Code, dated [DATE]. -Oxygen via nasal cannula 2 Liters (L) as needed, dated [DATE]. - Doxycycline Hyclate Oral Capsule 100 milligram (mg). Give 1 capsule by mouth every 12 hours for pneumonia for 5 Days, dated [DATE]. - Cefuroxime Axetil Oral Tablet 500 mg. Give 1 tablet by mouth two times a day for pneumonia for 5 Days, dated [DATE]. - RN (Registered Nurse) to release remains to funeral home of family's choice. [DATE] at 5:18 a.m. Review of Resident #1's medical record, a nurses' progress note entered by Staff B, RN on [DATE] at 5:15 a.m. showed Called to residents [sic] room by CNA [Certified Nursing Assistant] found resident absent of breath sounds and apical pulse for full two minutes. [Family member] and MD made aware of death. New order received to release remains to funeral home of family's choice. There was no documentation CPR was initiated for Resident #1 on [DATE] at 5:15 a.m. There was no additional documentation in the resident's medical record as to the condition of the resident when he was found, observations made, why a code blue was not called, or the time of death. Code blue indicates there is a resident requiring resuscitation or otherwise in need of immediate medical attention, often as the result of a respiratory or cardiac arrest. An interview was conducted on [DATE] at 12:19 p.m. with Staff E, CNA. She said on the morning of [DATE] she saw Resident #1 in bed when she did routine rounds around 3:00 a.m. She said Resident #1 was the same as he had been. Staff E said the resident had the pattern of breathing like people have when they are going to die but were still holding on. She said a few days prior to that, she could not remember the date, she had let the unit manager and nurse know Resident #1 was not breathing right and they put oxygen on him. She said on that day he was breathing a little shallow and low. She said at first, she thought he was gone but she called his name several times and he moaned letting her know he was still there. She said since that night he had been doing that breathing so the nurse should have known. She said he did not get any better. Staff E said on the morning of [DATE] she went in the room and was checking his brief, and he did not move. She said she rubbed his chest a little like she usually did, and he did not respond. She said Resident #1 was lying on his back and his eyes were partially open like they normally were when he slept. She said he often slept with his mouth open because he would breathe through his mouth all the time like he was trying to get more air. Staff E said the resident was floppy and she was scared. She confirmed Resident #1 had oxygen on during that shift. Staff E said she called the nurse and said she did not think Resident #1 was alive. She said both nurses on duty, Staff B, RN and Staff D, RN, came to assess and see if he was breathing. She said the nurses were like ok, they left out and no one ever came back. Staff E said the nurse never said if the resident was a full code or do not resuscitate (DNR). She said she figured he must have been a DNR because if he had been a full code the nurse would have grabbed the chart and normally they jump and run, and they did not do that. Staff E said she cleaned Resident #1 up and covered him like she normally did when someone died. She said when she touched him his body was still warm, only his face was a little cool. She said he was not stiff or anything. She said when she cleaned up his brief, he was still flexible, not rigid. Staff E said in her career she had it happen when a resident was cold and stiff and he [Resident #1] was not like that. Staff E said Resident #1's arm was flopping. She said, If I would have known he was a full code I would have expected us to get busy. Staff E said when she was leaving work that morning, Staff B, RN was outside crying and She [Staff B] said I think I messed up. He was a full code. I should have known. A follow-up interview was conducted on [DATE] at 2:46 p.m. with Staff E, CNA. Staff E said no other staff members helped with Resident #1 or came in the room on the morning of [DATE]. She said she provided a statement to the Nursing Home Administrator (NHA) about what happened. She said she let the NHA know Resident #1's face was a little cool, but not cold and his body was warm. Staff E said she did not know why others were saying he was stiff because when she rolled him from front to back to clean him, he just flopped over and if he was stiff he would not have done that. An interview was conducted on [DATE] at 4:57 a.m. with Staff B, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to Resident #1. Staff B said the CNA, Staff E, called the nurses. Staff B said Staff D, RN got to the room first and said she thought Resident #1 was dead. Staff B said I told her I think you are right. Staff B said Resident #1 was cold, stiff, his arms were rigid, he had a stare, he had no heart and lung sounds, and the top half of his body was stiff. Staff B said she could not move Resident #1's shoulders, his jaw was open and fixed, his lower arms were stiff, and he was completely immobile. Staff B said she decided there was no use in trying to code him. Staff B said she had not seen the resident since around 10:00 or 11:00 p.m. on [DATE], but the CNA had done rounds every 2 hours. Staff B said she called Resident #1's primary care provider's (PCP) answering service and left a message for the on-call provider to call her back. She said she left a message for the family of Resident #1 to call her. Staff B said when she left the faciity on [DATE] she had still not received a call back from a provider regarding Resident #1's death. When asked which provider gave her the order she entered on [DATE] at 5:15 a.m. to release Resident #1's remains to the funeral home, she said she put it in presumptively and reconfirmed she never spoke with a provider. Staff B said, that's on me. Staff B said on [DATE] around 6:40 a.m. the next shift started coming in. She said Staff C, Licensed Practical Nurse (LPN) was going to take over her assignment. Staff B said she let Staff C know Resident #1 had passed and they did not do CPR. Staff B said Staff C panicked and freaked out because he was a full code. She said Staff C told her she needed to call the Director of Nursing (DON) Staff B said Staff C called the DON but she did not hear what the conversation entailed she was just standing and waiting. Staff B said the next thing she knew a code blue was being called on the loudspeaker for Resident #1. Staff B said, it was told to me when EMS [Emergency Medical Services] got there you better be running that code. Staff B said she and Staff F, LPN started CPR on Resident #1 and continued for around 5-7 minutes until EMS arrived and took over. She said EMS did compressions, hooked the resident to their monitor and then pronounced him deceased . She said EMS packed up and left and she was allowed to leave work then. An interview was conducted on [DATE] at 11:37 a.m. with Staff D, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] with Staff B, RN. Staff D said Resident #1 was not assigned to her and she did not know the resident. She said the CNA came out and asked if she was assigned Resident #1 and she told her no. Staff B, RN walked up and [Staff B] said oh my god, don't tell me something happened. Staff D said she went to Resident #1's room with Staff B and they checked on him and he had no pulse. She said when they got to the room Resident #1 was stiff/rigid, his mouth was open, and he was cool to the touch. Staff D said if you see a patient deceased you cannot make that call. She said you still check the code status and if they are a full code, you have to do CPR on the resident. Staff D said she thought Staff B had checked Resident #1's code status. She said she asked Staff B if she needed her to do anything or needed her help. Staff B told her no she had already called the doctor and taken care of the paperwork. A follow-up interview was conducted on [DATE] at 10:55 a.m. with Staff D, RN. She said she assumed Staff B checked Resident #1's code status. Staff D said she figured he must have been a DNR. Staff D reiterated Resident #1 was cool, stiff, rigid, and mouth ajar. She said his whole body was cool, not cold. An interview was conducted on [DATE] at 1:09 p.m. with Staff C, LPN. She said on [DATE] she came on for her shift and Staff B, RN was giving her report when Staff B informed her Resident #1 had passed away. Staff C said she asked Staff B if CPR was done and she said no he was dead. Staff C said she told Staff B to call the DON because the facility protocol was to do CPR. Staff C said she told Staff B, I will not accept responsibility without DON notification of the incident. Staff C confirmed a code blue was called for Resident #1 after Staff B talked to the DON. Staff C said she did not go in Resident #1's room due to several others being in there already. She said EMS arrived and pronounced the resident. Staff C said when she originally spoke with Staff B, Staff B did not elaborate on why she did not do CPR for Resident #1 when they found him unresponsive approximately 2 hours earlier. A follow-up interview was conducted with Staff C, LPN on [DATE] at 11:29 a.m. Staff C said she did not call the DON the morning of [DATE] to notify her of the incident with Resident #1, she had Staff B, RN call her. Staff C said she did not call the doctor to get an order to release Resident #1's remains to the funeral home because Staff B, RN already had an order in the computer. Staff C said she did not hear the conversation Staff B had with the DON but she did witness her on the phone. A follow-up interview was conducted on [DATE] at 11:38 a.m. with Staff B, RN. Staff B initially reconfirmed she did not call the DON the morning of [DATE] then said she did. Staff B said she told the DON Resident #1 had passed, was a full code, and CPR was not done. She said the DON did not give her time to explain and did not ask why, she kind of panicked and started calling other people. Everyone's phone was ringing. Staff B said the DON did not mention anything to her about calling a code she only told her not to leave the facility and the DON started calling other people. When asked to verify the condition Resident #1 was in when he was found unresponsive at approximately 5:00 a.m. on [DATE], Staff B said she got her stethoscope and checked him, his jaw was still, and his upper arms were stiff at the shoulder. She said she did not check his body because he was still under the blankets. An interview was conducted on [DATE] at 12:16 p.m. with Staff H, LPN. She said she came in for the day shift on [DATE]. Staff H said Staff C, LPN told her what happened. Staff H said she saw Staff B, RN walk out the back door and called the DON. Staff B came back inside and said the DON told her they needed to call a code. Staff H said she got on the overhead speaker and called a code blue for Resident #1. Staff H said Staff B told her the resident was gone and she made the assessment there wasn't anything that could have been done for him. Staff H said that is not how it works because when someone was a full code, you have to do CPR. Staff H said, it is not at my discretion. That is like day one 1 basics. An interview was conducted on [DATE] at 1:50 p.m. with the DON. The DON said Staff B, RN called her on [DATE] around 7:05-7:10 a.m. to inform her Resident #1 was deceased and no CPR had been initiated. The DON said she told Staff B to initiate CPR. The DON said at this time of this discussion they did not talk about Resident #1 not breathing, being cold and rigid, or his chin being in a fixed position. She said CPR started and continued for approximately 5 minutes, EMS arrived at 7:34 a.m. and pronounced the resident at 7:40 a.m. The DON said Staff B did not tell her she did not call a code due to her observations. The DON said for Resident #1 she would have expected the staff to call a code blue and initiate CPR. The DON reviewed Resident #1's medical record and verified there had been no documentation of oxygen saturation during his stay. Regarding change in condition, she said she would expect staff to document oxygen saturation levels before and after applying supplemental oxygen and notify a provider if the resident was having breathing issues. She confirmed there were no vital signs recorded when the resident was found unresponsive on [DATE] at approximately 5:00 a.m. The DON said she would not expect staff to obtain vitals when CPR was initiated on a resident or if they are deceased . An interview was conducted on [DATE] at 4:12 p.m. with Resident #'1 PCP. She said Resident #1 was frail but stable. She said if she had been called and told a resident that was a full code expired and no interventions were done, she would have educated them. An interview was conducted on [DATE] at 2:24 p.m. with the Nursing Home Administrator (NHA), DON and the Regional Clinical Director. The NHA said he received a call on [DATE] from the DON telling him Resident #1 passed and they were doing a full code right then. He said he reported the incident to the state, the police, and the Department of Children and Families. He said they then began investigating. He said during the investigation he and the DON decided a code did not have to be called because rigor mortis was setting in for Resident #1. The DON said when the nurses went into Resident #1's room and there were signs of death, their observations should have been documented. An interview was conducted on [DATE] at 1:06 p.m. with the DON. She said with Resident #1 it was pretty cut and dry, if they were not a DNR you follow the process. Facility immediate actions to correct deficient practice and remove the Immediate Jeopardy included: 1. ADHOC (for this situation) QAPI (Quality Assessment Performance Improvement) Meeting for Honoring Advanced Directives / CPR. Completed [DATE]. 