**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, it was determined the facility failed to provide cardiopulmonary resuscitation (CPR) for a resident who had an order for full code (all resuscitation procedures will be provided to keep a person alive if their heart stops beating or they stop breathing) for 1 (Resident #1) of 5 residents reviewed for CPR. Specifically, Resident #1 had an order for full code and was found unresponsive, without a pulse or respirations, on [DATE] and staff did not provide CPR. This had the potential to affect 12 of 44 residents who resided in the facility and had elected full code. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The IJ began on [DATE] when CPR was not provided for Resident #1, who was a full code, when Resident #1 was found to be unresponsive. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Hospital Administrator were notified of the IJ and provided the IJ template on [DATE] at 10:05 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 12:03 PM. The surveyor performed onsite verification that the Removal Plan had been implemented. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. It was determined that the facility had completed implementation of the Removal Plan prior to the start of survey, and therefore, the IJ was considered past noncompliance. Findings included: Review of the facility's policy, titled, Code Blue, last revised in [DATE], indicated, Any signs of cardiac arrest or respiratory distress within The Retreat Nursing Home shall be treated according to the established standards of the American Heart Association except in those incidences where the physician has specific orders in place. Further review of the policy indicated, Procedure: The first person who responds shall assess the situation. If no pulse or respiration is found, initiate the first response procedures according to the American Heart Association BLS [Basic Life Support] guidelines. - Initiate CPR - Retreat [sic] over house page-CODE BLUE Rm # [room number] (Repeat Twice) - Activate the emergency alarm by removing the AED [automated external defibrillator] from the cabinet located [in] the central area of the facility. A review of Resident #1's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses that included congestive heart failure, type 2 diabetes mellitus, polyneuropathy, atherosclerotic heart disease, peripheral vascular disease, dysphagia, and seizures. The Face Sheet indicated the resident had an advance directive for full code. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated Resident #1 participated in the assessment. Review of physician's orders indicated that Resident #1 had an order, dated [DATE], that indicated, Advance Directive/Code Status: Full Code. A review of Resident #1's Care Plan, revised on [DATE], indicated the resident's advance directive status was Full Code. The approaches instructed staff to start cardiopulmonary resuscitation (CPR) should cardiac arrest occur and send the resident to the emergency department (call 911). Review of a death in facility MDS, dated [DATE], revealed Resident #1 was discharged due to death in the facility. Review of a Progress Note, dated [DATE] and written by Registered Nurse (RN) #3, revealed that at approximately 6:00 PM, a certified nurse aide (CNA) reported Resident #1 was unresponsive. The progress note indicated that RN #3 assessed Resident #1 and found no respirations, no pulse, the resident's skin was cool to touch, and there were no signs of life. The progress note indicated that RN #3 immediately called the hospital emergency room (ER) Doctor who came to the bedside to assess the resident. (Note that the hospital is located next to the facility.) According to progress note, the ER Doctor assessed Resident #1 and pronounced the resident deceased at 6:02 PM. RN #3 notified the Director of Nursing (DON) at 6:11 PM. The medical director and family member were also notified by phone. Resident #1's body was released to the funeral home at 8:45 PM. Review of Physician's Progress Notes, dated [DATE] at 6:02 PM and written by the ER Doctor, revealed he was called at 5:57 PM to assess Resident #1 due to staff indicating the resident had no vital signs and was not breathing. The progress note indicated on exam, pupils are fixed and dilated. No corneal reflex. No breath sounds and heart sounds heard on auscultation. Pt [Patient] pronounced dead at 1802 [6:02 PM] on [DATE]. Review of a written statement, dated [DATE] and written by CNA #1, revealed CNA #1 found Resident #1 unresponsive and called Licensed Practical Nurse (LPN) #2, who alerted