**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to honor advanced directives for a Do Not Resuscitate Order (DNRO) for 1 of 7 residents reviewed for advanced directives, (#1). This failure contributed to resident #1 receiving cardiopulmonary resuscitation (CPR) despite her explicit wishes for a natural, dignified death and placed her at likelihood for serious injury / impairment / prolonged death. While resident #1 suffered resuscitation attempts including chest compressions, there was likelihood she experienced severe pain, broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 8:30 AM, resident #1 was found unresponsive with no heart rate and no respirations. The nurse failed to identify the resident by name and instead identified her by the incorrect bed number to check the CPR status. Another resident's CPR status was reviewed in error and CPR was initiated for resident #1. Resident #1 had a signed Do Not Resuscitate Order (DNR)) in her medical record. The facility's failure to obtain the correct medical record to check CPR status and failure to honor the resident's DNRO resulted in the resident receiving CPR despite her explicit wishes for a natural, dignified death and placed her at risk for experiencing serious psychosocial harm by not honoring her wishes. Successful CPR may have resulted in major physical trauma including broken ribs, lung bruising, damage to her airway and internal organs, and internal bleeding. Along with physical trauma, residents who receive CPR may have to deal with serious long-term consequences such as possible brain damage from oxygen deprivation. The facility's failure to honor advanced directives placed all residents with advanced directives for DNR at risk and resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross Reference F726. Resident #1 was a [AGE] year-old, admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Arteriosclerotic Heart Disease (ASHD), Peripheral Vascular Disease (PVD), Dementia, and Atrial Fibrillation. The Minimum Data Set (MDS) discharge assessment dated [DATE] noted resident #1 died at the facility. Review of the care plan for Advanced Directives dated [DATE] noted the resident had requested her DNR wishes to be honored. The interventions included to discuss Advanced Directives with the resident and/or appointed healthcare representative, allow resident, if able to discuss her feelings regarding advance directives, and to notify the physician of resident's wishes regarding life prolonging procedures. Review of the resident's medical record revealed a physician's order dated [DATE] for DNR. A copy of the yellow DNR form was located inside the front cover of the chart. Review of a late entry nurses' progress notes dated [DATE] at 3:01 PM, by Licensed Practical Nurse (LPN) A documented resident #1 was observed lying in bed with the head of the bed elevated with oxygen at 2 liters per minute via nasal cannula for shortness of breath. The progress noted read LPN A called resident #1's name, rubbed her chest and then checked for a pulse. A Code Blue for cardiac arrest and 911 were called. There was no documentation regarding resident #1's medical record being obtained and reviewed for her CPR status and that CPR had been initiated. The next late entry in the progress note dated [DATE] at 3:03 PM documented resident #1's physician was notified that she had expired. On [DATE] at 1:30 PM, during a telephone interview, resident #1's son stated he received a telephone call from the facility on [DATE] notifying him that his mother had expired. He did not recall the name of the staff person. He said the staff person explained his mother had received CPR even though her advanced directives indicated she did not wish for any emergency interventions at the time of her death. Resident #1's son verbalized his mother made all her own decisions and she had decided not to be resuscitated. He explained his mother had been declining and she had verbalized numerous times that she wanted to die. He said, It was difficult to lose her especially at this time of the year but it is what she wanted. On [DATE] at 9:10 AM, Certified Nursing Assistant (CNA) E stated he was assigned to resident #1 on [DATE]. He recalled on [DATE] he had conducted rounds with the 11 PM-7 AM CNA, and resident #1 was fine. He said he delivered breakfast meal tray to resident #1 at approximately 8:30 AM in her room which was a four bed room. CNA E said, I set her tray down on the overbed table and noticed she did not look right. She was not responding. He said he immediately asked another CNA to get the nurse while he stayed with the resident. He remembered two nurses came into the room, LPN A and Registered Nurse (RN) B, the 200 Unit Manager (UM) and the Director of Nursing (DON) brought the crash cart to the room. He indicated LPN D brought the backboard and LPN A started CPR. CNA E said, I then heard someone tell the nurses to stop CPR, so LPN A stopped doing CPR. CNA E explained that in a 4-bed room, the A bed was always the first bed to the left as you entered the room. He said, I always identify a resident by their name and not by their room or bed number. On [DATE] at 2:27 PM, LPN A stated she had worked at the facility for 3 years and had completed the facility orientation program. LPN A was able to recall the timeline of events that occurred on [DATE] at approximately 8:30 AM. She stated she was assigned to resident #1 on [DATE] and one of the CNAs came to her and reported resident #1 did not look good. She said she immediately asked RN B, the 200 UM, to go to the room with her. She recalled when she entered the room, resident #1 was unresponsive. LPN A said, I called her name and shook her, but she did not respond. She explained she asked RN B UM to get resident #1's medical record as she needed to check her CPR status to see if CPR should be started. She recalled RN B UM returned to the room without the medical record and reported, She is a full code (meaning she should have CPR). She said she asked RN B 200 UM several times, Are you sure she is a full code? She said RN B again stated resident #1 was a full code so she started CPR. She stated while she performed CPR she heard someone yell out, the wrong chart, she is a DNR. She said she then stopped CPR. LPN A explained she was aware that CPR was not to be performed on a resident with a DNRO. She had no explanation as to why she did not insist on having residents #1's medical record brought to the room so she could have checked her CPR status. She said, I just started doing CPR because RN B 200 UM insisted she had reviewed the medical record and the order for resident #1 was a full code. On [DATE] at 3 PM, LPN D verbalized she worked on the 100 unit on [DATE] when she heard the Code Blue announcement over the paging system and responded to the 200 Unit to provide assistance. She said when she entered the resident's room, she heard a male voice saying, it was not the right resident. She said she ran to the nurses' station and brought resident #1's chart to the room. She recalled she located the CPR status order in front of the chart and called out, She is a DNR. LPN D indicated CPR was stopped when she called out the resident was a DNR. She explained a resident's identification had to be by name only and staff needed to have the correct medical chart in the room to be checked by 2 staff to ensure the correct code status order. She said, We had the wrong resident's medical chart. On [DATE] at 3:30 PM, LPN C recalled on [DATE] he worked on the 200 Unit when RN B UM asked him to pull resident in bed D's medical record. He said he retrieved the chart and placed it on the desk at the nurses' station. He said he and RN B UM reviewed resident in D bed's chart and saw a physician order for Full Code. He said, I then called 911 and proceeded to make copies of necessary paperwork required for the resident's transfer to the hospital. When I entered the room, I immediately identified the wrong resident had been identified. It was not the resident in the D bed, it was the resident in the A bed who was unresponsive. We had identified the CPR status for the resident in the D bed who was a full code and resident #1 was in the A bed and she had a DNRO. LPN C stated the problem was that RN B UM had identified the resident by room number and not by her name. LPN C verbalized that RN B UM had only worked at the facility for 3 to 4 weeks and she did not know the residents and the facility procedures. LPN C explained it was imperative to have the correct medical record in the room so 2 staff could ensure the right resident and correct CPR status order. On [DATE] at 9:35 AM, a review of the timeline was conducted with the Administrator and the Regional Nurse Consultant (RNC). The Administrator noted RN B UM was no longer employed at the facility. Telephone calls to RN B UM were not returned. The Administrator indicated on [DATE], RN B UM had incorrectly identified resident #1 as the resident in the D bed instead of the A bed. She directed LPN C to pull the medical record for the