2. QAA (Quality Assurance and Assessment)/QAPI review: [DATE] 3. QAA/QAPI review within 72 hours. Completed [DATE] 4. Initiate investigation through statements, record review, interview, and video review. Completed [DATE]. 5. Validate licenses, background check and clearinghouse of staff involved in incident. Completed [DATE]. 6. Validate CPR certification of staff involved in incident. Completed [DATE]. 7. Audit current residents to ensure advance directives/code status is entered in EMR and is accurate. Completed [DATE]. 8. Validate DNR transport paper is appropriately filled out and yellow paper is available to print transport paperwork. Completed [DATE]. 9. Validate CPR certification of all nurses. Completed [DATE]. 10. Education to all licensed nurses on the location of Advance Directives and code status in EMR and CPR procedure with emphasis on timely response to code status. Completed education with all licensed nurses on [DATE]. 11. Education to all licensed nurses on the appropriate documentation for Advance Directives, CPR process and obvious signs of death. Completed [DATE]. 12. CPR drills every shift for 7 consecutive days. To include validate unresponsive, review code status in EMR and initiate CPR or do not resuscitate per physician order and resident wishes. Completed [DATE]. Monitoring procedure to ensure that the removal plan is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: 13. Newly admitted residents will have Advance Directives / code status order in place. Ongoing 14. Residents will be evaluated quarterly and with significant change for accuracy of advance directives / code status and plan of care updated as warranted. Ongoing 15. Audit new admissions for advance directives daily and ensure order is in place. Ongoing 16. Conduct CPR drills once every shift every month. Ongoing 17. Newly hired RN/LPN will be educated on advanced directives and CPR procedure. Ongoing 18. NHA, Director of Nursing, ADON, SDC (Staff Development Coordinator), Unit Managers, Evening Supervisor and Weekend Supervisor will validate the nursing staff's retention of the education presented by conducting performance observation validation audits 3 times a week for 12 weeks. 19. Audits and drills audit will be reviewed in monthly QA&A/QAPI meeting. Ongoing 20. QA&A/QAPI Committee will determine need for further auditing or until substantial compliance is achieved. NHA, Director of Nursing, ADON, SDC, Unit Managers, Evening Supervisor and Weekend Supervisor will validate there is sufficient staffing to meet the residents needs. Ongoing. Verification of the facility's removal plan was conducted by the survey team on [DATE]. An interview was conducted on [DATE] at 6:12 p.m. with the NHA, DON, and [NAME] President of Operations (VPO). Copies of all education provided to staff were reviewed. Audits the facility completed related to code status were reviewed. They confirmed all nurses were educated on the CPR process and advanced directives. The DON was educated by the Regional Clinical Director. The VPO said going forward one of the key things is validating and verifying. The NHA said from a risk standpoint they need to validate what they expect and make sure things are done properly. Interviews were conducted and education confirmed for 11 out of 11 licensed nurses. Staff members signed in-service education and/or were able to state that they had been trained and were knowledgeable about the policies. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be past noncompliance with a correction date of [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to ensure cardiopulmonary resuscitation (CPR) was performed according to professional standards for one resident (#1) out of three reviewed for CPR. Resident #1 was found not breathing with no pulse. Nursing staff did not initiate CPR until approximately 2 hours after the resident was discovered. Resident #1 expired in the facility. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy starting on [DATE]/24. The findings of Immediate Jeopardy were determined to be Past noncompliance with a compliance date of [DATE] after surveyor verification of actions implemented removed and corrected the noncompliance. Findings included: Review of the resident's electronic medical record admission profile showed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia, syncope and collapse, chronic kidney disease, benign prostatic hyperplasia. Review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008, dated [DATE] showed the resident had a discharge diagnosis of pneumonia upon leaving the hospital, where he was admitted on [DATE]. Form 3008 showed the resident was discharged on antibiotics for pneumonia, on oxygen 2 liters (L) as needed, and requested Full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status. Review of Resident #1's MDS (Minimum Data Set) Assessment, completed [DATE], Section C, Cognitive Patterns, showed resident had a BIMS Score of 3, indicating severely impaired cognition. Review of Resident #1's medical records showed a care plan in place, dated [DATE], for Advance Directives (Full Code) with a goal of advance directives will be honored by staff. A review of Resident #1's physician orders revealed the following: -Full Code, dated [DATE]. -Oxygen via nasal cannula 2 Liters (L) as needed, dated [DATE]. - Doxycycline Hyclate Oral Capsule 100 milligram (mg). Give 1 capsule by mouth every 12 hours for pneumonia for 5 Days, dated [DATE]. - Cefuroxime Axetil Oral Tablet 500 mg. Give 1 tablet by mouth two times a day for pneumonia for 5 Days, dated [DATE]. - RN to release remains to funeral home of family's choice. [DATE] at 5:18 a.m. Review of Resident #1's medical record, a nurses' progress note entered by Staff B, RN on [DATE] at 5:15 a.m. showed Called to residents [sic] room by CNA [Certified Nursing Assistant] found resident absent of breath sounds and apical pulse for full two minutes. [Family member] and MD made aware of death. New order received to release remains to funeral home of family's choice. There was no documentation CPR was initiated for Resident #1 on [DATE] at 5:15 a.m. There was no additional documentation in the resident's medical record as to the condition of the resident when he was found, observations made, why a code blue was not called, or the time of death. Code blue indicates there is a resident requiring resuscitation or otherwise in need of immediate medical attention, often as the result of a respiratory or cardiac arrest. An interview was conducted on [DATE] at 12:19 p.m. with Staff E, CNA. She said on the morning of [DATE] she saw Resident #1 in bed when she did routine rounds around 3:00 a.m. She said Resident #1 was the same as he had been. Staff E said the resident had the pattern of breathing like people have when they are going to die but were still holding on. She said a few days prior to that, she could not remember the date, she had let the unit manager and nurse know Resident #1 was not breathing right and they put oxygen on him. She said on that day he was breathing a little shallow and low. She said at first, she thought he was gone but she called his name several times and he moaned letting her know he was still there. She said since that night he had been doing that breathing so the nurse should have known. She said he did not get any better. Staff E said on the morning of [DATE] she went in the room and was checking his brief, and he did not move. She said she rubbed his chest a little like she usually did, and he did not respond. She said Resident #1 was lying on his back and his eyes were partially open like they normally were when he slept. She said he often slept with his mouth open because he would breathe through his mouth all the time like he was trying to get more air. Staff E said the resident was floppy and she was scared. She confirmed Resident #1 had oxygen on during that shift. Staff E said she called the nurse and said she did not think Resident #1 was alive. She said both nurses on duty, Staff B, RN and Staff D, RN, came to assess and see if he was breathing. She said the nurses were like ok, they left out and no one ever came back. Staff E said the nurse never said if the resident was a full code or do not resuscitate (DNR). She said she figured he must have been a DNR because if he had been a full code the nurse would have grabbed the chart and normally they jump and run, and they did not do that. Staff E said she cleaned Resident #1 up and covered him like she normally did when someone died. She said when she touched him his body was still warm, only his face was a little cool. She said he was not stiff or anything. She said when she cleaned up his brief, he was still flexible, not rigid. Staff E said in her career she had it happen when a resident was cold and stiff and he [Resident #1] was not like that. Staff E said Resident #1's arm was flopping. She said, If I would have known he was a full code I would have expected us to get busy. Staff E said when she was leaving work that morning, Staff B, RN was outside crying and She [Staff B] said I think I messed up. He was a full code. I should have known. A follow-up interview was conducted on [DATE] at 2:46 p.m. with Staff E, CNA. Staff E said no other staff members helped with Resident #1 or came in the room on the morning of [DATE]. She said she provided a statement to the Nursing Home Administrator (NHA) about what happened. She said she let the NHA know Resident #1's face was a little cool, but not cold and his body was warm. Staff E said she did not know why others were saying he was stiff because when she rolled him from front to back to clean him, he just flopped over and if he was stiff he would not have done that. An interview was conducted on [DATE] at 4:57 a.m. with Staff B, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to Resident #1. Staff B said the CNA, Staff E, called the nurses. Staff B said Staff D, RN got to the room first and said she thought Resident #1 was dead. Staff B said I told her I think you are right. Staff B said Resident #1 was cold, stiff, his arms were rigid, he had a stare, he had no heart and lung sounds, and the top half of his body was stiff. Staff B said she could not move Resident #1's shoulders, his jaw was open and fixed, his lower arms were stiff, and he was completely immobile. Staff B said she decided there was no use in trying to code him. Staff B said she had not seen the resident since around 10:00 or 11:00 p.m. on [DATE], but the CNA had done rounds every 2 hours. Staff B said she called Resident #1's primary care provider's (PCP) answering service and left a message for the on-call provider to call her back. She said she left a message for the family of Resident #1 to call her. Staff B said when she left the faciity on [DATE] she had still not received a call back from a provider regarding Resident #1's death. When asked which provider gave her the order she entered on [DATE] at 5:15 a.m. to release Resident #1's remains to the funeral home, she said she put it in presumptively and reconfirmed she never spoke with a provider. Staff B said, that's on me. Staff