RN #3. Review of a written statement, dated [DATE] and written by LPN #2, revealed that just before 5:35 PM, CNA #1 notified her that Resident #1 was not responding. The statement indicated that LPN #2 went to Resident #1's room, called the resident's name and tapped on their arm, but got no response. According to the statement, LPN #2 went to retrieve the crash cart, found RN #3 in the hallway, and told RN #3 they needed to call a code. LPN #2's statement indicated that RN #3 said Resident #1 was already gone and was cold. RN #3 then phoned the ER Doctor. The statement indicated that when the ER Doctor arrived, LPN #2 restated that Resident #1 was a full code and asked if CPR should be started, and the ER Doctor said not to start CPR because the resident was already gone. Review of a written statement, dated [DATE] at 7:35 PM and written by RN #3, indicated that when she phoned the ER Doctor regarding Resident #1, she notified him that Resident #1 was a full code and asked if CPR should be started, the ER Doctor replied that he would come to see the resident immediately. The note indicated that once the ER Doctor arrived and assessed Resident #1, he said not to initiate CPR. Review of the 5-day investigation report, dated [DATE], revealed that CNA #1 found Resident #1 unresponsive on [DATE] around 5:50 PM. CNA #1 called for LPN #2 who was at the nurses' station. LPN #2 went to Resident #1's room to assess the resident and determined Resident #1 was unresponsive. LPN #2 called RN #3, who was assigned to provide care for Resident #1. RN #3 arrived at Resident #1's room at 5:53 PM and found Resident #1 unresponsive with no pulse, no respirations, and no verbal response. RN #3 phoned the hospital ER Doctor who immediately arrived at Resident #1's room. The ER Doctor found no respirations and no pulse, and the resident's pupils were fixed. The ER Doctor pronounced Resident #1 deceased at 6:02 PM. The Director of Nursing and the Administrator were notified shortly thereafter. Resident #1 had elected and had an order for full code and CPR was not initiated. RN #3 received basic life support (BLS) recertification on [DATE] and LPN #2 received BLS recertification on [DATE]. Both nurses were suspended pending the investigation and ultimately terminated. During an interview on [DATE] at 9:20 AM, the Director of Nursing (DON) described the incident on [DATE] that involved Resident #1. The DON stated CNA #1 was picking up meal trays from resident rooms and found Resident #1 unresponsive. CNA #1 called for LPN #2, who was at the nurses' station. LPN #2 arrived at Resident #1's room and tried to rouse Resident #1. At this time, the nurse assigned to Resident #1, RN #3, arrived at the resident's room. RN #3 called the hospital ER Doctor. The ER Doctor arrived, checked vitals, and pronounced Resident #1 expired. At 6:10 PM, RN #3 notified the DON that Resident #1 had expired. The DON said that she asked RN #3 if CPR had been conducted and RN #3 stated that CPR had not been initiated because the ER Doctor had pronounced Resident #1 expired. The DON stated that when she asked the nurses why CPR was not started, they did not have a real reason. The DON stated all the nursing staff were up to date on CPR training because they had just renewed training in [DATE]. The DON stated the facility had been running mock codes since 2021, so she could not understand what happened when the staff found the resident unresponsive and did not call code blue or start CPR. During an interview on [DATE] at 11:45 AM, CNA #1 stated she saw Resident #1 around 4:00 PM on [DATE] when Resident #1 was going down the hall with CNA #4 to take a shower. Later, CNA #1 reported she was picking up meal trays. Resident #1's room was the last room. CNA #1 stated she entered the room and was talking to Resident #1's roommate. CNA #1 picked up the roommate's meal tray, placed it on the tray cart in the hallway outside the room, then went back into the room to retrieve Resident #1's tray. CNA #1 stated she was looking at the tray, not Resident #1, as she walked around the privacy curtain. When she asked Resident #1 if the resident was finished eating, Resident #1 did not respond to her question. CNA #1 looked at Resident #1, who was sitting up in bed with their eyes closed. CNA #1 stated she ran out of the room to find RN #3. She did not see RN #3, so she returned to the room and tried rousing Resident #1. When Resident #1 did not respond, CNA #1 went to get LPN #2 who was at the nurses' station. LPN #2 told CNA #1 to get a cold washcloth and the CNA went to the whirlpool room to get the washcloth. When