**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow policy and procedure related to Full Code status leading to a delay in initiating Cardiopulmonary Resuscitation (CPR) for 1 of 5 residents reviewed for Advance Directives of a total sample of 68 residents, (#100). Resident #100 a-[AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included anemia, type II diabetes, occlusion and stenosis of the carotid artery. The resident was admitted to Hospice services on [DATE] with diagnosis of moderate protein-calorie malnutrition. The resident's physician's order dated [DATE] noted full resuscitation. Progress note dated [DATE] at 6:30 AM, documented by Licensed Practical Nurse (LPN) A read, Patient has expired Hospice notified MD (Medical Doctor) notified. Resident #100 died at the hospital on [DATE]. The facility's failure to provide CPR in a timely manner as per resident #100's wishes and physician's order placed all residents in the facility at risk, and could lead to potential injury/impairment or death if code status is not identified and addressed immediately in an emergent situation. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross Reference F609 Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact with a Brief Interview For Mental Status score of 13 out of 15. The resident's physician's order dated [DATE] noted his code status to be Full Resuscitation. Orders entered by LPN A on [DATE] at 6:29 AM, noted two contradictory orders, one for Full Resuscitation, and another for Do Not Resuscitate (DNR). A progress note dated [DATE] read, Advance care plan meeting held discussed code status wishes. Resident chooses to remain a full code at this time . hospice is caring for resident at this time for palliative comfort care. The Hospice Certification and Plan of Care with certification period [DATE] to [DATE] revealed his hospice diagnosis was moderate protein-calorie Malnutrition. Review of hospice orders for Advance Directive on [DATE] read, Do Not Resuscitate, and a different order dated two days later on [DATE] noted Resuscitate. Review of Hospice Note Reports dated [DATE], and [DATE] revealed the resident's code status was Full code. A progress note documented by LPN A, dated [DATE] at 6:29 AM, read, Patient has expired Hospice notified, MD notified. On [DATE] at 5:25 PM, the 200 Wing Registered Nurse/Unit Manager (RN/UM) stated he recalled resident #100 was on hospice services and had a full code status. He stated he was not at the facility when the resident coded but heard there may have been some confusion by hospice whether the resident was a DNR or full code. The resident's clinical records were reviewed with the RN/UM and he acknowledged the only documentation pertaining to the resident's change in condition was on [DATE] at 6:29 AM, that indicated the resident expired. The RN/UM stated the normal process when a resident passed was for staff to call the Director of Nursing (DON) who would instruct the staff on what to do. He said the facility's protocol for code status was to go by what was in the resident's medical record. On [DATE] at 5:43 PM, an interview was conducted with the DON, and the Regional Consultant Risk Management Specialist. The DON explained the facility's process regarding advance directives. She stated on admission if the resident was alert and oriented, staff would verify the resident's wishes for advanced directives, notify the physician, and place a physician order in the facility's electronic medical record (EMR). If the resident was not alert and oriented, code status would be confirmed with the responsible party. She explained the order for code status would be entered in the EMR, printed and placed at the front of the resident's physical chart. The DON said if a resident was found unresponsive, the nurse should verify the resident's code status in the physical chart, and the physician order in the EMR. She noted the code status orders were usually verified by two nurses. She explained if the resident was without pulse and respiration and was a Full Code, CPR should be initiated immediately. The DON described a code worksheet on the crash cart, that directed staff to record the time the resident was found without unresponsive, the time 911 was called, and who initiated CPR. The code worksheet included staff who assisted in CPR, 911 response time, and the time 911 assumed care of the resident. She said the code worksheet was a tool to guide documentation for the resident's clinical record. The DON and the Regional Consultant Risk Management Specialist reviewed the resident's physician's order, and progress note, and stated documentation on [DATE] at 6:29 AM, indicated the resident expired, and the physician and hospice services were notified. They acknowledged there was no other documentation other than the resident expired and notifications made. The DON stated a DNR order was initiated for the resident on [DATE] at 6:29 AM, discontinued at 8:44 AM, and a Full code order was initiated at 6:45 AM after resident 100 had expired. She said the following day, post code, the Interdisciplinary Team (IDT) usually reviewed code status and identified who initiated CPR. She stated she would have questioned the DNR, and Full Code orders both entered on [DATE]. On [DATE] at 6:13 PM, in a telephone interview, LPN A stated she worked at the facility full-time for six months on the 11 PM to 7 AM shift. She confirmed she was resident #100's primary nurse on [DATE], and noted the resident was very sick. LPN A recalled on [DATE] to [DATE] on the 11 PM to 7 AM shift, she did rounds between 12 AM to 1 AM, and at that time