**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to respect resident wishes for 1 of 3 residents (R1) reviewed for resuscitation status, resulting in receiving cardiac pulmonary resuscitation (CPR) against her wishes established in her Provider Orders for Life Sustaining Treatment (POLST). The IJ began on [DATE] when R1 was found unresponsive in her room and staff performed CPR based on an outdated POLST that was not corrected in R1's electronic medical record (EMR). R1's current POLST on [DATE] indicated DNR/DNI. The IJ was identified on [DATE]. The administrator, the director of nursing, and the regional clinical director were notified on [DATE] at 1:30 p.m. The IJ was removed on [DATE] and the deficient practice was corrected on [DATE], prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's hospital discharge paperwork indicated R1 was full code status, dated [DATE]. A physician order dated [DATE] at 9:36 a.m. was entered by a health information management (HIM)-A and verified by the clinical coordinator RN-A at 1:14 p.m. The order identified R1 to be a full code. R1's POLST, witnessed by RN-B and R1 on [DATE], and signed by the practitioner on [DATE], indicated R1 wished to be Do Not Attempt Resuscitation / DNR (Allow Natural Death). R1's POLST was uploaded to R1's EMR on [DATE]. R1's medical diagnosis list indicated R1 admitted to the facility on [DATE] for a displaced fracture of the left femur. R1's relevant diagnoses included fractures of the thoracic vertebrae, chronic pain, history of falling, and generalized muscle weakness. R1's Minimum Data Set (MDS) dated [DATE], indicated R1 admitted to the facility on [DATE]. R1's Brief Interview for Mental Status (BIMS) was 15, indicating she was fully cognitively intact. A progress note dated [DATE] at 5:12 a.m. indicated on [DATE] at approximately 11:40 p.m., RN-C and RN-D were alerted by the nursing assistant (NA)-A there was an emergency with R1. RN-C and RN-D responded to R1 and determined she was unresponsive without breathing or pulse. RN-C and RN-D began CPR. At 11:45 p.m. emergency medical services (EMS) were contacted. At 11:58 p.m., EMS arrived, assumed care, and continued providing CPR. The clinical administrator (DON) was contacted at 12:00 a.m. EMS pronounced R1's time of death at 12:15 a.m. on [DATE]. R1's family and provider were contacted. During an interview on [DATE] at 12:53 p.m., RN-E stated a resident's code status is displayed on the resident's home page in the EMR and in the physician order's tab. Part of their admission process is to obtain a POLST from the resident. The facility previously process was to have the resident sign a new POLST, then place it in the provider's box for review, which lead to a gap in communication of code statuses. They recently received training on the new process for changing code status. RN-E stated if a resident wants to change their code status and the provider is not available, they must go through POLST paperwork with the resident, and then call the on-call provider to get a verbal order, which is immediately entered into the resident's EMR. Entering the new code status order automatically changes the resident's banner in the EMR. The nurse must then fax the POLST form to the provider, and have the provider sign the POLST and fax it back. RN-E stated then they must scan the POLST into the EMR, put the physical copy in a box for filing, or give it directly to the HIM, then write a progress note detailing the resident's new code status. During an interview on [DATE] at 1:48 p.m., RN-F stated a resident's code status can be found in the resident's EMR profile on their banner. If a resident wants to change their code status, they need to complete a POLST form with them and call a provider for a verbal order. Then enter the verbal order on the resident's EMR, fax the form to the provider, and when a nurse receives the provider's signature, then uploads it to the EMR. RN-F stated then the POLST is put in the HIM's box for filing. During an interview on [DATE] at 2:18 p.m., RN-C indicated he was coming onto his shift the night of [DATE]. RN-C stated NA-A came running to him while he was receiving report from RN-D. RN-C and RN-D ran to R1's room and immediately took action. He retrieved an ambubag, and when he returned, R1 did not have a pulse. He and RN-D used the EMR to verify R1's code status as full code. He and RN-D initiated CPR, and EMS were contacted. RN-C stated when EMS arrived, they assumed care and requested R1's code status documentation and when they checked the paper chart, they found the physical POLST indicating R1 was DNR/DNI and