**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to provide Cardiopulmonary Resuscitation (CPR) to an unresponsive resident whose active Maryland Orders for Life Sustaining Treatment (MOLST) instructed to Attempt CPR if cardiac and/or pulmonary arrest occurs. This was evident for 1 (#137) of 21 residents reviewed for abuse during the survey. This deficient practice led to an immediate jeopardy for Resident #137 on [DATE]. Following the incident, the facility implemented effective and thorough corrective measures. The facility's plan and action were verified during this survey; therefore, this deficiency was cited as past noncompliance. The date of correction was [DATE]. The findings include: Cardiopulmonary resuscitation (CPR) refers to any medical intervention used to restore circulatory and respiratory function that has ceased. Maryland MOLST is a portable and enduring form for orders about cardiopulmonary resuscitation and other life-sustaining treatments. It makes one's treatment wishes known to healthcare professionals. Do Not Resuscitate (DNR)Order refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Code Status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops. A review of Resident #137's medical record revealed a MOLST, completed on [DATE], with Resident #137 as the decision maker and instructed to Attempt CPR. A review of a facility self-report MD00203965 for Resident #137, dated [DATE] indicated that, at approximately 4:30 AM on [DATE], staff #7, a geriatric nurse aid (GNA), noticed that Resident #137 was unresponsive upon entering his/her room. Staff #7 alerted the assigned nurse for Resident #137, staff #8, a registered nurse (RN). Further review revealed a clinical note for Resident #137 written by staff #8 and dated [DATE]. The note recorded that during routine check, resident was observed to have a cold clammy skin, no rise and fall of chest wall, pupils dilated to bright light. Vitals signs [respiration, pulse, blood pressure, temperature] weren't recordable. However, the review failed to show that staff #8 initiated CPR on Resident #137, as indicated on his/her MOLST form. A continued record review showed that staff #8 notified staff #9, the RN nurse supervisor, that Resident #137 was unresponsive and had a DNR order. Staff #9 then checked the resident's physical chart, which contained a MOLST that instructed staff to attempt CPR. The review failed to show that CPR was initiated at this point. In an interview on [DATE] at 1:04 PM with staff #1, an RN supervisor, she revealed that the form the nurses previously used for their change of shift report used to contain residents' code status. Staff #1 added that, due to inconsistencies, staff were educated to review the residents' physical charts for code status. In an interview on [DATE] at 9:06 AM, the director of nursing (DON) indicated that her investigation revealed that staff #8 used a form for her change of shift report with a code status for Resident #137. However, the DON was unaware of the form and expected staff # 8 to review Resident #137's MOLST for his/her code status. During an interview on [DATE] at 3:10 PM, staff #8 reported that this was her first time working with Resident #137 on [DATE]. Staff #8 continued to say that she did not initiate CPR on Resident #137 on that day because she was handed a report form at the start of her shift by the off-going nurse, which indicated that Resident #137's code status was DNR. Staff #8 added that she notified staff #9, who called Resident #137's attending provider. The provider ordered not to initiate CPR at that point because the resident was already cold to the touch and had no vital signs. A review of the certificate of death showed that Resident #137's date and time of death was [DATE] at 5:00 AM. In an interview on [DATE] at 8:33 AM, staff #16, a licensed practical nurse (LPN), indicated that the nursing staff used a form for their change of shift report, which contained residents' code status. However, after Resident #137's incident on [DATE], the nursing staff had been educated to check residents' physical charts for code status. A corrective action plan was developed and started on [DATE] after the incident occurred: 1) The staffing agency was notified of the occurrence, and staff #8 was placed on the Do Not Return list for the facility. 2) A document review was conducted on all units to ensure code status information was only available on the MOLST form in the residents' physical charts. 3) Nursing staff were re-educated on MOLST and the CPR process on [DATE]-[DATE] by the RN unit managers. 4) Policy on MOLST and CPR and education were activated in the facility's training software program for nursing staff review and acknowledgment. 5) The 3 Unit Managers (Care Coaches) also provided in-person training to all nursing staff. 6) The Medical Director provided education to all attending physicians (including Resident #137's attending provider) on [DATE]. 