**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Reference: The American Heart Association (AHA) 2010 . guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations . In the guidelines, AHA has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid Do Not Resuscitate (DNR) order is in place; 2) obvious clinical signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. Based on interview, review of facility records, and other pertinent facility documents on [DATE], it was determined that the facility failed to initiate life saving measures for a resident who was found unresponsive and was designated by the facility as a full code (Initiate Cardiopulmonary Resuscitation if the heart stops and respirations cease), as well as failed to follow the facility policy titled; Cardio Pulmonary Resuscitation. This deficient practice was identified for 1 of 3 residents for closed records review (Resident #122), when on [DATE] at 3:40 PM, Resident #122 was found by the Registered Nurse (RN #1) with no pulse or respirations. RN #1 failed to initiate CPR and pronounced the resident dead at 3:40 PM, without attempting to resuscitate the resident. This was not in accordance with the resident's wishes as documented in the medical record, as stated by the resident's physician, or according to the facility's policy. In addition, there was no documentation in the medical record to explain RN #1's decision to not attempt resuscitation. The facility's failure to honor the code status of a resident and initiate life saving measures (CPR) posed a serious and immediate threat to the safety and well being of Resident #122 and all other residents in the facility who were designated as full code status. This resulted in an Immediate Jeopardy (IJ) determination. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were notified of the IJ and provided the IJ template on [DATE] at 1:29 PM. The IJ began on [DATE] at 3:40 PM when Resident #122 was found unresponsive by the Registered Nurse (RN #1) assigned to the resident and continued until [DATE] at 2:38 PM when the facility provided an acceptable removal plan. The removal plan was verified on-site on [DATE], during survey. The evidence was as follows: On [DATE] at 9:00 AM the surveyor reviewed the Electronic and Hard copy medical records of Resident #122 which revealed the following: The nurses admission note was dated [DATE] 5:31 AM. The note read At 0100 AM receive a [AGE] year old [male] patient from [an acute care hospital] via ambulance on a stretcher accompanied by 2 MT [medical technician] staff, with a DX [diagnosis] OF S/P [status post] Fall, left hip fracture. s/p IM [intramedullary-inside of a bone] nailing wound vac.[vacuum]. Pt is awake alert and oriented x3 (with no cognitive deficits) denied pain at this time breathing even and easy unlabored, abdomen bowel sounds present in all quadrants with bulging hernia skin warm to touch with multiple bruises to both upper extremities surgical incision with 24 staples all intact with mild oozing, closed blister near the incision pitting edema to bilateral feet. Dry dressing applied to the surgical site APN [Advanced Practice Nurse] made aware of the admission and verified all the medication orders carried out and faxed to the pharmacy Covid rapid test done Negative. PPD [a test to evaluate exposure of a person to tuberculosis] Given To The Left Forearm . Patient cleaned and made comfortable. A review of the note by the APN dated [DATE] at 12:21 PM, revealed Resident #122 was admitted with diagnoses that included; Dementia, Hypertension, Anemia, Neuropathy, Hip Fracture, Subtrochanteric fracture of the left femur, Localized Edema, and Atrial Fibrillation. The note also included the code status of the resident. Under Code Status it read: Resuscitation status-ordered-[DATE] 1:56:00 EDT-Full Code. A review of the nurses note by RN #1 dated [DATE] 6:38 PM, read: Patient found in a supine position with NC [nasal cannula] in place, wound vac [vacuum assisted device to help close a wound] functioning, bed lowered, HOB [head of bed] up, no response to name or stimulus, no respiration, no pulse, no S1S2 on auscultation [sounds heard when listening to the heart]. Patient pronounce [sic] by this nurse at 3:40 pm. [The physician] informed immediately and ordered to inform the family. She was also going to follow up with a call to the family . This note was electronically signed by RN #1 at 7:40 PM. On [DATE] at 9:31 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #122 had been a full code. The [NAME] President of Operations and the LNHA were also present. The surveyor asked the DON