resident in bed D instead of requesting the medical record for the resident by name. The Administrator explained the resident in D bed had a Full Code order and resident #1 who was in bed A had a DNRO. He said RN B then communicated to LPN A that resident #1 was a Full Code and CPR was initiated, Immediately after LPN C entered the room, he identified that the wrong resident's medical record chart had been reviewed and yelled out, wrong resident. He noted LPN A immediately stopped chest compressions. The RNC stated the facility did not have a specific policy for resident identification, but it was standard practice that a nurse was required to identify a resident by name and not by room number since residents' rooms and bed location could change. Review of the Unit Manager's job description revealed the manager was responsible for nursing care and services on assigned unit and for ensuring implementation of physician orders based on individual resident needs and supervision of performance by licensed staff and CNAs . The job description included a Commitment to Honoring Advanced Directives/end of life wishes. Review of the Facility Assessment revealed the facility takes under consideration a residents decision related to death. On [DATE] at 1:50 PM, during a telephone interview with the facility's Medical Director, he stated he had been informed that resident #1 had received CPR although she had an order in place for a DNR. The Medical Director explained the facility was responsible to honor the Advanced Directive wishes of all residents. If a resident had a DNRO in place, CPR should not have been initiated. The Medical Director recalled he was informed the wrong resident's medical record had been pulled and this resident had an order for full code so CPR was started. Shortly after CPR had been started it was identified that the wrong medical record chart had been reviewed and resident #1's medical record identified she had a DNRO and CPR was stopped. The Medical Director stated he had been involved in several Ad Hoc Quality and Performance Improvement (QAPI) meetings and he suggested it was extremely important to continue staff education and the mock Code Blue drills to ensure this type of event does not happen again. Review of the facility's policy and procedure for CPR Code Status Orders and Response, effective February 2021 read, . The physician's order for full code or Do Not Resuscitate is based on the wishes of the resident/resident representative. Advanced Directives will be honored. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following which were verified by the survey team: *On [DATE], confirmation of the facility's investigation was completed with the Administrator and Regional Nurse Consultant. The investigation included re-enactment, staff statements and Root Cause Analysis. The facility identified the nurse had not brought the correct resident's medical record chart into the room to verify code status prior to initiating CPR. *The 200 Unit Manager was reported to the Board of Nursing. *A 30-day look back on all resident code blue events had been conducted on [DATE]. Audit form revealed 90 residents were reviewed with no issues identified. *Review of the current licensed nurses audit for CPR certification, reference checks, Agency for Healthcare Administration (AHCA) Background checks, and license verification completed [DATE]- [DATE]. The form revealed 100% of nurses (19) had been completed with no concerns. *Review of the [DATE]- [DATE] education sign-in sheets revealed 100% of the licensed nurses (19) had been educated on CPR, Code Status (CPR) Orders and Response. The education included a post-test with 100% of the licensed nurses with a passing grade of 100. *Review of the [DATE]- [DATE] education sign-in sheets revealed 100% of the licensed nurses (19) had been educated on identification of resident via 2 identifiers (not room number). The education included a post-test with 100% of the licensed nurse (19) with a passing grade of 100. *Review of the [DATE]- [DATE] education sign-in sheets revealed 100% of the licensed nurses (19) had been educated on Abuse Prevention Program. The education included a post-test with 100% of the licensed nurse with a passing grade of 100. 89/89 facility staff were also educated with post-test and passing grade of 100. *Review of the facility's licensed nurse orientation program checklist included: Honoring Advanced Directives, CPR/Code Status Orders and Response, Abuse Prevention, Resident Identification, Participation in Code Blue Drill. The facility had not hired any licensed nurses as of [DATE]. *Review of the Commitment to Honoring Advanced Directives Attestation forms revealed 100% of licensed nurses (19) had completed with signature by [DATE]. *Review of the facility's CPR Code Status Orders and Response Policy updated on [DATE] revealed 15/19 licensed nurses had completed education by [DATE]. The policy was updated with the addition that the resident will be verified utilizing 2 identifiers such as electronic medical record photo, arm band or verification with another nursing care center personnel, if resident is a full code CPR will be initiated. Room number or physical location is not used as an identifier. One of the 3 remaining licensed nurses was currently out of the country as of [DATE]. *Observations of the 100-unit and 200-unit emergency carts conducted on [DATE] revealed the laminated cards STOP!! CHECK CODE STATUS BEFORE STARTING CPR were attached to both carts. *Review of the Code Blue Drills signature forms revealed the drills were daily starting on [DATE] - [DATE] and are currently on-going on a weekly basis. The forms documented the drill, staff signatures and a critique of the drill. No issues identified since [DATE]. *Review of the [DATE] Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting with the Medical Director in attendance documented CPR Event reviewed. *Review of the [DATE] Ad Hoc QAPI meeting with the Medical Director in attendance documented review of Abuse, Neglect, Tracheostomy and CPR Event were reviewed. *Review of the [DATE] QAPI meeting with the Medical Director in attendance documented Education, Pharmacy, Respiratory, Policy and Procedures, Infection Control, Tracheostomy, CPR and Clinical Indicators were reviewed. *The next scheduled QAPI meeting is scheduled for [DATE] with agenda to review CPR plan, audits, code blue drill critiques and recommendations to determine continued compliance. On [DATE] to [DATE], interviews conducted with 6 LPNs and 2 RNs revealed they were knowledgeable regarding Advanced Directives, identification of resident by name only, CPR Policy and Procedure, chart to be brought into the room, and two staff to confirm correct resident's chart and code status order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure licensed nursing staff had the appropriate competency and skill sets to correctly identify a resident's medical record to ensure a Do Not Resuscitate order (DNRO) was honored for 1 of 7 residents reviewed for advanced directives, (#1). On [DATE] at approximately 8:30 AM, resident #1 was found unresponsive with no heart rate and no respirations. The nurse failed to identify the resident by name and instead identified her by the incorrect bed number to check the code status. Another resident's code status was reviewed in error and Cardiopulmonary Resuscitation (CPR) was initiated for resident #1. Resident #1 had a signed Do Not Resuscitate Order (DNR)) order in her medical record. Licensed Practical nurse (LPN) A and Registered Nurse (RN) B failed to ensure the correct medical record was identified by resident name not room number, failed to ensure the medical record was brought to the resident's room, failed to ensure two staff confirmed the correct identity of the medical record and failed to confirm correct code status order for resident #1. As a result of these failures, CPR including chest compressions and ventilation were initiated on a resident whose wishes were for a natural and dignified death. The facility's failure to ensure licensed nursing staff were educated and competent with resident identification during a life-threatening emergency situation resulted in Immediate Jeopardy beginning on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross reference F578 According to Wikipedia, A do-not resuscitate order (DNR) . no code . or allow natural death, is a medical order, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating . Review of the facility's policy and procedure for CPR Code Status Orders and Response, effective February 2021 read, . The physician's order for full code or Do Not Resuscitate is based on the wishes of the resident/resident representative. Advanced Directives will be honored. Do Not Resuscitate (DNR) order: Cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations . Upon identification that a resident is unresponsive the person making the identification will check for pulse and respirations, and immediately call for help; loudly calling a Code Blue Room (#). 