**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse. On the evening of 9/19/24, the resident became upset with Licensed Practical Nurse A (LPN A) when he/she removed the resident's oxygen concentrator from the room. The resident, who had diagnoses of anxiety and chronic obstructive pulmonary disease (COPD- a common lung disease that makes it difficult to breathe by restricting airflow in the lung), was observed following LPN A out of his/her room telling LPN A he/she needed the oxygen. The resident became angry, yelling and cursing, and hit LPN A in the face at least twice. LPN A forced the resident to the ground and placed a knee on top of the resident. After pulling the resident up to a standing position, LPN A forced the resident back to his/her room. LPN A then contacted the Director of Nurses (DON), who contacted the resident's psychiatrist, and received an order for a Haldol (an antipsychotic) injection. LPN A later entered the resident's room and administered the Haldol and Benadryl (antihistamine that can be used to induce sleep) while the resident was calm and no longer yelling, cursing or hitting. Five residents were sampled. The census was 89. The Administrator was notified on 10/1/24 at 1:37 P.M., of the Immediate Jeopardy (IJ) past non-compliance, which occurred on 9/19/24. The facility provided training and in-servicing that began on 9/20/24 and ended on 9/21/24, for all staff regarding their policies on Abuse and Neglect, Unnecessary Restraints, and De-escalating Situations. The IJ was corrected on 9/21/24. Review of the facility Abuse Prevention and Prohibition Program policy revised on 10/24/2022, showed: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff; -The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems -Procedure: -The Administrator may delegate coordination and implementation of components of the abuse prevention program to other staff within the Facility; -Covered individuals will be trained through orientation and on-going training sessions, no less than annually, on the following topics included: -Abuse prevention; -Identification and recognition of signs and symptoms of abuse/neglect; -Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. The Facility involves qualified psychiatrists and other mental health professionals to help Facility Staff manage difficult or aggressive residents. Identification and recognition of signs of burnout, frustration and stress that may lead to abuse. Review of the facility Behavioral - Management policy revised on 8/2022, showed: -Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. To ensure that facility staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being meet each resident's needs and include individualized approaches to care; -Policy: The concept of behavior management is an interdisciplinary process. The key components of this process are: Identifying residents whose behaviors may pose a risk to self or others. Developing individual and practical care strategies based on assessed needs. Implementing the behavior management program. Ongoing assessment, monitoring, and evaluation of the effectiveness of psychoactive drugs; -The goal of any behavior management process is to maintain function and improve quality of life. The goal of the interdisciplinary team (IDT) is to promptly identify behavior management issues and develop an effective management program; -It is important to understand that behavior management is not behavior modification. Behavior management means the interdisciplinary team seeks to accommodate the resident with behavioral problems as much as is practical in the facility; -When a resident displays adverse behavioral symptoms (e.g., crying, yelling, hitting, biting etc.), Licensed Nursing Staff will assess the behavioral symptoms to determine possible causal factors, contact the Attending Physician, and implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s); -The facility must provide necessary behavioral health care and services which include: Ensuring necessary care and services are person centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Ensure that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. Providing an environment and atmosphere that is conducive to mental and psychosocial well-being. Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated; -Assess Casual Factors: In assessing the resident for potential casual factors, Licensed Nursing Staff will consider the following factors and document their findings in the medical record: -Psychosocial or emotional stressors (e.g., change in resident's customary routine, loneliness, frustration, fear of the unknown, possible abuse by staff or other residents, incompatibility with roommate, lack of support system); - Medical conditions that require treatment (e.g., diabetes mellitus (high or low blood sugar levels), heart disease, COPD, infection); -Implementation of Interventions to Alleviate Possible Casual Factors: Possible non-psychotherapeutic drug interventions to consider, include, but are not limited to: -Environmental conditions - approach resident calmly, address resident by name, speak in clear tones (do not yell or act excited), touch the resident in a comforting manner if appropriate, use short simple sentences; -Psychosocial stressors - determine resident's preferred routine, offer comfort items, determine cause of frustration, determine if resident is upset regarding treatment by staff or other residents and address concern; - Medical Conditions - check oxygenation if COPD; -In trying to manage the behavioral problem: Work to build a positive, trusting relationship with the resident. Use effective verbal and non-verbal communication techniques. Encourage independence of the resident. Avoid arguing, having yes/no battles, or [NAME] with the resident. Obtain physician order if indicated to include but not limited to the use of physical or chemical restraints. Redirect or divert the resident's attention to a positive topic, activity, or object. Review of the facility De-Escalating policy, undated, showed: -Importance of De-Escalating: It is important that we de-escalate issues. You can do this by: 1. Recognizing and assessing the situation; 2. Responding calmly and showing concern; 3. Listening; 4. Show respect; 5. Avoid confrontation, remove triggers; -Ensure all residents are removed and safe; -Report all violence immediately to the Administrator/Director of Nursing (DON). Review of the facility LPN job description, undated, showed: -Responsibilities (include): Record resident's medical history accurately. Observe residents under treatment to identify progress, side-effects of medications, etc. Monitor resident's condition. Provide emotional and psychological support when needed. Communicate with residents' family or friends to provide advice, comfort and release instruction. Review of Resident #2's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated 7/22/24, showed: -Clear speech, distinct intelligible words; -Makes Self Understood. Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Ability to Understand Others. Understanding verbal content, however able: Understands, clear comprehension; -Moderately impaired cognition; -Physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior not exhibited. -Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others): Behavior not exhibited; -Rejection of Care: Behavior not exhibited; -Mobility Devices: Wheelchair; -Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space: Supervision or touching assistance; -Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns: Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as resident completes activity; -Diagnoses of Parkinson's disease (a chronic, progressive brain disorder that causes movement problems, stiffness, and other symptom), anxiety, depression, psychotic disorder (other than schizophrenia), asthma, COPD, or chronic bronchitis, or chronic lung diseases (e.g., chronic bronchitis and restrictive lung diseases such as asbestosis), and respiratory failure; -Respiratory Treatments: Oxygen therapy - blank. Review of the resident's care plan, located in the electronic healthcare record (EHR), showed: -9/17/24, Focus: Resident has emphysema (COPD). Goal: Resident will be free from signs/symptoms of respiratory infections. Interventions: Head of bed elevated or out of bed upright during episodes of difficulty breathing. Monitor for difficulty breathing on exertion. -6/4/24, Focus: Resistive to care related to anxiety and psych diagnosis. Interventions: Allow resident to make decisions about treatment regime, to provide sense of control. Educate resident/family of the possible outcomes of not complying with treatment or care; -2/5/24, Focus: Potential to be verbally aggressive related to mental/emotional illness. Interventions: Administer medications as ordered. Assess resident's understanding of the situation and allow time for resident to express self and feelings towards the situation. Review of the resident's physician's order sheet (POS), located in the EHR showed: -8/11/24: Tiotropium Bromide Monohydrate (a bronchodilator that relaxes muscles in the airways and increases airflow to the lungs) 1 capsule inhale orally one time a day for COPD; -9/4/24: Ipratropium-Albuterol solution (bronchodilators) inhale orally every 6 hours as needed (PRN); -9/4/24: Lorazepam (antianxiety) give 0.25 mg by mouth every 4 hours PRN; -9/10/24: Amitriptyline (antidepressant) 25 mg. Give 2 tablets at bedtime for insomnia; Review of the resident's physician's order sheet (POS), located in the EHR showed on 9/4/24, the resident may have Hospice consult due to failure to thrive; Review of the resident's Hospice Notification letter, dated 9/13/24, showed the resident began Hospice services on 9/4/24. Review of the resident's physician's order sheet (POS), located in the EHR showed no order for oxygen 2-3 lpm prior to 9/21/24, and no order to check the resident's oxygen saturation prior to 9/23/24. During a telephone interview on 10/8/24 at 12:55 P.M., the resident's family said the resident had used oxygen on and off since he/she had been at the facility. During an interview on 9/27/24 at 11:00 A.M., Resident #2 lay in bed with oxygen infusing per nasal cannula. The resident said a few nights ago, LPN A said he/she did not need his/her oxygen concentrator and took it away which made the resident mad. The resident followed LPN A into the hall and he/she hit LPN A in the face two times. LPN A put his/her arm around the resident's head and took him/her to the floor. Being forced to the floor hurt, but he/she was not injured. After being on the floor for about a minute, LPN A let the resident up and made him/her go back to his/her room. He/She told the DON the next day about what happened. The DON said it wouldn't happen again and the Administrator was investigating what happened. He/She had not seen LPN A since that night. He/She was afraid of LPN A now and did not want to see him/her again. The resident's roommate saw what happened. During an interview on 9/27/24 at 11:27 A.M., Resident #1 said he/she was in his/her room when he/she heard the resident hollering from the hall. He/She stepped into the hall and saw the resident on his/her back on the floor. LPN A had his/her knee on the resident's chest. There were other staff present but he/she did not see them trying to break up what was going on. LPN A seemed to be mad, yelling and telling the resident to stay down and he/she was going to take his/her oxygen concentrator. Resident #1 went back inside of the room while the resident was still on the floor. Review of the resident's progress note's, located in the EHR, showed, LPN A documented: -9/19/24 at 7:46 P.M.: Resident noted to be acting inappropriately this evening and this nurse attempted to educate resident on not changing the settings of how much oxygen is delivered via nasal cannula. Resident is noted to have oxygen saturation level of 99% (normal range is 95-100%) on room air. Resident insists that he/she be allowed to wear the supplemental oxygen and was ordered to have PRN oxygen at 2-3 lpm. Resident has been observed turning up the oxygen to 5 lpm. Resident has been educated and advised not to do this and continues to turn the oxygen up. Since resident does not appear to be in respiratory distress and has an oxygen level of 99% on room air, a decision was made to remove the oxygen concentrator from resident's room. Resident followed this nurse out of his/her room into the hallway. Resident's brief fell off as he/she was walking. This nurse turned and attempted to assist resident replacing his/her brief and resident swung and hit this nurse several times. Staff members present in the hallway at the time immediately intervened and assisted this nurse. Resident was then taken to his/her room and this