**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) in accordance with resident wishes and physician orders for full code status of CPR to 1 of 3 residents (R1) reviewed. This deficient practice resulted in an immediate jeopardy (IJ) situation when R1 was found not breathing, had no pulse, CPR was not initiated timely, and R1 passed away at the facility. The IJ began on 8/29/24, at 12:30 a.m. when R1 was noted to have no respirations or pulse, and no immediate action was taken by Registered Nurse (RN)-A, including CPR, which resulted in a missed opportunity to resuscitate R1, resulting in certain death. On 9/6/24, at 5:15 p.m. the administrator and director of nursing (DON) were notified of the IJ. The IJ was removed on 9/7/24, following verification of an acceptable removal plan however, noncompliance remained at the lower scope and severity level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's diagnoses list dated 9/5/24, identified: neoplasm (growth of abnormal cells) of bladder, aftercare following surgery for neoplasm, acute post hemorrhagic anemia (excess bleeding), abnormal uterine and vaginal bleeding, heart failure, presence of coronary angioplasty implant and graft, diabetes mellitus (type II), history of venous thrombosis and embolism (blood clot), and gross hematuria (visible blood in urine). R1's Provider Orders for Life-Sustaining Treatment (POLST) prepared and signed by healthcare agent family member (FM)-A on 8/27/24 (box checked: patient has capacity), and signed by provider on 8/28/24, identified: Attempt resuscitation /CPR (cardiac pulmonary resuscitation) (NOTE: selecting this requires selecting Full Treatment in section B). Section B Full Treatment. Use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. All patients will receive comfort-focused treatments. R1's orders from 8/27/24, through 8/29/24 included: Code Status - Full Resuscitation order date 8/27/24. R1's care plan dated 8/28/24, identified resident had Foley catheter due to bladder tumor diagnosis. Interventions directed staff to monitor/record/report to MD (medical doctor) for s/sx (signs and symptoms) of UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased [NAME], temperature, and urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. R1's progress notes (PN) dated 8/27/24, through 8/29/24, identified: -on 8/27/24 at 5:23 p.m., R1 arrived at facility via EMT (emergency medical technicians) transport on w/c (wheelchair) accompanied by son. R1 was A & O x4 (alert and oriented times four), forgetfulness noted. -on 8/28/24 at 10:30 p.m., administered Acetaminophen oral tablet 500 mg (milligrams) two for sign of mild pain. -on 8/28/24 at 11:30 p.m., PRN (as needed) administration of Acetaminophen was effective, follow up pain scale was 0 out of 10. -on 8/29/24 at 1:17 a.m. replace and re-insert pulled out Foley catheter. Send patient to emergency if resistance is met. -on 8/29/24 at 6:22 a.m. R1 pulled out indwelling catheter together with the water balloon that anchored it in place. Some bleeding noted, R1 was washed up and a brief was offered to patient pending an order from provider for further action. Writer put a call into provider and waited to be called back. (PN lacked detail on when R1 pulled out catheter and when call was made to provider). Later, nurse practitioner (NP)-A called back and after a thorough explanation of the situation, an order was given to re-insert catheter. R1 was approached for re-insertion but refused. Writer suspected pain and administered Tylenol then let R1 be for a while, leaving her door open for easy monitoring. At 12:30 a.m. patient was okay talking and breathing without any sign of impending doom. By around 1:00 a.m. writer saw patient lying across bed and was not responding to any stimulus and looked lifeless lying her head in vomited food and fluid with some in her mouth. Writer quickly called the other nurse who also noted that patient was lifeless and then left the room immediately. Writer then turned patient to her right side while the water was still oozing out. CNA [certified nursing assistant] then noted that patient had passage of bowel movement and quickly cleaned it. As more fluid was oozing out after the second nurse left. CNA left to go answer call light while writer let out the water in patient's mouth and raised head of bed [HOB] and went to the nursing station to check patient's code status. Have noted code status RESUSCITATION, writer dashed back and asked the other CNA for help with putting patient down and CPR initiated immediately. No time was wasted. Patient was on the floor with fluid oozing from the mouth and POLST status had to be ascertained. All these were satisfied in a short time, couple of minutes then CPR was started: 911 was called. Patient was not able to be resuscitated. Family was informed and family came and arranged funeral home. Patient has long been deposited in funeral home. R1's treatment administration record (TAR) documentation of urinary output entered per shift (a.m. 0700-1500, p.m. 1500-2300, night shift 2300-0700. 