**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record review of the admission Record dated [DATE] for Resident 18 revealed that Resident 18 admitted into the facility on [DATE]. Diagnoses included high blood pressure, atrial fibrillation (an irregular heart rhythm that can lead to blood clots and stroke), old myocardial infarction (heart attack), hyperlipidemia (elevated levels of cholesterol and triglycerides in the blood that can cause heart attack and stroke), coronary angioplasty implant and graft (surgery to repair blocked heart arteries), and history of malignant neoplasm of the prostate (prostate cancer). The admission Record revealed Do Not Resuscitate as another diagnoses. Record review of the care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated [DATE] for Resident 18 revealed a self-care deficit related to heart attack with damage to the heart muscle (NSTEMI). Record review of the resident profile page in the electronic health record dated [DATE] for Resident 18 revealed a code status of Full Code. Full code means that Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped/cardiac arrest) would be initiated if the resident's heart stopped. Record review of the Advanced Directives form dated [DATE] for Resident 18 revealed that Resident 18 chose the option that they Did not want CPR to be attempted should their heart stop beating. Record review of the Physician's Do Not Resuscitate (DNR) (A type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops) Order for the Medically Ill dated [DATE] for Resident 18 revealed the resident choice for DNR in the event of cardiac arrest. The form was signed by the physician on [DATE]. Interview on [DATE] at 12:05 PM with Medication Aide-D (MA-D) revealed that if MA-D found a resident not breathing with no pulse that MA-D would immediately let the nurse know. MA-D revealed that MA-D does not look up the resident code status to see if CPR should be started. MA-D revealed that MA-D is just responsible for letting the nurse know if the resident does not appear to be breathing or have a pulse. Interview on [DATE] at 12:06 PM with Registered Nurse-C (RN-C) revealed that if staff reports a resident not breathing or without a pulse, then RN-C would check the resident code status on the electronic health record profile page for the resident. RN-C confirmed that RN-C would determine if the resident wanted CPR or not by looking at the electronic health record profile page to determine the resident's code status. Interview on [DATE] at 12:09 PM with Resident 18 revealed that the resident chooses to be a DNR (the resident does not want staff to do CPR in the event of cardiac arrest) and that the resident has an advanced directive confirming their choice for DNR. Interview on [DATE] at 12:12 PM with the Assistant Director of Nursing (ADON) revealed that the resident's code status is on the resident profile page in the electronic health record. The ADON revealed that the nurses and aides have a pocket cheat sheet that also lists the resident's code status. Record review of the undated and unlabeled staff pocket cheat sheet revealed that Resident 18's code status was identified as Full Code. Interview on [DATE] at 12:27 PM with the ADON confirmed that the electronic health record profile page for Resident 18 revealed Resident 18 to be a full code (CPR to be performed in the event of cardiac arrest). The ADON confirmed that the Physician's Do Not Resuscitate (DNR) Order for the Medically Ill for Resident 18 revealed that Resident 18 chose to be a DNR. The ADON confirmed that the code status on the electronic health record profile did not match Resident 18's choice for DNR. The ADON confirmed that in the event of cardiac arrest the staff reviewing the electronic health record profile page would have performed CPR against the wishes of Resident 18. The ADON revealed that the ADON would fix it. Interview on [DATE] at 12:36 PM with the facility Assistant Administrator (AA) revealed that the listing of Resident 18 as a full code was an oversight. The AA confirmed that Resident 18 chose to be a DNR. The AA revealed that the ADON did update the electronic health record and placed a red dot on the resident's door to signify the resident is a DNR. The deficient practice of advanced directive/code status reviews have been corrected [DATE] by implementing the following: .-The code status for (Resident 1) has been reviewed with resident, signed by resident, and faxed to [gender] primary physician for signature. -The code status for (Resident 18) has been updated on the PCC eMAR. The pocket care plan, and the sticker on the resident's room door to reflect the current signed code status. System Changes: -The advanced directives/code status will be verified utilizing a 2-step process, with second nurse reviewing the signed order and verifying the PCC eMAR, the pocket care plan, and the stocker on the resident's name plate accurately reflects the current signed code status order. -Education regarding the system changes as it relates to advanced directives/code status, were provided [DATE] to all licensed nurses on site and the social worker. Education will be provided to all licensed nurses on site at the next shift change and will provide continued education with the next staff meeting. Monitoring and Auditing: -All current residents code status/advanced directives will be audited by the interdisciplinary team for compliance weekly and documented on Risk Management template. -All new residents code status/advanced directives will be audited by the interdisciplinary team for compliance weekly and documented on risk meeting template. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. Based on record reviews and interviews, the facility failed to ensure resident code status for life saving measures were accurate for all residents. This affected 2 (Resident 1 and Resident 18) of 23 sampled residents. The facility census was 23. [NAME] at Prairie Commons was notified on [DATE] at 1:43 PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] at 5:20 PM, as confirmed by surveyor onsite verification. Findings are: Record review of the facility policy Advanced Directives dated [DATE] stated the purpose of the policy was to recognize the Senior's rights to make decisions relating to their own medical care, including the right to accept or refuse treatment and the right to formulate an advanced directive (a document allowing a person to give directions about future medical care or to designate another person to make medical decisions if he or she should lose the ability to make decisions. consistent with state and federal regulations and the patient self-determination act (PSDA). A process to educate and inform seniors of their rights to formulate and advanced directive, to promote the senior's right to accept or refuse medical treatment to the extent allowed under state law and provide education regarding advanced directives. The procedure for the Advanced directives stated that upon admission staff would: 1.) provide services to the residents and family members or representatives with a copy of the statement of rights prepared by the Nebraska Department of Health and Human Services. 2.) Staff would identify if a senior had an Advanced Directive as well as their right to formulate one but not be required to do so. 5.) The admissions coordinator or social services staff would ensure the admission Application had been completed identifying the type of Advanced Directive, if any, the resident had, and if not available, request a copy. 7.) Copies of the Advanced directive would be maintained in the senior's clinical record- an electronic version would be in the electronic medical record. 8.) Upon admission the resident's Advanced Directive would be added to the resident care plan (facility plans of care that state how a patient wants to be cared for as well as interventions to assist with cares). Any Senior may revoke their advanced directive at any time without regard to the Senior's mental or physical condition. At that time, when a revocation happens, it is communicated to staff, the physician will be notified and the chance in advanced directive documented in the clinical record. The advanced directive will be removed from the clinical record. 9.) A durable power of Attorney for Health Care will go into effect when the client's Power of Attorney has been invoked and determined to be incapable of making health care decisions. This determination is to be made by the attending physician and documented in the clinical record. 10.) The facility will honor any Senior's choice to decline treatment. The senior may not be treated against their will. Record review of the undated policy and procedure CPR (Cardio-Pulmonary Resuscitation- a life saving measure for when one stops breathing or one's heart stops beating) stated Any client found unconscious without pulse and/or respirations will have CPR initiated immediately unless the client has a valid 'Do Not Resuscitate form on file. The procedure included the following instructions: 1.) When the client is found unconscious without pulse and respirations have been established, the first person to respond must confirm the resuscitation status by checking. 2.) After calling for assistance, CPR shall be initiated by certified responders at the scene. 6.) All nursing staff and medication aides to be current with CPR certification. Record review of electronic medical records for all 23 residents living in the facility revealed that for Resident 1 and Resident 18, the electronic medical record (EMR) did not match the signed requests or code status of these two, individual residents. Resident 1 had a current code status of Do Not Resuscitate with a code status of Full Code which was signed upon admission [DATE]. Resident 18 had a newly signed code status of Do Not Resuscitate and the EMR showed Resident 18 as a Full Code. A. Record review of the admission Minimum Data Set (MDS- a standardized assessment tool used to evaluate the health status of residents in long-term care facilities certified to participate in Medicare or Medicaid which helps facilities provide better care, create care plans, and meet regulatory requirements) dated [DATE] revealed that Resident 1 was legally blind, had a Brief Interview for Mental Status (BIMS - a tool used to assess the cognitive status of residents and is scored from 0 (severe impairment) to 15 (cognitively intact)) score