resident #100 was okay. She recalled Certified Nursing Assistant (CNA) B provided hygiene care for the resident, and when CNA B did her last round at about 5:30 AM, the resident was unresponsive. LPN A explained when she went into the resident's room, the resident appeared to have expired, he had no pulse, and was not breathing. The LPN said the resident was a full code, but in the hospice chart he had a DNR order. She recalled she called the hospice service, and was told the resident was a DNR. She remembered the hospice nurse on call was not familiar with the resident, and by the time she called back to say the resident was a full code, she had already verified the resident was a full code. LPN A said she called the physician to verify the resident's code status, reached out to the former DON, and she verified the resident had rescinded his DNR, and was a full code. She said CPR was initiated immediately after the resident's code status was confirmed by the physician. The LPN noted the facility had a CPR log, and information was documented on the log which was given to the former DON. On [DATE] at 6:42 PM, the DON and Administrator stated an investigation was initiated by the former Administrator and DON. They shared the former Administrator put together a file with timeline on the Code Blue, and included statements from LPN A, and CNA C. There were no statements obtained from other nurses on shift, or from CNA B who initially found the resident unresponsive. They shared the Code Blue Worksheet dated [DATE] identified the resident was found unresponsive at 6:15 AM by CNA B. The worksheet timeline indicated the Emergency Code cart arrived at the resident's room at 6:17 AM. LPN A checked the resident's chart for code status at 6:17 AM, initiated CPR and called 911 at 6:17 AM. The Worksheet indicated Emergency Medical Service (EMS) arrived at 6:27 AM. They acknowledged statements were obtained on [DATE] from LPN A, CNA C, and the Director of Rehabilitation, but not from CNA B. Review of the Code Blue Worksheet revealed staff involved in the code were LPN A, CNA B, and CNA C. On [DATE] at 11:28 AM, an interview was conducted with the Regional Nurse Consultant, DON, Regional Risk Management Specialist, Regional [NAME] President (VP) of Operations, and Administrator. The DON stated the facility called all parties involved in the code, and staff present at the time of the incident. The Administrator stated LPN A had called 911 from her personal phone and completed a post event report. The Administrator said LPN A identified resident #100 was found unresponsive on [DATE] at 6:15 AM. The resident's chart and crash cart were bought to the resident's room at 6:17 AM. The Administrator said a statement was obtained from CNA B the resident's assigned CNA on [DATE] during the survey. She verbalized that during the interview with CNA B, the CNA voiced that she spoke with the DON after the event but was not asked to write a statement. On [DATE] at 11:28 AM, the conflicting information from interviews and the Code Blue Worksheet timeline as to when the resident was found unresponsive was discussed with the Administrator and DON. They did not have a response, and stated the facility's Corporate staff reviewed the previous Administrator and DON's investigation after the event. The Administrator provided documentation of the interview conducted with CNA B on [DATE] that revealed the CNA found resident #100 unresponsive at approximately 2:30 AM to 3 AM which contradicted previous interviews with Administration and the Code Blue Worksheets which noted the resident was found unresponsive at 6:15 AM. The Administrator stated the facility had statements to refute the CNA's statement. The Administrator stated LPN F worked on the 300 Wing on [DATE], and in her statement obtained yesterday on [DATE], LPN F stated that on [DATE], the ambulance left the facility at approximately 6:30 AM to 7:00 AM. The Administrator said at the time resident #100 was found unresponsive, his code status in the facility's EMR was Full Code, and she was not aware of any DNR order in the hospice binder for the resident. She stated the facility follows the orders in the EMR. The Regional Nurse Consultant stated that based on the resident's physician's order, the resident was a full code from [DATE] and had never had a DNR order in place. She verbalized that based on new statement given today by LPN A, the LPN had looked in the resident's hospice binder that morning and the resident was a DNR. However, the facility could not identify any DNR order in the closed clinical records for resident #100. Review of statements obtained by the current Administrator between [DATE], and [DATE], revealed LPN A reported she was made aware resident #100 was unresponsive around 5 AM to 6 AM. She checked the electronic record for the resident's code status, called a code and started CPR by herself for approximately ten minutes. CNA B's statement indicated the resident was found unresponsive by the CNA between 2:30 AM and 3 AM. The typed statement read, Told (LPN A's name) he wasn't breathing. She checked the computer and she said he was a DNR. She called the hospice and they confirmed he was a DNR. Then about an hour later hospice called back and said he was a full code, so she went back to the room and started doing CPR. Review of the transcript of the call from the facility to hospice on [DATE] revealed the following: 6:09 AM call comes into triage with report patient expired at 6: 00 AM. LPN A We went into patients' room; he is not breathing. We are starting CPR and sending him out. He is still a full code. Triage