2. Staff will respond to room with the medical record and emergency cart. 3. Chart will be checked for code status . Review of the medical record revealed resident #1 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Arteriosclerotic Heart Disease, Peripheral Vascular Disease, Dementia, and Atrial Fibrillation. A physician's order dated [DATE] noted DNR code status. A care plan for Advanced Directives dated [DATE] documented the resident had requested her DNR wishes to be honored. Review of a late entry nursing progress notes dated [DATE] at 3:01 PM, by Licensed Practical Nurse (LPN) A revealed that resident #1 was observed lying in bed with the head of the bed elevated with oxygen at 2 liters per minute via nasal cannula for shortness of breath. The progress noted read LPN A called resident #1's name, rubbed her chest and then checked for a pulse. A Code Blue for cardiac arrest and 911 were called. There was no documentation regarding resident #1's medical record being obtained and reviewed for her code status or that CPR had been initiated. The next late entry in the progress note dated [DATE] at 3:03 PM, documented resident #1's physician was notified that she had expired. On [DATE] at 2:27 PM, LPN A stated she had worked at the facility for 3 years and had completed the facility's orientation program. LPN A was able to recall the timeline of events that occurred on [DATE] at approximately 8:30 AM. She stated she was assigned to resident #1 on [DATE] and one of the Certified Nursing Assistants (CNAs) came to her and reported resident #1 did not look good. She said she immediately asked RN B the 200 Unit Manager (UM) to go to the room with her. She recalled when she entered the room, resident #1 was unresponsive. I called her name and shook her, but she did not respond. She explained she asked RN B UM to get resident #1's medical record as she needed to check her code status to see if CPR should be started. She recalled RN B UM returned to the room without the medical record and reported, She is a full code. She said she asked RN B UM several times, Are you sure she is a full code? She said RN B again stated resident #1 was a full code so she started CPR. She stated while she performed CPR, she heard someone yell out, The wrong chart, she is a DNR. She said she then stopped CPR. LPN A explained she was aware that CPR was not to be performed on a resident with a DNR order. She had no explanation as to why she did not insist on having residents #1's medical record brought to the room to verify her code status. I just started doing CPR because RN B UM insisted she had reviewed the medical record and the order for resident #1 was a full code. Review of RN B's statement dated [DATE] at 9:30 AM, revealed she was asked by LPN A to go to resident #1's room on [DATE] at approximately 8:30 AM. After entering the room, she was asked to call a Code Blue for the resident in bed D. She then returned to the nurses' station and the resident in bed D's medical record had been pulled and was laying on the desk. None of the staff had identified the resident by name. RN B reviewed the chart of the resident in bed D and confirmed a physician order for full code. RN B UM then communicated to the staff in the room that the resident was a full code. It was not until after CPR had been initiated that it was identified RN B UM had reviewed the wrong chart and the correct medical record chart for resident #1 had a physician order for DNR. An interview had been conducted with RN B on [DATE] at 10 AM, by the Administrator and the Risk Manager. It was identified that RN B had reviewed the resident in bed D's medical record that noted full code order instead of resident #1's chart who was in bed A that contained a physician order for DNR. This was not realized until LPN D had questioned RN B UM and she returned to the nurses' station to check the medical record chart again. LPN D obtained resident #1's medical record, brought the chart into the room and called out, She is a DNR, and CPR was stopped. RN B UM voiced she was not familiar with resident #1 but knew her name. RN B's explanation as to why the wrong chart was reviewed was that she had not identified the resident by name and she had not looked at the resident's name on the medical chart to ensure it was the correct resident's record. On [DATE] at 9:35 AM, an interview was conducted with the Administrator and the Regional Nurse Consultant (RNC). The Administrator noted RN B UM was no longer employed at the facility. Telephone calls to RN B UM were not returned. The Administrator indicated on [DATE], RN B UM had incorrectly identified resident #1 as the resident in the D bed instead of the A bed. She had directed LPN C to pull the medical record for the resident in bed D instead of requesting the medical record for the resident by name. The Administrator explained the resident in D bed had a Full Code order and resident #1 who was in bed A had a DNR order. He said RN B then communicated to LPN A that resident #1 was a Full Code and CPR was initiated. Immediately after LPN C entered the room, he identified that the wrong resident's medical record had been reviewed and yelled out, wrong resident. He noted LPN D ran to the nurses' station, pulled resident #1's chart and verified the correct resident's code status of DNR and CPR was immediately stopped. The RNC indicated RN B UM had worked at the facility for approximately 3 to 4 weeks and had completed both the facility mandatory orientation and the clinical nursing orientation. Review of the Clinical Nursing Orientation High Risk and Safety Checklist revealed no requirement for Code Blue training during the orientation program which indicated neither LPN A nor RN B had received any training for Code Blue emergencies during orientation. Review of the most recent In-Service Training dated [DATE], documented CPR - Code Status orders that included to follow physician orders, CNAs could bring the crash cart and the medical chart to the room. The in-service signature form contained LPN A's signature that indicated she had attended the in-service and was aware the resident's medical chart was to be brought to the room during a code blue event. The in-service had not included training to ensure the correct resident's medical chart was to be brought to the room, or that staff were required to confirm the correct chart had been obtained and reviewed for code status order by two nurses. Review of the [DATE] In-Service Training Record conducted by the Assistant Director of Nursing (ADON)/Staff Development Coordinator documented Code Blue Drill. The Objectives included physician orders must be followed, the yellow DNR form orders to be kept in front of the chart, and to bring the medical chart to the room. RN B's signature indicated she had attended the in-service and had knowledge that the resident's medical chart was to be brought to the resident's room at the time of a Code Blue. There were no competency testing to ensure staff grasped the training in order to apply the learning during actual emergencies. Review of the LPN Job Description revealed the position included maintaining professional standards of professional nursing; handles emergency situations in a prompt, precise, and professional manner; provides care for resident/patients according to division/unit specific competencies, policy and procedures; and Commitment to Honoring Advanced Directives/End of life wishes. Review of the facility's Unit Manager- RN Job Description revealed the position included: oversees resident care to promote highest level of physical, mental and psychosocial functioning possible and commitment to honoring Advanced Directive/End of life wishes. Review of the facility's policy and procedure for CPR Code Status Orders and Response, effective February 2021 read, . The physician's order for full code or Do Not Resuscitate is based on the wishes of the resident/resident representative. Advanced Directives will be honored. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following which were verified by the survey team: *On [DATE] confirmation of the facility's investigation was completed with the Administrator and Regional Nurse Consultant. The investigation included re-enactment, staff statements and Root Cause Analysis. The facility identified the nurse had not brought the correct resident's medical record chart into the room to verify code status prior to initiating CPR. *The 200 Unit Manager was reported to the Board of Nursing. *A 30 day look back on all resident code blue events had been conducted on [DATE]. Audit form revealed 90 residents were reviewed with no issues identified. *Review of the current licensed nurses audit for CPR certification, reference checks, Agency for Healthcare Administration (AHCA) Background checks, and license verification completed [DATE]- [DATE]. The form revealed 100% of nurses (19) had been completed with no concerns. *Review of the [DATE]- [DATE] education sign-in sheets revealed 100% of the licensed nurses (19) had been educated on CPR, Code Status Orders and Response. The education included a post-test with 100% of the licensed nurses with a passing grade of 100. *Review of the [DATE]- [DATE] education sign-in sheets revealed 100% of the licensed nurses (19) had been educated on identification of resident via 2 identifiers (not room number). The education included a post-test with 100% of the licensed nurse (19) with a passing grade of 100. *Review of the [DATE]- [DATE] education sign-in sheets revealed 100% of the licensed nurses (19) had been educated on Abuse Prevention Program. The education included a post-test with 100% of the licensed nurse with a passing grade of 100. 