of 8, had no behavior issues, was used a wheelchair, had mobility issues due to Parkinson's, and had limited range of motion to both upper extremities, had diagnoses for diabetes, arthritis, Chronic Obstructive Pulmonary Disorder, macular degeneration, Parkinson's Disease, and frequently suffered from pain. Resident 1 took medications to control anxiety and depression, diuretics for edema, high blood pressure, and fluid retention, opioids for pain control, and antiplatelets to prevent blood clots. Record review of the working Care Plan for Resident 1 revealed that the code status for Resident 1 was Do Not Resuscitate. Record review of the Physician Orders for Life Sustaining Treatment (POLST) for Resident 1 was dated [DATE] and signed by Resident 1's Power of Attorney on [DATE]. The Advanced directive was then signed by the physician on [DATE]. This information revealed that Resident 1 had chosen to die a natural death and asked to be a DNR (do not attempt resuscitation). The resident wanted comfort focused treatment. The facility obtained a facsimile of this document on [DATE]. Record review of the Advanced Directive document dated [DATE] and signed by Resident 1 upon admission to the facility on [DATE] revealed the resident did have a living will and would provide a copy to the facility, did have a durable power of attorney and would provide a copy to the facility. The directive stated I do want cardiopulmonary resuscitation (CPR) should my heart stop beating. I understand that I will receive cardiopulmonary resuscitation and life sustaining treatment to the extent of the provider's ability. This was signed by Resident 1 on [DATE] at 7:17 PM and witnessed by the Assistant Administrator (AA) at the time of admission to the facility. Record review of Resident 1's online Electronic Medical Record on [DATE] revealed that the code status for Resident 1 was DNR. Record review of the daily nursing staff pocket care plan (a single sheet of paper used in daily report of all residents during staff change and report) revealed that Resident 1 was listed as a Full Code and wanted CPR. Observation of the name plate at the room entrance to the room of Resident 1 revealed there was a Red Dot on the door that indicated Resident 1 was to be a DNR and did not want CPR or life saving measures. Interview at 11:38 AM on [DATE] with Resident 1. My attorney signs most everything for me. But I would expect that I would be a full code because I would like to be transferred to the hospital to see if I could be saved. That's what I would want. Interview on [DATE] at 12:00 PM with Medication Aide (MA)-B, who revealed that if a resident becomes unconscious and needs life saving measures, then those residents who are full codes (want CPR) and those who do not want CPR (also called a DNR) are on a list. MA-B stated [gender] has everyone's code status memorized. When asked about Resident 1, [gender] did not know because MA-B rarely works with the residents in the south hall and works almost primarily in the north hall. MA-B did look at the door and stated that there is a Red Dot on the name plate at the door entrance for Resident 1 and that signifies that individual would be a DNR. Looking at the other doors in the south hall, where MA-B worked on [DATE], MA-B was able to point to several doors that had red dots on the name plates at the entrance and a couple doors with a green dot on the name plate. MA-B stated that the green dots mean those individuals living in those rooms are a full code and would want to have CPR and life saving measures. Sometimes the new residents may not have a red or green dot on their door nameplate for a few days. We can also look in the Electronic medical record, but the first thing medication aides and nursing assistants must do is to tell the charge nurse. Interview on [DATE] at 12:10 PM with Licensed Practical Nurse (LPN)-A stated that the best place to look to see if a resident is a DNR or a Full Code is in the Electronic Medical Record (EMR) as it is posted on the bar at the top of each resident's page. We also make sure there is a red or green dot on the name plate at the entrance door of every room. This gives us the information at a quick glance. [NAME] dots mean full code and those residents want CPR. Red dots mean DNR and do not want to have life saving measures in the event something happens to them. Interview on [DATE] at 12:25 PM with the Director of Nursing (DON) stated that everyone is a full code whether anything is signed or not until the doctor's sign the orders. After the doctor signs the orders, then the resident is either a DNR or a Full Code. This information should be listed in every resident's Care Plan. In the EMR, the information is stated at the top of the page for each resident and is on all pages. Interview on [DATE] at 12:30 PM with the Assistant Director of Nursing (ADON). Confirmed the Code status signed on [DATE] for Resident 1 does not match the code status on the EMR. Resident 1 requested to be a full code. The EMR stated Resident 1 was a DNR. Interview on [DATE] at 12:31 PM with the DON who also confirmed the code status for Resident 1 does not match on the EMR and on the Code document signed upon admission by Resident 1.