B said on [DATE] around 6:40 a.m. the next shift started coming in. She said Staff C, Licensed Practical Nurse (LPN) was going to take over her assignment. Staff B said she let Staff C know Resident #1 had passed and they did not do CPR. Staff B said Staff C panicked and freaked out because he was a full code. She said Staff C told her she needed to call the Director of Nursing (DON) Staff B said Staff C called the DON but she did not hear what the conversation entailed she was just standing and waiting. Staff B said the next thing she knew a code blue was being called on the loudspeaker for Resident #1. Staff B said, it was told to me when EMS [Emergency Medical Services] got there you better be running that code. Staff B said she and Staff F, LPN started CPR on Resident #1 and continued for around 5-7 minutes until EMS arrived and took over. She said EMS did compressions, hooked the resident to their monitor and then pronounced him deceased . She said EMS packed up and left and she was allowed to leave work then. An interview was conducted on [DATE] at 11:37 a.m. with Staff D, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] with Staff B, RN. Staff D said Resident #1 was not assigned to her and she did not know the resident. She said the CNA came out and asked if she was assigned Resident #1 and she told her no. Staff B, RN walked up and [Staff B] said oh my god, don't tell me something happened. Staff D said she went to Resident #1's room with Staff B and they checked on him and he had no pulse. She said when they got to the room Resident #1 was stiff/rigid, his mouth was open, and he was cool to the touch. Staff D said if you see a patient deceased you cannot make that call. She said you still check the code status and if they are a full code, you have to do CPR on the resident. Staff D said she thought Staff B had checked Resident #1's code status. She said she asked Staff B if she needed her to do anything or needed her help. Staff B told her no she had already called the doctor and taken care of the paperwork. A follow-up interview was conducted on [DATE] at 10:55 a.m. with Staff D, RN. She said she assumed Staff B checked Resident #1's code status. Staff D said she figured he must have been a DNR. Staff D reiterated Resident #1 was cool, stiff, rigid, and mouth ajar. She she his whole body was cool, not cold. An interview was conducted on [DATE] at 1:09 p.m. with Staff C, LPN. She said on [DATE] she came on for her shift and Staff B, RN was giving her report when Staff B informed her Resident #1 had passed away. Staff C said she asked Staff B if CPR was done and she said no he was dead. Staff C said she told Staff B to call the DON because the facility protocol was to do CPR. Staff C said she told Staff B, I will not accept responsibility without DON notification of the incident. Staff C confirmed a code blue was called for Resident #1 after Staff B talked to the DON. Staff C said she did not go in Resident #1's room due to several others being in there already. She said EMS arrived and pronounced the resident. Staff C said when she originally spoke with Staff B, Staff B did not elaborate on why she did not do CPR for Resident #1 when they found him unresponsive approximately 2 hours earlier. A follow-up interview was conducted with Staff C, LPN on [DATE] at 11:29 a.m. Staff C said she did not call the DON the morning of [DATE] to notify her of the incident with Resident #1, she had Staff B, RN call her. Staff C said she did not call the doctor to get an order to release Resident #1's remains to the funeral home because Staff B, RN already had an order in the computer. Staff C said she did not hear the conversation Staff B had with the DON but she did witness her on the phone. A follow-up interview was conducted on [DATE] at 11:38 a.m. with Staff B, RN. Staff B initially reconfirmed she did not call the DON the morning of [DATE] then said she did. Staff B said she told the DON Resident #1 had passed, was a full code, and CPR was not done. She said the DON did not give her time to explain and did not ask why, she kind of panicked and started calling other people. Everyone's phone was ringing. Staff B said the DON did not mention anything to her about calling a code she only told her not to leave the facility and the DON started calling other people. When asked to verify the condition Resident #1 was in when he was found unresponsive at approximately 5:00 a.m. on [DATE], Staff B said she got her stethoscope and checked him, his jaw was still, and his upper arms were stiff at the shoulder. She said she did not check his body because he was still under the blankets. An interview was conducted on [DATE] at 12:16 p.m. with Staff H, LPN. She said she came in for the day shift on [DATE]. Staff H said Staff C, LPN told her what happened. Staff H said she saw Staff B, RN walk out the back door and called the DON. Staff B came back inside and said the DON told her they needed to call a code. Staff H said she got on the overhead speaker and called a code blue for Resident #1. Staff H said Staff B told her the resident was gone and she made the assessment there wasn't anything that could have been done for him. Staff H said that is not how it works because when someone was a full code, you have to do CPR. Staff H said, it is not at my discretion. That is like day one basics. An interview was conducted on [DATE] at 1:50 p.m. with the DON. The DON said Staff B, RN called her on [DATE] around 7:05-7:10 a.m. to inform her Resident #1 was deceased and no CPR had been initiated. The DON said she told Staff B to initiate CPR. The DON said at this time of this discussion they did not talk about Resident #1 not breathing, being cold and rigid, or his chin being in a fixed position. She said CPR started and continued for approximately 5 minutes, EMS arrived at 7:34 a.m. and pronounced the resident at 7:40 a.m. The DON said Staff B did not tell her she did not call a code due to her observations. The DON said for Resident #1 she would have expected the staff to call a code blue and initiate CPR. The DON reviewed Resident #1's medical record and verified there had been no documentation of oxygen saturation during his stay. Regarding change in condition, she said she would expect staff to document oxygen saturation levels before and after applying supplemental oxygen and notify a provider if the resident was having breathing issues. She confirmed there were no vital signs recorded when the resident was found unresponsive on [DATE] at approximately 5:00 a.m. The DON said she would not expect staff to obtain vitals when CPR was initiated on a resident or if they are deceased . An interview was conducted on [DATE] at 4:12 p.m. with Resident #'1 PCP. She said Resident #1 was frail but stable. She said if she had been called and told a resident that was a full code expired and no interventions were done, she would have educated them. An interview was conducted on [DATE] at 2:24 p.m. with the Nursing Home Administrator (NHA), DON and the Regional Clinical Director. The NHA said he received a call on [DATE] from the DON telling him Resident #1 passed and they were doing a full code right then. He said he reported the incident to the state, the police, and the Department of Children and Families. He said they then began investigating. He said during the investigation he and the DON decided a code did not have to be called because rigor mortis was setting in for Resident #1. The DON said when the nurses went into Resident #1's room and there were signs of death, their observations should have been documented. An interview was conducted on [DATE] at 1:06 p.m. with the DON. She said with Resident #1 it was pretty cut and dry, if they were not a DNR you follow the process. Review of a facility policy titled Cardiopulmonary Resuscitation, revised [DATE], showed the following: The center shall provide basic life support, including CPR - Cardiopulmonary Resuscitation when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order, and resident choice indicated in the resident's advance directives. CPR will be initiated unless: -A valid Do Not Resuscitate Order (DNR) is in place or -Resident presents with obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) or -Initiating CPR could cause injury or peril to the rescuer. CPR certified licensed staff will be available on all shifts. Procedure: 1. In the event of cardiac or respiratory arrest, identify code status. If no DNR order exists, or if the resident has no obvious clinical signs of irreversible death, begin CPR. 2. Activate emergency response system by clearly paging over the PA system. Code Blue and the area/room number. 3. Continue CPR until either: -the resident responds or -healthcare practitioner arrives and takes over or -EMS arrives and takes over 4. Notify the physician of resident status and obtain further orders. 5. Notify family/resident representative. 6. Document appropriate information in the medical record. Review of a facility policy titled Death of a Resident in the Facility, revised [DATE], showed the following: Policy Upon death of a resident, the facility will notify the MD and responsible party. If there is not a do not resuscitate order, emergency response will be called. The resident will receive proper postmortem care, including bathing, clean linens and gown. Upon physician's release of the body, the mortician will be notified for transportation of the body to the mortuary of choice. The family/responsible party will be provided the opportunity to spend time alone with the body prior to mortician removal. Resident belongings will be packed and stored for removal by family/responsible party. Facility immediate actions to correct deficient practice included: 1. ADHOC (for this situation) QAPI (Quality Assessment Performance Improvement) Meeting for Honoring Advanced Directives / CPR. Completed [DATE]. 2. QAA (Quality Assurance and Assessment)/QAPI review: [DATE] 3. QAA/QAPI review within 72 hours. Completed [DATE]. 4. Initiate investigation through statements, record review, interview, and video review. Completed [DATE]. 5. Validate licenses, background check and clearinghouse of staff involved in incident. Completed [DATE]. 6. Validate CPR certification of staff involved in incident. Completed [DATE]. 7. Audit current residents to ensure advance directives/code status is entered in EMR (Electronic Medical Record) and is accurate. Completed [DATE]. 8. Validate DNR transport paper is appropriately filled out and yellow paper is available to print transport paperwork. Completed [DATE]. 9. Validate CPR certification of all nurses. Completed [DATE]. 10. Education to all licensed nurses on the location of Advance Directives and code status in EMR and CPR procedure with emphasis on timely response to code status. Completed education with all licensed nurses on [DATE]. 11. Education to all licensed nurses on the appropriate documentation for Advance Directives, CPR process and obvious signs of death. Completed [DATE]. 12. CPR drills every shift times 7 consecutive days. To include validate unresponsive, review code status in EMR and initiate CPR or do not resuscitate per physician order and resident wishes. Completed [DATE]. Monitoring procedure to ensure that the removal plan is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: 13. Newly admitted residents will have Advance Directives / code status order in place. Ongoing 14. Residents will be evaluated quarterly and with significant change for accuracy of advance directives / code status and plan of care updated as warranted. Ongoing 15. Audit new admissions for advance directives daily and ensure order is in place. Ongoing 16. Conduct CPR drills once every shift every month. Ongoing 17. Newly hired RN/LPN will be educated on advance directives and CPR procedure. Ongoing 18. NHA, Director of Nursing, ADON, SDC, Unit Managers, Evening Supervisor and Weekend Supervisor will validate the nursing staff's retention of the education presented by conducting performance observation validation audits 3 times a week for 12 weeks. 