**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an effective system was in place to ensure the resident record accurately reflected the code status for residents, and that staff knew how to confirm a resident's code status if an emergency occurred for 2 (Resident #7 and Resident #9) of 25 (Resident #4, Resident #5, Resident #7, Resident #9, Resident #15, Resident #20, Resident #25, Resident #34, Resident #35, Resident #36, Resident #40, Resident #41, Resident #43, Resident #44, Resident #45, Resident #48, Resident #50, Resident #51, Resident #53, Resident #66, Resident #67, Resident #76, Resident #80, Resident #84, and Resident #237) sampled residents reviewed for advanced directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE], when Resident #7 had a physician's order to Do Not Resuscitate (DNR) in which no lifesaving measures were to be performed, and to allow natural death. Resident #7's advanced directive instructed that cardiopulmonary resuscitation (CPR), a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped, was to be performed. An interview with S11Licensed Practical Nurse (LPN) revealed the facility's procedure to verify a resident's code status in case of an emergency was to follow the order located in the electronic medical record. S11LPN stated Resident #7's electronic medical record indicated Resident #7 was a DNR, so she would not provide CPR to Resident #7 in the event of an emergency. The Immediate Jeopardy situation continued on [DATE], which revealed Resident #9 had a DNR physician's order in the electronic medical record. Further review of Resident #9's electronic medical record revealed a Louisiana Physician Orders for Scope of Treatment (LaPOST) advance directive for CPR which was signed by the physician on [DATE]. Review of the code status binder located at the nurse's station, revealed Resident #9 had a LaPOST advance directive for CPR which was signed by the physician on [DATE]. An interview with S10Licensed Practical Nurse (LPN) revealed the facility's procedure to verify a resident's code status in case of an emergency was to follow the LaPOST in the code status binder located at each nurse's station. S10LPN reviewed the code status binder at the nurse's station and stated that Resident #9 was not on the DNR resident list. S10LPN then reviewed Resident #9's LaPOST located inside the code status binder and stated she would perform CPR on Resident #9 in the event of an emergency. Resident #9's nurse then reviewed Resident #9's electronic medical record and indicated Resident #9's code status was listed as a DNR, so with this information, she would not perform CPR on Resident #9. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 4:47 p.m. The Immediate Jeopardy was removed on [DATE] at 4:28 p.m., after it was verified through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to the remaining 99 residents who reside in the facility and may need to receive emergency care. Findings: Review of the facility's policy and procedure titled, Advanced Directives and last revised in [DATE] revealed, in part, advance directives will be respected in accordance with state and facility policy. Further review revealed advanced directive information shall be displayed in the medical record and be consistent with his or her documented treatment preferences and/or directive. Resident #7 Review of Resident #7's Electronic Medical Record revealed Resident #7 was admitted to the facility on [DATE]. Review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, in part, Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #7's cognition was severely impaired. Review of Resident #7's Louisiana Physician Orders for Scope of Treatment (LaPOST) revealed, in part, Resident #7's advanced directive was signed by Resident #7's personal health care representative on [DATE] and indicated Resident #7 was to receive CPR. Review of Resident #7's care plan dated [DATE], revealed, in part, Resident #7's was a full code (CPR). Review of Resident #7's Hospice Certification and Plan of Care dated [DATE] revealed, in part, Resident #7's advanced directive was to receive CPR. Review of Resident #7's of Resident #7's physician's orders related to code status revealed the following: [DATE]- Resident #7 was a full code and was to receive CPR; [DATE]- Resident #7 was admitted to hospice as of [DATE] with a code status was DNR; [DATE]-Resident #7 was admitted to hospice as of [DATE], was a full code, and was to receive CPR; and, [DATE]- Resident #7's code status was DNR. In an interview on [DATE] at 10:00 a.m., Residents #7's son/responsible party stated Resident's #7's code status was CPR/full code. Resident #7's son/responsible party further stated he signed the paperwork indicating CPR when Resident #7 was admitted to the facility and it was discussed again with the hospice nurse when she was admitted to hospice services. Resident #7's son/responsible party further stated he understood what CPR meant as he was a firefighter, and if the facility did not do CPR on his mother, then he would. In an interview on [DATE] at 10:03 a.m., S11Licensed Practical Nurse (LPN) stated