8/27/24 evening output 350 cubic centimeters (cc) and night output 700 cc. 8/28/24 Evening output 500 cc and night output 300 cc. R1's electronic medical record did not identify R1's urinary output on 8/28/24 day shift. Review of NP-B visit dated 8/28/24, identified R1's advanced directives: Full Code. R1 had been hospitalized from [DATE], through 8/27/24, due to vaginal bleeding and concern for urinary source bleeding which resulted in increasing lightheadedness, dyspnea (shortness of breath), and a low hemoglobin 5.9 hemoglobin (Hgb) grams per deciliter (g/dL) (normal range 11.5 to 15). R1 received two units of red packed blood cells (RBC) upon admission and Hgb improved to 7.9, 8.4, and 8.3. On 8/21/24, R1 underwent D & C (dilation and curettage) (removed tissue from uterus), cystoscopy with fulguration of vessels (heat derived from an electrical current to destroy atypical /cancer tissue), and 50% removal of the bladder tumor. Additionally, on 8/22/24, R1 had an inferior vena cava filter placed due to unable to restart anticoagulant. R1 had an indwelling foley catheter placed to have remained in while at TCU. R1 was seen today 8/29/24, for an admission visit in the TCU. R1 had just finished up therapy and reported she was worn out from therapy. Appetite fair and no further bleeding. R1's vital signs 107/67, 97.3 Fahrenheit (F), pulse 86 per minute, 16 breathes per minute, and oxygen saturation level (Sa02) 98% (normal range 90 to 100%). R1's last Hgb on 8/27/24, was 8.9 g/dL. The facility's Incident Report submitted to the State Agency (SA) on 8/29/24 at 9:44 p.m., identified incident occurred on 8/29/24 at 1:00 a.m., administrator was notified of incident on 8/29/24 at 2:36 a.m. Nursing staff noted R1 had cessation of pulse and respirations on the morning of 8/29/24 at 1:00 a.m. The timeline of events from nurse progress notes were not conclusive as to when CPR (Cardiac pulmonary resuscitation) was initiated. Registered Nurse (RN)-A was suspended pending further investigation. Investigation was started. The facility's investigation submitted to the MDH on 9/6/24 at 9:17 a.m., identified this was an isolated incident, resident expired. The facility findings were inconclusive due to inconsistencies with staff statements and inability to establish and verify timeline of events. The resident's primary nurse resigned from her position effective immediately 8/30/24. Review of [NAME] St. [NAME] Police Incident Report with a creation date and time of 8/29/24 at 5:43 a.m. revealed the following: [RN-B] was agitated and noted that [R1] had been unconscious for an extended period and that [RN-A] had failed to provide or render proper aid for an extended period. [RN-B] alleged that [R1] had been unconscious since midnight, approximately one hour before the call for service. [RN-B] was upset and contacted the state because of the neglect. I spoke with Mhealth's supervisor, who noted he asked [RN-B] if she had contacted first responders to assist with the medical, and she said she had not because it was not her patient. I spoke with [RN-A], who noted she was in [R1]'s room around 00:40. Around 01:00, she walked past the room and saw [R1] lying across the bed, so she entered the room to assist her. [RN-A] found another employee to help with moving [R1] when she realized she had been vomiting. [RN-A] ran and found [RN-B] and advised her of the situation. [RN-B] followed her to the room and eventually left. [RN-A] saw food in [R1]'s mouth, so she moved her to the floor to begin to render aid. While speaking with [RN-A], [RN-B] approached and began to allege she was lying about what had occurred. I separated the two and asked [RN-B] to provide us with some privacy. After speaking with [RN-A], I found [RN-B] and learned the following: anytime the facility has a death, nurses will request a second nurse to verify the information. This includes checking the heart, checking the pupils, and confirming the individual is deceased . [RN-A] called [RN-B] to the room at 00:30 hours, where she checked the pulse and pupils. [R1] showed no pupillary response and had no heartbeat; however, she was still warm. [RN-B] asked if this was an expected death, which is frequent due to the facility's nature, and [RN-A] advised it was. [RN-A] and the nursing assistant began straightening the body and cleaning the bed. Around 01:00, [RN-A] asked for the nursing assistants help, entered [R1]'s room, and began to perform CPR. According to [RN-B], before requesting the nursing assistant to perform aid, there were no resuscitation attempts, and aid took 35 minutes before [RN-A] began to render assistance. But there should have been. [RN-B] stated she tried to contact management, but they had not contacted her, and she needed to contact the state within two hours since R1 was a vulnerable adult. Medics continued to render assistance, but [R1] was eventually declared deceased at 01:47 hours .Due to the neglect and serious allegations, I contacted on-duty