19. Audits and drills audit will be reviewed in monthly QA&A/QAPI meetings. Ongoing 20. QA&A/QAPI Committee will determine need for further auditing or until substantial compliance is achieved. NHA, Director of Nursing, ADON, SDC, Unit Managers, Evening Supervisor and Weekend Supervisor will validate there is sufficient staffing to meet the resident's needs. Ongoing. Verification of the facility's removal plan was conducted by the survey team on [DATE]. An interview was conducted on [DATE] at 6:12 p.m. with the NHA, DON, and [NAME] President of Operations (VPO). Copies of all education provided to staff were reviewed. Audits the facility completed related to code status were reviewed. They confirmed all nurses were educated on the CPR process and advance directives. The DON was educated by the Regional Clinical Director. The VPO said going forward one of the key things is validating and verifying. The NHA said from a risk standpoint they need to validate what they expect and make sure things are done properly. Interviews were conducted and education confirmed for 11 out of 11 licensed nurses. Staff members signed in-service education and/or were able to state during an interview that they had been trained and were knowledgeable about the policies. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be past noncompliance with a correction date of [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review the facility failed to protect the residents' right to be free from neglect related to neglecting to complete ordered laboratory tests for one resident (#3), not noticing a change of condition and notifying the physician and for two residents (#3 and #1) out of three reviewed for change of condition, and not performing cardiopulmonary resuscitation (CPR) according to policy for one resident (#1) out of three reviewed for the CPR process. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #3 and #1 and resulted in the determination of Immediate Jeopardy which began on 2/3/24. The findings of Immediate Jeopardy were determined to be removed on 3/14/24 and the severity and scope was reduced to an E after verification of removal of the Immediate Jeopardy. Findings included: Review of a facility policy titled Abuse & Neglect Prohibition, effective 10/24/22, showed the following: Policy, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation, and misappropriation of property. Definitions: Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Procedure: Screening 1. The center will screen for employees with a history of abusive behavior or who may be at risk for being abusive. 2. The center will ensure that prospective temporary or agency staff will have background screen conducted in accordance with state law. 3. The center will observe for potentially abusive individuals involved with the resident who are not providing a professional service. 4. The center will screen for potentially abusive residents. Training 1. The center will train each employee regarding these policies. 2. The center will ensure that such training is provided during orientation, annually, and more often as determined by the center. 3. The center will provide ancillary training regarding related policies and procedures. 4. The center will provide auxiliary education for those additional individuals involved with the resident. Prevention 2. Center supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. Identification 1. The administrator will designate an Abuse Coordinator who shall be responsible for the implementation and oversight of the centers [sic] Abuse Prohibition Program. 2. The center Quality Assessment & Assurance (QA&A) Committee will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect, or misappropriation of resident property and to determine the direction of the investigation/intervention, through analysis of systems, audits, and reports. 3. The center supervisory staff will integrate into the supervisory process monitoring the behavior of staff members and residents, which are indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression. 4. The center staff may accommodate special needs of a resident or staff member who have [sic] been affected by past abuse experiences. Investigation 1. The center will investigate any alleged abuse/neglect or misappropriation of resident property in accordance with state or federal law. 2. The center will report such allegations to the state, as per state/federal regulation. The center will report immediately but not later than 2 hours after forming the suspicion if the events that cause the allegation involve abuse or result in serious bodily injury. 3. The center will report reportable investigation findings in accordance with State law, including to the state survey agency within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action will be taken. 4. The center will investigate patterns, trends or incidents that suggest the possible presence of abuse, neglect or misappropriation of property and exploitation related to unauthorized photos identified though analysis conducted by the QA&A Committee, with intervention, reporting or policy/procedure modification conducted as appropriate. Protection 1. The center will protect residents from harm during the investigation. 2. The center will make referrals to the appropriate state agencies as necessary, to ensure the protection of the resident or resident's property. Reporting and Response 1. The center will report all allegations and substantiated occurrences of abuse, neglect, and misappropriation of property to the state/federal agency and law enforcement officials as designated by state/federal law. Resident #3 Review of the Resident #3's electronic medical record admission profile showed she was admitted on [DATE] with diagnoses including dementia with other behavioral disturbances, hypertension, hypothyroidism, encephalopathy, anxiety disorder, and low back pain. Review of Resident #3's most recent Minimum Data Set (MDS) for Significant Change, completed 2/1/24, revealed Section C, Cognitive Patterns, showed resident had a Brief Interview for Mental Status (BIMS) Score of 4, indicating severely impaired cognition. Section GG, Functional Abilities and Goals, showed Resident #3 was dependent for eating, toileting, hygiene, transfers, sitting to lying and lying to sitting. It showed the resident used a wheelchair but was dependent for locomotion. The significant change assessment was completed due to a new skin tear. Review of lab results dated 2/3/24 for Resident #3 showed she had scheduled monthly labs drawn on 2/3/24 which were reported back to the facility with critical values the same day. Results showed her white blood cell count (WBC) was critically high at 36.2 with the reference range being 4.1-10.9 and her Blood Urea Nitrogen (BUN) level was critically high at 97 with a reference range of 6-20. A high white blood cell count usually means one of the following has increased the making of white blood cells: An infection, Reaction to a medicine, A bone marrow disease, An immune system issue, Sudden stress such as hard exercise, Smoking. According to the Mayo Clinic at https://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym-20050611, viewed on 3/26/2024. A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys are working. A BUN test measures the amount of urea nitrogen that's in your blood. A BUN test can reveal whether your urea nitrogen levels are higher than normal, suggesting that your kidneys may not be working properly, according to the Mayo Clinic at https://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/about/pac-2038482, viewed on 3/26/2024. Review of progress notes for Resident #3 showed a nurse's note written by Staff B, Registered Nurse (RN) dated 2/3/2024 at 6:23 p.m., reviewed critical labs with [primary care provider (PCP)] with new orders to start IV (intravenous solution), D 5 1/2 NS [normal saline] at 75 [milliliters]mL/[hour] hr x 3 days, UA [urinalysis], CXR [chest x-ray], repeat CBC [completed blood count]/BMP [basic metabolic panel] in 4 days Review of physician orders for Resident #3 showed the following orders entered into the computer by Staff B, RN: -2/3/24 at 3:13 p.m. Dextrose-NaCL (Sodium) Solution 5-0 0.45%. Use 75 ml/hr intravenously every hour for abnormal labs for 3 days. -2/3/24 at 3:21 p.m. May insert IV for delivery of fluids. One time for 3 days. -2/3/24 4:09 p.m. Urinalysis. Culture and Sensitivity. STAT(immediately) for abnormal labs. -2/3/24 6:43 p.m. Chest x-ray STAT. According to the progress notes, these orders were all received from the provider in the same phone call, however they were entered into the computer over a 3 ½ hour period. Review of Resident #3's Treatment Administration Record (TAR) for February 2024 showed the STAT urinalysis and STAT chest x-ray were not signed off as completed on 2/3/24. Review of Resident #3's lab and radiology results did not show results for the STAT urinalysis or chest x-ray on 2/3/24. An interview was conducted on 3/13/24 at 2:02 p.m. with the third-party lab that processed labs for this facility. The lab representative reviewed their records for Resident #3 and stated they did not have orders for a STAT urinalysis in their system for Resident #3 on 2/3/24 and had no documentation indicating the nurse notified the lab of STAT orders. The lab representative said STAT orders were typically completed and reported back to the facility within 4-5 hours. An interview was conducted on 3/13/24 at 2:17 p.m. with the x-ray service that provided imaging services for this facility. The company representative reviewed their records for Resident #3 and said they did not receive orders for x-rays on 2/3/24 for the resident. They said the nurse typically placed the STAT orders into their system online and would sometimes call if it was STAT. The company representative said they did show an order for a chest x-ray placed into the system on 2/4/24 at 4:00 a.m. but it was not a STAT order. Review of Resident #3's vital signs on 2/4/24 at 10:19 a.m. showed a blood pressure (BP) of 69/54, a pulse (P) of 121, respirations (RR) of 20 per minute, and a temperature (T) of 97.5 Fahrenheit (F.) The resident's routine weekly blood pressure typically ran 116-135/66-90 and her heart rate was normally 65-82. Review of Resident #3's medical record did not show documentation that a provider was notified of the abnormal vital signs of BP 69/54 and P 121. There was no documentation an assessment was performed on 2/4/24 at 10:19 a.m. when the resident had these abnormal vital signs. Review of Resident #3's progress notes showed a nurses note on 2/4/2024 11:40 a.m.Attempted to reach [family member], concerning residents condition. No answer but did leave message to contact the facility at his earliest convenience[sic]. Review of radiology results showed a chest x-ray was completed due to a cough on 2/4/24 at 5:30 p.m. with the following finding: The heart is normal in size and configuration. The mediastinum is unremarkable. There is a mild airspace opacity in the right upper lobe. No acute osseous abnormality is visualized. The lungs are hyperinflated, consistent with chronic obstructive pulmonary disease. Mild degenerative changes are seen. CONCLUSION: Mild right upper lobe infiltrate. The differential primarily includes subsegmental atelectasis or infection. Correlation with history and symptomatology is advised. Review of Resident #3's medical records showed a Change of Condition Evaluation, dated 2/4/24 at 8:42 p.m. The evaluation showed the resident had shortness of breath and was unresponsive. Her blood pressure was 150/62, heart rate was 32 and irregular, her respirations were 32 per minute, and oxygen saturation was 84%. Nursing observations, evaluations, and recommendations showed Resident noted to have shortness of breath with order received to send resident to the hospital, and in the process of being sent to the hospital ER when she stopped breathing. Code Blue initiated by nurses with CPR in progress as resident is a Full Code [if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive]. 