what she remembered about the death of Resident #122. The DON stated I learned that the resident had expired the day after it happened, I spoke with the nurse involved, because when I read the note it looked like nothing had been done. The nurse involved said when he saw the resident earlier in the shift it looked like the resident was asleep, he checked the resident later and it appeared that the resident was far gone so he called the family. The surveyor asked the DON what she would expect the nurse to do if they came upon a resident who was unresponsive and a full code. The DON stated I would expect that they would call an emergency. There is someone assigned to arrive to the unit when there is an emergency. The surveyor asked the DON what she would expect the nurse to do if they found the resident unresponsive. The DON stated To start CPR and start the code [Cardiopulmonary Resuscitation]. The nurse said the resident looked far gone so he called the family he called the family and said your loved one just died. We did an in-service (education) and explained that CPR should have been initiated for a resident who was a full code and found unresponsive. The DON provided an in-service sign in sheet dated [DATE], (the DON said the year 2022 was an error). The topic was Code Status/CPR. Under Summary it read; If a resident is found unresponsive and upon assessment needs to be coded, Licensed Nurse needs to check first if resident has an advance directive. If resident is full code, CPR should be started immediately and 911 should be alerted. There were 11 signatures on the sign in sheet to indicate they attended the in-service. RN #1 was not one of the 11 people that signed to indicate they attended the in-service. The surveyor asked the DON why they did not provide the in-service training to all of the staff. The DON said they didn't have time. The DON also provided a form that she identified as an in-service that was conducted the day after the incident but it did not document the in-service that she conducted with RN #1. The DON stated that RN #1 was called in to the facility the morning the current survey was being conducted ([DATE]) and asked RN #1 to sign that he had been spoken to the day after he failed to initiate CPR for Resident #122. The topic was listed as Protocol on code status. Under Agenda it read: In-service with [RN #1]. The Nurse (RN#1) stated that resident was far gone when he assessed resident and had expired. No HR [heart rate], RR [respiratory rate], O2 Sat [oxygen level measured in the blood], Skin was cold, Notified family resident had expired and pronounced resident. Protocol on code status and how to address was reviewed with [RN #1]. Start CPR no matter how far gone unless family indicates beforehand that they did not want CPR. Always better to get a witness to family statement. It was signed by RN #1 and dated [DATE]. On [DATE] at 10:37 AM, the surveyor interviewed RN #1 who stated Doing rounds the patient was in bed and looked okay at around 3:20-3:30 [pm]. I did a quick sweep through. Then during the second round about 3:40 pm, the patient wasn't responding, the patient was cold, the feet were cold, the patient had no respirations, pulse, was not responding to their name. I called the doctor and asked if I should start CPR. I told her the patient was cold, looked like [the resident] was dead for a while. The doctor said no do not start CPR. Then I called the family. The family did not want to come in. The surveyor asked RN #1 if he was aware the resident was a full code. RN #1 stated Yes, I checked. I've been a nurse for 23 years. This patient was [AGE] years old, the patient was fragile, the patient was dead cold. It wasn't that I neglected that part of the CPR but the patient was really gone. The surveyor asked why he did not initiate CPR. RN #1 stated. The patient's history and the patient was already gone. I would have started CPR, there is a procedure that you would follow but I called the doctor and told her the resident was gone and cold. It looked like the resident was dead for a while, the feet were purple, the patient was cold, the eyes were shut, there was no carotid pulse, O2 (oxygen) saturation was zero. The resident had changed, the color, the resident was cold, not responding, what caught my attention the patient was cold. The surveyor asked RN #1 if he felt he honored the resident's wishes to be a full code. RN #1 stated No I didn't do that. I was thinking the resident was [AGE] years old, frail, do we want to crack the ribs, I called the doctor. Moving forward I would start CPR right away. I wouldn't care about