**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified when a resident (Resident B) complained of bilateral shoulder pain and malfunctioning of his automatic implantable cardioverter defibrillator for 1 of 3 residents reviewed for physician notification. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility staff failed to notify the physician of a resident's complaint of bilateral shoulder pain and malfunctioning of the residents' automatic implantable cardioverter defibrillator. The resident was found unresponsive on [DATE] and died. The Executive Director (ED) and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 4:35 p.m. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The clinical record for Resident B was reviewed on [DATE] at 11:11 a.m. The diagnoses included, but were not limited to, hypertension and presence of automatic (implanted) cardiac defibrillator. The quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident's cognition was intact. The care plan, dated [DATE], indicated the resident had an AICD (automatic implantable cardioverter defibrillator) related to a complete atrioventricular block. The interventions included, but were not limited to, defibrillator checks as ordered and follow up with cardiology as ordered. The progress note, dated [DATE] at 1:28 p.m., indicated the resident refused to go to his appointment for his AICD check due to complaints of not feeling well. The resident requested his oxygenation be checked and complained of nausea. The resident's oxygenation was 90% on 2 liters of oxygen and he was administered 4 mg (milligrams) of Zofran (antiemetic) as ordered by the physician on [DATE]. The progress note, dated [DATE] at 4:44 p.m., indicated the resident complained of bilateral shoulder pain and pacemaker complications. The resident was assessed with the following findings: apical heart rate of 67 after one minute of auscultation, temperature was 97.8, respirations were 18, and blood pressure was 151/81. The resident was educated that he would be discharged tomorrow. The resident asked to be sent to the hospital. Upon education that he was to be discharged tomorrow, the resident decided to contact his spouse prior to his decision to be sent to the hospital. The progress note, dated [DATE] at 1:21 p.m., indicated the resident complained of nausea at times and his as needed Zofran was administered as prescribed. Review of the [DATE] medication administration record (MAR) indicated the resident received Zofran 4 mg at 8:34 a.m. and 5:49 p.m. for nausea and meclizine (medication for dizziness) 12.5 mg at 8:34 a.m., per standing order, on [DATE]. Between [DATE] and [DATE], the resident's MAR indicated [DATE] was the first time the resident had requested 2 doses of the Zofran and the first time the resident had requested the meclizine. The progress note, dated [DATE] at 9:30 p.m., indicated the resident was found unresponsive lying in his bed. There were no respirations and no pulse. CPR (Cardiopulmonary Resuscitation) and defibrillating was initiated and 911 called. CPR was continued until 9:09 p.m. when EMT's (emergency medical technicians) arrived. The paramedics were unable to resuscitate the resident and time of death was called at 9:29 p.m. The clinical record lacked documentation of the physician's notification related to Resident B's bilateral shoulder pain and complaints of the malfunctioning AICD or any resident education on refusing to go for his AICD check. During an interview on [DATE] at 11:43 a.m., LPN (Licensed Practical Nurse) 3 indicated he did not notify the physician of the resident's complaints of shoulder pain and possible AICD malfunctioning. He was unaware he had to do so and thought that the physician was to be notified when the resident was sent out. The resident had not made that decision at that point. It was towards the end of his shift, and he passed the information on the LPN 4 during shift change. At 12:55 p.m., LPN 3 clarified malfunctions as the resident reported to him that his heartbeat felt irregular and his AICD was malfunctioning. During an interview on [DATE] at 11:57 a.m., LPN 4 indicated she was not told anything about the resident complaining of bilateral shoulder pain or malfunctioning AICD. The only thing she was told was that the resident was going to be discharged on Monday and the resident had been coming up with all kinds of excuses not to go home. LPN 3 told her he had checked everything, and the resident was fine. LPN 4 passed medication to the resident between 7:00 p.m. and 7:30 p.m. on [DATE]. There was no documented nursing assessment related to the resident's prior complaints of bilateral shoulder pain or complaints of AICD malfunctions during LPN 4's shift. On [DATE] at 2:43 p.m., the Executive Director provided a current undated copy of the document titled Notification of Change in Condition. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care that meets the .needs .concerns of the residents. The safety of residents .is of primary importance .The Centers for Medicaid and Medicare Services (CMS) requires that processes be in place for notifications of acute changes such as cardio .The center must inform the resident, consult with the resident's physician .when there is a change requiring such notification .Significant change in the residents physical condition .including but not limited to .life-threatening condition .clinical complications .Notifications .The attending practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition The Immediate Jeopardy, that began on [DATE], was removed on [DATE], when the facility conducted the following: The DON/Designee reviewed all residents with a change of condition for the last 14 days to ensure physician notification, family notification, and follow-up was completed as appropriate. The DON/Designee reviewed all residents with an AICD and implemented daily monitoring orders for completion by licensed nurses to ensure compliance with daily monitoring to include no symptoms of malfunction/failure, slowed or irregular heartbeat, pain with potential to related to cardiac concern, shortness of breath, faintness/dizziness, unexplained falls, and unexplained weakness. An audit was conducted for all resident appointments for the last 30 days to ensure all appointments were completed as ordered and if resident refused appointment, including AICD follow-up appointments, education would be provided on the risk for potential adverse outcomes and physician notified of refusals. All licensed nurses were educated on the facility's policy for notification of COC to MD/NP and family, internal devices/pacemaker and follow-up appointments to include refusal of appointments and cardiac signs and symptoms, potential negative outcomes of missed AICD follow-up appointments to include device failure, cardiac arrest, and potential death, completion of resident education and notification to physician related to missed or refused AICD follow-up appointments, and on the daily monitoring of signs and symptoms of potential problems with AICD. This Federal tag relates to Complaint IN00412084 3.1-5(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's advanced directive were honored for 1 of 26 residents reviewed for advanced directives. The resident had persistent rib pain, anxiety, and negative emotions related to being revived when he had wanted to be a DNR. (Resident D) The immediate jeopardy began on [DATE], when the facility failed to follow a resident's advance directive of a do not resuscitate. The Executive and Director of Nursing Services were notified of the immediate jeopardy at 2:12 p.m., on [DATE]. The immediate jeopardy was removed on [DATE] at 3:22 p.m., but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings include: During an observation, on [DATE] at 3:00 p.m. Resident D's physical chart had a sign taped to the front of it with a red stop sign on it. The sign indicated in case of hospice crisis, to contact the resident's hospice provider, with the phone number listed on it. Under the condition alert tab, DNR was written in both dark blue marker, and an orange highlighter, with the resident's name, room number, and status as a hospice patient written on it. There was no indication the resident was a full code for CPR to be performed on the chart, or in the first page of the chart. The clinical record for Resident D was reviewed on [DATE] at 1:11 p.m. The diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), lung disorders, opioid dependence, chronic active hepatitis, history of pulmonary embolism, type 2 diabetes mellitus, rheumatoid arthritis, major depressive disorder, history of malignant neoplasm of large intestine, primary osteoarthritis, and scoliosis. The Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact, the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months. The POST (Physician Orders for Scope of Treatment) form, dated [DATE], indicated the resident had chosen to be a DNR (do not resuscitate) and wanted comfort measures only. The form was signed by the resident and the physician on [DATE]. The physician's order, dated [DATE], indicated the resident received dialudid 8 mg tablet six times daily for pain. The Care Plan, dated [DATE] and last revised on [DATE], indicated the resident had chosen a DNR code status. The goal included the resident's code status would be honored through the next review date. The interventions included, but were not limited to, code status will be established at time of admission or readmission and reviewed quarterly and as needed and verify presence of DNR status POST form. The physician's order, dated [DATE], indicated the resident was a DNR. The physician's order, dated [DATE] indicated to give morphine