911 called, MD on call notified. [Name] Fire and Rescue Paramedics and [Name] Paramedics came to facility and took over CPR. Resident transferred to [hospital name] ER [emergency room] for evaluation and treatment. Review of Resident #3's progress notes showed a nursing progress note, written by Staff B RN, dated 2/4/24 at 10:25 p.m., showing the hospital called and notified the nurse that the resident expired in the emergency room. An interview was conducted on 3/12/24 at 4:57 p.m. with Staff B, RN. Staff B said she cared for Resident #3 every time she worked. She said she received critical lab values on 2/3/24 and notified the doctor. She said the doctor gave STAT orders. She said she put the orders in and called the lab and x-ray to tell them. Staff B said she assumed the labs and x-ray were completed. She said she was assigned to care for Resident #3 on 2/4/24. Staff B said she did not check if the orders had been completed, she assumed they came in and got the labs. She said the lab would do STAT labs immediately if they had time. Staff B said she did not remember Resident #3's low blood pressure on 2/4/24 and did not talk to any providers about it. Staff B said Resident #3 was weak, wanted to sleep, and was laying down and did not want to get up. Staff B said she only worked weekends and had the resident the previous Saturday and Sunday 1/27 and 1/28/24. She said the previous weekend the resident was on a restorative program and was sitting up eating while being cued by a staff member and was more alert. (A restorative program helps resident function at their highest potential) Staff B said the weekend of 2/3/24 and 2/4/24 Resident #3 was totally different, had a poor appetite, would moan, only take small bites or food, and was lethargic. Staff B said she did not recall the resident having breathing issues. An interview was conducted on 3/12/24 at 1:49 p.m. with the Director of Nursing (DON). She said when STAT labs or imaging was ordered the nurse should put the order in then call the lab and/or x-ray to let them know. The DON said STAT orders should be completed within 2-4 hours. She said labs and x-rays could be done anytime day or night, even on weekends. She said for the urinalysis the nurse would collect the specimen and the lab would pick it up. The DON reviewed Resident #3's medical record and confirmed there was a STAT order for the urinalysis and chest x-ray and they were not marked off as completed. She said the lab results populated in the medical record directly from the lab, so if they were done the results would have been in the medical record. She reviewed the orders and confirmed the resident's STAT orders were entered into the computer over a 3 ½ hour window and she did not know why there was a delay between the (intravenous)IV order, the urinalysis order and the chest x-ray order for Resident #3. The DON said when a provider gave orders for STAT labs she would expect them to be put in immediately. The DON reviewed Resident #3's vital signs in the medical record. The DON said, I want to say they sent her out when she had the BP of 69/54. She then verified the resident was still at the facility the evening of 2/4/24 when she went into cardiac arrest. The DON said she would have expected the provider to be notified of the abnormal vital signs Resident #3 had on 2/4/24 at 10:19 a.m. The DON confirmed there was no documentation in the record a provider had been notified and no intervention was put in place by the nurse. An interview was conducted on 3/12/24 at 4:12 p.m. with Resident #3's primary care doctor. The doctor said she knew Resident #3 well. She said she was notified of the resident's critical lab values on 2/3/24 by text message. She said the facility should call the answering service after hours and on weekends for a timely response. She said she was not on call and fortunately happened to see her phone but was only provided with the lab results not an assessment of how the resident was doing. The doctor said she responded, giving orders for STAT labs and x-rays and told the nurse to call the on-call provider as soon as the results came back. She said she would expect STAT labs and x-rays to be completed within four hours, but it can vary by facility. The doctor said she was unaware the STAT orders were not completed on 2/3/24 and that would be considered a delay in care. The doctor stated she was not notified of Resident #3's blood pressure of 69/54 and heart rate of 121 on the morning of 2/4/24. She said, she [Resident #3] should have gone to the hospital. She said with the resident having the high WBC the day before and having a BP of 69/54 and heart rate of 121 she should have been sent out because by definition that was sepsis. The doctor said after the resident passed, she saw a chest x-ray result from 2/4/24 and the resident at a minimum had pneumonia. She said the portable x-rays were not as detailed and clear but taking the results showing subsegmental atelectasis or infection combined with the abnormal labs from 2/3/24, the resident most likely had pneumonia and possibly additional infections. She said it had been a struggle to get staff to let me know right away and don't wait with changes in resident's condition and they were still working on it. The doctor said with Resident #3, definitely things were not carried out the way they should have. A Cleveland Clinic article titled Sepsis, reviewed on 1/19/23, provided the following information: Sepsis occurs when your immune system has a dangerous reaction to an infection. It causes extensive inflammation throughout your body that can lead to tissue damage, organ failure and even death. Many different kinds of infections can trigger sepsis, which is a medical emergency. The quicker you receive treatment, the better your outcome will be. Common sepsis symptoms include urinary issues, low energy/weakness, fast heart rate, low blood pressure, fever or hypothermia, shaking or chills, warm or clammy sweaty skin, confusion or agitation, hyperventilation (rapid breathing) or extreme pain or discomfort. Sepsis treatment needs to begin immediately. The most important concern in sepsis protocol is a quick diagnosis and prompt treatment. If your provider diagnoses you with sepsis, they'll usually place you in the intensive care unit (ICU) of the hospital for special treatment. With quick diagnosis and treatment, many people with mild sepsis survive. Without treatment, most people with more serious stages of sepsis will die. Septic shock can cause death in as little as 12 hours. (The article was accessed on 3/18/24 at https://my.clevelandclinic.org/health/diseases/12361-sepsis ) Resident #1 Review of the resident's electronic medical record admission profile showed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia, syncope and collapse, chronic kidney disease, benign prostatic hyperplasia. Review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008, dated 1/29/24 showed the resident had a discharge diagnosis of pneumonia upon leaving the hospital, where he was admitted on [DATE]. Form 3008 showed the resident was discharged on antibiotics for pneumonia, on oxygen 2 liters (L) as needed, and requested Full code status. Review of Resident #1's MDS, completed 2/8/24, Section C, Cognitive Patterns, showed resident had a BIMS Score of 3, indicating severely impaired cognition. Review of Resident #1's medical records showed a care plan in place, dated 1/30/24, for Advance Directives (Full Code) with a goal of advance directives will be honored by staff. A review of Resident #1's physician orders revealed the following: -Full Code, dated 1/30/24. -Oxygen via nasal cannula 2 Liters (L) as needed, dated 1/30/24. - Doxycycline Hyclate Oral Capsule 100 milligram (mg). Give 1 capsule by mouth every 12 hours for pneumonia for 5 Days, dated 1/30/24. - Cefuroxime Axetil Oral Tablet 500 mg. Give 1 tablet by mouth two times a day for pneumonia for 5 Days, dated 1/29/24. - RN to release remains to funeral home of family's choice. 2/18/24 at 5:18 a.m. Review of Resident #1's January and February 2024 Medication Administration Record (MAR) showed the resident completed the physician ordered antibiotics for pneumonia, Doxycycline Hyclate and Cefuroxime Axetil, on 2/3/24. Review of Resident #1's medical records showed Skilled Nursing Notes on 2/10, 2/11, and 2/12/24 noting resident had normal breathing, clear lung sounds, and no respiratory complications. There was no Skilled Nursing Note completed on 2/13/24. Review of the Skilled Nursing Note, dated 2/14/24 at 4:19 p.m., entered by Staff F, Licensed Practical Nurse (LPN) as follows: Resident has intermittent confusion. Mood indicators displayed by resident: Little interest/pleasure in doing things. Poor appetite or overeating. Behaviors displayed: See eMAR for behavior(s) exhibited & pharmacological/non-pharmacological interventions provided . RESPIRATORY: Normal breathing noted. Abnormal lung sounds noted in RUL [right upper lobe,] RLL [right lower lobe,] LUL [left upper lobe,] LLL [left lower lobe.] diminished. Free from respiratory complications. Respiratory equipment in use: oxygen supplies. Nursing services provided: Head of bed elevated. Encouraged pursed-lip breathing. O2 tubing changed/filter cleaned. Response/Comments: Resident is confused and unable to make his needs known. Residents [sic] lung sounds are diminished in all four fields. Resident is on 3l [liters] oxygen via nasal cannula. Residents [sic] appetite is poor. Resident refuses to eat and take his medication. Residents [sic] abdomen is soft with positive bowel sounds in all four quadrants. Resident is incontinent of bowel and bladder. Resident shows no s/s of pain. Resident does not complain of pain or discomfort. Nurse will continue to monitor for comfort and safety. A Skilled Nursing Note written by Staff B, RN, dated 2/17/24, noted normal breathing and clear lungs, but noted she encouraged pursed-lip breathing. A Healthline article titled Pursed Lip Breathing, updated 4/14/23, gave the following information: Pursed lip breathing is a technique designed to make your breaths more effective by making them slower and more intentional . Pursed lip breathing gives you more control over your breathing, which is particularly important for people with lung conditions such as COPD [Chronic obstructive pulmonary disease] .Pursed lip breathing can help improve and control your breathing in several ways, including: -relieving shortness of breath by slowing the breath rate -keeping the airways open longer, which decreases the work that goes into breathing -improving ventilation by moving old air (carbon dioxide) trapped in the lungs out and making room for new, fresh oxygen. (Accessed on 3/18/24 at https://www.healthline.com/health/pursed-lip-breathing ) Review of Resident #1's medical records and vital signs dated 1/29/84 to 2/18/24 revealed no documentation of Oxygen saturation readings; on 2/14/24 respiratory rate was not documented when the resident began using PRN (as needed) oxygen and had diminished lung sounds. Oxygen saturation is a crucial measure of how well the lungs are working. A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person at sea level. People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia, a condition in which not enough oxygen reaches the body's tissues. If blood oxygen saturation levels fall to 88% or lower, seek immediate medical attention . According to Yalemedicinje.org, viewed on 3.26.2024 at https://www.yalemedicine.org/conditions/pulse-oximetry Review of the progress notes for Resident #1 showed no documentation of provider notification of Resident #1 having diminished lung sounds, requiring the as needed oxygen or that the resident was refusing his medication. Review of Resident #1's February 2024 MAR did not show documentation that Oxygen was being administered from 2/1/24 to 2/18/24. Review of Resident #1's medical record, a nurses' progress note entered by Staff B, RN on 2/18/24 at 5:15 a.m. showed Called to residents [sic] room by CNA [Certified Nursing Assistant] found resident absent of breath sounds and apical pulse for full two minutes. [Family member] and MD made aware of death. New order received to release remains to funeral home of family's choice. There was no documentation CPR was initiated for Resident #1 on 2/18/24 at 5:15 a.m. There was no additional documentation in the resident's medical record as to the condition of the resident when he was found, observations made, why a code blue was not called, or the time of death. Code blue indicates there is a resident requiring resuscitation or otherwise in need of immediate medical attention, often as the result of a respiratory or cardiac arrest. An interview was conducted on 3/14/24 at 11:12 a.m. with Staff F, LPN. She said she knew Resident #1 and took care of him on 2/17/24. She said as days went on after his admission, Resident #1 did not want to eat or drink, and he stopped having interest in food. Staff F said Resident #1 took medications and never refused for her. She said she did not remember if Resident #1 had breathing issues or was on oxygen. She said if a resident needed oxygen when they had a PRN order, the nurse would take their oxygen saturation and document it under vital signs and call and let the doctor know. She said if the resident stayed on oxygen their saturation