the age I would just do it. RN #1 also stated that the failure to initiate resuscitative measures was due to the fact that the resident was [AGE] years old and frail, and additionally stated the resident was cold and it looked as if the resident had been dead for a while. RN #1 did not report any of the following as a reason for not initiating Cardiopulmonary Resuscitation; rigor mortis, dependent lividity, decapitation, transection, or decomposition, which are the conditions under which a health care professional would not initiate Cardiopulmonary Resuscitation according to the American Heart Association. In addition, there was no documentation in the medical record to explain RN #1's decision to not attempt resuscitation. On [DATE] at 11:00 AM, the surveyor reviewed the certification card of RN #1 from the American Heart Association which verified that RN #1 was certified as a Basic Life Support Provider. The issue date was [DATE], and the renewal date was 3/2023. On [DATE] at 12:32 PM, the surveyor interviewed the Physician who stated He [RN #1] called me and said [the resident] expired not unresponsive, I don't remember what time, in the afternoon, he told me [the resident] expired, after the resident expired I called the family and they said [the resident] said that [the resident] didn't want to live anymore. In the past I had the conversation with the family about [the resident's] code status and they said they didn't want any aggressive measures but they did want [the resident] to be a full code. I wasn't in the building so I could not assess for myself, if I was in the building then I would assess but I was not there and the nurse said the resident was expired. You can't perform CPR on a dead person. On [DATE] at 12:45 PM, the surveyor reviewed the facility's policy and procedure titled Cardio Pulmonary Resuscitation date implemented [DATE], and date reviewed/revised [DATE]/21. Under Policy it read; In the absence of a Do Not Resuscitate Order by a licensed MD or APN or in accordance to resident's advance directive or if resident does not show signs of clinical death, a witnessed respiratory or cardiac arrest at [the facility], basic Cardio Pulmonary Resuscitation (CPR) will be initiated on all persons by CPR trained staff. CPR is provided as per the current American Heart Association and Emergency Cardiovascular Care (ECC) guidelines. Under Procedure bullet point one read: Initiate CPR and have someone page code blue and the emergency team will respond. Bullet point two read: The Supervisor is notified immediately. The MD/APN is notified and 911 is called. Bullet point three read: CPR continues until the Mobile Intensive Care Unit (MICU) arrives, or the licensed MD/APN is present to discontinue resuscitation. Bullet point number four read: After the resident is transferred, the following must be documented: a. Time the resident was found to be totally unresponsive and by whom. b. Time CPR was initiated and outcome of CPR. c. Time MICU arrived and transported the resident. d. Use of resuscitation bag and/or O2. e. MD/APN notified. f. Relative notified and time of call. The surveyor asked the DON if the facility had a separate policy for an unwitnessed respiratory or cardiac arrest. She said they did not, but moving forward they would add that to the policy. The IJ was identified on [DATE], and the LNHA was notified of the IJ at 1:29 PM. A removal plan was received the same day at 2:38 PM, which included: that the facility updated the pre-admissions process to include; the admissions staff requesting a copy of the advance directive from the sending facility and providing a copy to the admitting nurse, verification of the code status by the admitting nurse, applying a code status identifier on the resident, daily audits of identifiers by the Unit Managers and House Supervisor on all shifts. The code status of residents will be reviewed the first day after admission, at the first clinical meeting about the resident, quarterly, at care plan meetings, and during family meetings. Education started on [DATE], after the LNHA was notified of the IJ situation. All staff were being educated on how to identify a resident who required a code, their responsibilities during a code, and how to document the event. Mock codes will be re-instated at the facility that were halted due to the Covid-19 Pandemic. The implementation of the Removal Plan was verified on-site on [DATE], through observations, interviews with facility staff, and a review of in-service education and revised facility's Cardio Pulmonary Resuscitation policy. NJAC 8:39-4.1(31)iii NJAC 8:39-9.6(g) )