89/89 facility staff were also educated with post-test and passing grade of 100. *Review of the facility's licensed nurse orientation program checklist included: Honoring Advanced Directives, CPR/Code Status Orders and Response, Abuse Prevention, Resident Identification, Participation in Code Blue Drill. The facility had not hired any licensed nurses as of [DATE]. *Review of the Commitment to Honoring Advanced Directives Attestation forms revealed 100% of licensed nurses (19) had completed with signature by [DATE]. *Review of the facility's CPR Code Status Orders and Response Policy updated on [DATE] revealed 15/19 licensed nurses had completed education by [DATE]. The policy was updated with the addition that the resident will be verified utilizing 2 identifiers such as electronic medical record photo, arm band or verification with another nursing care center personnel, if resident is a full code CPR will be initiated. Room number or physical location is not used as an identifier. One of the 3 remaining licensed nurses was currently out of the country as of [DATE]. *Observations of the 100-unit and 200-unit emergency carts conducted on [DATE] revealed the laminated cards STOP!! CHECK CODE STATUS BEFORE STARTING CPR were attached to both carts. *Review of the Code Blue Drills signature forms revealed the drills were daily starting on [DATE] - [DATE] and are currently on-going on a weekly basis. The forms documented the drill, staff signatures and a critique of the drill. No issues identified since [DATE]. *Review of the [DATE] Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting with the Medical Director in attendance documented CPR Event reviewed. *Review of the [DATE] Ad Hoc QAPI meeting with the Medical Director in attendance documented review of Abuse, Neglect, Tracheostomy and CPR Event were reviewed. *Review of the [DATE] QAPI meeting with the Medical Director in attendance documented Education, Pharmacy, Respiratory, Policy and Procedures, Infection Control, Tracheostomy, CPR and Clinical Indicators were reviewed. *The next scheduled QAPI meeting is scheduled for [DATE] with agenda to review CPR plan, audits, code blue drill critiques and recommendations to determine continued compliance. On [DATE] to [DATE], interviews conducted with 6 LPNs and 2 RNs revealed they were knowledgeable regarding Advanced Directives, identification of resident by name only, CPR Policy and Procedure, chart to be brought into the room, and two staff to confirm correct resident's chart and code status order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility neglected to ensure a replacement tracheostomy set was available at the bedside for resident care needs, neglected to locate a new replacement tracheostomy set for emergency tracheostomy tube reinsertion after dislodgement and failed to complete a thorough investigation for neglect for tracheostomy care and services for 1 of 2 residents reviewed for tracheostomy care, (#2). On 12/04/22 at approximately 5:30 PM, resident #2 removed his tracheostomy tube. The facility failed to keep a replacement tracheostomy set at his bedside and staff failed to obtain a new tracheostomy set from the supply room to reinsert the tracheostomy tube. The resident's assigned nurse washed the dislodged tracheostomy tube in the sink with the intention of reinsertion. If this non sterile tracheostomy tube had been reinserted into the resident, there was reasonable likelihood of respiratory infection, sepsis and/or death. While resident #2's tracheostomy tube was out, there was reasonable likelihood of respiratory compromise, respiratory failure, respiratory arrest and/or cardiac arrest. The facility's failure to obtain a replacement tracheostomy set for reinsertion resulted in transfer to the hospital, surgical intervention for insertion of a new tracheostomy, placement on mechanical ventilation and transfer to an Intensive Care Unit (ICU). The facility's failure to identify and conduct a complete and thorough investigation for neglect for tracheostomy care and services placed all residents with tracheostomy dislodgement at risk of respiratory compromise, respiratory failure, respiratory arrest and/or cardiac arrest. These failures resulted in Immediate Jeopardy starting on 12/04/22. The Immediate Jeopardy was removed on 12/20/22. Findings: Cross reference F695 and F726 According to www.Mayoclinic.org, A tracheostomy is a hole that surgeons make through the front of the neck and into the windpipe (trachea). A tracheostomy tube is placed into the hole to keep it open for breathing . A tracheostomy provides air passage to help you breathe when the usual route for breathing is somehow blocked or reduced . Resident #2 was a [AGE] year-old, cognitively impaired male, admitted to the facility on [DATE] with Cerebral Vascular Accident (CVA) paraplegia, Acute and Chronic Respiratory Failure, Pulmonary Nodule, Pneumonitis, Tracheostomy and Cognitive Communication Deficit. Resident #2's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documented he had short-term and long-term memory problems, severely impaired cognitive skills for decision making, unable to speak, totally dependent on staff with all activities of daily living (ADLs), an indwelling urinary catheter, feeding tube, tracheostomy and multiple pressure ulcers. Review of resident #2's tracheostomy care plan related to impaired breathing mechanics included interventions to provide tracheostomy care per physician order. Review of resident #2's December 2022 physician's orders noted tracheostomy size 8, change or replace as needed if displaced or dislodged, maintain a replacement tracheostomy of equal size and one size down at bedside and to check every shift. Review of the December 2022 Treatment Administration Record (TAR) documented replacement tracheostomy of equal size and one size down to be maintained at bedside and to check every shift. The TAR was initialed by the nurse on 12/03/22 night shift, 12/04/22 day shift, and on 12/04/22 evening shift indicating licensed nurses had checked that a replacement tracheostomy set was at bedside for emergency reinsertion. Review of Licensed Practical Nurse (LPN) A's nursing progress note dated 12/04/22 at 5:45 PM, documented that during rounds at approximately 5:30 PM, she observed resident #2 had pulled out his tracheostomy tube. The neck piece had been pulled off, the tracheostomy tube was sitting on his right upper chest/shoulder area and the nursing supervisor was called. The progress note contained no documentation that LPN A looked for a replacement tracheostomy set at his bedside or that she had attempted to obtain a replacement tracheostomy set located in the supply room on the unit. On 12/18/22 at 2 PM, during a telephone interview, LPN A recalled on 12/04/22 at approximately 5:30 PM, she entered resident #2's room and observed his tracheostomy tube was near his shoulder. She said at the time, she did not look for a replacement tracheostomy set at his bedside. She stated she began washing the existing tracheostomy tube to get the secretions off the tube so it could be reinserted back into the tracheostomy. She reported, You have to get the germs off the tube if you want to reinsert it. LPN A explained it was policy to have an extra replacement tracheostomy set at bedside and she could not remember if she looked for a replacement tracheostomy set. All I did was call for help. LPN A explained she had attended orientation and her education/clinical competency for tracheostomy care included only handouts to read. She said, I had no education on how to reinsert a tracheostomy tube if it became dislodged. Review of Registered Nurse (RN) B's (Nursing Supervisor) Initial Event Note for resident #2 dated 12/04/22 at 6 PM, documented tracheostomy was pulled out, resident was cognitively impaired and oxygen applied. The nurse (LPN A) had walked into the room and observed resident #2's tracheostomy tube laying on his chest with his hands up near his neck. Attempts were made to replace the existing tracheostomy tube which were unsuccessful because the stoma (opening) had shrunken in size. On 12/17/22 at 11:45 AM, RN B revealed she had responded to LPN A's call for assistance on 12/04/22 at approximately 5:30 PM. When she entered resident #2's room she observed LPN A washing the dislodged tracheostomy tube at the sink in the room. She stated, you never put a soiled dislodged tracheostomy