CNA #1 returned to Resident #1's room with the cold washcloth, LPN #2 was coming out of the room and told CNA #1 that Resident #1 had fully coded. LPN #2 left to get RN #3 while CNA #1 stayed in the resident's room. CNA #1 recalled an activities assistant was also in the resident's room, and the activities assistant stated Resident #1 was gone. CNA #1 stated that LPN #2 tried to page for a full code, but LPN #2 did not know how to use the intercom system. RN #3 entered the resident's room and then made a motion indicating that Resident #1 was gone. CNA #1 stated she recalled seeing the crash cart in the room beside the bed. CNA #1 stated the ER Doctor then arrived, and she saw him signing a paper. CNA #1 stated she did not see LPN #2 or RN #3 assessing Resident #1 because she was not in the room at the time. During an interview on [DATE] at 12:30 PM, the Assistant Director of Nursing (ADON), who also served as the staff education coordinator, stated they kept a code status list and the signed advanced directives at the nurses' station. The code status list was also maintained in the automated external defibrillator (AED) case and on the crash cart. The individual resident code status was also posted on the resident's closet door. The ADON stated she was not involved in this incident but stated that when a resident was found unresponsive and was designated full code, a staff member should announce Code Blue over the intercom system to alert staff to perform CPR; the intercom system also notified the hospital next door. Staff would then immediately start CPR and continue performing CPR until relieved by hospital staff. During an interview on [DATE] at 1:00 PM, the ER Doctor stated he was called on the ER phone from the facility and was told the resident was unresponsive with no vital signs. He immediately walked over to the facility and into the resident's room. He estimated it took him two to three minutes to get there. When he arrived and assessed Resident #1, Resident #1 was cold to the touch, pupils were dilated and nonreactive, and there were no heart sounds. The ER Doctor stated in his assessment that it was too late to administer CPR. He stated that normally when he was called to the facility the nursing home staff had already initiated CPR if the resident was designated full code. During an interview on [DATE] at 4:50 PM, the Administrator stated that before the evening meal on [DATE], RN #3 went to the resident's room to administer medications for Resident #1, but CNA #4 was helping Resident #1 to get dressed, so RN #3 planned to return later for medication administration. The Administrator said that at 5:30 PM, RN #3 returned to Resident #1's room for medication administration. Resident #1 was eating, and RN #3 did not notice anything unusual. The Administrator stated that based on staff statements and camera footage, no one else entered the room until CNA #1 went into the room to pick up Resident #1's meal tray and found Resident #1 unresponsive. During an interview on [DATE] at 1:30 PM, CNA #4 stated she worked 3:00 PM to 11:00 PM on [DATE]. CNA #4 said she assisted Resident #1 to bathe right before the 5:00 PM meal and Resident #1 seemed their normal self. While she was assisting Resident #1 with dressing, she recalled that RN #3 entered the resident's room to administer medications and then indicated she would return after Resident #1 was dressed. After assisting Resident #1 to dress, CNA #4 went to the dining room to help assist other residents with the evening meal. CNA #4 stated it would have been around 5:00 PM when she left Resident #1's room. On [DATE] at 2:00 PM, RN #3 was interviewed regarding the incident on [DATE] involving Resident #1. RN #3 stated that when she arrived at Resident #1's room, she shook the resident and called their name, trying to rouse the resident. RN #3 stated she checked Resident #1's carotid and radial pulses and did a sternum rub. RN #3 stated Resident #1 was cool to the touch and had no rigidity when she was checking the resident's vital signs. RN #3 stated that after she assessed the resident, she went to the nurses' station, called the ER Doctor, and told him Resident #1 was a full code and was unresponsive. RN #3 stated she asked the ER Doctor if staff should start CPR, and the ER Doctor responded that he would be right there. RN #3 said when the ER Doctor arrived, he checked Resident #1's pupils with a light, listened to Resident #1's heart with a stethoscope, and pronounced Resident #1 dead. RN #3 reiterated that when she called the ER Doctor on the phone and told him that Resident #1 was a full