nurse exited the resident's room to follow per facility protocol. When this nurse returned to the resident's room this nurse was notified that the resident had hit his/her roommate in the face. The resident was noted to be standing in the doorway of his/her room again with no brief on. Staff assisted to place appropriate articles of clothing on the resident and the DON and Administrator were notified. Both residents were separated for safety. -LPN A did not document if the resident's physician or hospice had been consulted prior to removing the resident's oxygen concentrator. During an interview on 9/27/24 at 9:13 A.M., CNA D said he/she worked on the evening of 9/19/24. CNA D witnessed LPN A take the resident's oxygen concentrator out of his/her room. The resident followed LPN A out of the room and into the hall. LPN A took the oxygen concentrator to the nurse's station, but the resident stopped halfway down the hall. The resident was telling the nurse he/she could not breathe without the oxygen concentrator. The resident was yelling and cursing at LPN A. LPN A walked back to the resident who was still standing in the hall and they were facing each other. LPN A was holding the resident's hands to prevent the resident from hitting him/her. He/She was standing right there and was trying to get the resident to go back to his/her room, but the resident refused to go back. The resident's incontinent brief fell down, LPN A bent down and pulled it back up. That's when the resident punched LPN A in the face. LPN A put one of his/her arms behind the resident's head, then placed his/her hand on the resident's face and pushed the resident backwards and onto the floor. He/She did not hear a thud when the resident reached the ground. While on the ground, the resident was on his/her side and LPN A used one hand to hold the resident's hand down, and had a phone in his/her other hand. LPN A placed his/her knee on top of the resident to hold the resident down. The resident was still cursing. LPN A stood up and the resident went from his/her side to his/her back. LPN A bent down, placed his/her hands underneath the resident's armpits from behind the resident and pulled the resident up to a standing position. LPN A then let the resident go, but the resident stumbled. LPN A placed his/her hands back under the resident's armpits and dragged the to the resident's room and put the resident in bed. The resident was kicking and screaming and did not want to go to his/her room. No one at the facility had inserviced him/her on resident take down techniques. He/she sent the DON a statement that same evening. Review of CNA D's written statement, undated and unsigned (the CNA typed his/her name at the bottom of the statement), showed he/she was standing in the hallway when the resident followed LPN A into the hall. When the resident walked up on LPN A he/she swung and hit LPN A and called him/her a racial slur. LPN A walked away and said the resident can't hit people and he/she was going to call the doctor. After LPN A walked back up, the resident stated that he/she was going to hit LPN A again and LPN A said the resident had to stop. When LPN A bent down and came back up, the resident punched LPN A in the mouth and LPN A took the resident down to the ground. During an interview on 9/27/24 at 10:12 A.M., CMT E said he/she worked on the evening shift on 9/19/24. CMT E saw LPN A take two oxygen concentrators from the resident's room to the nurse's station and lock them up. The resident followed LPN A out into the hall and stopped in the hall about two or three doors away from his/her room, which was about halfway to the nurse's station. This surprised him/her because he/she had never seen the resident walk that far without assistance before. The resident was angry. He/She thought the resident was beginning to calm down while LPN A was at the nurse's station. LPN A walked from the nurse's station to where the resident was standing, and LPN A and the resident began yelling at each other. LPN A told the resident he/she did not need his/her oxygen concentrator because his/her oxygen saturation level was 98%. When the resident's incontinence brief fell down, LPN A bent down to pull the brief back up and that was when the resident hit LPN A twice in the face. LPN A was upset and tried to stop the resident from hitting him/her. CMT E tried to get LPN A to allow him/her to help de-escalate the situation, but LPN A would not allow CMT E to help. LPN A said no he/she had this. After the resident hit LPN A, LPN A placed one arm around the back of the resident's neck and placed his/her other hand on the resident's face. LPN A pushed the resident backward and took the resident to the floor. This all escalated quickly and it looked like LPN A and the resident were in tussle. The resident was on his/her back on the floor and LPN A put his/her knee on the resident's chest telling the resident to calm down. The resident was yelling at LPN A to get off of him/her. The resident was on the floor about 30 seconds. LPN A got up and told the resident he/she was going to his/her room. The resident sat up at that time and LPN A went behind the resident, placed his/her hands underneath the resident's armpits and lifted the resident up to a standing position. LPN A forced the resident to his/her room and put the resident in bed. He/She reviewed his/her statement where it showed the resident fell to the floor and said that was not correct. LPN A forced the resident to the floor. He/She had never seen the resident punch anyone in the past. As far as CMT E was aware, the facility did not train staff on resident take down techniques. Review of the resident's progress note's, located in the EHR, showed, LPN A documented: -9/19/24 at 7:46 P.M.: A call was placed to the Psychiatrist and new orders received for PRN medication, as per medication administration record the medication was administered as tolerated with staff assistance. No further concerns noted at this time. Review of the resident's physician's order sheet (POS), located in the EHR showed no documentation of a one-time order dated 9/19/24 on the POS for Haldol (antipsychotic) 5 milligrams (mg) intramuscular (IM) or Benadryl (antihistamine that can be used to induce sleep) 25 mg by mouth (PO). During an interview on 9/27/24 at 9:13 A.M., CNA D said a short time after Resident #2 was taken to his/her room by LPN A, CNA D was in the room when LPN