**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #NJ 00163449 Based on interviews and review of the medical records (MRs) and other facility documentation on [DATE] and [DATE], it was determined the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) (an emergency lifesaving procedure performed when the heart stops beating) and activate their emergency response system (ERS) which includes calling 911, notify other staff by announcing the emergency code, and retrieving the crash cart and the automatic external defibrillator (AED) when Resident #1 who was a full code (all resuscitative measures should be taken if the heartbeat or breathing stops) and did not have a physician order (PO) for Do Not Resuscitate (DNR) was found unresponsive and without a pulse or respirations in bed. This was not in accordance with their policy for Emergency Procedure-CPR and the American Heart Association (AHA) and the Basic Life Support (BLS) guidelines for Healthcare Providers. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Hypertension, Congestive Heart Failure, and Right Thalamic Intracerebral Hemorrhage with left hemiparesis (stroke with left-sided weakness). According to documentation and interviews, the facility did not immediately perform CPR or activate their ERS due to not having an order for a full code or DNR in the MR when Resident #1, who was a full code and without a PO for DNR, was found unresponsive without a pulse and respirations on [DATE] at 11:00 PM. Resident #1 was last seen responsive, trying to get out of bed an hour ago by Certified Nursing Assistant (CNA) #1. At that time, CNA #1 repositioned the resident in bed. At 11:00 PM, CNA #1 notified the Licensed Practical Nurse (LPN) #1, the resident was not looking good. LPN #1, a newly assigned agency nurse, went in the room, checked for pulse and vital signs, and found out the resident expired. LPN #1 confirmed during a telephone interview on [DATE] at 1:44 PM he was certified in CPR and did not provide CPR to Resident #1 because he was trying to figure out the resident's code status. He stated that he did not convey or explain to the Physician that he was unsure of the resident's code status. He called the Physician only to inform that Resident #1 had expired so the resident could be pronounced. He confirmed that instead of initiating CPR, he called the Director of Nursing (DON) and Assistant DON (ADON) on the telephone for instructions. However, the DON and ADON were unavailable. Although there was no PO for DNR, LPN #1 strongly insisted that because the POLST form was blank and there was no full code written anywhere in the MR, he would not start CPR at all. The nursing progress notes (PN) indicated that at 11:55 PM, the Registered Nurse/Nursing Supervisor (RN/NS) arrived on the unit for the night shift (11PM-7AM) and was notified by LPN #1 that Resident #1 expired at 11PM. The RN/NS documented that Resident #1 was a full code, CPR was initiated at 12:20 AM, LPN #2 called 911 at 12:50 AM, and the paramedics and team pronounced Resident #1 expired at 01:43 AM. During a telephone interview on [DATE] at 4:07 PM, the RN/NS stated he called the facility prior to his shift because he was going to be late; and at that time 11-7 shift LPN #2 informed him on the phone the resident had expired, and he assumed Resident #1 was not a full code or resuscitation effort was unsuccessful. The RN/NS explained that when he arrived on the unit, he received reports and asked LPN #1 what Resident #1's code status was. LPN #1 responded, I think it's not DNR. He was also informed that the Physician had already been notified the resident had expired. At that time, the RN/NS checked the chart to verify Resident #1's code status and confirmed there was no PO for DNR. He then called the DON, who instructed him to initiate CPR and call 911 An Immediate Jeopardy (IJ) past noncompliance (PNC) began on [DATE] when the facility's failed to initiate CPR and activate their ERS immediately when Resident #1, who was a full code, did not have a PO for DNR, and was found unresponsive, and without a pulse or respirations. This practice placed all residents who are a full code or had no accurate code status in the MR at risk for imminent death if found to be unresponsive without a pulse and respirations. The IJ PNC was determined to have existed on [DATE] and there was sufficient evidence that on [DATE] that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the specific regulatory requirement. The Administrator and Assistant Director of Nursing (ADON) were informed of the of the past IJ situation on [DATE]. The deficient practice is evidenced by the following: Reference: https://www.ahajournals.org/toc/circ/122/18_suppl_3 The American Heart Association (AHA) publishes 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. The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. Prompt emergency activation and initiation of CPR requires rapid recognition of cardiac arrest. A cardiac arrest victim is not responsive. Breathing is absent or is not normal. Consequently, rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally. Reference: https://www.nj.gov/health/advancedirective/polst/ The Practitioner Orders for Life Sustaining Treatment (POLST) form enables patients to indicate their preferences regarding life-sustaining treatment. This form, signed by a patient's attending physician, advanced practice nurse or physician's assistant, provides instructions for health care personnel to follow for a range of life-prolonging interventions. This form becomes part of a patient's medical records, following the patient from one healthcare setting to another, including hospital, nursing home or hospice. 