sulfate 100 mg (milligrams) per 5ml (milliliters) 0.75 mg by mouth every 2 hours as needed for air hunger. The nurse's note, dated [DATE] at 11:29 a.m., indicated the resident asked for pain medication at 11:00 a.m. The nurse went in and found the resident almost on the floor, sitting half in his wheelchair. There was a small amount of blood and saliva coming out of his mouth. A sweep of his throat was done and nothing was found. The resident had no pulse. He was lowered to the floor and CPR (cardiopulmonary resuscitation) was started. After 2 minutes of CPR a pulse was observed. EMS (Emergency Medical Services) and hospice were notified. EMS arrived and transported the resident to the hospital. The nurse's note, dated [DATE] at 2:52 p.m., indicated the resident would be returning to the facility. Report was received from the local hospital that the resident was COVID-19 negative and the resident had pneumonia and would return with orders for prednisone 2 mg for two days and Cefdinir 300 mg 1 tablet every 12 hours for 7 days. The hospice note, dated [DATE], indicated the hospice nurse received a message from the facility indicating the resident had been found unresponsive, 911 was called, and CPR was started. The resident was a DNR. Before the call was returned the on call hospice nurse called to report the patient was breathing and had a pulse, and was being transported to the local hospital. The hospice nurse instructed the on-call hospice nurse to call the hospital to give report and emphasized the patient was on hospice and was a DNR. The hospice note, dated [DATE], indicated LPN 3 called hospice and reported the resident went unresponsive. EMS was called and CPR was performed before hospice was informed and despite the patients DNR status. The hospice nurse spoke with LPN 4 and informed her the patient was a hospice patient and a DNR. The hospice note, dated [DATE], indicated the resident was at the local hospital. He was complaining of chest pain which was likely related to CPR being performed per hospital staff, but a chest x-ray was performed and the resident had pneumonia. He was given morphine to assist with the pain. The hospital summary report, dated [DATE], indicated the resident was brought in from the nursing home with complaints of shortness of breath. He was a DNR but CPR was performed for 3 minutes at the nursing home when he was found unresponsive and not breathing. By the time EMS came he was alert. The patient improved over an hour but his wheezing had not resolved. The hospital recommended admission for continued treatment, however the resident refused and stated he wanted to go back to the nursing home. He had metastatic lung cancer and was a DNR. He would be treated with antibiotics, steroids, and continued nebulizer treatments at the nursing home. The diagnoses included, but were not limited to, metastatic lung cancer, pneumonia, and COPD exacerbation. The nurse's note, dated [DATE], indicated a message was left with hospice regarding a need for a new script for morphine. The hospice note, dated [DATE], indicated the resident had shortness of breath on minimal exertion, his lung sounds were diminished throughout all lobes with wheezing in the left lobes. The resident stated he had ribs broken on both sides. The hospice note, dated [DATE], indicated the resident stated he wanted to remain hospice and be a DNR. The hospice nurse told him she would see him the following day for his final decision. A new post form, dated [DATE], indicated the resident had chosen to be a DNR and wanted comfort measures only. The form was signed by the resident and the physician on [DATE]. The hospice note, dated [DATE], indicated the resident was uncomfortable due to pain from broken ribs due to CPR. He told the chaplain there was no part of his body that did not hurt. He shared his experience of passing and being brought back to life. He wanted to be a DNR. The chaplain had a conversation with the resident about not going through the CPR. The resident completed his post form and signed it. The Pain Observation tool, dated [DATE] at 8:23 a.m., indicated the resident was verbalizing or exhibiting non-verbal symptoms of pain. The onset was [DATE]. The location of the pain was the chest and ribs. The pain was worse in the morning, afternoon, evening, and night. The feeling of the pain was described as internal, external, and acute. The resident was able to verbally express his pain level as an 8 on a numerical scale, which indicated 0 was no hurt, and 10 hurt the worst. A numerical 8 on the scale meant the pain hurts a whole lot. The pain was described as feeling like a sharp, throbbing, stab feeling. The pain affected the resident's ability to sleep or rest, toilet self or maintain continence, bath himself, perform personal hygiene, and dress himself. The pain resulted in a change in his appetite, participation