A came in and gave the resident an injection. The resident was not combative at that time. The resident told LPN A he/she could give the resident the injection but it was not going to work. LPN A gave the resident the injection at that time. CNA D said he/she did not think any of this had to happen had LPN A not taken the resident's oxygen concentrator away. During an interview on 9/27/24 at 10:12 A.M., CMT E said he/she walked into the resident's room after LPN A made the resident get into bed, but before the resident was given an injection. The resident was calm at that time, was laying on top of his/her bed. The resident took his/her evening medications from CMT E with no problems. He/She did not think the resident needed an injection at that point. He/She was not present when LPN A came back and gave the resident the injection. Review of the resident's Psychiatrist written statement dated 9/27/24, showed: This is to confirm that we discussed on 9/19/24 the status of the behavior of the resident, who in the midst of the manic episode demonstrated exacerbation of psychosis, and as a result struck a nurse several times in the hallway with other residents around. Order for temporary manual hold were given as well as Haldol 5 mg IM and Benadryl 25 mg by PO. This was effectively administered. During a telephone interview on 9/30/24 at 2:52 P.M., the resident's Psychiatrist who wrote the note dated 9/27/24, said he recalled a nurse calling him but was not sure who. The nurse told him the resident was swinging at staff and out of control. The nurse did not tell him the resident's oxygen concentrator had been removed against the resident's wishes causing the resident to get upset. Based on that information it seemed like the resident's behavior was provoked and not due to a manic episode. Had he been aware of that he would not have ordered the Haldol IM or Benadryl. He probably would have recommended the nurse give the oxygen concentrator back to the resident. If the resident was not agitated when the nurse went to give the Haldol IM and the Benadryl, the nurse should have withheld the medications. Review of the facility investigation dated 9/19/24 and completed by the Administrator, showed: - Name of Alleged Abuser: Licensed Practical Nurse A; -Initial Investigation: Resident #2 is diagnosed with multiple conditions, including but not limited to acute and chronic respiratory failure, COPD, psychotic disorder with delusions, and Parkinson's disease with dyskinesia (the inability to control movements). Cognition is moderately impaired. On September 19, 2024, the Administrator was notified by the DON about an evening incident involving Resident #2 and LPN A, during which Resident #2 struck LPN A on the head several times. The Administrator was also notified Resident #2 attempted to hit his/her roommate; -Initial Intervention: The resident was put on 1:1 supervision. Roommates were separated. Staff members were questioned. Residents were interviewed. Facility wide Abuse and Neglect in-servicing was conducted. -Conclusion of facility investigation: The investigation concluded that the resident struck LPN A several times out of frustration after his/her oxygen concentrator was removed. Witnesses stated LPN A held the resident's arms to avoid being struck, while trying to assist the resident with his/her brief before guiding the resident back to his/her room. The resident also attempted to make contact with his/her roommate on his/her face. To prevent potential issues, the resident's room assignments were adjusted, and staff continued to monitor the resident closely. No further incidents have been reported since. All residents' feel safe at the facility. LPN A acted in self-defense after being hit multiple times. The IDT team questions if LPN A acted without incorporating all possible de-escalation tactics that could have avoided the need for restrain. For this reason, LPN A will be terminated. In this case the question begs as to why LPN A did not remove himself/herself from the scene and allow another employee an attempt at calming the resident down. During an interview on 9/27/24 at 11:45 A.M., CNA C said he/she was not present when the incident between the resident and LPN A occurred. He/She had taken care of the resident several times. The resident was alert and oriented. He/She had never seen the resident hit anyone before. During a telephone interview on 10/1/24 at 6:42 A.M., LPN I said he/she worked the night shift on 9/19/24 and replaced LPN A. During shift report, LPN A did not say anything to him/her about what had happened on the evening shift with the resident. The resident had been using the oxygen for quite a while. The resident could walk short distances. The facility trained staff to de-escalate tense situations. They did not train staff to do resident take downs and it was not part of their policy as far as he/she knew. LPN I would not have taken the resident to the floor. He/She would have just walked away until the resident calmed down. He/She would not have removed the resident's oxygen without speaking to the physician first. During an interview on 10/1/24 at 1:54 P.M., LPN K said he/she would not have removed the resident's oxygen concentrator without first speaking to the physician. He/She would not have confronted the resident about the oxygen. If a resident hit him/her, he/she would remove himself/herself from the situation. The facility provided in-services on de-escalation techniques but not resident take downs. LPN K would not have tried to take the resident down to the floor. He/She would not force a resident to go to their room if the resident was not willing to go. LPN K would not have given the resident the Haldol IM and Benadryl if the resident had calmed down and no longer needed it. During an interview on 9/30/24 at 2:30 P.M., the MDS/Care Plan Coordinator said she had worked at the facility since 8/22/24. She was not sure about the resident's background, but as far as she was aware, the only physical altercation the resident had been involved in was with LPN A on 9/19/24. She thought an intervention to that situation would have been for LPN A to have backed off when he/she knew the resident was upset and allowed the resident to calm down. During an interview on 9/30/24 at 3:25 P.M., CNA G said he/she worked the same hall where the resident resided but was not assigned to care for the resident on the evening of 