7) The facility audited and reviewed all residents' MOLST forms and orders. On [DATE] at 12:28 PM, after a review of the credible evidence of education, audits, and interviews with multiple staff, it was determined that the facility had identified this deficient practice and implemented interventions to prevent a recurrence. The date of compliance, as identified by the date on which the training was completed, was determined to be [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10-21-19, review of the clinical record for Resident #221 revealed that the resident was admitted on [DATE] with a physician's order for a left boot to be worn at all times, secondary to foot drop. There were no orders at the time of admission for donning or doffing (putting on or taking off) the boot to assess the skin integrity underneath the boot. On 10-04-19, a nursing skin assessment revealed that Resident #221 developed a blister which opened. (pressure injury-stage II) on the left calf area due to pressure from the boot. Further review of the clinical record revealed that the facility staff continued to document that the boot remained on at all times as previously ordered. On 10-11-19, facility staff documented that Resident #221's left calf area wound had deteriorated to an unstageable pressure injury; full thickness tissue loss,in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) dead tissue in the wound bed. The attending physician for Resident #221 wrote an order on 10-11-19 for the facility staff to discontinue application of the left boot. There was no evidence documented in the clinical record to indicate that the facility staff assessed resident #221's skin or provided care to the skin underneath the boot prior to the development of the left calf wound on 10-04-19. There was documented evidence in the clinical record that the facility staff continued to apply the boot after the pressure injury was identified on 10-04-19. The facility staff failed to adequately assess, in a timely manner, the risk for impairment of Resident #221's skin integrity as a result of continuous use of the boot which resulted in a facility acquired pressure injury. On 10-21-19 at 1:00 PM, interview with the ADON revealed no additional information regarding the care or assessment of resident #221's wound. 3. On 10-21-19, review of the clinical record for Resident #11 revealed that the resident was admitted on [DATE] with score of 19 on the Braden Scale for pressure ulcers/injury. (low risk for impaired skin integrity) The facility staff implemented three interventions at that time: (1-encourage good nutrition and hydration in order to promote healthier skin; 2- keep skin clean and dry, use lotion on dry skin and 3-offer or assist to the bathroom as needed.). On 03-10-19, Resident #11 developed a stage II lumbar (low back) pressure injury measuring 1.5cm x 1.5cm x 0.1cm. (A Braden scale done on the day the wound developed (03-10-19) revealed the resident remained at moderate risk for pressure injury. The resident's care plan had the following revisions added on 03-10-19: Air mattress every shift, check pump for proper functioning & setting, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Orders for scheduled toileting for bowel and bladder upon arising, before and/or after meals & activities, before bedtime, and during the night as needed added to the care plan on 03-17-19. The area healed on 04-19-19. Further review of the clinical record revealed that subsequent Braden scale scores for Resident #11 (completed on 06-10-19 and 09-10-19) continued to reflect a score of 13 (moderate risk for impaired skin integrity). In addition, on 10-11-19, the facility wound doctor documented that resident #11 developed a pressure injury of the thoracic spine that was unstageable at the time of his assessment. The National Pressure Ulcer Advisory Panel describes an unstageable injury as one in which the extent of tissue damage within the?ulcer?cannot be confirmed because it is obscured by slough or eschar (dead tissue). The wound doctor recommended extensive turning precautions and pressure reduction to reduce pressure related injury at the time of this 10-11-19 visit, however, the facility staff did not obtain an order to turn and reposition the resident until 10-18-19 (9 days after development of the 2nd facility acquired pressure injury). The facility staff failed to implement turning and repositioning for resident #11 after the initial development of the 1st pressure injury. On 10-21-19 at 12:00 PM, surveyor interview with the assistant director of nursing (ADON-designated facility wound nurse) revealed that the facility staff does not implement preventive measures unless resident is identified as severe risk for skin breakdown pursuant to the Braden Scale. On 10-21-19 at 4:15 PM, an immediate jeopardy (IJ) for residents at low (mild) to moderate risk for pressure injury was determined. On 10-21-19 at 6:43 PM the facility staff submitted the following removal plan for the immediate jeopardy citation which included the following measures: -On October 21, 2019, for Resident #105: the following orders and interventions were put in place, turning and repositioning, pressure relieving wheelchair cushion, float heels, nutritional supplement, and, air loss mattress. For resident #221: the following orders and interventions were put in place, turning and repositioning, float heels, pressure relieving wheelchair cushion, air loss mattress, and daily skin checks under brace when in use. For resident #11: the following orders and interventions were put in place, turning and repositioning, pressure relieving wheelchair cushion, nutritional supplement, and, air loss mattress, and float heels. -In addition, on October 18, 2019, members of the clinical team reviewed 100% of residents Braden scale score. The clinical team reviewed residents identified as High Risk, as well as a few identified as moderate risk, totaling twenty-seven (27) residents, and updated care plans to reflect interventions, completed a Braden Scale assessment as needed, and, orders added as appropriate. -By October 23, 2019, 100% of residents with splints/braces will be assessed for potential skin breakdown. Appropriate preventative measure intervention(s) in care planning, and orders, including turning and repositioning, will be added as clinically indicated. -Clinical Director worked with electronic medical record to place the prompt for an order of turning and repositioning, as clinically indicated, for newly admitted residents effective Friday, October 18, 2019. -By October 23, 2019, each newly admitted resident ' s Braden Scale Assessment will be reviewed by the Assistant Director of Nursing or Director of Nursing for accuracy, preventative measure intervention(s) in care planning, and orders, including turning and repositioning, as indicated. -By October 23, 2019, one-hundred twenty-one (121) residents identified as low risk or moderate risk on the Braden scale, as well as residents with orders for a splint or brace, will be reviewed for appropriate preventative measures in care plan, interventions, orders in place, and referral to Registered Dietitian, if appropriate. -By October 23, 2019, 100% of licensed nurses will be in-serviced regarding Braden Scale assessments, preventative measures for pressure ulcer, and updated policy. PRN licensed nurses and those on leave (FMLA, PTO, Leave of Absence) will not work until they have had the necessary in-service. -By October 23, 2019, to prevent skin breakdown, the clinical team will update policy to reflect appropriate preventative actions and/or interventions within each Braden Scale risk category (Low, Moderate, High). The updated policy will address residents with an order for splint/brace as well as residents who are non-compliant with interventions. -If residents go from one risk level to another (i.e. moderate risk to high risk), Registered Dietitian will assess for appropriate nutritional interventions. -Clinical team, including Registered Dietitians, will conduct 100% audit of new admissions, residents with Minimum Data Set (MDS assessments) of significant change of condition, and, residents with splint/brace orders weekly x3 months, then, monthly x3, then, quarterly x2; and, will report findings to Quality Assurance Performance Improvement (QAPI) committee monthly x3, then, quarterly x2 for further recommendations. The licensed nursing home administrator was designated as ultimately responsible for oversight of this plan. -On 10-23-19, surveyors verified in-service training as stated in removal plan, revision of facility policy on Pressure Injury Prevention and Wound Care which included interventions for residents at low (mild) and moderate risk for pressure injury, and auditing of new interventions for all residents who had been identified as low (mild) and moderate risk for pressure injury. As a result, the immediate jeopardy was abated on 10-23-19 at 8:25 AM. Based on surveyor observation(s), review of clinical records, facility policies and procedures, and resident and staff interview(s), it was determined that facility staff failed to implement preventive measures to prevent a pressure injury for residents identified at low (mild) or moderate risk for impaired skin integrity. These failures resulted in 3 of 3 residents with facility acquired pressure injuries that were reviewed during the survey (#105, #221 and #11). On 10-21-19 at 4:15 PM, an immediate jeopardy (IJ) for residents at low (mild) to moderate risk for pressure injury was determined. On 10-21-19 at 6:43 PM, the facility staff submitted an IJ removal plan related to residents at low (mild) to moderate risk for pressure injury to the Office of Health Care Quality (OHCQ) which was accepted. On 10-23-19 at 8:25 AM, the IJ related to low (mild) to moderate risk for pressure injury was removed. After removal of the immediacy the deficient practice remained at a scope and severity level H. The findings include: 1. On 10-21-19 at 8:50 AM, review of the facility policy on Pressure Injury Prevention and