informed EMS of the current POLST. R1 was pronounced dead shortly afterwards. POLST reeducation was received from the DON regarding respecting resident wishes and rights. Their process for new code statuses is to complete a POLST with a resident and then contact a provider for a verbal order immediately. RN-C stated once the POLST is faxed and signed by the provider, he would upload it into the computer and put the document on the HIM's desk for filing. During an interview on [DATE] at 3:15 p.m., RN-D stated when she and RN-C arrived in R1's room, R1's respirations were shallow, and her pulse was thready. She checked R1's code status in the EMR while RN-C retrieved an ambubag, and identified R1 was a full code. When she and RN-C reentered the room, R1 did not have a pulse and was not breathing, so they initiated CPR. RN-D stated EMS was called and when they arrived, they assumed care, pulled R1 onto the ground, continued CPR, and asked for R1's code status paperwork. RN-D went to the nursing station, retrieved R1's POLST, and saw R1 had a signed POLST indicating she was DNR/DNI. RN-D stated she immediately called the DON for guidance, and the DON directed her to have EMS stop CPR. EMS stopped CPR and announced R1 was deceased . RN-D stated she received reeducation that night from the DON about honoring a resident's wishes and signed it before leaving the facility on [DATE] at approximately 2:30 a.m. During her shift on [DATE], the DON held an all-staff meeting regarding code statuses. Their process if a resident wants to change their code status is to go through a POLST form with the resident and then call the provider. They will receive a verbal order from the provider and enter it as an order in the resident's EMR. RN-D stated the POLST is then uploaded to the EMR by herself or the HIM. During an interview on [DATE] at 3:34 p.m., RN-A stated any orders entered by the HIM must be confirmed by a licensed RN. Their new process for changing code status documentation is to obtain a new POLST from the resident and contact the provider for a verbal order. RN-A stated the nurse would enter the order into the EMR. This would either be done by the resident's nurse, or herself or the DON if they were available. It was the responsibility of the nurse who completed the POLST that did not match their current code status to contact the provider and update the EMR. RN-A stated there was reeducation completed with all staff regarding this process and their preexisting expectations and policies, including individual education for RN-A, RN-B, RN-C, and RN-D. During an interview on [DATE], the DON stated on [DATE] at approximately 12:00 a.m., he got a call at home from RN-D. RN-D explained she and RN-C completed CPR under the understanding R1 was full code per the EMR, but discovered when reviewing the paper charts R1 had a DNR/DNI POLST signed by the provider on [DATE]. He instructed RN-D to inform EMS of R1's code status, at which point CPR stopped and R1 was pronounced dead. The DON stated he immediately conducted an audit of all other remaining residents to ensure their documented code statuses matched their most recent signed POLST orders. Starting [DATE], he and RN-A completed reeducation for all staff on their new process for changing a resident's code status. Their new process if a resident wants to change their code status is for nursing staff to receive a new POLST, and then immediately contact the on-call provider to receive a verbal code status order. The nurse must then enter the verbal order into the EMR, then either upload it directly to the EMR, or give it to the HIM for uploading if they are present in the building. The POLST then goes to the in-house provider's box for review. This process can either be completed by the resident's nurse, or by himself or RN-A. RN-A received reeducation on ensuring the POLST orders match in PCC prior to giving it to the HIM for filing. RN-B received reeducation to make a progress note if a resident wants to change their code status. RN-C and RN-D received reeducation about respecting resident rights and wishes immediately following R1's death. The DON stated the facility has added this process to their QAPI initiates. The facility began conducting Code Blue drills for unresponsive residents on [DATE] and will continue with these initiatives monthly for four months, and then quarterly. During an interview on [DATE] at 8:50 a.m., RN-B stated she admitted R1 to the facility on [DATE]. R1 informed her she wanted to be DNR/DNI, and she completed a POLST with R1. She then put the POLST in the provider's box to be reviewed. She