in activities, and his ability to concentrate or focus. The pain was caused by CPR, and was increased by movement. The resident received routine dilauded which was effective, and also used roxanol as needed. The nurse's note, dated [DATE] at 7:57 p.m., indicated a new order to give morphine sulfate 100 mg per 5 ml 0.75 mL every 1 hour as needed for pain until dilaudid arrived, then delete and go back to original order. The physician's order, dated [DATE], indicated the resident received morphine sulfate 100 mg/ 5 mL, give 0.75 mL every 1 hour as needed until Dilaudid arrived. The nurse's note, dated [DATE] 9:50 a.m., indicated the pharmacy said they did not have a script from the doctor. Hospice was notified and they indicated they would reorder again. At 11:00 a.m. the pharmacy was contacted and they still did not have the prescription. Hospice was contacted and indicated they would send it again. The pharmacy was contacted and indicated the medication would arrive at 3:00 p.m. and 4:00 p.m. The facility was awaiting the medication, the resident was upset and requesting morphine every hour. The hospice note, dated [DATE], indicated the resident told the chaplain he could not get over his experience of bring revived. His ribs were still sore and he was not happy. The nurse's note, dated [DATE] 2:25 p.m., indicated the hospice nurse was in to check on the patient's pain medications. The resident indicated he was feeling more anxious than normal. The hospice nurse advised the resident's Ativan was changed from every six hours as needed to every 4 hours as needed. The hospice note, dated [DATE], indicated the resident stated he was in pain and sore since his hospital visit when they did CPR. The social worker informed the facility the patient said he was sore from breaking ribs when they did CPR. The facility nurse indicated the patient had routine and as needed pain medication and she did not know how he could have such high amounts without sleeping. The social worker encouraged making the resident comfortable and hospice mindset, and that the patient might have a high tolerance and to call hospice with concerns. The hospice note, dated [DATE], indicated the resident vented frustrations to the chaplain. He felt ignored and neglected by his team of caregivers. The nurse's note, dated [DATE] 1:27 p.m., indicated the resident's liquid morphine was changed to MS Contin 20 mg three times daily and his Dilaudid was changed from scheduled to every 4 hours as needed. The physician's order, dated [DATE], indicated the resident received Dilaudid 8 mg tablet by mouth every 4 hours as needed for pain. The physician's order, dated [DATE], indicated the resident received MS contin 30 mg three times daily for pain. The nurse's note, dated [DATE] 6:46 a.m., indicated the resident complained of left lower tooth pain and he thought he may need to see a dentist due to his mouth hurting. He believed it may be going into an abscess. Hospice was notified. The physician's order, dated [DATE], indicated the resident received morphine sulfate 30 mg three times daily for pain. The nurse's note, dated [DATE] at 2:04 p.m., indicated a new order for MS contin 30 mg 1 tablet four times daily for pain. The physician's order, dated [DATE], indicated the resident received, MS Contin 30 mg 4 times daily for pain. The nurse's note, dated [DATE] at 6:42 a.m., indicated a new order for morphine sulfate 20 mg/mL, give one mL every hour as needed for shortness of breath or pain. The physician's orders, dated [DATE], indicated the resident's pain medication orders were changed to morphine sulfate 20 mg/mL 1 mL every 1 hour as needed for shortness of breath of pain, and fentanyl patch 72 hour 50 mcg/hr 1 patch transdermally every 72 hours for pain. During an interview, on [DATE] at 8:40 a.m., the resident indicated he was upset because he had a DNR order and he had been revived. He died and stopped breathing, and the nurse found him on the floor. She performed CPR and broke his ribs and his sternum. It happened about a month and a half to two months ago. He was still sore from it and it really hurt. The nurse didn't know he was a DNR, a lot of them didn't. He was on Hospice to keep him comfortable because he had cancer. When he revived he indicated he was almost home and then he didn't know how to feel when he woke up in the ER. After a day or two he wished she had never touched him because he was in so much pain. The resident stated, She broke all that stuff inside me and I had to live through it and I wouldn't have had to live through it if she hadn't of done that. I tell everyone now personally I'm a DNR. I don't want it to happen again. During an interview, on [DATE] at 1:45p.m., LPN 4 indicated she performed CPR on Resident D. An aide came and told her that he wanted pain medication. She was discharging a patient and said she would be