Wound Care with a revision date of January 2019, revealed there were no preventive interventions for residents identified by the Braden Scale as being at risk for alterations in skin integrity. On 10-21-19, review of the clinical record for Resident #105 revealed the resident was admitted on [DATE]. An admission Braden Scale risk for pressure ulcer development completed by registered nurse (RN) #1, dated 08-04-19, identified Resident #105 as being at a low (mild) risk for pressure ulcer development with a score of 15. However, the admission summary, also completed by RN #1, conflicted with the Braden Scale. The admission summary indicated that Resident #105 needed 2 people to assist with turning and repositioning and stated the resident was incontinent of bowel and bladder. The Braden Scale risk assessment tool is an evidenced-based tool that predicts the risk for developing a hospital or facility acquired pressure injury. The Braden Scale uses scores from less than or equal to 9 to as high as 23. The higher the score, the lower the risk. Further review of the clinical record revealed that the interventions implemented in the plan of care for Resident #105 on 08-04-19 did not include turning and repositioning the resident, who required 2-person assistance for bed mobility as described during interview and in the admission summary, nor did they include any specific toileting interventions for this resident identified as being incontinent of both bowel and bladder. On 10-11-19 Resident #105's Braden Scale was reassessed with a score of 17, which again reflected a low (mild) risk for skin breakdown, however, the resident on this same date was identified as having developed a stage III pressure injury. A stage III injury involves a full thickness loss of skin with adipose (fat) visible in the ulcer and slough, and/or eschar (dead tissue) may also be visible. Further review of the clinical record revealed that Resident #105 was seen by the wound doctor on 10-11-19, who documented the resident's immobility and nutrition as clinical factors affecting healing. A new Braden Scale, completed on 10-11-19, did not reflect the wound doctor's assessment of Resident #105's mobility and nutrition as contributing factors to the impaired skin integrity. These factors, along with the resident's continued urinary and bowel incontinence, would have resulted in a Braden Scale score change from low (mild) risk to a score of 12 (high risk). The wound doctor also documented in the 10-11-19 comprehensive wound care notes for Resident #105 that he/she had discussed pressure reduction and turning precautions with facility staff and recommended extensive turning precautions and pressure reduction to reduce pressure related injury at time of visit. On 10-15-19, Resident #105 developed two additional facility acquired areas. On this date, the facility staff obtained a physician's order for ProSource (protein supplement) to be administered twice daily to promote wound healing, and an air mattress and pressure relieving cushion to be used when the resident was in the wheelchair. On 10-17-19, facility staff obtained a physician's order to turn and reposition Resident #105 every 2 hours. It should be noted that this intervention came six days after the wound doctor recommended extensive turning precautions, and two days after the development of two additional pressure areas. On 10-21-19 at 10:15 AM, interview with RN #1 and geriatric nursing assistant (GNA) #6 revealed that Resident #105 was very weak and required the assistance of 1-2 staff for all activities of daily living (ADLs) at the time of admission. Both RN #1 and GNA #6 stated the resident was totally incontinent of urine and had a groin rash which required treatment. Both also stated that the resident was constantly moist. However, the Braden Scale did not reflect the constant moisture, nor did the Braden Scale reflect the moderate to maximum assistance in moving that the resident required (2 person assist). These changes would have decreased the overall risk score and increased the risk category. On 10-21-19 at 11:00 AM, interview with registered nurse (RN) #2 confirmed that Resident #105 was dependent in all ADLs at the time of admission. On 10-21-19 at 11:10 AM, interview with GNA #3 revealed Resident #105 was totally dependent at the time of admission, however, began to get a little better sometime toward the end of September. GNA #3 stated that the resident continued to remain incontinent of bowel and bladder. On 10-21-19 at 9:00 AM, interview with the Assistant Director of Nursing (ADON) (who was the designated facility wound nurse) revealed that facility staff did not implement preventive measures for potential skin breakdown unless a resident's Braden Scale indicated severe risk. Upon further questioning, the ADON confirmed that facility staff did not implement turning and repositioning or other preventive measures (i.e. pressure relieving devices) unless the Braden Scale reflected a severe risk for skin breakdown.