should be checked every shift. An interview was conducted on 3/12/24 at 12:19 p.m. with Staff E, CNA. She said on the morning of 2/18/24 she saw Resident #1 in bed when she did routine rounds around 3:00 a.m. She said Resident #1 was the same as he had been. Staff E said the resident had the pattern of breathing like people have when they are going to die but were still holding on. She said a few days prior to that, she could not remember the date, she had let the unit manager and nurse know Resident #1 was not breathing right and they put oxygen on him. She said on that day he was breathing a little shallow and low. She said at first, she thought he was gone but she called his name several times and he moaned letting her know he was still there. She said since that night he had been doing that breathing so the nurse should have known. She said he did not get any better. Staff E said on the morning of 2/18/24 she went in the room and was checking his brief, and he did not move. She said she rubbed his chest a little like she usually did, and he did not respond. She said Resident #1 was lying on his back and his eyes were partially open like they normally were when he slept. She said he often slept with his mouth open because he would breathe through his mouth all the time like he was trying to get more air. Staff E said the resident was floppy and she was scared. She confirmed Resident #1 had oxygen on during that shift. Staff E said she called the nurse and said she did not think Resident #1 was alive. She said both nurses on duty, Staff B, RN and Staff D, RN, came to assess and see if he was breathing. She said the nurses were like ok, they left out and no one ever came back. Staff E said the nurse never said if the resident was a full code or do not resuscitate (DNR). She said she figured he must have been a DNR because if he had been a full code the nurse would have grabbed the chart and normally they jump and run, and they did not do that. Staff E said she cleaned Resident #1 up and covered him like she normally did when someone died. She said when she touched him his body was still warm, only his face was a little cool. She said he was not stiff or anything. She said when she cleaned up his brief, he was still flexible, not rigid. Staff E said in her career she had it happen when a resident was cold and stiff and he [Resident #1] was not like that. Staff E said Resident #1's arm was flopping. She said, If I would have known he was a full code I would have expected us to get busy. Staff E said when she was leaving work that morning, Staff B, RN was outside crying and She [Staff B] said I think I messed up. He was a full code. I should have known. A follow-up interview was conducted on 3/12/24 at 2:46 p.m. with Staff E, CNA. Staff E said no other staff members helped with Resident #1 or came in the room on the morning of 2/18/24. She said she provided a statement to the Nursing Home Administrator (NHA) about what happened. She said she let the NHA know Resident #1's face was a little cool, but not cold and his body was warm. Staff E said she did not know why others were saying he was stiff because when she rolled him from front to back to clean him, he just flopped over and if he was stiff he would not have done that. An interview was conducted on 3/12/24 at 4:57 a.m. with Staff B, RN. She confirmed she worked the shift from 7:00 p.m. on 2/17/24 to 7:00 a.m. on 2/18/24 and was assigned to Resident #1. Staff B said she tried several times throughout the evening to get the resident to take his medication and he refused. She said Resident #1 often refused his medication. Staff B said when a resident refused medication, she would try a few times to coerce them and after a few tries she would mark in the MAR that the resident refused. She said during that shift Resident #1 was normal, he slept, he had oxygen on, and he was not having breathing problems. She said when a resident was on oxygen, saturation should be checked every shift and documented in the MAR. She said she did not know why Resident #1 was on oxygen. Staff B said the CNA, Staff E, called the nurses. Staff B said Staff D, RN got to the room first and said she thought Resident #1 was dead. Staff B said I told her I think you are right. Staff B said Resident #1 was cold, stiff, his arms were rigid, he had a stare, he had no heart and lung sounds, and the top half of his body was stiff. Staff B said she could not move Resident #1's shoulders, his jaw was open and fixed, his lower arms were stiff, and he was completely immobile. Staff B said she decided there was no use in trying to code him. Staff B said she had not seen the resident since around 10:00 or 11:00 p.m. on 2/17/24, but the CNA had done rounds every 2 hours. Staff B said she called Resident #1's primary care provider's (PCP) answering service and left a message for the on-call provider to call her back. She said she left a message for the family of Resident #1 to call her. Staff B said when she left the faciity on 2/18/24 she had still not received a call back from a provider regarding Resident #1's death. When asked which provider gave her the order she entered on 2/18/24 at 5:15 a.m. to release Resident #1's remains to the funeral home, she said she put it in presumptively and reconfirmed she never spoke with a provider. Staff B said, that's on me. Staff B said on 2/18/24 around 6:40 a.m. the next shift started coming in. She said Staff C, Licensed Practical Nurse (LPN) was going to take over her assignment. Staff B said she let Staff C know Resident #1 had passed and they did not do CPR. Staff B said Staff C panicked and freaked out because he was a full code. She said Staff C told her she needed to call the Director of Nursing (DON). Staff B said Staff C called the DON but she did not hear what the conversation entailed she was just standing and waiting. Staff B said the next thing she knew a code blue was being called on the loudspeaker for Resident #1. Staff B said, it was told to me when EMS [Emergency Medical Services] got there you better be running that code. Staff B said she and Staff F, LPN started CPR on Resident #1 and continued for around 5-7 minutes until EMS arrived and took over. She said EMS did compressions, hooked the resident to their monitor and then pronounced him deceased . She said EMS packed up and left and she was allowed to leave work then. An interview was conducted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, facility documentation, and policy review, the facility failed to ensure the nursing staff was competent to recognize and respond to a change in condition for two (#3 and #1), out of three residents reviewed for change in condition, failed to ensure nursing staff were competent to process labs and x-rays appropriately for one (#3) out of three residents reviewed for change in condition and failed to ensure nursing staff were competent to initiate Cardiopulmonary Resuscitation (CPR) according to policy for one (#3) out of three residents reviewed for CPR administration. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #3 and Resident #1 and resulted in the determination of Immediate Jeopardy which began on 2/3/24 with a scope and severity of K. The findings of Immediate Jeopardy were determined to be removed on 3/14/24 and the severity and scope was reduced to an E after verification of removal of the Immediate Jeopardy. Findings included: Resident #3 Review of the Resident #3's electronic medical record admission profile showed she was admitted on [DATE] with diagnoses including dementia with other behavioral disturbances, hypertension, hypothyroidism, encephalopathy, anxiety disorder, and low back pain. Review of Resident #3's most recent Minimum Data Set (MDS) for Significant Change, completed 2/1/24, revealed Section C, Cognitive Patterns, showed resident had a Brief Interview for Mental Status (BIMS) Score of 4, indicating severely impaired cognition. Section GG, Functional Abilities and Goals, showed Resident #3 was dependent for eating, toileting, hygiene, transfers, sitting to lying and lying to sitting. It showed the resident used a wheelchair but was dependent for locomotion. The significant change assessment was completed due to a new skin tear. Review of lab results dated 2/3/24 for Resident #3 showed she had scheduled monthly labs drawn on 2/3/24 which were reported back to the facility with critical values the same day. Results showed her white blood cell count (WBC) was critically high at 36.2 with the reference range being 4.1-10.9 and her Blood Urea Nitrogen (BUN) level was critically high at 97 with a reference range of 6-20. A high white blood cell count usually means one of the following has increased the making of white blood cells: An infection, Reaction to a medicine, A bone marrow disease, An immune system issue, Sudden stress such as hard exercise, Smoking. According to the Mayo Clinic at https://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym-20050611, viewed on 3/26/2024. A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys are working. A BUN test measures the amount of urea nitrogen that's in your blood. A BUN test can reveal whether your urea nitrogen levels are higher than normal, suggesting that your kidneys may not be working properly, according to the Mayo Clinic at https://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/about/pac-2038482, viewed on 3/26/2024. Review of progress notes for Resident #3 showed a nurse's note written by Staff B, Registered Nurse (RN) dated 2/3/2024 at 6:23 p.m., reviewed critical labs with [primary care provider (PCP)] with new orders to start IV (intravenous solution), D 5 1/2 NS [normal saline] at 75 [milliliters]mL/[hour] hr x 3 days, UA [urinalysis], CXR [chest x-ray], repeat CBC [completed blood count]/BMP [basic metabolic panel] in 4 days Review of physician orders for Resident #3 showed the following orders entered into the computer by Staff B, RN: -2/3/24 at 3:13 p.m. Dextrose-NaCL (Sodium) Solution 5-0 0.45%. Use 75 ml/hr intravenously every hour for abnormal labs for 3 days. -2/3/24 at 3:21 p.m. May insert IV for delivery of fluids. One time for 3 days. -2/3/24 4:09 p.m. Urinalysis. Culture and Sensitivity. STAT(immediately) for abnormal labs. -2/3/24 6:43 p.m. Chest x-ray STAT. According to the progress notes, these orders were all received from the provider in the same phone call, however they were entered into the computer over a 3 ½ hour period. Review of Resident #3's Treatment Administration Record (TAR) for February 2024 showed the STAT urinalysis and STAT chest x-ray were not signed off as completed on 2/3/24. Review of Resident #3's lab and radiology results did not show results for the STAT urinalysis or chest x-ray on 2/3/24. An interview was conducted on 3/13/24 at 2:02 p.m. with the third-party lab that processed labs for this facility. The lab representative reviewed their records for Resident #3 and stated they did not have orders for a STAT urinalysis in their system for Resident #3 on 2/3/24 and had no documentation indicating the nurse notified the lab of STAT orders. The lab representative said STAT orders were typically completed and reported back to the facility within 4-5 hours. An interview was conducted on 3/13/24 at 2:17 p.m. with the x-ray service that provided imaging services for this facility. The company representative reviewed their records for Resident #3 and said they did not receive orders for x-rays on 2/3/24 for the resident. They said the nurse typically placed the STAT orders into their system online and would sometimes call if it was STAT. The company representative said they did show an order for a chest x-ray placed into the system on 2/4/24 at 4:00 a.m. but it was not a STAT order. Review of Resident #3's vital signs on 2/4/24 at 10:19 a.m. showed a blood pressure (BP) of 69/54, a pulse (P) of 121, respirations (RR) of 20 per minute, and a temperature (T) of 97.5 Fahrenheit (F.) The resident's routine weekly blood pressure typically ran 116-135/66-90 and her heart rate was normally 65-82. Review of Resident #3's medical record did not show documentation that a provider was notified of the abnormal vital signs of BP 69/54 and P 121. There was no documentation an assessment was performed on 2/4/24 at 10:19 a.m. when the resident had these abnormal vital signs. Review of Resident #3's progress notes showed a nurses note on 2/4/2024 at 11:40 a.m.Attempted to reach [family member], concerning residents condition. No answer but did leave message to contact the facility at his earliest convenience[sic]. Review of radiology results showed a chest x-ray was completed due to a cough on 2/4/24 at 5:30 p.m. with the following finding: The heart is normal in size and configuration. The mediastinum is unremarkable. There is a mild airspace opacity in the right upper lobe. No acute osseous abnormality is visualized. The lungs are hyperinflated, consistent with chronic obstructive pulmonary disease. Mild degenerative changes are seen. CONCLUSION: Mild right upper lobe infiltrate. The differential primarily includes subsegmental atelectasis or infection. Correlation with history and symptomatology is advised. Review of Resident #3's medical records showed a Change of Condition Evaluation, dated 2/4/24 at 8:42 p.m. The evaluation showed the resident had shortness of breath and was unresponsive. Her blood pressure was 150/62, heart rate was 32 and irregular, her respirations were 32 per minute, and oxygen saturation was 84%. Nursing observations, evaluations, and recommendations showed Resident noted to have shortness of breath with order received to send resident to the hospital, and in the process of being sent to the hospital ER when she stopped breathing. Code Blue initiated by nurses with CPR in progress as resident is a Full Code [if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive]. 