back into a resident for infection control reasons, you use a new sterile tracheostomy tube. RN B explained she looked for a replacement tracheostomy set at his bedside but could not find one. There is supposed to be a second size smaller tracheostomy set at the resident's bedside at all times. I have been telling them to have a size smaller tracheostomy at the resident's bedside. She noted the tracheostomy opening was very small and even if she had a replacement tube, she did not think she would be able to reinsert a new tube. RN B gave no indication that she had attempted to obtain a new sterile tracheostomy set from the supply closet on the unit. She did not explain why a replacement tracheostomy set was not at his bedside as per physician orders. RN B explained she had attended orientation and had received education on tracheostomy care. On 12/19/22 at 3:15 PM, the Respiratory Therapist (RT) revealed if a tracheostomy is dislodged, the existing tracheostomy should never be washed under tap water and reinserted into the resident. A new sterile tracheostomy set was always obtained for reinsertion. She explained the tracheostomy set contained an obturator which was used to facilitate opening the existing stoma so a new tracheostomy tube could be placed. The RT explained she had provided respiratory services at the facility for approximately three years and there had been times she found replacement sets not available at the bedside. On 12/19/22 at 2:30 PM, an interview was conducted with the Administrator, Regional Nurse Consultant (RNC) and Risk Manager (RM) (by phone). The RM stated the Tracheostomy Care Policy had been reviewed as part of the investigation however the facility had not included interviews with licensed staff to determine if a replacement tracheostomy set was at resident #2's bedside at the time the incident occurred, on 12/04/22. LPN A's written statement was reviewed and revealed no documentation of attempting to obtain a replacement tracheostomy set. The Administrator was unable to produce a written statement from RN B for resident #2's 12/04/22 event. Review of resident #2's hospital records revealed on 12/04/22 he was seen in the Emergency Department (ED) for dislodged tracheostomy tube with significant granulation tissue, pinpoint hole with yellow mucus permeating from the hole and altered mental status. A chest X-showed atelectasis (partial or complete collapse of lung) and aspiration pneumonia. The History and Physical (H&P) dated 12/05/22 revealed the resident had multiple episodes of similar dislodgement and aspiration pneumonia in the past. The tracheostomy site had been completely closed with granulation tissue and required surgical exploration to effectively reinsert the tracheostomy and a Pulmonary Consultation was ordered. The Pulmonary Consultation dated 12/05/22 documented tracheostomy site is sealed shut. On 12/08/22 the resident developed chest wall retractions with decreased breath sounds and rhonchi. Review of the hospital staff Nurses Notes dated 12/07/22 at 11:32 PM, documented resident #2's oxygen saturations were 68-70 percent (%) on 3 Liters (L) via nasal cannula (nc), his oxygen was increased to 5 L nc and he was transferred to the Cardiovascular Intensive Care Unit (CVICU) where Bilevel Positive Airway Pressure (BIPAP) was initiated for airway management. On 12/12/22 resident #2 required surgical intervention for tracheostomy and he was placed on a ventilator for respiratory support. Review of the Tracheostomy Tube Emergency Care Policy and Procedure, dated 2013, read, If a tracheostomy tube becomes blocked or comes out, an Emergency Plan is needed. It's recommended to have two back up tracheostomy tubes at bedside. These backup tubes should be readily available at all times . On 12/19/22 at 10:30 AM, the Administrator explained the facility had only conducted an investigation for allegation of neglect for resident #2's tracheostomy being out for 12-24 hours. He stated as part of the investigation process, the Director of Nursing (DON) and 100 Unit Manager had verified the Tracheostomy Care Policy had been followed for having replacement tracheostomy supplies at the bedside. The Administrator confirmed he was present during the interview with RN B and that he had heard RN B say that there was not a replacement tracheostomy set at the bedside on 12/04/22. The Administrator acknowledged LPN A's statement had not documented if she had attempted to find the replacement tracheostomy set at his bedside and the investigation had not contained a written statement from RN B who responded and provided care and services to resident #2 on 12/04/22. Review of the Facility's Abuse Prevention Program Policy, dated August 2020, read, Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness . Investigation: . The Administrator or designee is notified and will initiate and conclude a complete and thorough investigation within a specific time frame. Investigation will include, but may not be limited to: . Employee statements/interviews . Document review i.e. chart reviews, policy review, education programs, appropriate resource review (such as medical literature) etc. Re-enactment of event when indicated . Reporting . Facility will be in compliance with Federal regulations . Review of the Facility Assessment, update 12/01/2022, documented the facility is able to provide care and services for residents with CVA, paraplegia and tracheostomy. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified the survey team: * An Ad Hoc Quality Assurance and Performance Improvement meeting was held on 12/20/22 with Medical Director review and approval of the facility's Performance Improvement Plan related to tracheostomy care and services. * Staff education on Abuse, Neglect, and Exploitation Policy was conducted 12/07/22 - 12/17/22 by the Administrator, Director of Nursing and Unit Managers. The education included a post-test to validate competency and 100% of staff were educated with 100% passing grade. Validation was confirmed by signatures on Attendance Record. * Licensed nurses will be educated by the (Contracted Respiratory Therapy Company) Respiratory Therapist and/or designee and demonstrate competency per Tracheostomy Policy and Procedure and Standards of Practice with an emphasis on emergency replacement of a dislodged tracheostomy. * Nine licensed nurses had completed education and competency conducted by the Respiratory Therapist on 12/20/22. The education included: Tracheostomy Care Policy, Tracheostomy Tube Emergency Care Policy, Manual Resuscitators Policy, Tracheostomy Tube Site Care Policy and Procedure, Tracheostomy Suctioning Policy and Procedure, Tracheostomy Tube Removal Policy and Procedure, Monitoring the Tube and Care and a Clinical Competency Evaluation with pass/fail grade. * Interview with the Respiratory Therapist on 12/20/22 at 3 PM revealed all nine staff had completed the education program which included policy and procedures and a return demonstration with tracheostomy tube insertion. All nine nurse had passed. Review of the Attendance Record confirmed nine licensed nurse signatures and review of the Clinical Competency Evaluation revealed all nurses had passed. Interviews conducted on 12/20/22 at 3:25 PM, to 12/20/22 at 3:33 PM, with 2 RNs and 3 LPNs confirmed they were knowledgeable regarding the Tracheostomy Policy for requiring a replacement tracheostomy set at bedside for all residents with tracheostomy and reinsertion of a new sterile tracheostomy. Licensed staff will not be permitted to work prior to completing the facility tracheostomy education and competency program. Newly hired licensed nurses will be educated and demonstrate competency with tracheostomy Policy and Procedure and standards of practice with emphasis on emergency replacement of a dislodged tracheostomy during orientation. Validation confirmed by review of the licensed nurse orientation checklist which now included tracheostomy reinsertion and oxygen. Observation of resident #3 with tracheostomy on 12/17/22 at 3:30 PM, and on 12/20/22 at 11:07 AM, confirmed multiple size 6 tracheostomy sets in the top drawer of his nightstand. On 12/18/22 at 2 PM, an interview was conducted by telephone with resident #3's daughter who stated she visited daily and had no concerns related to his tracheostomy care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide tracheostomy care and services per facility policy and accepted standards of practice for 1 of 2 residents reviewed for tracheostomy care, (#2). On 12/04/22 at approximately 5:30 PM, resident #2 removed his tracheostomy tube. The facility failed to keep a replacement tracheostomy set at his bedside and staff failed to obtain a new tracheostomy set from the supply room to reinsert the tracheostomy tube. The resident's assigned nurse washed the dislodged tracheostomy tube in the sink with the intention of reinsertion. If this non sterile tracheostomy tube had been reinserted into the resident, there was reasonable likelihood of respiratory infection, sepsis and/or death. While