code and unresponsive, she asked if staff should start CPR, and the ER Doctor said he would be right over to see the resident. RN #3 stated she asked the ER Doctor again in the resident's room if they should start CPR, and the ER Doctor said, No. RN #3 stated she was terminated by the facility. During an interview on [DATE] at 3:37 PM, Activities Assistant #9 stated she was present shortly after Resident #1 was found unresponsive. She said she was the staff member who opened the closet door to check Resident #1's status and saw the resident was a full code. She said she checked Resident #1's carotid pulse and there was no pulse, and Resident #1 was cold and pale. Activity Assistant #9 stated she was there when the ER Doctor arrived. She stated the nurses asked the ER Doctor if they should start CPR, and he assessed Resident #1 for vital signs and checked the resident's pupils and pronounced Resident #1 deceased . She believed it was about eight to nine minutes between the time she was made aware of the resident being unresponsive and the ER Doctor's assessment of Resident #1. Removal Plan The following IJ Removal Plan was provided by the facility and accepted by the State Survey Agency on [DATE] at 12:03 PM: 1. On [DATE] at approximately 5:50 PM, a certified nursing assistant (CNA) went in Resident #1's room to pick up a dinner tray and found the resident was not responsive. The CNA reported to the licensed practical nurse (LPN) at the nurses' station that the resident was not responding. The LPN went to the resident's room to assess. After finding the resident unresponsive, the LPN notified the registered nurse (RN) assigned to the resident. The RN went into the resident's room at 5:53 PM and found the resident unresponsive with no pulse, no respirations, and no verbal response. The RN phoned the emergency room (ER) doctor at hospital who immediately came to the resident's room. The doctor found no respirations, no pulse, and pupils were fixed and dilated. The doctor pronounced the resident deceased at 6:02 PM. 2. The Director of Nursing (DON) and Administrator responded immediately to the facility. After interviews with staff, the DON immediately began re-education with staff on the date of the incident, [DATE], to include the code blue policy and procedure, location of resident's code status, call a code, and utilization of the overhead paging system. The facility conducted an ad hoc meeting to discuss the event on the evening of [DATE]. All licensed nurses and certified nursing assistants on duty attended, which included the two nurses involved in the incident. The two nurses involved were immediately removed from the schedule on [DATE] and subsequently terminated on [DATE]. 3. On [DATE], the DON and Assistant Director of Nursing (ADON) began code blue in-services for licensed nurses and certified nursing assistants which included what to do if a staff member finds a resident with signs of cardiac arrest or respiratory distress. The first person who responds shall assess the situation. If no pulse or respirations is found, immediately check resident's code status. If the resident is a full code, initiate CPR. CPR can be initiated by a RN or LPN, with a BLS certification. The nurse does not wait for the physician before initiating CPR. The staff is also trained on irreversible signs of death as outlined in our Code Blue policy. As of [DATE], there was a total of 24 full time licensed nurses and certified nursing assistants available for work. As of [DATE], 95.8% of full-time licensed nurses and certified nursing assistants received training. This included 5 of 5 registered nurses, 7 of 7 licensed practical nurses, and 11 of 12 certified nursing assistants. The remaining PRN (as needed) staff who have not received training will be re-educated prior to the next scheduled shift. Any licensed nurse or CNA (including agency staff) not receiving the code status education due to scheduled time off or FMLA (Family and Medical Leave Act) will be in-serviced prior to their next scheduled shift. New hire nurses and CNAs will be educated on the 1st shift of orientation. Prior to [DATE], code blue education with the mock codes were provided monthly by the ADON. 4. All staff have current Basic Life Support Certifications (BLS) on file. As of [DATE], 100% of licensed nurses and CNAs, which included 12 of 12 RNs, 10 of 10 LPNs, and 23 of 23 certified nursing assistants have BLS certification. In [DATE] and [DATE], we conducted on-site American Heart Association (AHA) BLS training by an AHA BLS instructor. 