9/19/24. LPN A took the resident's oxygen concentrator out of the resident's room. The resident was standing in the hall. LPN A went down the hall and told the resident he/she could not turn his/her oxygen all the way up. That was when the resident hit LPN A. He/She saw LPN A put the resident onto the floor but it did not appear harsh. He/She did not see LPN A hold the resident's hands down. CNA G did see LPN A put his/her knee on the resident's back. He/She was not sure if LPN A forced the resident into his/her room or not because everything he/she saw was from the nurse's station and there were other staff in the hall at the time. During a telephone interview on 10/4/24 at 10:20 A.M., LPN A said the resident had two oxygen concentrators in his/her room, and was using one of them on the evening shift of 9/19/24. The resident was turning his/her oxygen up to 5 lpm when his order was for 2-3 lpm. The resident's oxygen saturation level was 99% on room air so LPN A decided the resident did not need the oxygen. LPN A told the resident he/she did not need the oxygen or he/she would hyperinflate his/her lungs. LPN A did not consult the resident's physician prior to removing the oxygen concentrators out of the resident's room. When he/she removed the concentrators, the resident followed him/her into the hall. The resident was able to walk, but used a wheelchair for long distances. The resident did not object that he/she removed the oxygen concentrators. The resident was not mad, did not yell or curse. LPN A continued to the nurses' station and put the concentrators in the storage room. The resident was standing in the hall about halfway between the resident's room and the nurse's station when the resident's incontinent brief fell down. He/She walked back to the resident and pulled the resident's incontinent brief up. That's when the resident hit him/her. The resident was not yelling or cursing at LPN A, and he/she was not yelling at the resident. LPN A said he/she had been in-serviced at the facility on de-escalation techniques, but not take-down techniques for residents with behavioral issues. He/She did not attempt de-escalation techniques like walking away from the resident because the resident was swinging on him/her. There were other staff in the hall but no one offered to help de-escalate the situation. LPN A's first response was to do a takedown of the resident, not de-escalate. He/She placed one hand on the resident's back and one hand on the resident's chest. He/She pulled the resident forward and the resident went down to his/her knees, then onto his/her stomach. He/She did not put his/her knee on the resident to keep him/her down. The resident was not angry or cursing while on the floor. The resident was on the floor for less than a minute when he/she helped the resident to stand up. He/She did not pull the resident up by placing his/her hands under the resident's armpits. He/She did not drag the resident backwards to his/her room or force the resident to go to his/her room. The resident was calm once he/she stood up and he/she walked with the resident back to his/her room and the resident got into bed. The resident was calm and no longer swinging at him/her at this time. After he/she left the resident's room, LPN A placed a call to the resident's physician and Psychiatrist. He/She also called the DON and left a message for the resident's family. LPN A told the DON he/she put the resident onto the floor because the resident had hit him/her. The DON told LPN A to document what happened and to monitor the resident to make sure he/she was alright. LPN A forgot to document about forcing the resident onto the floor. He/She did not speak to the resident's psychiatrist; the DON spoke to the psychiatrist. She called LPN A with the orders for the Haldol IM and Benadryl. When

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide basic life support in a timely manner, including cardiopulmonary resuscitation (CPR, an emergency lifesaving technique used when someone's breathing or heartbeat has stopped) for one of four sampled residents who was a full code (all life saving measures to be performed) and found by staff without a pulse (Resident #1). The census was 91. The Administrator was informed on [DATE] at 3:18 P.M. of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's policy titled, Medical Emergencies-Code Blue, revised [DATE], showed the purpose of the policy was to ensure the prompt and effective response by facility personnel during medical emergencies through the use of the code blue procedure. A medical emergency was defined as conditions requiring immediate medical intervention and the initiation of the code blue procedure including respiratory or cardiac arrest, hemorrhage (excessive, uncontrolled bleeding), severe respiratory distress, serious injury accidental or self-inflicted, and severe allergic reaction. The facility was to perform CPR in accordance with the guidelines set forth by the American Heart Association. Once CPR was initiated, it was to continue until paramedics arrived. The first of facility personnel to arrive and find the resident with any of the above conditions was to: call for help, send available staff to call a code blue and retrieve emergency medical equipment, assess the resident's level of consciousness, circulation, airway and breathing, begin CPR according to current practice. Note: the first responder should not leave the victim, to call for help, unless absolutely necessary according to the situation. When the second responder arrives, have the second responder place the cardiac arrest board under the resident and assist with two-rescuer CPR. Subsequent responder(s) were to activate the emergency response system-call 911, direct all needed personnel to the code blue site, send a staff member to the entrance door to wait where the ambulance was expected to arrive. The first Registered Nurse (RN) to respond will lead the code unless responsibility is transferred to another licensed staff member (RN or MD). Note: one person CPR will be maintained, until there is a second responder available to begin two person CPR. CPR will continue until the paramedics arrive and assume responsibility. Any available nursing staff was to complete the first responder and subsequent responder tasks. Other staff (social workers, security, housekeepers, etc.) will be available to assist in placing phone calls and/or keeping