resident #2's tracheostomy tube was out, there was reasonable likelihood of respiratory compromise, respiratory failure, respiratory arrest and/or cardiac arrest. The facility's failure to provide required tracheostomy care and services for a resident who had dislodged his tracheostomy by not ensuring a replacement tracheostomy set was at bedside, not following infection control policy for a dislodged tracheostomy tube, and failure to obtain and insert a new sterile tracheostomy tube resulted in the resident being transferred to the hospital requiring surgical intervention for insertion of a new tracheostomy. These failures resulted in Immediate Jeopardy starting on 12/04/22. The Immediate Jeopardy was removed on 12/20/22. Findings: Cross reference F600 and F726 According to www.Mayoclinic.org, A tracheostomy is a hole that surgeons make through the front of the neck and into the windpipe (trachea). A tracheostomy tube is placed into the hole to keep it open for breathing . A tracheostomy provides air passage to help you breathe when the usual route for breathing is somehow blocked or reduced . Resident #2 was a [AGE] year-old cognitively impaired male admitted to the facility on [DATE] with Cerebral Vascular Accident (CVA), paraplegia, Acute and Chronic Respiratory Failure, Pulmonary Nodule, Pneumonitis, Tracheostomy and Cognitive Communication Deficit. Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documented he had short-term and long-term memory problems, severely impaired cognitive skills for decision making, unable to speak, totally dependent on staff with all activities of daily living (ADLs), an indwelling urinary catheter, feeding tube, tracheostomy and multiple pressure ulcers. Review of resident #2's tracheostomy care plan related to impaired breathing mechanics included interventions to provide tracheostomy care per physician order. Review of the December 2022 physician's orders documented tracheostomy size 8, change or replace as needed if displaced or dislodged, to maintain a replacement tracheostomy of equal size and one size down at bedside and to check every shift. Review of the December 2022 Treatment Administration Record (TAR) documented replacement tracheostomy of equal size and one size down to be maintained at bedside and to check every shift. The TAR was initialed by the nurse on 12/03/22 night shift, 12/04/22 day shift, and on 12/04/22 evening shift indicating the nurses had checked that a replacement tracheostomy set was at bedside for emergency reinsertion. Review of Licensed Practical Nurse (LPN) A's nursing progress note dated 12/04/22 at 5:45 PM, documented that during rounds at approximately 5:30 PM, she observed resident #2 had pulled out his tracheostomy tube. The neck piece had been pulled off, the tracheostomy tube was sitting on his right upper chest/shoulder area and the nursing supervisor was called. The progress note contained no documentation that LPN A looked for a replacement tracheostomy set at his bedside or that she had attempted to obtain a replacement tracheostomy set located in the supply room on the unit. On 12/18/22 at 2 PM, during a telephone interview, LPN A recalled on 12/04/22 at approximately 5:30 PM, she entered resident #2's room and observed his tracheostomy tube was near his shoulder. She said at the time, she did not look for a replacement tracheostomy set at his bedside. She stated she began washing the existing tracheostomy tube to get the secretions off the tube so it could be reinserted back into the tracheostomy. She reported, You have to get the germs off the tube if you want to reinsert it. LPN A explained it was policy to have an extra replacement tracheostomy set at bedside and she could not remember if she looked for a replacement tracheostomy set. All I did was call for help. LPN A explained she had attended orientation and her education/clinical competency for tracheostomy care included only handouts to read. She said, I had no education on how to reinsert a tracheostomy tube if it became dislodged. Review of the list of licensed staff assigned to resident #2 (provided by the facility) on 12/01/22 - 12/04/22 revealed LPN A was assigned and responsible for resident #2's care and services on 12/03/22 3 PM - 11 PM shift and on 12/04/22 on 3 PM - 11 PM shift. Review of Registered Nurse (RN) B's (Nursing Supervisor) Initial Event Note for resident #2 dated 12/04/22 at 6 PM, documented tracheostomy was pulled out, resident was cognitively impaired and oxygen applied. The nurse (LPN A) had walked into the room and observed resident #2's tracheostomy tube laying on his chest with his hands up near his neck. Attempts were made to replace the existing tracheostomy tube which were unsuccessful because the stoma (opening) had shrunken in size. On 12/17/22 at 11:45 AM, RN B revealed she had responded to LPN A's call for assistance on 12/04/22 at approximately 5:30 PM. When she entered resident #2's room she observed LPN A washing the dislodged tracheostomy tube at the sink in the room. She stated she told the LPN, you never put a soiled dislodged tracheostomy back into a resident for infection control reasons, you use a new sterile tracheostomy tube. RN B explained she looked for a replacement tracheostomy set at his bedside but could not find one. There is supposed to be a second size smaller tracheostomy set at the resident's bedside at all times. She said there was no replacement sets at the bedside and she acknowledged she did not look in the supply room so she could insert a replacement tracheostomy tube. She noted the tracheostomy opening was very small and even if she had a replacement tube, she did not think she would be able to reinsert a new tube. She did not explain why a replacement tracheostomy set was not at his bedside as per physician orders. RN B explained they called the physician to obtain an order to transfer the resident to the hospital. RN B indicated she had attended orientation and had received education on tracheostomy care. On 12/19/22 at 3:15 PM, the Respiratory Therapist (RT) revealed if a tracheostomy is dislodged, the existing tracheostomy should never be washed under tap water and reinserted into the resident. A new sterile tracheostomy set was always obtained for reinsertion. She explained the tracheostomy set contained an obturator which was used to facilitate opening the existing stoma so a new tracheostomy tube could be placed. The RT explained she had provided respiratory services at the facility for approximately three years and there had been times she found replacement sets not available at the bedside. On 12/19/22 at 2:30 PM, an interview was conducted with the Administrator, Regional Nurse Consultant (RNC) and Risk Manager (RM) (by phone). The RM stated the Tracheostomy Care Policy had been reviewed by the Director of Nursing and they felt they had followed their policy. They were informed that RN B had noted there was no replacement tracheostomy set at the bedside as required by policy. The Administrator stated, I guess we didn't follow our policy. They acknowledged they were not aware that a replacement tracheostomy set was not available at the bedside to immediately insert a new tracheostomy tube. Review of resident #2's hospital records revealed on 12/04/22 he was seen in the Emergency Department (ED) for dislodged tracheostomy tube with significant granulation tissue, pinpoint hole with yellow mucus permeating from the hole and altered mental status. A chest X-showed atelectasis (partial or complete collapse of lung) and aspiration pneumonia. The History and Physical (H&P) dated 12/05/22 revealed the resident had multiple episodes of similar dislodgement and aspiration pneumonia in the past. The tracheostomy site had been completely closed with granulation tissue and required surgical exploration to effectively reinsert the tracheostomy and a Pulmonary Consultation was ordered. The Pulmonary Consultation dated 12/05/22 documented tracheostomy site is sealed shut. On 12/08/22 the resident developed chest wall retractions with decreased breath sounds and rhonchi. Review of the hospital staff Nurses Notes dated 12/07/22 at 11:32 PM, documented resident #2's oxygen saturations were 68-70 percent (%) on 3 Liters (L) via nasal cannula (nc), his oxygen was increased to 5 L nc and he was transferred to the Cardiovascular Intensive Care Unit (CVICU) where Bilevel Positive Airway Pressure (BIPAP) was initiated for airway management. On 12/12/22 resident #2 required surgical intervention for tracheostomy and he was placed on a ventilator for respiratory support. Review of the (Contracted Respiratory Therapy Company Name) Tracheostomy Care Policy, not dated, read, c. Emergency tracheostomy tube replacement, the same size and 1 size smaller . e. Sterile normal saline or sterile water . 