did not know R1 had been full code in the hospital, and that she could not see the order on her EMR. RN-B stated orders can be entered by the HIM but will not become visible on the EMR until they are approved by an RN. RN-B stated if she had known R1 wanted to change her code status, she would have called the provider immediately and gotten a verbal order, then placed the POLST in the box for provider review and HIM to file. During an interview on [DATE] at 10:45 a.m., HIM-A stated she is no longer allowed to put code status orders from the hospital into the EMR. HIM-A stated she does not remember if she saw R1's POLST order. During an interview on [DATE] at 10:45 a.m., RN-A stated POLSTs go to the HIM for scanning if they are in the building, otherwise it is the responsibility of the RN obtaining the new POLST. RN-A stated the HIM does not enter the code status orders for residents. A RN must enter new code status orders. This IJ was called at past noncompliance due to action the facility took prior to the survey entrance. Action included all staff were educated on how to change a resident's code status. The Code Status: Physician's Order for Life Sustaining Treatment policy reviewed by management and reviewed with all licensed staff. All staff directly involved in the incident and inputting code status order were reeducated on existing system and the importance of a code status. All the facility residents were audited to ensure their code status was correctly input in the software system and was current. A policy titled Code Status: Physician's Order for Life Sustaining Treatment Policy, dated [DATE], indicated resident orders must match the resident's POLST. The policy indicated if a resident chooses to become DNR/DNI, a telephone order should be obtained until the original document can be reviewed and signed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure manufacturer recommendations were followed for a mechanical lift transfers and failed to a comprehensive assessment residents safety when using a mechanical lift. This resulted in immediate jeopardy (IJ) when one sling loop detached resulting in head injury, broken neck, and death. In addition the facility failed to comprehensively assess for sling style and size to ensure safe transfers for 1 of 8 residents (R2) that used a full body mechanical lift. The IJ began on [DATE], at approximately 4:45 p.m. when R1 fell from a mechanical lift when two aides did not follow the care plan and facility policy resulting in R1's death. The interim administrator, administrator, director of nursing (DON), and clinical coordinator (CC)-A, were notified of the immediate jeopardy on [DATE], at 5:18 p.m. The immediate jeopardy was removed on [DATE], at 1:34 p.m. but non compliance remained at a lower scope and severity of an D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings Include: A facility reported incident (FRI) dated [DATE], at 4:45 p.m. indicated that R1 was being transferred from bed to wheelchair via a Golvo full body mechanical lift. The report indicated that during the transfer one of the loops of the sling (a fabric device that directly hooks to the lift that provides patient stability) slipped off the lift hook resulting in R1 falling out of the sling and onto the floor. R1 sustained a laceration to the back of the head and R1 was transferred to the hospital. R1's face sheet identified diagnoses of dementia, unspecified Alzheimer's disease, and osteoporosis. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment. R1 required total dependence of two staff assist with transfers. R1's Resident Transfer assessment dated [DATE], indicated R1 required two person assist for a full body mechanical lift for transfers. The assessment indicated R1 weighed 96.9 pounds (lbs.). Further indicated R1 required three different style slings: a universal sling size medium slim (99-154 lbs.), amputee sling size medium (88-132 lbs.), high back sling size medium (88-176 lbs.) The assessment did not specify which style sling R1 was to use and had the wrong size sling according to her weight. R1's care plan revision, dated [DATE], identified R1 was non-ambulatory. R1 required assist of two staff with a full body mechanical lift and a MEDIUM sized sling to transfer. R1's care plan did not identify the style of the sling as indicated in her transfer assessment. R1's care guide (abbreviated care plan for direct care staff) dated [DATE], indicated R1 required assist of 2 with the use of a full body lift, and an (orange) small size sling, which was inconsistent with the care plan. R1's nursing progress notes dated [DATE] at 4:45 p.m. indicated R1 had a fall from the mechanical full body lift. When (registered nurse (RN-A)) arrived, R1 was lying on the floor on her right side between the lift's leg. (NA-A and NA-B) said they don't know how it happened. R1 had two cuts on the backside of her head that measured 2.0 centimeters (cm) x 0.5 cm, and 1.0 cm by 0.5 cm. Bruising noted to the right side of R1's face. Intervention based on root cause analysis: education given on total lift and sit to stand machine by director of nursing (DON) to all employees on duty. During a phone interview on [DATE], at 2:14 p.m., family member (FM)-A stated R1 had died this morning from her traumatic injury sustained from the lift transfer. FM-A indicated R1 was completely bruised on one whole side of her body, on her arms and legs and suffered horribly. During a phone interview on [DATE], at 2:28 p.m. family member (FM)-B stated she had filed grievances about lift transfers being completed with only one staff; she did not get timely responses. FM-B explained she was at the facility on [DATE] and left at 3:15 p.m. When FM-B left R1 was dressed and had just been laid down in bed. FM-B indicated that she received a call from her brother reporting that R1 had fallen. FM-B arrived back at the facility around 5:45 p.m. R1 was lying in bed actively bleeding from her head and a pool of blood on the floor. FM-B stated the DON informed her R1 had fallen about 3 feet from the lift. FM-B stated she informed and instructed the DON that R1 needed to be transferred to the hospital after she visualized the extent of R1's injuries. A summary record, M Health Fairview, University of Minnesota Medical Center (UMMC) admission date, [DATE]. Record indicated that R1 sustained a T1 compression fracture (a type of broken bone that can cause your vertebrae to collapse, making them shorter), a C2 left transverse process fracture (cervical spine fracture), left distal vertebral artery dissection (occurs when a tear forms in one of the blood vessels running up the back of your neck), and a scalp laceration that required stitches. Further indicated that R1 was initially sent to Woodwinds emergency department (ED), although ultimately sent to UMMC for further work up. R1 went unresponsive on [DATE] and palliative care was initiated. R1 was pronounced dead on [DATE] at 10:08 a.m. During a phone interview on [DATE], at 3:59 p.m., NA-A indicated that on [DATE] at 4:15 p.m. she and NA-B went into R1's room to transfer R1 from the bed to wheelchair. NA-A explained she was in charge of making sure R1 was in the sling correctly; she was the spotter. NA-B was in charge of the operation of the lift. NA-A reported they placed the sling under R1 then had attached the four pieces of the sling loops to the lift and made sure it was fastened correctly; they completed a pause for a cause (double checking the loop positioning prior to the transfer). NA-A then informed NA-B she was going to get R1's wheelchair from the bathroom. While NA-A was getting the wheelchair from the bathroom, NA-B moved the lift backwards away from the bed while R1 was suspended in the air by the sling. NA-A reported NA-B had the lift all the way into the hallway of the room (5 feet) as she was trying to get the chair from the bathroom. When she (NA-A) was in the bathroom R1 fell out of the lift. NA-A indicated the full body mechanical lifts did not require two staff to complete the entire transfer (inconsistent with facility policy). NA-A indicated that R1 was moved too far, too quickly. However, NA-A could not confirm what was happening prior to the fall as she was in the bathroom and could not visualize R1. During a phone interview on [DATE] at 4:26 p.m. NA-B reported during R1's transfer on [DATE], NA-A connected R1 to the lift, verified placement of the sling loops on the machine. NA-B then pulled the machine out from underneath the bed. NA-A walked away and went into the bathroom, and she (NA-B) continued to pull the lift backward towards the hallway approximately 5 feet. NA-B explained in the process, the loop from the right side of the sling came off the lift, causing R1 to fall out of the sling onto the floor. NA-A was not in visual eyesight or R1's reach when the incident occurred. NA-B explained R1's wheelchair was always in the bathroom, so someone always had to step away when getting the wheelchair during the transfer. NA-B indicated R1 was transferred back to bed using the same type of sling that she had fallen from; NA-B was not aware of the difference between a high back sling and a universal sling. During a phone interview on [DATE], at 11:33 