911 called, MD on call notified. [Name] Fire and Rescue Paramedics and [Name] Paramedics came to facility and took over CPR. Resident transferred to [hospital name] ER [emergency room] for evaluation and treatment. Review of Resident #3's progress notes showed a nursing progress note, written by Staff B RN, dated 2/4/24 at 10:25 p.m., showing the hospital called and notified the nurse that the resident expired in the emergency room. An interview was conducted on 3/12/24 at 4:57 p.m. with Staff B, RN. Staff B said she cared for Resident #3 every time she worked. She said she received critical lab values on 2/3/24 and notified the doctor. She said the doctor gave STAT orders. She said she put the orders in and called the lab and x-ray to tell them. Staff B said she assumed the labs and x-ray were completed. She said she was assigned to care for Resident #3 on 2/4/24. Staff B said she did not check if the orders had been completed, she assumed they came in and got the labs. She said the lab would do STAT labs immediately if they had time. Staff B said she did not remember Resident #3's low blood pressure on 2/4/24 and did not talk to any providers about it. Staff B said Resident #3 was weak, wanted to sleep, and was laying down and did not want to get up. Staff B said she only worked weekends and had the resident the previous Saturday and Sunday 1/27 and 1/28/24. She said the previous weekend the resident was on a restorative program and was sitting up eating while being cued by a staff member and was more alert. (A restorative program helps resident function at their highest potential) Staff B said the weekend of 2/3/24 and 2/4/24 Resident #3 was totally different, had a poor appetite, would moan, only take small bites or food, and was lethargic. Staff B said she did not recall the resident having breathing issues. An interview was conducted on 3/12/24 at 1:49 p.m. with the Director of Nursing (DON). She said when STAT labs or imaging was ordered the nurse should put the order in then call the lab and/or x-ray to let them know. The DON said STAT orders should be completed within 2-4 hours. She said labs and x-rays could be done anytime day or night, even on weekends. She said for the urinalysis the nurse would collect the specimen and the lab would pick it up. The DON reviewed Resident #3's medical record and confirmed there was a STAT order for the urinalysis and chest x-ray and they were not marked off as completed. She said the lab results populated in the medical record directly from the lab, so if they were done the results would have been in the medical record. She reviewed the orders and confirmed the resident's STAT orders were entered into the computer over a 3 ½ hour window and she did not know why there was a delay between the (intravenous)IV order, the urinalysis order and the chest x-ray order for Resident #3. The DON said when a provider gave orders for STAT labs she would expect them to be put in immediately. The DON reviewed Resident #3's vital signs in the medical record. The DON said, I want to say they sent her out when she had the BP of 69/54. She then verified the resident was still at the facility the evening of 2/4/24 when she went into cardiac arrest. The DON said she would have expected the provider to be notified of the abnormal vital signs Resident #3 had on 2/4/24 at 10:19 a.m. The DON confirmed there was no documentation in the record a provider had been notified and no intervention was put in place by the nurse. An interview was conducted on 3/12/24 at 4:12 p.m. with Resident #3's primary care doctor. The doctor said she knew Resident #3 well. She said she was notified of the resident's critical lab values on 2/3/24 by text message. She said the facility should call the answering service after hours and on weekends for a timely response. She said she was not on call and fortunately happened to see her phone but was only provided with the lab results not an assessment of how the resident was doing. The doctor said she responded, giving orders for STAT labs and x-rays and told the nurse to call the on-call provider as soon as the results came back. She said she would expect STAT labs and x-rays to be completed within four hours, but it can vary by facility. The doctor said she was unaware the STAT orders were not completed on 2/3/24 and that would be considered a delay in care. The doctor stated she was not notified of Resident #3's blood pressure of 69/54 and heart rate of 121 on the morning of 2/4/24. She said, she [Resident #3] should have gone to the hospital. She said with the resident having the high WBC the day before and having a BP of 69/54 and heart rate of 121 she should have been sent out because by definition that was sepsis. The doctor said after the resident passed, she saw a chest x-ray result from 2/4/24 and the resident at a minimum had pneumonia. She said the portable x-rays were not as detailed and clear but taking the results showing subsegmental atelectasis or infection combined with the abnormal labs from 2/3/24, the resident most likely had pneumonia and possibly additional infections. She said it had been a struggle to get staff to let me know right away and don't wait with changes in resident's condition and they were still working on it. The doctor said with Resident #3, definitely things were not carried out the way they should have. A Cleveland Clinic article titled Sepsis, reviewed on 1/19/23, provided the following information: Sepsis occurs when your immune system has a dangerous reaction to an infection. It causes extensive inflammation throughout your body that can lead to tissue damage, organ failure and even death. Many different kinds of infections can trigger sepsis, which is a medical emergency. The quicker you receive treatment, the better your outcome will be. Common sepsis symptoms include urinary issues, low energy/weakness, fast heart rate, low blood pressure, fever or hypothermia, shaking or chills, warm or clammy sweaty skin, confusion or agitation, hyperventilation (rapid breathing) or extreme pain or discomfort. Sepsis treatment needs to begin immediately. The most important concern in sepsis protocol is a quick diagnosis and prompt treatment. If your provider diagnoses you with sepsis, they'll usually place you in the intensive care unit (ICU) of the hospital for special treatment. With quick diagnosis and treatment, many people with mild sepsis survive. Without treatment, most people with more serious stages of sepsis will die. Septic shock can cause death in as little as 12 hours. (The article was accessed on 3/18/24 at https://my.clevelandclinic.org/health/diseases/12361-sepsis ) Resident #1 Review of the resident's electronic medical record admission profile showed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia, syncope and collapse, chronic kidney disease, benign prostatic hyperplasia. Review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008, dated 1/29/24 showed the resident had a discharge diagnosis of pneumonia upon leaving the hospital, where he was admitted on [DATE]. Form 3008 showed the resident was discharged on antibiotics for pneumonia, on oxygen 2 liters (L) as needed, and requested Full code status. Review of Resident #1's MDS, completed 2/8/24, Section C, Cognitive Patterns, showed resident had a BIMS Score of 3, indicating severely impaired cognition. Review of Resident #1's medical records showed a care plan in place, dated 1/30/24, for Advance Directives (Full Code) with a goal of advance directives will be honored by staff. A review of Resident #1's physician orders revealed the following: -Full Code, dated 1/30/24. -Oxygen via nasal cannula 2 Liters (L) as needed, dated 1/30/24. - Doxycycline Hyclate Oral Capsule 100 milligram (mg). Give 1 capsule by mouth every 12 hours for pneumonia for 5 Days, dated 1/30/24. - Cefuroxime Axetil Oral Tablet 500 mg. Give 1 tablet by mouth two times a day for pneumonia for 5 Days, dated 1/29/24. - RN to release remains to funeral home of family's choice. 2/18/24 at 5:18 a.m. Review of Resident #1's January and February 2024 Medication Administration Record (MAR) showed the resident completed the physician ordered antibiotics for pneumonia, Doxycycline Hyclate and Cefuroxime Axetil, on 2/3/24. Review of Resident #1's medical records showed Skilled Nursing Notes on 2/10, 2/11, and 2/12/24 noting resident had normal breathing, clear lung sounds, and no respiratory complications. There was no Skilled Nursing Note completed on 2/13/24. Review of the Skilled Nursing Note, dated 2/14/24 at 4:19 p.m., entered by Staff F, Licensed Practical Nurse (LPN) as follows: Resident has intermittent confusion. Mood indicators displayed by resident: Little interest/pleasure in doing things. Poor appetite or overeating. Behaviors displayed: See eMAR for behavior(s) exhibited & pharmacological/non-pharmacological interventions provided . RESPIRATORY: Normal breathing noted. Abnormal lung sounds noted in RUL [right upper lobe,] RLL [right lower lobe,] LUL [left upper lobe,] LLL [left lower lobe.] diminished. Free from respiratory complications. Respiratory equipment in use: oxygen supplies. Nursing services provided: Head of bed elevated. Encouraged pursed-lip breathing. O2 tubing changed/filter cleaned. Response/Comments: Resident is confused and unable to make his needs known. Residents [sic] lung sounds are diminished in all four fields. Resident is on 3l [liters] oxygen via nasal cannula. Residents [sic] appetite is poor. Resident refuses to eat and take his medication. Residents [sic] abdomen is soft with positive bowel sounds in all four quadrants. Resident is incontinent of bowel and bladder. Resident shows no s/s of pain. Resident does not complain of pain or discomfort. Nurse will continue to monitor for comfort and safety. A Skilled Nursing Note written by Staff B, RN, dated 2/17/24, noted normal breathing and clear lungs, but also noted she encouraged pursed-lip breathing. A Healthline article titled Pursed Lip Breathing, updated 4/14/23, gave the following information: Pursed lip breathing is a technique designed to make your breaths more effective by making them slower and more intentional . Pursed lip breathing gives you more control over your breathing, which is particularly important for people with lung conditions such as COPD [Chronic obstructive pulmonary disease] .Pursed lip breathing can help improve and control your breathing in several ways, including: -relieving shortness of breath by slowing the breath rate -keeping the airways open longer, which decreases the work that goes into breathing -improving ventilation by moving old air (carbon dioxide) trapped in the lungs out and making room for new, fresh oxygen. (Accessed on 3/18/24 at https://www.healthline.com/health/pursed-lip-breathing ) Review of Resident #1's medical records and vital signs dated 1/29/84 to 2/18/24 revealed no documentation of Oxygen saturation readings; on 2/14/24 respiratory rate was not documented when the resident began using PRN (as needed) oxygen and had diminished lung sounds. Oxygen saturation is a crucial measure of how well the lungs are working. A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person