RN: He is still a full code? LPN A I believe he is a full code unless you have something different 6:15 AM Triage RN returns to state will need to get access to the chart will follow up with a call and will be making a visit with appropriate paperwork if it is there. LPN A Well I do not have an actual DNR, but I am looking at his hospice book you guys give and under the Medicare thing (the election of benefit) it says, 'I request no cardiopulmonary resuscitative measures at the time of my death'. I mean he is gone at this point so there is nothing I can do anyway. I just need to know whether he is a full DNR or not. 6:23 AM hospice nurse calls LPN A stating she sees a DNR, but LPN A says, our records state full code. The hospice nurse let her know she was on the way to the facility to make a visit and told LPN A if you know if your records show full code, then continue to do CPR and call 911. 6:34 AM hospice nurse called LPN A back to confirm patient was in fact a full code which confirms what LPN A stated at 6:09 AM Review of the report from Emergency Medical Services (EMS) provided by the Administrator revealed EMS arrived at the hospital from the facility on [DATE] at 7:09 AM. On [DATE] at 1:47 PM, the Corporate Director of Risk Management (RM) stated she was made aware by the facility there was a code blue on [DATE]. She said CPR was performed after the code status was identified, and in the middle of the code when hospice was made aware, hospice reported they had record of the resident being a DNR but instructed the nurse to follow physician orders on file. The nurse, LPN A, called the DON during the code, and the DON reassured her that once CPR was started, CPR could not be stopped. Later hospice called back and verbalized they made a mistake, and the resident's code status was not DNR, he was a full code. EMS arrived and assumed care for the resident, he was transferred to the hospital, and passed away. The RM said she provided guidance to facility leadership to investigate the event, interview all staff present, and validate there was no pause in CPR. She recalled she reviewed some statements, and there were no concerns, CPR continued until EMS arrived. The RM said the facility was concerned hospice had an incorrect order for the resident's code status that could have resulted in a potential negative effect. She recalled she had a follow-up phone call within the week of the event with the Administrator, and there were no additional concerns. She stated it was her understanding the facility did a thorough investigation. The RM said the statement obtained from CNA B on [DATE] had errors in the timeline, as evidenced by the resident's clinical condition when he arrived to the emergency room (ER). She said the statement from the assigned LPN A indicated she was made aware of the resident's condition at 6:15 AM. The RM explained the statements, code blue timeline, and verbal interviews were used to determine the timeline of the event was correct. She acknowledged there were conflicts between the statements obtained, interviews, and the timeline on the Code Blue Worksheet. She stated review of the progress note documented on [DATE] at 6:29 AM, indicated the resident expired, but the resident expired in the hospital. The RM said the hospital had documentation that conflicted with the facility's documentation, and the review left her with questions. On [DATE] at 3:41 PM, the RM provided the Fire Rescue Patient Care Record dated [DATE]. Documentation on the EMS Patient Care Record-Admin/Hospital form indicated the initial call from the facility was received by EMS on [DATE] at 7:35 AM. The report revealed EMS arrived to the facility a few minutes later at 6:41 AM and arrived to the resident at 6:48 AM. The report read, Rehab staff relates pt (patient) was last seen normal @-1:00 AM during medication administration with no issue noted at that time. Staff relates coming in @-6:30 AM to find pt unresponsive, pulseless, apneic. Staff relates delay in initiating CPR over confusion involving pt's DNR- staff initially believed DNR was current, however realized shortly after that DNR was rescinded by pt. Staff relates CPR was initiated ~ 5-10 mins PTA [Prior to arrival] of EMS. The emergency room Record dated [DATE] revealed, Patient was found last seen around 2 AM found unresponsive and asystole [heart not beating] no bystander CPR. Documentation indicated the time of death was 7:13 AM. Information from EMS, and the ER conflicted with the statements obtained from LPN A, CNA B, the Code Blue Worksheet timeline, and the Triage call to the hospice. The EMS record indicated CPR was provided by facility staff approximately 5 to 10 minutes prior to their arrival on scene at 6:48 AM. This would indicate CPR was initiated by facility staff at approximately 6:30 to 6:35 AM and not at 6:17 AM, as documented on the Code Blue worksheet. This was acknowledged by the RM. On [DATE] at 4:40 PM, CNA B stated she had worked at the facility for four years, on the 3 PM to 11 PM shifts, and on the 11 PM to 7 AM shifts, twice weekly. She confirmed she worked on the 11 PM to 7 AM shift on [DATE] through [DATE], and resident #100 was in her assignment. CNA B recalled she checked on the resident between 2:30 AM to 3 AM, found him unresponsive, and immediately alerted LPN A. She recalled LPN A went to the computer to check the resident's code status, and said the resident was DNR. The LPN checked the book, CNA B said she was not sure of which book, and LPN A said it showed DNR. CNA B related CPR was not initiated at that time. CNA B said LPN A instead called hospice, and was told