right there. When she finished her paperwork she went in and the resident was slumped over and he did not have a pulse. She tried to arouse him and he had no pulse. She went out and the other nurse and CNAs were at the nurses station. She went for the crash cart and asked the other nurse to check for his code status and call the DON. When she was coming back she asked the nurse and she said he was a CPR. Another nurse and her went in and started performing CPR and sent him out to the hospital. When he got back she checked the chart and the DNR was marked out and CPR was wrote above it. That was on the first page in his physical chart. She did not check his POST form or his electronic orders. She did not look. The other nurse was looking for her. When it was all done and over she looked at the first page of the chart. She had no idea why it was crossed out. They wondered why it looked like that. She was told after the fact he was a DNR, but she followed what she was told. The other nurse, LPN 3 that confirmed the status. When she first went in and raised him up he had a little bit of saliva coming from his mouth. She did do a sweep because she thought he might have been choking. He did not say anything at all. He was not breathing. She didn't feel any cracking or anything, he's a larger man. She had cared for him since that time. He had complained several times. He said I can't believe your 100 pounds self-hurt my ribs. It made my ribs hurt. The last couple of times she'd had him he had not said anything related to his ribs. She indicated he had thanked her for saving his life. He had told her about the pain a few times, he had described it on more than one occasion. She did not ask him to rate the pain or describe it. She was not aware of anyone notifying the doctor of the pain or obtaining any imaging. She was not aware if they had a policy to check the electronic chart for code status orders. They had let hospice know he had talked about his ribs hurting. During an interview, on [DATE], at 8:20 a.m., the ED indicated she had completed a timeline the night prior. Some of her staff members told her the resident had been thankful they had performed CPR on him. They found a POST form for the resident, dated [DATE] that indicated the resident was a full code. They had just seen the hospice notes for the first time that the resident complained of his ribs being cracked but did not see that mentioned on his chest x-ray from the hospital. The hospital told them he wanted to return as a full code because he wanted to keep going. On [DATE] the hospice nurse documented that he wanted to remain with hospice and remain a DNR. She told him she would revisit on [DATE] for his final decision. On [DATE] that post form with a DNR was signed. At that time the order was placed and the care plan with the DNR status was placed. It was concerning to her they just got the notes from hospice, she didn't know why they didn't send them after their visit. During an interview, on [DATE] at 8:22 a.m., the Administrator in Training indicated what he knew of their process was that hospice was to print the notes and put them in the binder. They had a DNR form for the resident that was prepared on [DATE] which was before he was on service with them and was signed by the physician. He did not come on service with them until [DATE]. He was a transfer from another hospice provider. They had an additional post form after he came back from the hospital again that was on [DATE] that they obtained after the incident, which indicated he was a DNR again. His DNR status was confirmed with him upon his admission. It was in their admission documentation. There was a conversation between the admission nurse and the patient. In their electronic system he was flagged as a DNR. He did momentarily decide to be full code at the hospital after he had been revived, but she was told he ultimately stayed DNR. They were not contacted she believed until after he was sent out to the hospital. During an interview, on [DATE] at 9:22 a.m., Hospice RN 6 indicated she saw the resident personally twice weekly. He was in a high rate of pain. He came on service with the hospice service in July, and she had seen him regularly since then. He had always been a DNR. They had a POST form signed from the previous hospice group he was with, and that was dated a year before they got him as a patient. When they got him in July of 2022 he verified he wanted to be a DNR the day they admitted him. The only time she was aware of him not wanting to be a DNR, was after they coded him. There was approximately 48 hours where he wanted to be a full code, but all she had heard after that time was that he wanted to be a DNR and he should have always been a DNR. He had a tendency to agree with who was in front of him. She took her time to make sure his decisions were completely his own. He