**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to initiate CPR (Cardiopulmonary Resuscitation) for a resident (R2) with full code status. The facility also failed to have a system in place to ensure that Advance Directives were accurate and complete (R1, R5, R11, R12). These failures resulted in R2 not receiving CPR as desired; and R1 being sent to the hospital, intubated, and later compassionately extubated at the hospital. These failures have the potential to affect all 22 residents residing in the facility. Findings include: These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE] when the facility failed to initiate CPR for R2. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:45 AM. The surveyor confirmed by observation, record review, and interview that the immediacy was removed on [DATE]. Although the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level II because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including the in-servicing of staff, the completion/accuracy of all resident Advance Directives, review of policies and Quality Assurance monitoring. The [DATE] Facility Data Sheet showed 22 residents reside at the facility. 1. R2's Face Sheet dated [DATE] identified R2 as a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include Rhabdomyolysis and DVT (Deep Vein Thrombosis). The Department of Public Health Practitioner Ordered for Life Sustaining Treatment Form (POLST), completed [DATE], documents R2 as a full code. R2's Nursing Notes dated [DATE], completed by V6 (Agency Registered Nurse), document, Received report from night nurse at 7:35 AM that resident expired in bed at 7:10 AM. Verified death at 7:45 AM, no respirations, no pulse, no BP (blood pressure). Notified MD (physician) of resident death that resident expired at 7:50 AM. On [DATE] at 12:48 PM, V8 (Certified Nursing Assistant) stated around 6 AM on [DATE] she observed R2 in her bed without any concerns, asleep and breathing. V8 stated sometime shortly after 7 AM she went back into R2's room and she noted R2 was not breathing. V8 stated R2 was newly admitted , and she was not aware of her code status, so she immediately alerted V7 (Agency Licensed Practical Nurse), also requesting V7 to check the code status. V8 stated V7 responded to the room, assessed R2, but did not start cardiopulmonary resuscitation (CPR) so she assumed R2 was a DNR. On [DATE] at 11:52 AM, V6 (Agency Nurse) stated, when she arrived to begin her shift on [DATE], V7 (Agency Nurse) reported to her that R2 had expired at 7:10 AM. On [DATE] 10:59 AM, V3 (Medical Director) stated he had reviewed R2's history and confirmed R2 was a [AGE] year-old with no apparent prior significant medical history, a full code status, and was living at home independently prior to her [DATE] hospitalization for DVT (Deep Vein Thrombosis) and Rhabdomyolysis. V3 stated he was aware an agency nurse failed to code R2 when she was found expired in bed on [DATE] and he expects them to initiate CPR if they are a full code status as she was. The facility's code blue policy dated 01/2023 documents, The Procedure: Cardiopulmonary Resuscitation (CPR) and Code Blue policy documents if an individual is found unresponsive and not breathing the staff member who is certified in CPR shall initiate CPR. The chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. The facility Serious Injury and Communicable Disease Report dated [DATE] documents at 7AM R2 was found unresponsive and not breathing. The investigation determined R2 was a full code status and CPR was not administered. 2. R1's Face Sheet dated [DATE] documents R1 as a [AGE] year-old admitted to the facility on this date at 9:42 PM with diagnoses to include herpes viral disease. R1's emergency contact is listed as V9 (R1's Daughter). R1's [DATE] Physician Ordered Sheet shows R1 with a Do Not Resuscitate Order (DNR/do no attempt CPR) dated [DATE]. On [DATE] at 9:20 AM, V4 (Registered Nurse Manager) stated on [DATE] she provided R1 medications at approximately 8:30 AM and R1 was talking and had no identified change. Approximately an hour later R1 was not responding but was breathing and had a pulse; 911 was called. During this event V4 was unable to locate R1's POLST form but there was a physician order in the electronic medical record (EMR) indicating R1 was a DNR. V4 stated without the POLST form the resident is always a full code and considered without advanced directives so the DNR order was not honored. V4 contacted R1's family who stated R1 was a DNR. A final Serious Injury and Communicable Disease Form dated [DATE] documents R1 was found unresponsive but was breathing and had a pulse. This form documents a POLST form could not be located and V9 (R1's Power of Attorney/POA) was contacted and confirmed R1's code status as no intubation or CPR; R1 was transferred to the hospital due to not having a POLST form. R1 was intubated at the hospital where she expired later that day. The facility investigation identified the POLST form had not been completed after admission on [DATE]. R1's Initial