a.m. registered nurse (RN)-A indicated that she entered the room on [DATE] just before supper, after hearing screaming. RN-A found R1 on the ground between the lift legs. RN-A indicated NA-A had not witnessed the fall because NA-A had gone into the bathroom to get the wheelchair during lift transfer. RN-A indicated that she applied pressure to R1's head with a washcloth to try and stop the bleeding. RN-A stated, the lift and sling were immediately removed from service. RN-A and the DON transferred R1 from the floor back to R1's bed using a different full body lift and a different universal lift sling. RN-A could not articulate the difference between a high back and universal slings. During a phone interview on [DATE], at 12:29 p.m. lift representative (LR)-B indicated the lift, and the sling were inspected by the manufacturer. There was no equipment failure identified and it could only have been operator error. During a phone interview on [DATE], at 11:07 a.m. LR-A stated, when moving the full body lift around, this could cause the sling to go back and forth with or without someone in the lift. It's best practice and has always been the company's expectation to have two people when transferring with a full body mechanical lift. One person acts as the operator and the other as the spotter. The spotter would be observing the situation including the loop latch and providing protection and compensation to the patient. To ensure safety during the transfer, it is too much for one person to do alone. LR-A stated R1's fall could have been prevented had a second person or spotter been there to lead the lift and the movement of the sling. During an interview on [DATE], at 12:16 p.m. DON stated that NA-A and NA-B did not follow the facility policy when both aides were not in visual line of site during the full body lift transfer with R1. Additionally, R1's wheelchair the shortest distance possible from the transfer (R1 would have had to pushed in the lift while suspended to the transfer surface versus turning the lift to the transfer surface). DON expected staff to follow manufacturer's recommendations and facility policy when transferring residents with mechanical lifts. R2 R2's face sheet indicated diagnoses of dementia with other behavioral disturbance, Alzheimer's disease, delusional disorder, and anxiety disorder. R2's quarterly MDS assessment dated [DATE], indicated R2 has severe cognitive impairment and was dependent on two or more staff with transfers. R2's quarterly Resident Transfer Assessment, dated [DATE], indicated R2 weighed 104.4 lbs. The assessment indicated R1 incorrectly identified R2 required a medium universal sling (132 to 198 lbs.); according to R2's weight the R2 required the universal medium slim sling (99-154 lbs.) Assessment further identified R2 required a medium full back sling (88-176 lbs). The assessment did not specifically identify which sling was appropriate for R2. R2's care plan revision date [DATE], indicated R2 was transferred with a full body mechanical lift with two staff and directed to use medium slim sling. R2's undated care guide directed staff to use a yellow medium slim sling (however indicated the wrong color of yellow, the corresponding sling was gray). During an observation on [DATE], at 12:29 p.m., R2 was transferred via full body mechanical lift with a medium yellow high back sling from the chair to the bed. This was completed by NA-C and NA-D. The sling used was not in accordance with the care plan. During an interview on [DATE], at 9:33 a.m. clinical coordinator (CC)-A indicated the DON completed all of the Resident Transfer Assessments (that were not referred to therapy). The care plan and care guide were then updated to reflect the size sling; care guides were updated daily with any changes. CC-A reviewed R2's record, CC-A stated R2's assessment identified all three sling styles (universal, high back, and amputee sling) for R2, but did not specifically identify which sling R2 required and/or appropriate for transfers. CC-A was unable to articulate which sling should be used for any residents when all three slings were identified on the assessment. During an interview on [DATE], at 12:16 p.m. DON stated that R2 was transferred on [DATE], with the wrong size sling. R2 should have been transferred with the high back medium slim gray sling. During interview on [DATE] at 12:18 p.m. occupational therapist (OT-A) indicated sling sizes were determined by weight and sometimes physical attributes such as being an amputee. OT-A stated there were not any other contributing factors when choosing universal sling versus high