3) Follow relevant infection control procedures as appropriate . Review of the (Contracted Respiratory Therapy Company Name) Tracheostomy Tube Emergency Care Policy and Procedure, dated 2013, read, If a tracheostomy tube becomes blocked or comes out, an Emergency Plan is needed. It's recommended to have two back up tracheostomy tubes at bedside. These backup tubes should be readily available at all times . Review of the Facility Assessment, update 12/01/2022, documented the facility was able to provide care and services for residents with CVA, paraplegia and tracheostomy. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified the survey team: * An Ad Hoc Quality Assurance and Performance Improvement meeting was held on 12/20/22 with Medical Director review and approval of the facility's Performance Improvement Plan related to tracheostomy care and services. * Staff education on Abuse, Neglect, and Exploitation Policy was conducted 12/07/22 - 12/17/22 by the Administrator, Director of Nursing and Unit Managers. The education included a post-test to validate competency and 100% of staff were educated with 100% passing grade. Validation was confirmed by signatures on Attendance Record. * Licensed nurses will be educated by the (Contracted Respiratory Therapy Company) Respiratory Therapist and/or designee and demonstrate competency per Tracheostomy Policy and Procedure and Standards of Practice with an emphasis on emergency replacement of a dislodged tracheostomy. * Nine licensed nurses had completed education and competency conducted by the Respiratory Therapist on 12/20/22. The education included: Tracheostomy Care Policy, Tracheostomy Tube Emergency Care Policy, Manual Resuscitators Policy, Tracheostomy Tube Site Care Policy and Procedure, Tracheostomy Suctioning Policy and Procedure, Tracheostomy Tube Removal Policy and Procedure, Monitoring the Tube and Care and a Clinical Competency Evaluation with pass/fail grade. * Interview with the Respiratory Therapist on 12/20/22 at 3 PM revealed all nine staff had completed the education program which included policy and procedures and a return demonstration with tracheostomy tube insertion. All nine nurse had passed. Review of the Attendance Record confirmed nine licensed nurse signatures and review of the Clinical Competency Evaluation revealed all nurses had passed. Interviews conducted on 12/20/22 at 3:25 PM to 12/20/22 at 3:33 PM with 2 RN's and 3 LPN's confirmed they were knowledgeable regarding the Tracheostomy Policy for requiring a replacement tracheostomy set at bedside for all residents with tracheostomy and reinsertion of a new sterile tracheostomy. Licensed staff will not be permitted to work prior to completing the facility tracheostomy education and competency program. Newly hired licensed nurses will be educated and demonstrate competency with tracheostomy Policy and Procedure and standards of practice with emphasis on emergency replacement of a dislodged tracheostomy during orientation. Validation confirmed by review of the licensed nurse orientation checklist which now included tracheostomy reinsertion and oxygen. Observation of resident #3 with tracheostomy on 12/17/22 at 3:30 PM, and on 12/20/22 at 11:07 AM, confirmed multiple size 6 tracheostomy sets in the top drawer of his nightstand. On 12/18/22 at 2 PM, an interview was conducted by telephone with resident #3's daughter who stated she visited daily and had no concerns related to his tracheostomy care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure licensed nurses caring for residents with tracheostomy were educated and demonstrated competency related to tracheostomy care for 1 of 2 residents with a tracheostomy, (#2). On 12/04/22 at approximately 5:30 PM, resident #2 removed his tracheostomy tube. The facility failed to keep a replacement tracheostomy set at his bedside and staff failed to obtain a new tracheostomy set from the supply room to reinsert the tracheostomy tube. The resident's assigned nurse washed the dislodged tracheostomy tube in the sink with the intention of reinsertion. If this non sterile tracheostomy tube had been reinserted into the resident, there was reasonable likelihood of respiratory infection, sepsis and/or death. While resident #2's tracheostomy tube was out, there was reasonable likelihood of respiratory compromise, respiratory failure, respiratory arrest and/or cardiac arrest. The facility's failure to ensure licensed nurses were educated and competent to care for residents with a tracheostomy resulted in his transfer to the hospital requiring surgical intervention for insertion of a new tracheostomy and placement on mechanical ventilation and transfer to the Intensive Care Unit (ICU). These failures resulted in Immediate Jeopardy starting on 12/04/22. The Immediate Jeopardy was removed on 12/20/22. Findings: Cross reference F600 and F695 According to www.Mayoclinic.org, A tracheostomy is a hole that surgeons make through the front of the neck and into the windpipe (trachea). A tracheostomy tube is placed into the hole to keep it open for breathing . A tracheostomy provides air passage to help you breathe when the usual route for breathing is somehow blocked or reduced . Resident #2 was a [AGE] year-old, cognitively impaired male, admitted to the facility on [DATE] with Cerebral Vascular Accident (CVA) paraplegia, Acute and Chronic Respiratory Failure, Pulmonary Nodule, Pneumonitis, Tracheostomy and Cognitive Communication Deficit. Resident #2's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documented he had short-term and long-term memory problems, severely impaired cognitive skills for decision making, unable to speak, totally dependent on staff with all activities of daily living (ADLs), an indwelling urinary catheter, feeding tube, tracheostomy and multiple pressure ulcers. Review of resident #2's tracheostomy care plan related to impaired breathing mechanics included interventions to provide tracheostomy care per physician order. Review of resident #2's December 2022 physician's orders noted tracheostomy size 8, change or replace as needed if displaced or dislodged, maintain a replacement tracheostomy of equal size and one size down at bedside and to check every shift. Review of the December 2022 Treatment Administration Record (TAR) documented replacement tracheostomy of equal size and one size down to be maintained at bedside and to check every shift. The TAR was initialed by the nurse on 12/03/22 night shift, 12/04/22 day shift, and on 12/04/22 evening shift indicating licensed nurses had checked that a replacement tracheostomy set was at bedside for emergency reinsertion. Review of Licensed Practical Nurse (LPN) A's nursing progress note dated 12/04/22 at 5:45 PM, documented that during rounds at approximately 5:30 PM, she observed resident #2 had pulled out his tracheostomy tube. The neck piece had been pulled off, the tracheostomy tube was sitting on his right upper chest/shoulder area and the nursing supervisor was called. The progress note contained no documentation the LPN had looked for a replacement tracheostomy set at his bedside or that she had attempted to obtain a sterile replacement tracheostomy set located in the storage room for a tracheostomy tube to be inserted. On 12/18/22 at 2 PM, during a telephone interview, LPN A recalled on 12/04/22 at approximately 5:30 PM, she entered resident #2's room and observed his tracheostomy tube was near his shoulder. She said at the time, she did not look for a replacement tracheostomy set at his bedside. She stated she began washing the existing tracheostomy tube to get the secretions off the tube so it could be reinserted back into the tracheostomy. She reported, You have to get the germs off the tube if you want to reinsert it. LPN A explained it was policy to have an extra replacement tracheostomy set at bedside and she could not remember if she looked for a replacement tracheostomy set. All I did was call for help. LPN A explained she had attended orientation and her education/clinical competency for tracheostomy care included only handouts to read. She said, I had no education on how to reinsert a tracheostomy tube if it became dislodged. Review of LPN A's Checklist New Employee Orientation, dated 08/19/22, revealed no clinical orientation or clinical competency for tracheostomy care and tracheostomy reinsertion. On 10/21/21, the LPN signed acknowledgement of education on protocols that included handwashing, proper use of Personal Protective Equipment (PPE), isolation and tracheostomy care . Review of the Respiratory Policy and Procedure Manual In-Service Training Record, dated 10/25/22, included Tracheostomy Care: emergency tracheostomy supplies at bedside, Oxygen Care: lung sounds competency, Tubing Changes Weekly and (as needed) PRN (bagged, dated and functioning), Tracheostomy/Oxygen Orders, Nebulizer Orders and Vital Signs Prior/During/After Treatment. The form did not include LPN A's signature indicating she had been trained. Review of Nursing Supervisor Registered Nurse (RN) B's Event Note for resident #2 dated 12/04/22 at 6 PM, documented tracheostomy was pulled out, resident is cognitively impaired and oxygen applied. The nurse (LPN A) had walked into the room and observed resident #2's tracheostomy tube laying on his chest with his hands up near his