residents away from the area. Review of the facility's policy titled, Cardiopulmonary Resuscitation, revised [DATE], showed CPR was instituted in cases of recognized cardiac and/or pulmonary arrest to support a resident's cardiac and/or pulmonary function(s) until medical emergency personnel were available to take over the resuscitation efforts. CPR was instituted on all residents except those designated as no code or no CPR. In the absence of a DNR order, CPR was to be performed by individuals certified in basic CPR. The facility will perform CPR in accordance with the guidelines set forth by the American Heart Association. Review of the 2015 American Heart Association guidelines update for CPR and emergency cardiac care (ECC) facility training materials, showed if the victim was unresponsive with absent or abnormal breathing, the rescuer and dispatcher should assume that the victim is in cardiac arrest. Look for no breathing or only gasping and check pulse simultaneously. Healthcare Professionals (HCPs) must shout or use a mobile device to call for nearby help upon finding the victim unresponsive. The recommended sequence for a single rescuer has been confirmed: the single rescuer was to initiate chest compressions (to restore blood circulation) before giving rescue breaths (Compressions-Airway (tilt the victims head back and lift the chin to open the airway)-Breathing (give mouth-to-mouth rescue breaths) (C-A-B) rather than Airway-Breathing-Compressions (A-B-C)) to reduce delay to first compression. The single rescuer should begin CPR via cycles of 30 chest compressions followed by two breaths (one breath every five to six seconds, or about 10-12 breaths per minute). The number and duration of interruptions in chest compressions should be minimized to less than 10 seconds. Review of the facility's policy titled, Emergency Medical Supplies, revised [DATE], showed the secondary responder to a medical emergency was to bring the emergency cart to the scene. Review of Resident #1's undated face sheet, showed the following: -Responsible party: self; -Initial admission date: [DATE]; -admission type: skilled (in-patient rehabilitation and medical treatment and care provided by trained registered LPNs (Licensed Practical Nurses) in a medical setting under a physician's supervision). Review of the resident's hospital history and physical, dated [DATE], showed the resident had recently been discharged from the hospital, having been transferred for many hour episodes of non-responsiveness for which cardiac evaluation was negative. In the emergency department (ED), he/she was flaccid (soft, limp) and unresponsive, but did open his/her eyes and regard occasionally. The resident was back to his/her baseline within 10 minutes. The differential diagnosis (analysis of a patient's history and physical examination to arrive at the correct diagnosis) was psychogenic unresponsiveness (state of unconsciousness in which voluntary motor response is absent, muscle tension and deep tendon reflexes remain normal, all brain stem reflexes are preserved and vital signs are usually not affected), transient neurogenic episodes (brief disturbances in motor, somatosensory (sensory system concerned with the conscious perception of touch, pressure and pain), visual or language functions) due to possible cerebral amyloid angiopathy (CAA, condition in which proteins build up on the walls of the arteries of the brain causing bleeding into the brain and dementia) or much less likely atypical (and uncaptured) seizure. Review of the resident's physician's orders, showed a full code order, dated [DATE]. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included unspecified atrial fibrillation (a-fib, an abnormal heart rhythm (quivering or irregular) characterized by rapid and irregular beating), heart failure, high blood pressure, Type II diabetes mellitus, malnutrition, morbid (severe) obesity due to excess calories; -Required set up or clean up assistance with eating and oral hygiene; -Required substantial/maximal assistance with personal hygiene, rolling right/left; -Dependent on full staff performance of toileting, showering/bathing, dressing hygiene, sit-to-lying, lying-to-sitting in bed, chair/bed-to-chair transfer; -One-sided impairment of upper extremity; -Wheelchair mobility. Review of the resident's undated care plan, showed the following: -Full code status; -The resident has a-fib; -Administer medications as ordered; -Monitor for edema (swelling due to accumulation of excess watery fluid collecting in the cavities or tissues of the body); -If the resident goes into cardiac arrest, perform CPR, and call 911. Review of the resident's progress notes, dated [DATE], showed the following: -1:01 P.M., the resident remains on antibiotics (ABT) for right arm swelling with no noted adverse reactions to therapy and no change in status noted. Observed sleeping sound at this time. No signs or symptoms of pain or distress noted. Call light within reach. During an interview on [DATE] at 11:29 A.M., the resident's family member said on [DATE], the resident was up and speaking like normal at 8:00 P.M., asking the family member to bring the resident something to eat the next day. On [DATE], the family visited for an hour and left the facility at 3:00 P.M. The resident had been previously hospitalized for periods of unresponsiveness. Review of Certified Nurse Aide (CNA) C's written statement, dated [DATE], showed the resident was still alive and breathing at 3:00 P.M., when CNA C did his/her rounds. During an interview on [DATE] at 1:52 P.M., CNA G said on [DATE], he/she performed rounds as an oncoming staff with CNA C. CNA G had gone into the resident's room at 7:30 A.M., at lunch time, and at 3:15 P.M. The resident had been awake and talking at lunchtime. At 3:15 P.M., the resident seemed fine. CNA G was on a smoke break when he/she received a call from CNA E saying they had a code. CNA E went inside and saw LPN B and CNA C performing CPR. CNA C was performing chest compressions and LPN B was relieving CNA C and providing chest compressions only. LPN A was at the nurses's station on the phone. Review of the resident's progress notes, dated [DATE], showed the following: -9:22 P.M., at approximately 5:00 P.M., LPN A entered the resident's room and found the resident unresponsive with no pulse and no respirations, warm to the touch. LPN B started CPR along with CNA C. LPN A called 