5. A mock code blue was conducted on [DATE]. Prior to the [DATE] incident, mock code blues were conducted monthly by the ADON. 6. On [DATE], the DON, following the Mortality Review Policy and Procedure, completed the mortality review form with the interdisciplinary team The Mortality Review is when the team provides a forum to identify adverse patient outcomes and their contributing factors, openly discuss the situation and disseminate information learned from the review to maximize patient safety. The team includes the Medical Director, DON, and three administrative nurses. 7. A root cause analysis was started on [DATE] and completed on [DATE]. This meeting was held as an executive session under the QAPI [quality assurance performance improvement] meeting. The following were involved: the DON, Retreat Administrator, [NAME] Health Services Administrator, [NAME] Health Services Assistant Administrator, ADON, MDS/Care Plan Coordinator and the Medical Director. The outcome was a failure of the staff to initiate basic life support and call a code, complying with established and policy and procedure. During the interviews, the LPN could not provide a reason, even though she admitted she knew to start CPR. The RN stated the resident was gone and it was too late. Follow up interviews did not identify changes in their statements. 8. Code status audits have been completed monthly and will continue monthly by the ADON and the MDS/Care Plan Coordinator. The DON, Administrator or designee will provide oversight. Code Status audits are done monthly and include verification that the resident code status is on the electronic health record (EHR) banner, on the code status list in the crash cart, on the signed documents scanned into the EHR, on the signed documents in the resident information notebooks at the nurse's station, in the resident's orders, in the resident care plan and posted on the sign in the resident's closet. It includes verification that code status is correct and matches in all these locations. The last Code Status audit was done [DATE]. 9. The Administrator or DON will conduct oversight of the education and the audits daily until 100% of licensed nurses and certified nursing assistants receive the training which started on [DATE]. Additional training includes education on the code blue policy using scenarios with participants performing return demonstration of basic life support measures following facility policy and procedure. This training is provided by the ADON. As part of this education, a code blue documentation form is completed during the mock code to record the real time events performed, which allows for immediate feedback and correction of participants. Following the mock codes, participants complete a participant self-evaluation. In addition, on-site basic life support courses are provided. 10. All corrective actions will be completed on [DATE]. 11. The immediacy of the IJ was removed on [DATE]. Onsite Verification of Removal Plan Onsite verification of the Removal Plan was completed on [DATE] and [DATE]. In an interview on [DATE] at 9:45 AM, the Administrator stated that as part of their 5-day investigation and plan of correction, they reeducated all CNAs and nurses, conducted mock codes, educated staff on how to use the paging system, audited the code status list, and audited the staff CPR training. Resident code status was posted inside each resident's closet door, a full list of residents and their code status was kept on the crash cart and inside the AED case, and a full list of residents and their code status was kept at the nurses' station. Code status was also in the electronic medical record. The surveyor verified this was completed during the survey. In an interview on [DATE] at 12:30 PM, the Assistant Director of Nursing (ADON) stated they kept a code status list and the signed advanced directives at the nurses' station. The code status list was also maintained in the AED case and on the crash cart. The ADON stated that all staff were in-serviced on use of the intercom system; where to find code status, the crash cart, and the AED; and all staff were provided training on the procedures for immediately initiating CPR. The instructions for using the intercom were also placed near the phone. The surveyor verified this was completed during the survey. Review of the code blue in-service log provided by the DON on [DATE] revealed 31 of 45 total facility staff had received re-in servicing. Three of the 45 staff were on medical leave and seven staff were scheduled to work in the next few days and were currently being in-serviced by phone before their next shift. Of the 45 staff, there were