neck. Attempts were made to replace the existing tracheostomy tube which were unsuccessful because the stoma (opening) had shrunken in size. On 12/17/22 at 11:45 AM, RN B revealed she had responded to LPN A's call for assistance on 12/04/22 at approximately 5:30 PM. When she entered resident #2's room she observed LPN A washing the dislodged tracheostomy tube at the sink in the room. She stated, you never put a soiled dislodged tracheostomy back into a resident for infection control reasons, you use a new sterile tracheostomy tube. RN B explained she looked for a replacement tracheostomy set at his bedside but could not find one. There is supposed to be a second size smaller tracheostomy set at the resident's bedside at all times. She noted the tracheostomy opening was very small and even if she had a replacement tube, she did not think she would be able to reinsert a new tube. RN B however, gave no indication that she had attempted to obtain a new sterile tracheostomy set from the supply closet on the unit to attempt insertion of new tube. She did not explain why a replacement tracheostomy set was not at his bedside as per physician orders. She could not explain why nurses had signed there were replacement tracheostomy sets at the bedside in the TAR when there were none. RN B explained she had attended orientation and had received education on tracheostomy care. Review of RN B's Checklist New Employee Orientation, dated 05/10/22, revealed no clinical orientation or clinical competency for tracheostomy care and tracheostomy reinsertion. On 12/18/22 at 11:05 AM, an interview with LPN F revealed he had been assigned to care for a resident with a tracheostomy. I have attended tracheostomy education several times which included protocol for bag valve mask (ambu) bagging, suction, and having a replacement tracheostomy set at bedside. The education was only verbal and visual and included no practice with with how to reinsert a tracheostomy tube. Review of the list of licensed staff assigned to resident #2 (provided by the facility) on 12/01/22 - 12/04/22 revealed LPN F had been assigned and responsible for resident #2's care and services on three shifts: 12/02/22 on the 7 AM - 3 PM shift, on 12/03/22 on the 7 AM - 3 PM shift and on 12/04/22 on the 7 AM - 3 PM shift. On 12/20/22 at 10:53 AM, LPN C stated she had been assigned to care for a resident with a tracheostomy. She recalled she had attended tracheostomy inservice but the inservice was just reading information and verbal instruction. On 12/20/22 at 10:54 AM, LPN D stated she had been assigned to care for a resident with a tracheostomy. I attended a tracheostomy inservice about 3 years ago where I had only observed the presenter demonstrating how to reinsert a tracheostomy. On 12/20/22 at 11 AM, RN G stated she had cared for a resident with a tracheostomy. I attended tracheostomy inservice but was never educated on how to reinsert a tracheostomy. On 12/20/22 at 11:14 AM, LPN H stated she had been assigned to care for a resident with a tracheostomy on two occasions. I attended an inservice on tracheostomy's but was not specifically taught how to reinsert a tracheostomy. On 12/20/22 at 2:25 PM, the Regional Nurse Consultant (RNC) explained the Staff Development position is currently vacant and the Director of Nursing (DON) is tasked with oversight of licensed staff competency. If the DON is not here the RNC was responsible to oversee the process for competency. The Unit Managers do assist with the facility inservices and support for clinical education as needed. She said, I don't think the Unit Managers have been involved with clinical competencies. The RNC stated the facility nurses are capable to accept any assignment or type of resident the facility accepts. All nurses receive the same clinical education and training as needed. On 12/20/22 at 2:21 PM the 100 Unit Manager stated she had never conducted any new employee orientation or clinical skills checklist and she did not know who was responsible for staff competency requirements. The RNC would know who is covering for clinical competency and education. On 12/19/22 at 3:15 PM, and interview with the (Contracted Respiratory Therapy Company Name) Respiratory Therapist (RT) revealed she had been providing respiratory services at the facility for approximately 3 years and she was familiar with resident #2. She explained that she had provided tracheostomy education and clinical competency in the past. It has been a while and the facility was supposed to schedule a date for tracheostomy education/competency in August 2022. The RT said that she had spoken to the facility about conducting a tracheostomy class but was told the facility was waiting for a new staff educator. She recalled she had communicated with the facility that there was a need for tracheostomy education because the facility had a number of new licensed nurses and had two residents with tracheostomy's but she never heard back from management staff. The last time I communicated with the facility about the need for tracheostomy education was over the summer. The last time I completed tracheostomy education/competency with the nurses was in 2021. The RT stated she was in the facility every week when there was a resident with a tracheostomy. There have been times when I identified a resident did not have a replacement tracheostomy set at bedside. Review of the (Contracted Respiratory Therapy Company Name) Tracheostomy Tube Emergency Care Policy and Procedure, dated 2013, read, If a tracheostomy tube becomes blocked or comes out, an Emergency Plan is needed. It's recommended to have two back up tracheostomy tubes at bedside. These backup tubes should be readily available at all times . Review of the Registered Nurse (RN) Job Description, dated May 2014, read, . Summary of Position: The Registered Nurse (RN) Handles emergency situations in a prompt, precise, and professional manner . Modifies resident's/patient's treatment plans according to physician orders . Review of the Facility Assessment, update 12/01/2022, documented the facility is able to provide care and services for residents with CVA, paraplegia and tracheostomy. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified the survey team: * An Ad Hoc Quality Assurance and Performance Improvement meeting was held on 12/20/22 with Medical Director review and approval of the facility's Performance Improvement Plan related to tracheostomy care and services. * Staff education on Abuse, Neglect, and Exploitation Policy was conducted 12/07/22 - 12/17/22 by the Administrator, Director of Nursing and Unit Managers. The education included a post-test to validate competency and 100% of staff were educated with 100% passing grade. Validation was confirmed by signatures on Attendance Record. * Licensed nurses will be educated by the (Contracted Respiratory Therapy Company) Respiratory Therapist and/or designee and demonstrate competency per Tracheostomy Policy and Procedure and Standards of Practice with an emphasis on emergency replacement of a dislodged tracheostomy. * Nine licensed nurses had completed education and competency conducted by the Respiratory Therapist on 12/20/22. The education included: Tracheostomy Care Policy, Tracheostomy Tube Emergency Care Policy, Manual Resuscitators Policy, Tracheostomy Tube Site Care Policy and Procedure, Tracheostomy Suctioning Policy and Procedure, Tracheostomy Tube Removal Policy and Procedure, Monitoring the Tube and Care and a Clinical Competency Evaluation with pass/fail grade. * Interview with the Respiratory Therapist on 12/20/22 at 3 PM revealed all nine staff had completed the education program which included policy and procedures and a return demonstration with tracheostomy tube insertion. All nine nurse had passed. Review of the Attendance Record confirmed nine licensed nurse signatures and review of the Clinical Competency Evaluation revealed all nurses had passed. Interviews conducted on 12/20/22 at 3:25 PM to 12/20/22 at 3:33 PM with 2 RN's and 3 LPN's confirmed they were knowledgeable regarding the Tracheostomy Policy for requiring a replacement tracheostomy set at bedside for all residents with tracheostomy and reinsertion of a new sterile tracheostomy. Licensed staff will not be permitted to work prior to completing the facility tracheostomy education and competency program. Newly hired licensed nurses will be educated and demonstrate competency with tracheostomy Policy and Procedure and standards of practice with emphasis on emergency replacement of a dislodged tracheostomy during orientation. Validation confirmed by review of the licensed nurse orientation checklist which now included tracheostomy reinsertion and oxygen. Observation of resident #3 with tracheostomy on 12/17/22 at 3:30 PM, and on 12/20/22 at 11:07 AM, confirmed multiple size 6 tracheostomy sets in the top drawer of his nightstand. On 12/18/22 at 2 PM, an interview was conducted by telephone with resident #3's daughter who stated she visited daily and had no concerns related to his tracheostomy care and services.