911. Emergency Medical Services (EMS) arrived times four and took over CPR, while contacting their medical director, who gave time of death as 5:22 P.M. Staff notified the resident's family member and physician at 5:47 P.M. Review of LPN A's written statement, dated [DATE], showed at approximately 5:00 P.M., LPN A entered the resident's room and found him/her unresponsive with no pulse, no respirations warm to the touch. LPN B started CPR along with CNA C. LPN A called 911. EMS arrived and took over CPR, while contacting their Medical Director who gave time of death as 5:22 P.M. During an interview on [DATE] at 1:25 P.M., LPN A said on [DATE], LPN A started his/her shift at 3:00 P.M. LPN A did not conduct rounds at the beginning of his/her shift on [DATE]. He/She gave the CNAs their assignments. The CNAs always conducted the first rounds and then reported any concerns to LPN A. On [DATE], no one reported any concerns about the resident to LPN A. At 5:00 P.M., LPN A entered the resident's room for the first time that day to check the resident's blood sugar. The resident normally snored while asleep. On [DATE], he/she was not snoring when LPN A entered the room. LPN A got up close to the resident's mouth, which was more drooped than normal, and did not hear snoring. The resident also did not appear to be breathing. A sternal rub (painful stimulus performed by rubbing the knuckles of a closed fist firmly and vigorously on an unconscious resident's breastbone, in order to test his/her responsiveness) did not arouse him/her. The resident was warm to the touch. LPN A checked for a pulse and could not find one. Certified Medication Technician (CMT) D was in the hallway of the resident's unit (on the East side of the building), when LPN A exited the resident's room. LPN A asked him/her if the other LPN was on the other side of the building. CMT D said, yes. LPN A ran to get LPN B. LPN A did not instruct CMT D to go and get the LPN. LPN A went and found LPN B, telling him/her the resident was unresponsive, that LPN A could not get a pulse or wake the resident up and the resident was a full code. LPN A did not call a code blue (full code announcement) and return to the room to start CPR, because he/she was never trained or instructed during orientation that it was a facility policy or procedure to call a code blue. LPN A had never been shown how to operate the facility's loudspeaker. LPN B entered the room, confirmed the resident had no pulse, and began performing chest compressions. LPN A left the room and called 911. There was no one else who could have made the call to 911, because the resident's medical information had to be pulled up in the database to answer the 911 operator's questions. A CNA would not be able to access that information in the database. LPN A also attempted to phone the resident's family member multiple times. While on the phone, LPN A waited by the door for about two minutes to see if the ambulance was coming. LPN F arrived at the facility, asked LPN A what was happening and asked if LPN A had called the resident's family member. LPN F started helping contact the resident's family member. While LPN A was at the nurse's station, LPN B had sent CNA E to get the crash cart. CNA E started walking to the other side of the building. LPN A said, no there's one on this side. LPN A pulled out the crash cart and the two of them returned to the resident's room. LPN B performed chest compressions. CNA C was not helping while LPN A was present. However, LPN A later found out that CNA C had stepped in to relieve LPN B. LPN B took the AMBU bag and laid it on the bed next to the resident's head. LPN A gave LPN B a break and did compressions for two minutes, while LPN B provided rescue breaths with the AMBU bag for two to three minutes. Then LPN B resumed compressions, LPN A went out and opened the door for EMS. EMS asked a few questions, including when the last time had been that staff saw the resident breathing. CNA C said the resident was breathing when he/she conducted his/her first round at 3:00 P.M. That is why EMS documented the onset of the resident's change in condition as 3:00 P.M. EMS started compressions and contacted their Medical Director. Review of LPN B's written statement, dated [DATE], showed LPN B was rushed into the resident's room with LPN A. The resident was observed lying in bed supine (lying face upward), eyes closed, no respirations, no pulse, warm to the touch. Chest compressions were initiated immediately. CNA C assisted. CPR lasted approximately seven minutes before EMS arrived and took over. LPN B then assisted with family members at the resident's bedside. During interviews on [DATE] at 9:17 A.M. and 2:34 P.M., LPN B said at dinnertime on [DATE], he/she was on the [NAME] side of the building at the opposite end of the hall from CMT D. LPN B was setting up glucose meter checks. LPN A came over to their unit and asked CMT D, where is the LPN? LPN A came and told LPN B that LPN A had a concern with the resident, who did not appear to be breathing. In a situation like that, staff normally made a code blue announcement over the loudspeaker. No one made a code announcement on [DATE]. LPN B rushed to the resident's room with LPN A and assessed the resident, who had no respirations, no pulse, was warm to the touch and had his/her eyes closed. The resident did not respond to a sternal rub. LPN B immediately started chest compressions. LPN A left the resident's room and returned with the crash cart. CNA C entered the room less than a minute later and took over providing chest compressions. LPN B got the AMBU bag out and administered rescue breaths. LPN B administered 30 chest compressions and two breaths, alternating with CNA C and checking for a pulse. They did about 10 rounds of CPR without stopping until EMS arrived. The resident's body was warm head-to-toe, but was not responding to the CPR. During interviews on [DATE] at 7:19 A.M. and [DATE] at 7:27 A.M., CMT D said on [DATE], he/she worked on the [NAME] side of the building, opposite from the East side where the resident resided. It was dinnertime (which starts at 5:00 P.M.) when LPN A walked over to the [NAME] side of the building, stood, looked up and down the hallway and left. A minute or two later, LPN A returned and walked over to CMT D who was on the opposite end of the hall from the dining room passing medications. LPN A asked CMT D if the other LPN was on the