to verify Resident #7's code status she would refer to the medication administration record in Resident #7's electronic medical record. S11LPN stated Resident #7's electronic medical record indicated Resident #7 was a DNR, so she would not provide CPR to Resident #7 in the event of an emergency. In an interview on [DATE] at 12:55 p.m., S6RegisteredNurse (RN) Medical Records stated she was responsible to ensure residents' electronic medical record matched their advance directives. S6RN Medical Records confirmed Resident #7's advanced directives were for resuscitation. S6RN Medical Records stated she entered the DNR order for Resident #7 on [DATE] by mistake. S6RN Medical Records agreed in the event of an emergency, had staff followed the Resident #7's electronic medical record which indicated Resident #7 was a DNR, Resident #7 would not have been resuscitated which could have resulted in death. Resident #9 Review of the Clinical Record revealed Resident #9 was admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, in part, Resident #9 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated his cognition was moderately impaired. Review of Resident #9's current care plan with an initiation date of [DATE] and a target date of [DATE], revealed he was a full code. Review of Resident #9's physician's orders related to code status revealed the following: [DATE]- Resident #9 was a full code, and CPR was listed on Resident #9's LaPOST in the Electronic Medical Record and on the LaPOST in the Code Status Binder located at the nurse's station; [DATE]- Resident #9 was admitted to hospice; and [DATE]-Resident #9's CPR order was discontinued, and a DNR order was placed in the electronic record under physician's orders. Review of Resident #9's Advanced Directives (LaPOST) in the electronic medical record and Code Status Binder, signed by Resident #9's representative on [DATE], revealed Resident #9 indicated he wanted to receive CPR. Review of Resident #9's LaPOST located in Hospice Binder #1 revealed, in part, Resident #9 was a DNR. Further review revealed, the LaPOST was signed by Resident #9 on [DATE], but was not signed by the physician. Review of Resident #9's Advance Directive (LaPOST) in Hospice Binder #2 revealed the LaPOST, indicating Resident #9 was a DNR, was signed by Resident #9 and by the physician on [DATE]. In an interview on [DATE] at 10:12 a.m., Resident #9 stated he did not want to be given life saving measures if he had an emergency. Resident #9 further stated he told the facility staff to just let him die and not to touch him if he had a life threatening emergency. Resident #9 stated he did not want CPR. In an interview on [DATE] at 10:26 a.m., S10Licensed Practical Nurse (S10LPN) stated in the event of an emergency, she would refer to the resident's Physical LaPOST in the Code Status Binder located at the nurse's station where all of the LaPOST forms for each resident were kept. S10LPN further stated she would also look at the DNR resident list located on the first page in the Code Status Binder and Resident #9's LaPOST in the Code Status Binder identified Resident #9 as a full code, so she would perform CPR on Resident #9 based on this LaPOST. S10LPN also indicated Resident #9's code status was also located under Resident #9's picture in the electronic medical record, but was unable to access it because the computer system was not working at this time. In an interview on [DATE] at 10:33 a.m., S10LPN stated she was now able to access Resident #9's code status in the electronic medical record. S10LPN further stated Resident #9's code status displayed he was a DNR in the electronic medical record, and now with this information, she would not perform CPR on Resident #9. S10LPN acknowledged Resident #9's code status was a DNR in the physician's orders and was a full code in the code binder. In an interview on [DATE] at 12:03 p.m., Resident #9's hospice company representative stated she received a call from S6RN/Medical Records on [DATE] asking her to send the signed copy Resident #9's LaPOST to put in Resident #9's Hospice chart. In an interview [DATE] at 12:52 p.m., S6RN/Medical Records stated she was responsible for updating Resident #9's code status in the Hospice Chart, Code Binder, and Electronic Medical Record. S6RN/Medical Records stated Resident #9 had two different binders because Hospice Binder #1 was lost and replaced with Hospice Binder #2. S6RN/Medical Records further stated Hospice Binder #1 was located but she did not place an updated LaPOST signed by the physician in Hospice Binder #1. S6RN/Medical Records stated the nurse should have used the code status that was listed in the Hospice Binder. S6RN/Medical Records stated it was a mix up with the hospice records. S6RN/Medical Records stated she found out Hospice Binder #1 was lost and then Hospice Binder #2 was created to replace Hospice Binder #1. When Hospice Binder #1 was located, someone combined the information in the two binders together. S6RN/Medical Records stated Resident #9's Hospice Binder #1 did not have a LaPOST signed by the doctor and should not be used staff. S6RN/Medical