expressed that he shouldn't be alive and he was. His ribs were hurting for weeks afterwards which constantly reminded him that he was revived and how much pain that caused and how he never wanted to go through that again. Probably until the first of September he would ask her, I'm a DNR right? She always asked the nurses to reiterate that he was a DNR. She would say, if she could localize one of his pains, he had back pain, mouth pain, rib pain, lung issues that cause pain. Discerning between which one hurt the most would be difficult. He absolutely expressed how bad his ribs were hurting. For a couple of weeks it was all he spoke of. It was his main point of pain. He should not have had CPR, he was a DNR. It did hurt his ribs and it added to his pain. It reaffirmed the DNR for him. He was his own person, he was capable of making his own choices. His thought processes were not inaccurate. During an interview, on [DATE] at 10:57 a.m., LPN 3 indicated She did recall the incident. LPN 4 came and hollered we needed everybody on deck. They were trying to figure out if he was a full code or a DNR. So I looked on the computer, the computer said he was a DNR, some of the aides said in the book we had was CPR, so I looked in the book and that's what it said. I called hospice to get clarification. I was waiting for a reply back from them. During that waiting period we initiated CPR and called 911. Hospice called me back but by the time I got that call back everything was taken care of. The electronic health record said he was a DNR. She did not check his orders. Usually the code status is right at the top. She did check the physical chart. It said CPR. She thought it had said DNR and had been marked out and changed. She did not know if they were supposed to use the physical chart or the electronic chart. All she knew was to call hospice for clarification. The paper chart is the quickest to reach. The paper chart and electronic chart should reflect one another. She did indicate the resident expressed to her upon his return he was grateful they saved his life. The Initiate CPR policy and procedure, last reviewed [DATE], provided on [DATE] at 3:15 p.m. by the ED, included, but was not limited to, . Procedure . 3) Residents found unresponsive, not breathing or without a pulse, will have staff immediately locate the Code Status and communicate this to the team . 4) If CPR is indicated, staff will begin CPR and call 9-1-1 with these exceptions: a. There is a valid DNR order in place . The General Code Status policy and procedure, last reviewed [DATE], provided on [DATE] at 3:15 p.m., included but was not limited to, . It is the intent of this facility to honor the residents wishes and rigts of the resident/representative to make the determination of what, if any, resuscitative measures will be implemented in the event the resident's respirations and/or pulse cease either by natural or unnatural causes . The purpose of this policy is to guide clinical staff to quickly and accurately identify residents in the facility that do and do not request CPR as a treatment for respiratory and cardiac arrest. An efficient and accurate method of determining the code status of a resident during a medical emergency is needed. The use of an electronic health record (EHR) provides for fast retrieval to identify and how to appropriately respond to respiratory and cardiac arrested based upon the resident/representative wishes . Procedures . I . c. Code Status is found in the electronic health record and will be used by the nurse to validate Code Status before initiating CPR . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the DON completed an audit of all residents to ensure accuracy of their Advanced Directives to include the validation of the POST form, physician's order, and care plan matching the desired Advanced Directives, and all staff were educated related to the General Code Status policy as it related to verification of the code status, where to look for the code status and what to do in the event there was conflicting information during a resident code. The Immediate jeopardy was removed on [DATE] but remained at the lower scope and severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy, because the facility still needed to conduct further education to include expectations of notification to contracted companies involved in care of mutual residents, ensure social services involvement for psychosocial support during the decision making process, ensure psychiatric and social services were offered related to advanced directives decisions for residents, communication to contracted companies would include a copy of the POST form, or any form utilized to identify the residents' advanced directives, code blue drills on random shifts and audits would need to be conducted. This Federal tag relates to Complaint IN00388039 3.1-4(a)