unit. LPN A asked, is the other LPN over there?, indicating the opposite end of the hallway. LPN B was in the dining room. LPN A went and got LPN B, then they walked very fast towards the East side of the building. No one made a code announcement. During an interview on [DATE] at 8:10 A.M., CNA E said at around 5:00 P.M. on [DATE], CNA E, CNA C and LPN A were sitting at the nurse's station. CNA E got up to get ice for a resident and returned about two minutes later. LPN A and CNA C were gone from the nurses's station. Then LPN A ran up to the nurses's station and used the phone. No code blue announcement or shout for help had been made, so CNA E did not know what was going on until another resident informed him/her. CNA E went down to Resident #1's room and saw LPN B and CNA C alternately doing chest compressions. Staff only provided chest compressions. LPN A was on the phone attempting to contact the resident's family member. Review of the facility's incident investigation, dated [DATE], showed: -The resident was at baseline with no issues noted and was speaking to his/her family during CNA's initial rounds at 3:00 P.M. CNA C reported the resident did not appear to be distressed. -At 5:00 P.M., LPN A noted while rounding the resident appeared not to be breathing. Code status was verified as full code and CPR was started immediately. -LPN B stated the resident was lying supine in bed. LPN B initiated CPR while LPN A went to get the crash cart and call EMS. The crash cart was delivered. CNA C arrived to assist with CPR. LPN B stated he/she initiated one full round of CPR prior to assistance coming and LPN A assisted as well. -The code was run for approximately seven minutes with LPN B and CNA C rotating rounds of CPR. -EMS arrived, placed telemetry (an observation tool that allows continuous monitoring and display of a patient's vital signs) on the resident, and confirmed there was no heartbeat. EMS contacted the (hospital) physician and called time of death at 5:22 P.M. -Staff notified the resident's family, physician, coroner, and funeral home. -Upon conclusion of the investigation, staff responded appropriately to the code. Supplies needed for the code were available on the crash cart (a wheeled container storing medicine and equipment for use in critical care situations). Staff notified EMS in a timely manner. Staff also notified the resident's family and physician, who voiced no concerns. Review of the resident's EMS patient care record, dated [DATE] showed the following: -Onset time: 3:00 P.M.; -Dispatcher notified: 5:09 P.M.; -En route: 5:11 P.M.; -Primary impression: cardiac arrest; -Skin: trunk remains warm to touch with cold hands and feet; -Eyes: right and left 3 mm (millimeters), nonreactive; -Lung sounds: breath sounds absent; -5:16 P.M. unresponsive, Pulse=0, respiratory rate (RR)=0, advanced life support (ALS) assessment patient response: unchanged, complication: altered mental status, apnea (cessation of breathing); -5:17 P.M., unresponsive, Pulse=0, RR=0, 3-lead electrocardiogram (ECG, non-invasive device that records the electrical activity of the heart), patient response: unchanged; -Resident found lying supine in bed. CPR being performed by nursing home staff. The resident was pulseless and apneic. Staff reports last well check was at 3:00 P.M. Nursing home's staff came in about 15 minutes ago to check the resident's blood sugar and noticed that he/she was unresponsive, did not have a pulse and was not breathing. Staff went to get paperwork. CPR continued. He/She remained pulseless and apneic. Hands and feet were cold to the touch with no cap refill (capillary refill; the time it takes for color to return to a network of blood vessels after pressure is applied to temporarily obstruct blood flow to that area). Pupils were fixed and non-reactive. The hospital was contacted and the physician gave orders to cease resuscitation and pronounce (death) in the field. No obvious signs of trauma. Staff reported that he/she had no complaints today during previous well checks. During interviews on [DATE] at 10:22 A.M. and [DATE] at 11:05 A.M., the Director of Nursing (DON) said the code announcement policy was discussed with staff during orientation. Staff were shown how to use the intercom system to make code announcements and the location of the crash carts. Staff orientation was not documented, nor did staff sign an acknowledgement that they received and understood what was discussed. When staff found a resident unresponsive, they were expected to check for a pulse and call out, hey, I need help. I need help. Next, they were to look out of the room and if no one was there, then they had to go and get help. LPN A went and found LPN B, telling him/her the resident was unresponsive, that LPN A could not get a pulse or wake the resident up and the resident was a full code. During an interview on [DATE] at 1:59 P.M., the Regional RN Consultant said the facility did not have a policy regarding making overhead code announcements. However, staff were expected to yell out that there was a code blue. Staff were taught to immediately perform CPR on an unresponsive full code resident who was not breathing and pulseless. During interviews on [DATE] at 10:35 A.M. and 1:59 P.M., the resident's physician said there was a low chance of survival once staff found the resident unresponsive with no pulse or respirations. However, staff should have started right away with chest compressions and rescue breaths. During an interview on [DATE] at 10:05 A.M., the Administrator said if staff found a resident unresponsive, the expectation was that they would assess the resident (for pulse and respirations), call for help and stay with the resident. They were to have the staff who responded to the call for help, verify the resident's code status and get the crash cart. If the resident was full code, then the staff who were CPR certified were expected to immediately provide CPR. Note: At the time of the complaint investigation, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review, it was determined the facility had implemented corrective action to address and lower the violation at that time. A revisit/final revisit will be conducted to determine if the facility is in substantial compliance with the participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State Law (Section 198.0261 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO00231777 MO00231834