investigators and informed them of the situation. I also called the Hennepin County Coroner's Office and explained the situation. They said they would not respond to the location based on what they had learned. During a telephone interview on 9/4/24 at 10:30 a.m., RN-B indicated at 12:30 a.m. on 8/29/24, RN-A walked over to the 400 Wing of the nursing home; did not appear frantic or hurried and stated to her, 300 just died, come over to verify the death. RN-B stated she grabbed her stethoscope and one minute later entered R1's room. RN-B stated nursing assistant (NA)-A and RN-A were in R1's room, stood together one side of R1's bed, had repositioned R1's bed sheets, there was no sign of emesis on or around R1, and no CPR was being done. RN-B indicated she checked R1's apical pulse, with no pulse response, then both pupils (nonresponsive), skin was pale but remained warm, no breathing noted, and unresponsive. RN-B stated she asked RN-A if R1's death was expected, and she replied yes. RN-B stated an expected death only meant one thing which was a hospice death, so no code status was checked, and RN-A never requested and further help so she exited R1's room. RN-B stated she informed NA-B there had been a death because now many resident call lights had gone off. RN-B stated then at 12:55 a.m. she observed RN-A walking down the 400 hallway again and asked where NA-B was, so she informed her NA-B was at the end of the 400 hallway. RN-A indicated RN-A walked down to end of 400 hallway yelling out NA-B's name loudly three times. RN-A stated NA-B and RN-A walked together into R1's room and closed the door. RN-A stated right before 1:08 a.m. RN-A exited R1's room and right after that she received a text message from NA-B that said, not sure what was going on but RN-A had us place [R1] on the floor and we are doing CPR . she was already dead . adding, then she looked up from her computer and NA-B was frantically waved at her and she looked scared, so RN-B indicated she got up and went over to NA-B immediately and into R1's room. RN-B stated NA-B informed her RN-A completed some compressions, then left the room, to call EMS, adding NA-B stated she was not comfortable doing CPR by herself, then turned around, and RN-A had returned to R1's room with no exchange of conversation and just started chest compressions on R1 again. RN-B stated when EMS arrived shortly after and entered R1's room, RN-A mislead the entire R1 situation. RN-B stated when EMS had taken her statement, she informed them at 12:30 a.m. she confirmed with RN-A that R1 had died, body was warm, and RN-A informed her it was an expected death. RN-B stated there was no crash cart or ambu bag in R1's room. RN-B stated at 2:23 a.m. she called DON, but got no response, then called floor manager licensed practical nurse (LPN)-D and reviewed the events with her, which most likely met state notification, and unexpected death of a vulnerable adult (VA). RN-B received a call back at 2:47 a.m. from LPN-D who had informed the administrator. During a telephone interview on 9/4/24 at 3:40 p.m., NA-A stated RN-A stood in front of R1's door and asked for help, R1 needed to be repositioned. NA-A verified both of us entered R1's room as she laid on her back across the bed with her feet on the floor and head towards the window. NA-A stated as they walked closer to R1 they realized she was dead, color was [NAME]/yellow and unresponsive. RN-A indicated as they repositioned and boosted R1 up into the bed throw up came out of her mouth. NA-A also stated RN-A checked R1's hear rate and said out loud no heart rate. RN-B also entered R1's room, assessed R1's pupils and confirmed she was not breathing, and left R1's room. NA-A stated no CPR was started and she changed R1's sheets twice with RN-A's assistance due to the throw up and bowel. NA-A confirmed R1's body was still warm and stated she said out loud to RN-A that this must have just happened. NA-A stated RN-A told her she had to call 911, her son, and the DON and left the room. NA-A stated she left her room after 10 or more minutes and answered other call lights. During an interview on 9/5/24 at 10:36 a.m., NA-B stated at about 12:30 a.m. RN-B informed her R1 had passed away. NA-B stated she walked down to R1's room, peaked into the room and R1 looked white, was not moving, and appeared deceased . NA-B stated there was no one in the room with R1. NA-B stated at about 12:45 a.m. she heard hollering in the hallway, and it was RN-A yelling for her to come help her. NA-B stated she followed RN-A to R1's room and was told to hurry, R1 needed to be placed on the ground. NA-B stated she was confused as to what was going on as she was previously told R1 was deceased . NA-B verified she assisted RN-A and lifted R1 from the bed with a lift sheet located underneath her and placed her onto the floor, her body was still warm and R1 was unresponsive the entire time. NA-B stated she felt very uneasy with the situation, but RN-A was very confrontational and not easy to work with, so she did what