back. During interview on [DATE] on 2:58 physical therapist (PT-A) indicated the therapy staff is at times involved in sling determination. When therapy completed the lift assessments they would determine sling sized based on resident weights. Therapy would then fill out an interdisciplinary team communication sheet, the clinical coordinator would put it in the care plan. Facility used small, medium, and large size slings. PT-A stated that the facility had only been using universal slings and not high back or amputee slings. During interview on [DATE] at 3:05 Director of Therapy (DOT-A) indicated an unawareness of the facility's sling inventory and would need to verify what size and style slings were on hand. DOT-A was unable to articulate an indication for a high back sling. DOT-A indicated staff need to reference the color coded chart on the lift for what sling to use. DOT-A explained if a resident's weight was not accurate to the size or if manufactures recommendations were not followed then serious risks can occur. During an interview on [DATE], at 9:56 a.m. DON could not articulate the difference between the styles of the slings and indication of use. Further indicated that the facility was not completing individualized comprehensive assessments for the appropriate lift sling size and style and confirmed all residents care plans and care guides were not accurate for identification of sling style and size. Facility policy Resident Transfer Assessment Policy dated [DATE] indicates that the assessment is to be completed by a licensed nurse or therapist. Licensed nurse or therapist will review documentation, interview direct caregivers, and observe a transfer of the resident. If the resident requires a mechanical lift the resident will be assessed for proper sling or harness using the manufactures guidelines. This will be noted in the assessment. The policy indicates that assist of two staff are required for all residents requiring a full mechanical lift. Facility Mechanical Lift Transfer Policy dated [DATE] directed the following: staff to always follow manufacturer's recommendation for the proper use of the equipment and slings. Two staff must remain present through the process of the transfer until the lift is no longer engaged and sling straps are unhooked. Staff are not to leave the resident out of visual line of site while the resident is attached to the lift. Further directs staff to place a wheelchair or other equipment, which the resident is to be transferred to, within the shortest distance possible from the bed, facing the head of the bed. Residents cannot be left hooked to the mechanical lift unless staff are present or directly visualizing. Manufacturer's recommendations for Universal and high-backed slings, dated 2020, indicated, It is important to choose the correct size in order to achieve the highest level of comfort and safety. A sling which is too large increases the risk of the patient sliding out of it, while one which is too small can cut into the groin and cause discomfort. Manufacturer instructions for the Liko Golvo lift dated 2017 included Before lifting always make certain that: -the lift strap is not twisted or worn and that it can move freely in and out of the lift unit; · the lifting accessories is selected appropriately in terms of type, size, material and design with regard to the patient's needs; ·the lifting accessory is correctly applied to the lifting equipment; ·the lifting accessory is correctly and securely applied to the patient, so that no personal injury can occur; ·the sling's strap loops are correctly fastened to the slingbar hooks when the sling strap is extended, but before the patient is lifted from the underlying surface. Never leave a patient unattended in a lifting situation! The immediate jeopardy that began on [DATE], was removed on [DATE], when it was verified the facility implemented the following: -The facility reviewed and revised the full body mechanical lift policy to include directives on completing the comprehensive assessment for sling sizes and styles. -The facility comprehensively assessed all residents who utilized full body lifts in accordance with the manufacturers recommendations. -The facility revised care plans and care guides based on the comprehensive assessment for all residents who utilized full body lifts. -The facility educated all nursing staff on required two staff assist for full body transfers, double checking the position of the loops, completing comprehensive assessments for sling style and size, and on the types of slings and sizes. In addition, staff completed competency tested.