resident #100 was a DNR. She related hospice called back about one hour later and said the resident was a full code, so LPN A then went into the room and started CPR. CNA B stated LPN A performed compressions until EMS arrived and took over. The CNA stated LPN A called 911 before she initiated CPR, and thought CPR was started somewhere between 3:30 AM to 4 AM. She said she would not forget this event, because it was her first death. CNA B stated the Code Blue Worksheet timeline was inaccurate, and the resident was not found unresponsive at 6:15 AM, as documented. She stated her statement was obtained yesterday on [DATE] when the Administrator called her. On [DATE] at 11:44 AM, another interview was conducted with the Regional Nurse Consultant, DON, Regional Risk Management Specialist, Regional VP of Operations, Corporate Director of RM, and the Administrator. The RM stated the facility identified the need for additional investigation, because of the discrepancies identified on the Code Blue worksheet, the documentation in the resident's EMR, the hospital records, and the EMS run report. When asked if CPR was provided timely, or delayed, the RM stated documentation from the hospice triage call indicated LPN A called at 6:09 AM to notify the resident expired at 6:00 AM. She said in the event report 6:00 AM was when the resident expired as per documentation and if 6:09 AM was when CPR was started, it would indicate a nine-minute delay. The RM stated staff were taught to follow physician orders in the EMR regarding code status, not to look at the hospice book. She stated after they received the EMS report, it confirmed the Code Blue Worksheet was not accurate. The RM said the EMS run report showed they arrived at the facility on [DATE] at 6:35 AM, and it appears there may have been a delay in providing CPR based on the EMS run report. (This statement of the EMS arrival time was found to be inaccurate per the EMS record, which indicated 911 call to EMS was at 6:35, with actual arrival time on scene at 6:41 AM.) On [DATE] at 3:12 PM, the Medical Director stated he was not aware of the concern with the discrepancy in code status for resident #100 until today ([DATE]). He stated proper documentation of code status should be in the resident's chart, and if there was no documentation, the resident remained as a full code. He stated the education to the nurse was lacking, and the facility needed to review and put some education in place. The Medical Director said some of the new nurses believed if a resident received hospice services, then the resident would be DNR, which was not always the case. He stated he was not the physician LPN A was reported to have called. He explained it would take the nurse approximately 15 minutes to complete a call to the physician in his opinion. The potential delay in providing CPR to resident #100 was discussed with the Medical Director. He said the facility did not have an AD Hoc Quality Assurance Performance Improvement meeting for this incident. Essential duties and responsibilities listed on the Job description for Licensed Practical Nurse with date of [DATE] included, Handles emergency situations in a prompt, precise, and professional manner. Perform CPR as required .Maintains accurate, detailed reports and records. The policy CPR Code Status Orders & Response updated February 2023, revealed the procedure for initiating CPR directed that Code Status and resident will be verified by 2 identifiers .with another nursing care center personnel, if resident is a full code CPR will be initiated. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: *[DATE] CPR was initiated for resident #100 and resident was transferred from the facility with a rhythm via EMS and passed away at the hospital. *[DATE] Assistant DON initiated staff education on Code Status Orders and Response Policy and Procedure to include procedure for initiating CPR and documentation of the event. 31 out of 31 licensed nurses were educated as of [DATE]. Re-education was initiated for licensed nursing clinical staff to be completed [DATE]. *[DATE] Facility audit of 100 out of 100 residents advance directives was completed, to confirm accuracy of code status present in the front of the medical records and that it matched the physician's orders in the EMR. *[DATE] additional audit of 21 out of 21 residents receiving hospice services conducted to confirm code status of record with hospice matches the facility's record. The hospice chart stored at the facility was combined with the facility's hard chart, removing individual hospice binders. *[DATE] the Regional [NAME] President provided education to the Administrator and Interim DON on their essential core functions and the code of conduct. *[DATE] the Risk Management Consultant provided education to the Administrator and DON on the Abuse Prevention Program and conducting through investigations. *A total of 9 Code Blue Drills has been completed since [DATE] covering all shifts in order to ensure staff are knowledgeable and prepared to accurately verify resident code status in an emergency and ensure staff provide CPR in a timely manner. *[DATE] Ad Hoc Quality Assurance and Compliance committee reviewed removal plan. Review of the in-service attendance sheets revealed evidence to reflect staff participation in education on CPR & Advance Directives. Between [DATE] and [DATE], interviews were conducted with 4 RNs, 4 LPNs, and 3 CNAs. They all verbalized understanding of the education provided. Interviews, and record reviews revealed no concerns for residents #1, #11, #25 and #87 related to Advance Directives and code status.