she asked. NA-B indicated RN-A and RN-B do not get along and she felt that was why she walked past RN-B and had chosen her go to R1's room. NA-B verified RN-A started chest compressions on R1 and stopped after one minute at around 1:05 a.m. NA-B stated RN-A instructed her to keep doing the compressions, and she had her CPR certification so she started compressions when RN-A left the room stating she was going to call 911. NA-B stated nothing had been put in place for CPR, no crash cart, no oxygen, no ambu bag and RN-A had not completed an assessment on R1's heartbeat/pulse while she was in the room. NA-B stated she was left in the room alone with R1 and completed chest compressions until she got tired, then stopped, opened R1's door, waved down RN-B and informed what they were doing (CPR/chest compressions only). NA-B stated RN-A had not returned to R1's room to help with CPR until she saw RN-B in R1's doorway. NA-B indicated at that time she heard the EMS sirens and went to front door and let them in. EMS went directly into R1's room and stated CPR. NA-B indicated unsure if or when RN-A checked R1's code status but felt like she panicked when she realized she was a full code. During a telephone interview on 9/5/24 at 11:07 a.m., RN-A stated on 8/28/24 between 6:30 p.m. and 7:00 p.m. she was notified R1 had pulled out her indwelling catheter. RN-A she stated she decided to wait to call provider, checked another resident's orders, completed a wound dressing changed, and finished up with her medication pass. RN-A stated it was later in the evening NP-A provided an order: re-insert and if resistance was met send to ER. RN-A stated she entered the order into the electronic health record and finished a few other things, then went to R1's room. RN-A stated R1 refused to have catheter re-inserted, denied pain but could see her face frown so she administered Tylenol between 10:00 p.m. and 11:00 p.m. RN-A stated she returned back to R1's room at 12:30 a.m. and again she refused re-insertion of the catheter. After finishing up a few things, RN-A stated she was then going to call 911 and send her to the ER but at 1:00 a.m. she noticed R1 laid across her bed with her feet on the floor, quickly went to room [ROOM NUMBER] and got a NA-A. RN-A stated both staff entered R1's room and she was lifeless and so quiet. RN-A stated she removed fluid from R1's mouth three times, turned her onto her side, and within a few seconds called RN-B and she rushed into R1's room. RN-A stated RN-B placed a stethoscope on her chest over her heart and stated she's dead. RN-A stated she shouted out, I had just talked to her. RN-A verified she checked as soon as she could R1's carotid and apical pulses and no heartbeat, skin color had not changed, and R1's body was still warm. RN-A stated RN-B rushed out of room, adding voluntarily, we are enemies, she had been fighting with all of us, accused me of things, and liked to control people. RN-A indicated R1's mouth continued to drain a cloudy fluid that smelled like undigested food with particles in it. RN-A stated she assisted NA-A to clean R1 up (brief change) and change her sheets twice. RN-A stated she had left R1's room and checked her POLST for code status and confirmed she was a full code. RN-A stated NA-A had left R1's room. RN-A indicated RN-B sat at the 300 nurse's station, she saw NA-B down the hallway and said come, come, come and together they entered R1's room. RN-A stated she chose NA-B because she was stronger and RN-A would not have helped immediately, said R1 was already dead, and asked a lot of questions. RN-A stated together with NA-B they lifted R1 off the bed with a lift sheet located underneath her and placed her onto the floor. RN-A stated no urine output was noted and unsure of what time this had been done. RN-A stated she started CPR without assistance, two minutes after she found her, I did not keep track of time, completed 30 chest compressions, stopped, checked neck pulse and no pulse then asked NA-B to complete chest compressions. RN-A stated she left the room called 911 and planned on grabbing ambu bag. RN-A stated she called DON first, didn't answer, left message, adding R1 was confirmed not breathing and like she was dead. RN-A verified she then called 911 but knew she should have called 911 prior to starting CPR and this was all completed in two seconds. RN-A indicated she returned back to R1's room and RN-B stood outside her bedroom door and said you are doing CPR on someone that has died, while NA-B continued chest compressions alone. RN-A stated EMS arrived, entered R1's room and took over. RN-A verified she should have asked RN-B to check R1's code status, would have saved time then CPR could have been started sooner. RN-A stated if this situation happened again, would do it differently and after no pulse, started CPR even if code status was not verified, to avoid something like this happening again. RN-A stated, it would have been a good idea to start CPR right away. RN-A also indicated she would have checked