Emergency Department (ED) History and Physical dated [DATE] at 10:22 AM documents R1 with respiratory arrest and arriving in the emergency room biting at her intubation tube which was placed by emergency medical personnel prior to arriving to the ED. This report shows R1 was found with bradycardia (slow heart rate) and liver shock. R1's ED Triage Notes [DATE] at 10:13 AM show R1 arrived in the ED in respiratory distress, breathing over the intubation tube and fighting the placement of the tube. R1's Social Service/Case Manager Note, dated [DATE] at 12:27 PM, completed by V10 (Hospital Social Worker), documents V9 as R1's POA. This note documents V9 reporting to V10 on the phone, a DNR had been done previously at another hospital, but it was unsigned by the physician (invalid). V9 stated R1 was not supposed to be intubated. V10 made V9 aware that R1 was currently intubated, and V9 stated no treatment was to be discontinued until V9 arrived at the hospital to assess R1. V9 provided V10 with direction to include R1 was not to receive CPR and was to be provided comfort treatment only. V10 initiated the DNR per V9's wishes, had the physician sign and the advanced directive was implemented after the phone conversation. The ED Note [DATE] at 3:40 PM documents V9 agreed R1 could be extubated under comfort measures. The ED Notes Addendum [DATE] at 4:47 PM documents R1 expired at 4:38 PM. On [DATE] at 10:27 AM, V5 (Social Service Director) states upon admission the admitting nurse is to clarify advance directive status and V5 then additionally meets with resident and/or family to verify and discuss their advanced directive wishes. V5 stated R1 arrived at the facility on [DATE] late in the evening and V5 was busy on 10/26-27/2023 and unable to find time to meet with R1 and/or family to review R1's advanced directive status. V5 stated it is facility policy that all residents are a full code until a completed, signed POLST form is received. On [DATE] 10:45 AM, V5 further stated, advanced directives are completed within the first 24 hours except weekends, in which V5 then follows-up on the following Monday. V5 stated she is responsible to follow up with the resident's physician to obtain a signature to activate the POLST form. V5 verified on weekends no staff are available at the facility to finalize advanced directives. V5 stated she educates the resident and family at the time of completion of the POLST that it will not be in effect until the physician signs. [DATE] at 10:59 AM, V3 (Medical Director) stated he was aware R1 was admitted to the facility on [DATE] and her advanced directives were not obtained timely after her admission. V3 stated on [DATE] R1 was noted unresponsive, and the facility did not have her POLST form showing her as a DNR. V3 stated when the facility called him, he instructed them to send R1 to the emergency department (ED) and R1 was intubated. V3 stated he spoke with R1's family at the hospital and they were upset she had been intubated. V3 stated after further discussions in the ED, R1's family decided to extubate her where she passed away shortly after. V3 confirmed that the facility should have advanced directives put in place timely so R1's wishes (DNR) could have been addressed at the time she had a change in condition. V3 stated, Yes, she would have had a more peaceful death had she remained at the facility as a DNR status. V3 confirmed if her advanced directives had been in place R1 would not have experienced the trauma from insertion of the intubation tube, hospital transfer, and unnecessary treatments. 3. R11's Face Sheet dated [DATE] documents R11 admitted on this date. On [DATE] at 11:20 AM R11 stated, Today is the first time they (advanced directives) were discussed. R11's POLST form dated and signed by V3 on [DATE] shows R11 requests no intubation or mechanical ventilation. R11's BIMS dated [DATE] documents R11 as cognitively intact. 4. R5's Face Sheet dated [DATE] documents R5 admitted on this date. On [DATE] at 11:30 AM, R5 stated she has a POLST form completed through a lawyer years ago and requesting no intubation. R5's POLST form dated [DATE] shows R5 requests all treatment, including intubation. R5's BIMS dated [DATE] documents R5 as cognitively intact. 5. R12's Face Sheet dated [DATE] documents R12 admitted on this date. R12's POLST form signed on [DATE] shows R12 as a DNR. R12's November Physician Orders List shows R12's code status as full code dated [DATE]. [DATE] at 11:52 AM, V6 (Agency Registered Nurse) stated, It is not correct, I will fix that. R12's November Physician Orders form documents a new ordered dated [DATE] for R12 to be a DNR. The policy Advanced Directives dated 3/2023 states it is the policy of the facility to inform residents/residents representatives about Advanced Directives to assist those who wish to complete advanced directives, honor choices identified in the advanced directives and to maintain records of advanced directives. Upon admission, the resident will be provided with information concerning the right to refuse or accept treatment and to formulate an advanced directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advanced directive, the information may be provided to the resident's representative. Prior to or upon admission of a resident the Social Services Director or designees will inquire about the existence of any written advance directives. Advanced directives shall be displayed prominently in the medical record. If the resident indicates that he or she has not established advanced directives, the facility will offer assistance in establishing advanced directives. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. A resident will not be treated against his or her own wishes the Director of Nursing Services or designee will notify the Attending Physician of advanced directives so that appropriate orders can be documented in the resident's medial record. The Immediate Jeopardy that began on [DATE] and was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. Corrective action for residents noted to have been affected by the deficient practice. a) R2 expired [DATE] after staff failed to initiate CPR when the resident was found unresponsive, and vital signs absent. No further resident follow up required at this time. b) R1 was transferred to the hospital with no POLST which resulted in intubation requiring compassionate extubation. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? a) Residents currently residing in the community on [DATE] have the potential to be affected by the identified practice. b) A review of all current resident's medical records was completed by DON/designee on [DATE] to ensure that a current and valid POLST was on the resident's file and coincides with the provider order and care plan updated. Any incomplete POLST forms will be updated and completed by the social services director or designee and provider orders updated by the DON or designee by [DATE]. c) Mock Code drills were performed on all shifts on 11/10, 11/11, 11/15 and [DATE]. Education was provided during drills to associates. 3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. a) AdHoc QAPI meeting held by the interdisciplinary team on [DATE] and this plan of correction was developed and implemented. b) The Medical Director was notified by the Executive Director on [DATE] and the plan of correction was reviewed and approved. c) All direct care licensed nurses, all agency nurses and CNAs will be re-educated by the Director of Nursing or designee by [DATE] or prior to working the next scheduled shift on Do Not Resuscitate Order, POLST forms, and Cardiopulmonary Resuscitation and Protected Code Blue. d) Executive Director notified staffing agency of the incident on [DATE]. e) Interdisciplinary team has reviewed policies and procedures Do Not Resuscitate Order, POLST forms, and Cardiopulmonary Resuscitation and Protected Code Blue and is in compliance with CMS regulation F Tag 678. f) The nurse on duty will verify the presence of advance directives or the resident's wishes with regard to CPR, upon admission. If the resident's wishes are different than the admission orders, or if the admission orders do not address the resident's code status and the resident does not want to receive CPR, the admitting nurse will document the resident's wishes in the medical record and contact the physician to obtain the order. A verbal declination of CPR by a resident, or if applicable a resident's representative, should be witnessed by two staff members and documented. While the physician's order is pending, staff will honor the documented verbal wishes of the resident or the resident's representative, regarding CPR. g) Social Services Director or designee has been educated on the expectation to follow up and complete POLST forms within 72 hours of admission that coordinate with advance directive orders. h) Reviews of POLST, physician orders and care plans will be completed by the DON or designee weekly at Resident at Risk for all admissions and readmissions. Monthly reviews will be completed by the Executive Director or designee. i) Any nursing staff receiving any changes in provider's orders r/t change in CPR status will notify the Social Service Director to update the POLST form. 4. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. a) Monthly reviews of POLST forms to ensure any changes to advanced directives or new admission are completed and initiated in a timely manner will be completed by the Executive Director or designee and reported at QAPI. b) The DON or designee will interview 3 nurses per week to ensure they are able to verbalize the expectations on how to respond when finding a resident unresponsive and what to do when a change of condition was observed. c) The Director of Nursing, or designee, will complete 2 mock code drills weekly with all direct care staff on varying shifts for three months. d) A summary report of findings will be provided to the QAPI committee for review. The QAPI committee will review findings and trends monthly and will reevaluate if further monitoring is indicated.