four as needed staff who were not scheduled to work in the near future. On [DATE] mock code blue training exercises were conducted. During an interview on [DATE] at 9:20 AM, the DON stated all the nursing staff were up to date on CPR training because they had just renewed training in [DATE]. BLS certification was verified for 100% of direct care staff. Staff interviews were conducted to verify that training occurred. The interviews included the following: - During an interview on [DATE] at 11:45 AM, CNA #1 stated that on [DATE] following the incident, she underwent training on how to use the intercom, the procedures for code blue, where to find resident code status, and where to find the crash carts. - During an interview on [DATE] at 1:22 PM, RN #11 stated she was provided training the week before the survey on how to call a code blue; the location of the crash cart, AED, and resident code status lists; and the procedure for initiating CPR immediately. - During an interview on [DATE] at 3:00 PM, LPN #6 stated she received CPR and code blue training, but it was not on [DATE]; it was a day or so later, because she had not worked on [DATE]. She explained where to find the code status posted in resident closets, identified the location of the crash cart, and stated she was trained on using the intercom system to call code blue. She verbalized that CPR was to be initiated as soon as possible. - During an interview on [DATE] at 3:17 PM, CNA #7 stated she was re-in serviced on where to find code status, code blue procedures, and how to call a code blue on the intercom system. CNA #7 stated she felt confident responding to an unresponsive resident. - During an interview on [DATE] at 3:25 PM, CNA #8 stated she had received training the week before the survey on code blue procedures. Training included the importance of starting CPR immediately, where to locate code status (closet, chart, nurses station, and crash cart) and where the crash cart was located. - During an interview on [DATE] at 8:15 AM, Activities Assistant #10 stated she received training about responding to a code blue and understood how to use the intercom system and where to find code status for residents. - During an interview on [DATE] at 12:36 PM, RN #12, who worked as needed, stated she received re-in servicing prior to her shift. She said the training included the location of resident code status lists and crash cart, and code blue policies/procedures including how to call a code blue. RN #12 stated she was instructed to initiate CPR immediately and not stop until back up arrived. - During an interview on [DATE] at 4:00 PM, LPN #15, who worked full time, stated she received code blue training last week right after the incident with Resident #1. She was able to describe where to locate resident code status, crash carts and the AED, and stated she was instructed to start CPR immediately and not wait. - During an interview on [DATE] at 4:10 PM, CNA #16 stated she received training the week before the survey. CNA #16 knew the location of the crash cart and resident code status, could explain the CPR process, and knew that she was responsible for initiating CPR right away. During an observation on [DATE] at 4:38 PM, a mock code blue exercise was in progress. Staff participated in calling and responding to the code and administering BLS measures and CPR. Feedback was provided following the mock code and staff completed self-assessments. Two emergency room staff arrived in response to the mock code blue. It was verified that the Mortality Review was completed on [DATE] and the root cause analysis was completed as part of a QAPI meeting with executive personnel on [DATE]. The code status audit conducted by the ADON, dated [DATE], was reviewed and verified. Identification of code status and posting for sampled residents was reviewed and verified. Administrative oversight of the above measures was reviewed and verified. In an interview on [DATE] at 10:30 AM, the Administrator stated that in terms of the Removal Plan, if the ADON was not available to complete code list audits and update the code list, the MDS Nurse was responsible for ensuring the code list and audits were done. If the DON was not available to provide staff education regarding code blue policy/procedures, then the ADON ensured the training was done prior to a staff member's shift. Regarding mock codes, the Administrator stated if a staff person or group of staff performed subpar or voiced they had concerns on the self-evaluation, then staff were retrained. All corrective action was completed on [DATE]. The IJ was removed on [DATE].