the code status for each resident at the beginning of the shift so that there would be no wasted time to go look. During a telephone interview on 9/4/24 at 4:00 p.m., family member FM-A stated on 8/28/24, R1 was a little sluggish, tired, refused to eat lunch and supper which was rather odd for her. FM indicated around 6:00 p.m. requested bathroom and he stepped out of room while staff assisted her. FM stated a few minutes later RN-A came out of the room looking flustered and informed him R1 had pulled out her urinary catheter, if they could get the bleeding under control, they would reinsert catheter and if not, she would be transferred back to the hospital. FM stated did not get a sense that this was an everyday event but none of the staff seemed concerned, requested to be called with an update that evening, and left facility to go back home. FM stated had not heard received a call from the RN-A, called and talked to her and was informed my mother was doing fine, had not gotten a chance to re-insert the urinary catheter. FM stated then at 1:15 a.m. on 8/29/24, received a call from RN-A and was informed R1 was unresponsive and medical emergency had done CPR on her. FM stated RN-A had informed him they had packed a pullup with a hand towel used to prevent her from bleeding. FM stated R1 had not moved to TCU to die and was expected to have returned to the hospital in two weeks for the remainder of the tumor to be removed. During an interview on 9/6/24 at 2:20 p.m., director of nursing (DON) verified interviews were completed with all staff working the night shift the evening of R1's passing. DON indicated timelines varied, staff were unable to identify times things occurred, events were not consistent with RN-A's interview, and verification of consistencies was challenging. DON stated certain aspects aligned with RN-A's interview but what stood out was when the staff NA completed chest compressions, she indicated the body was warm. DON stated RN-A informed her she removed fluid from her mouth, cleaned her up and applied a new brief. DON stated a code status should have been checked, CPR started immediately instead, and another staff should have brought the crash cart into the room with suction machine on it, which would have helped remove R1's secretions out of her mouth. DON verified CPR should only be completed by certified licensed staff to assure the resident was getting high quality CPR, timing, and document the incident. DON also verified the staff NA should not be asked to complete chest compressions, especially after RN-A left the room. DON indicted R1's cause of death was not identified, and her death was unexpected. During a telephone interview on 9/6/24 at 5:00 p.m. medical director (MD) stated there were poor nursing decisions made throughout the night regarding R1. MD stated after review of the incident, it was identified CPR should have been initiated sooner and was not completed in a timely manner. MD stated R1's death appeared to be unexpected, could have been a cardiac arrest or maybe threw a big blood clot and had a PE (pulmonary embolism), this is unknown, but chance of survival would be about 80% and with her type of diagnoses could still have lived for another 6 months. Facility policy Emergency Response Cardiopulmonary Resuscitation (CPR) dated 7/26/24, basic life support including initiation of CPR to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with the resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. The facility will ensure that properly trained personnel and certified in CPR for Healthcare Providers are available immediately 24 hours a day to provide basic life support, including CPR to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the advance directives and physician orders. All licensed nurses are required to maintain current CPR BLS certification through certification through training that includes hands-on practice and in person skills assessment. Per American Heart Association (AHA) recommendations, all potential rescuers initiate CPR unless: 1. A valid DNR is in place. 2. Obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present. Continue CPR until emergency personnel arrive and take over. The licensed nurse will run the code, instruct staff to obtain the medical record to verify the code status prior to initiating CPR. Once the code status is verified, the licensed nurse will give further directions to staff. The IJ which began on 8/29/24, was removed on 9/7/24, when the facility successfully implemented a removal plan which included: -All nursing staff will be retrained on CPR policy, responding to unresponsive residents, code status and any revisions made to the policy. -All facility staff will be trained on who in the facility should and should not perform CPR -Include the necessity for an immediate response -Outline how those who may not participate in performing CPR should assist to expedite emergency procedures (such as call 911, assist with timely repositioning for CPR preparation .etc.).