Records acknowledged that Hospice Binder #2 had a LaPOST signed by the physician with a DNR order. S6RN/Medical Records acknowledged that the electronic medical record had Resident #9 listed as a Do Not Resuscitate and the LaPOST in the electronic chart had Resident #9 listed as a as a full code which was signed by the physician. S6RN/Medical Records stated she should have ensured the accuracy of Resident #9's code status as being a DNR, and she did not. In an interview on [DATE] at 3:20 p.m., S2DON stated Resident #9's nurse should have looked in the Hospice Binder for the correct code status for Resident #9. S2DON further stated Resident #9's nurse should not have relied on the Code Status Binder to determine a hospice resident's code status. S2DON was presented with Resident #9's LaPOST located in Hospice Binder #1. The LaPOST in Hospice Binder #1 was not signed and she stated it was not valid if not signed. S2DON further stated if the LaPOST was not signed, life saving measures should be initiated if a resident has an emergency. In an interview on [DATE] at 4:57 p.m., S1Administrator stated S6RN/Medical Records nurse was responsible for ensuring the resident's clinical records accurately reflected the code status for residents in accordance with their advance directives. In an interview on [DATE] at 5:50 p.m., S6RN/Medical Records further stated the corporate office was responsible for ensuring her work was correct. S6RN/Medical Records stated that she found on yesterday [DATE] that Resident #9's code statuses were different in his physical and electronic medical records and did not do anything to correct the issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to meet the needs of the residents by failing to provide oversight to ensure an effective system was in place where the resident record accurately reflected the code status for advanced directives, and that staff knew how to confirm a resident's code status if an emergency occurred for 2 (Resident #7 and Resident #9) of 25 (Resident #4, Resident #5, Resident #7, Resident #9, Resident #15, Resident #20, Resident #25, Resident #34, Resident #35, Resident #36, Resident #40, Resident #41, Resident #43, Resident #44, Resident #45, Resident #48, Resident #50, Resident #51, Resident #53, Resident #66, Resident #67, Resident #76, Resident #80, Resident #84, and Resident #237) sampled residents reviewed for Advanced Directives. This lack of administrative oversight resulted in an Immediate Jeopardy situation on [DATE], when Resident #7 had a physician's order to Do Not Resuscitate (DNR) in which no lifesaving measures were to be performed, and to allow natural death. Resident #7's advanced directive instructed that cardiopulmonary resuscitation (CPR), a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped, was to be performed. An interview with Resident #7's nurse revealed the facility's procedure to verify a resident's code status in case of an emergency was to follow the order located in the electronic medical record. The Immediate Jeopardy situation continued on [DATE], which revealed Resident #9 had a DNR physician's order in the electronic medical record. Further review of Resident #9's electronic medical record revealed a Louisiana Physician Orders for Scope of Treatment (LaPOST) advance directive for CPR which was signed by the physician on [DATE]. Review of the code status binder located at the nurse's station, revealed Resident #9 had a LaPOST advance directive for CPR which was signed by the physician on [DATE]. An interview with Resident #9's nurse revealed the facility's procedure to verify a resident's code status in case of an emergency was to follow the LaPOST in the code status binder located at each nurse's station. Resident #9's nurse reviewed the code status binder at the nurse's station and stated that Resident #9 was not on the DNR resident list. Resident 9's nurse then reviewed Resident #9's LaPOST located inside the code status binder and stated she would perform CPR on Resident #9 in the event of an emergency. Resident #9's nurse then reviewed Resident #9's electronic medical record and indicated Resident #9's code status was listed as a DNR, so with this information, she would not perform CPR on Resident #9. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 11:19 a.m. The Immediate Jeopardy was removed on [DATE] at 4:28 p.m., after it was verified through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to the remaining 99 residents who reside in the facility and may need to receive emergency care. Findings: Cross Reference F678. In an interview on [DATE] at 4:58 p.m., S3Corporate Nurse stated the facility had no current plan in place to ensure a resident's code status was accurate throughout the medical record. She further stated S2Director of Nursing was responsible for ensuring staff were trained and educated on how to confirm a resident's code status. In an interview on [DATE] at 4:59 p.m., S2Director of Nursing stated she had not had provided the facility's nursing staff with any education on ensuring a resident's code status was consistent throughout their record.