at sea level. People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia, a condition in which not enough oxygen reaches the body's tissues. If blood oxygen saturation levels fall to 88% or lower, seek immediate medical attention . According to Yalemedicinje.org, viewed on 3.26.2024 at https://www.yalemedicine.org/conditions/pulse-oximetry Review of the progress notes for Resident #1 showed no documentation of provider notification of Resident #1 having diminished lung sounds, requiring the as needed oxygen or that the resident was refusing his medication. Review of Resident #1's February 2024 MAR did not show documentation that Oxygen was being administered from 2/1/24 to 2/18/24. Review of Resident #1's medical record, a nurses' progress note entered by Staff B, RN on 2/18/24 at 5:15 a.m. showed Called to residents [sic] room by CNA [Certified Nursing Assistant] found resident absent of breath sounds and apical pulse for full two minutes. [Family member] and MD made aware of death. New order received to release remains to funeral home of family's choice. There was no documentation CPR was initiated for Resident #1 on 2/18/24 at 5:15 a.m. There was no additional documentation in the resident's medical record as to the condition of the resident when he was found, observations made, why a code blue was not called, or the time of death. Code blue indicates there is a resident requiring resuscitation or otherwise in need of immediate medical attention, often as the result of a respiratory or cardiac arrest. An interview was conducted on 3/14/24 at 11:12 a.m. with Staff F, LPN. She said she knew Resident #1 and took care of him on 2/17/24. She said as days went on after his admission, Resident #1 did not want to eat or drink, and he stopped having interest in food. Staff F said Resident #1 took medications and never refused for her. She said she did not remember if Resident #1 had breathing issues or was on oxygen. She said if a resident needed oxygen when they had a PRN order, the nurse would take their oxygen saturation and document it under vital signs and call and let the doctor know. She said if the resident stayed on oxygen their saturation should be checked every shift. An interview was conducted on 3/12/24 at 12:19 p.m. with Staff E, CNA. She said on the morning of 2/18/24 she saw Resident #1 in bed when she did routine rounds around 3:00 a.m. She said Resident #1 was the same as he had been. Staff E said the resident had the pattern of breathing like people have when they are going to die but were still holding on. She said a few days prior to that, she could not remember the date, she had let the unit manager and nurse know Resident #1 was not breathing right and they put oxygen on him. She said on that day he was breathing a little shallow and low. She said at first, she thought he was gone but she called his name several times and he moaned letting her know he was still there. She said since that night he had been doing that breathing so the nurse should have known. She said he did not get any better. Staff E said on the morning of 2/18/24 she went in the room and was checking his brief, and he did not move. She said she rubbed his chest a little like she usually did, and he did not respond. She said Resident #1 was lying on his back and his eyes were partially open like they normally were when he slept. She said he often slept with his mouth open because he would breathe through his mouth all the time like he was trying to get more air. Staff E said the resident was floppy and she was scared. She confirmed Resident #1 had oxygen on during that shift. Staff E said she called the nurse and said she did not think Resident #1 was alive. She said both nurses on duty, Staff B, RN and Staff D, RN, came to assess and see if he was breathing. She said the nurses were like ok, they left out and no one ever came back. Staff E said the nurse never said if the resident was a full code or do not resuscitate (DNR). She said she figured he must have been a DNR because if he had been a full code the nurse would have grabbed the chart and normally they jump and run, and they did not do that. Staff E said she cleaned Resident #1 up and covered him like she normally did when someone died. She said when she touched him his body was still warm, only his face was a little cool. She said he was not stiff or anything. She said when she cleaned up his brief, he was still flexible, not rigid. Staff E said in her career she had it happen when a resident was cold and stiff and he [Resident #1] was not like that. Staff E said Resident #1's arm was flopping. She said, If I would have known he was a full code I would have expected us to get busy. Staff E said when she was leaving work that morning, Staff B, RN was outside crying and She [Staff B] said I think I messed up. He was a full code. I should have known. A follow-up interview was conducted on 3/12/24 at 2:46 p.m. with Staff E, CNA. Staff E said no other staff members helped with Resident #1 or came in the room on the morning of 2/18/24. She said she provided a statement to the Nursing Home Administrator (NHA) about what happened. She said she let the NHA know Resident #1's face was a little cool, but not cold and his body was warm. Staff E said she did not know why others were saying he was stiff because when she rolled him from front to back to clean him, he just flopped over and if he was stiff he would not have done that. An interview was conducted on 3/12/24 at 4:57 a.m. with Staff B, RN. She confirmed she worked the shift from 7:00 p.m. on 2/17/24 to 7:00 a.m. on 2/18/24 and was assigned to Resident #1. Staff B said she tried several times throughout the evening to get the resident to take his medication and he refused. She said Resident #1 often refused his medication. Staff B said when a resident refused medication, she would try a few times to coerce them and after a few tries she would mark in the MAR that the resident refused. She said during that shift Resident #1 was normal, he slept, he had oxygen on, and he was not having breathing problems. She said when a resident was on oxygen, saturation should be checked every shift and documented in the MAR. She said she did not know why Resident #1 was on oxygen. Staff B said the CNA, Staff E, called the nurses. Staff B said Staff D, RN got to the room first and said she thought Resident #1 was dead. Staff B said I told her I think you are right. Staff B said Resident #1 was cold, stiff, his arms were rigid, he had a stare, he had no heart and lung sounds, and the top half of his body was stiff. Staff B said she could not move Resident #1's shoulders, his jaw was open and fixed, his lower arms were stiff, and he was completely immobile. Staff B said she decided there was no use in trying to code him. Staff B said she had not seen the resident since around 10:00 or 11:00 p.m. on 2/17/24, but the CNA had done rounds every 2 hours. Staff B said she called Resident #1's primary care provider's (PCP) answering service and left a message for the on-call provider to call her back. She said she left a message for the family of Resident #1 to call her. Staff B said when she left the faciity on 2/18/24 she had still not received a call back from a provider regarding Resident #1's death. When asked which provider gave her the order she entered on 2/18/24 at 5:15 a.m. to release Resident #1's remains to the funeral home, she said she put it in presumptively and reconfirmed she never spoke with a provider. Staff B said, that's on me. Staff B said on 2/18/24 around 6:40 a.m. the next shift started coming in. She said Staff C, Licensed Practical Nurse (LPN) was going to take over her assignment. Staff B said she let Staff C know Resident #1 had passed and they did not do CPR. Staff B said Staff C panicked and freaked out because he was a full code. She said Staff C told her she needed to call the Director of Nursing (DON). Staff B said Staff C called the DON but she did not hear what the conversation entailed she was just standing and waiting. Staff B said the next thing she knew a code blue was being called on the loudspeaker for Resident #1. Staff B said, it was told to me when EMS [Emergency Medical Services] got there you better be running that code. Staff B said she and Staff F, LPN started CPR on Resident #1 and continued for around 5-7 minutes until EMS arrived and took over. She said EMS did compressions, hooked the resident to their monitor and then pronounced him deceased . She said EMS packed up and left and she was allowed to leave work then. An interview was conducted on 3/12/24 at 11:37 a.m. with Staff D, RN. She confirmed she worked the shift from 7:00 p.m. on 2/17/24 to 7:00 a.m. on 2/18/24 with Staff B, RN. Staff D said Resident #1 was not assigned to her and she did not know the resident. She said the CNA came out and asked if she was assigned Resident #1 and she told her no. Staff B, RN walked up and [Staff B] said oh my god, don't tell me something happened. Staff D said she went to Resident #1's room with Staff B and they checked on him and he had no pulse. She said when they got to the room Resident #1 was stiff/rigid, his mouth was open, and he was cool to the touch. Staff D said if you see a patient deceased you cannot make that call. She said you still check the code status and if they are a full code, you have to do CPR on the resident. Staff D said she thought Staff B had checked Resident #1's code status. She said she asked Staff B if she needed her to do anything or needed her help. Staff B told her no she had already called the doctor and taken care of the paperwork. A follow-up interview was conducted on 3/13/24 at 10:55 a.m. with Staff D, RN. She said she assumed Staff B checked Resident #1's code status. Staff D said she figured he must have been a DNR. Staff D reiterated Resident #1 was cool, stiff, rigid, and mouth ajar. She said his whole body was cool, not cold. An interview was conducted on 3/12/24 at 1:09 p.m. with Staff C, LPN. She said on 2/18/24 she came on for her shift and Staff B, RN was giving her report when Staff B informed her Resident #1 had passed away. Staff C said she asked Staff B if CPR was done and she said no he was dead. Staff C said she told Staff B to call the DON because the facility protocol was to do CPR. Staff C said she told Staff B, I will not accept responsibility without DON notification of the incident. Staff C confirmed a code blue was called for Resident #1 after Staff B talked to the DON. Staff C said she did not go in Resident #1's room due to several others being in there already. She said EMS arrived and pronounced the resident. Staff C said when she originally spoke with Staff B, Staff B did not elaborate on why she did not do CPR for Resident #1 when they found him unresponsive approximately 2 hours earlier. A follow-up interview was conducted with Staff C, LPN on 3/13/24 at 11:29 a.m. Staff C said she did not call the DON the morning of 2/18/24 to notify her of the incident with Resident #1, she had Staff B, RN call her. Staff C said she did not call the doctor to get an order to release Resident #1's remains to the funeral home because Staff B, RN already had an order in the computer. Staff C said she did not hear the conversation Staff B had with the DON but she did witness her on the phone. A follow-up interview was conducted on 3/13/24 at 11:38 a.m. with Staff B, RN. Staff B initially reconfirmed she did not call the DON the morning of 2/18/24 then said she did. Staff B said she told the DON Resident #1 had passed, was a full code, and CPR was not done. She said the DON did not give her time to explain and did not ask why, she kind of panicked and started calling other people. Everyone's phone was ringing. Staff B said the DON did not mention anything to her about calling a code she only told her not to leave the facility and the DON started calling other people. When asked to verify the condition Resident #1 was in when he was found unresponsive at approximately 5:00 a.m. on 2/18/24, Staff B said she got her stethoscope and checked him, his jaw was still, and his upper arms were stiff at the shoulder. She said she did not check his body because he was still under the blankets. An interview was conducted on 3/13/24 at 12:16 p.m. with Staff H, LPN. She said she came in for the day shift on 2/18/24. Staff H said Staff C, LPN told her what happened. Staff H said she saw Staff B, RN walk out the back door and called the DON. Staff B came back inside and said the DON[TRUNCATED]