1. According to the admission Record, Resident #1 was admitted to the facility on [DATE]. A Physician's progress notes (PN) dated [DATE] indicated diagnoses which included but were not limited to Hypertension, Congestive Heart Failure, and Right Thalamic Intracerebral Hemorrhage with left hemiparesis (stroke with left-sided weakness) A Minimum Data Set (MDS), an assessment tool, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition and the resident required extensive assistance with activities of daily living (ADLs). A review of the Order Summary Report (OSR) did not include a physician order (PO) for DNR. A review of the care plan (CP) did not include a CP for the resident's code status, DNR or full code. Review of a document titled Social Service Evaluation (SSE) dated [DATE] indicated that the Social Worker documented Full Code under Advance Directive (AD). A review of Resident #1's closed chart/MR on [DATE] did not include a Physicians Orders for Life- Sustaining Treatment (POLST) form in the chart. A review of the nursing PN dated [DATE] at 12:20 AM, signed by LPN #1, indicated that Resident #1 was last seen on [DATE] at 7 PM complaining of cough and was given cough medication. Resident #1 was found unresponsive at 11 PM by CNA #1. LPN #1 went into the room, checked for pulse and vital signs, and found out the resident expired. A review of nursing PN dated [DATE] at 01:52 AM, signed by LPN #2, indicated at 11:23 PM received report that Resident #1 had expired. The outgoing nurse (LPN #1) called the Physician to notify the resident expired. Called placed to DON message left for a return call. At 11:40 PM, the supervisor was notified (over the phone) of the resident's status. At 12:50 AM, CPR was initiated, and family and 911 were called. At 1:00 AM, the police arrived, and CPR continued. Further review of nursing PN dated [DATE] at 3:37 AM signed by the RN/NS indicated at 11:55 PM, he arrived on the floor and was notified by 3-11 shift nurse (LPN#1) that Resident #1 expired at 11 PM and Physician on-call had been notified. The RN/NS documented that Resident #1 was a full code. At that time, the RN/NS noted the resident was unresponsive and had no heart sounds on auscultation. The DON was notified, and CPR was initiated at 12:20 AM. The charge nurse (LPN #2) called 911 at 12:50 AM. The paramedics pronounced Resident #1 expired at 1:43 AM on [DATE]. A review of a written employee statement signed by CNA #1 and dated [DATE] revealed on [DATE] at 10 PM, CNA #1 indicated Resident #1 was trying to get out of bed, and she went to reposition the resident's legs. At 11 PM, CNA #1 was notified by Temporary Nursing Assistant (TNA) #1 that Resident #1 was unresponsive, CNA #1 checked and confirmed the resident was unresponsive, then immediately informed the nurse (LPN #1). During a telephone interview with the surveyor on [DATE] at 10:50 AM, CNA #1 confirmed that when she checked, Resident #1 was unresponsive, not stiff and skin was warm. During a telephone interview with the surveyor on [DATE] at 1:44 PM, LPN #1 confirmed he did not initiate CPR when he found Resident #1 to be unresponsive and not breathing on [DATE] at 11 PM because he was trying to figure out the resident's code status. LPN #1 confirmed the resident had no palpable pulse and was not cold or stiff at that time. He explained that the POLST form in the resident's chart was blank, and there was no PO for a full code. He continued to explain that he notified the Physician on call only to inform Resident #1 had expired so the resident could be pronounced expired. LPN #1 confirmed he did not convey or explain to the Physician he was unsure of the resident's code status, and CPR was not initiated despite not having a PO for DNR. He continued to state he called the DON and ADON but could not be reached. Although the OSR did not indicate a PO for DNR, LPN #1 strongly insisted that because the POLST form was blank, there was no clear instructions, so the code status was not clear. He added, if a resident code status cannot be found despite not having a PO for DNR, he would not start CPR at all. During a telephone interview with the surveyor on [DATE] at 4:07 PM, the RN/NS confirmed he was the night shift (11PM-7AM) nursing supervisor on [DATE]. He stated on [DATE] after 11 PM, he called the facility to inform the nurses he was going to be late, and at that time, the nurse informed him a resident had expired. The RN/NS explained he did not ask questions because he assumed the resident was not a full code or the resuscitation effort was unsuccessful. When he arrived, he received report and asked LPN #1 what Resident #1's code status was. LPN #1 responded, I think it's not DNR and informed him the Physician had already been notified the resident had expired so that the resident could be pronounced. At that time, he found out there was no PO for DNR. The RN/NS called the DON for instructions. The RN/NS assessed Resident #1 and was noted to be unresponsive, warm to the touch, had no pulse or VS, and pupils were non-reactive. He called the DON and started CPR and call 911 after the call. During a telephone interview with the surveyor on [DATE] at 5:34 PM, LPN #2 confirmed that she was the night shift nurse on [DATE]. She stated, at around 11:20 PM, LPN #1 reported to her that Resident #1 had expired at 11 PM and the Physician had already been notified that the resident expired. She remembered LPN #1 stating, Right now, I have a situation; I have a patient that expired, LPN #1 told her to call the RP and the funeral home. At that time, there was no funeral home listed on the resident's chart, so she called the DON and left a message. LPN #2 agreed that the RN/NS aforementioned interview statement was correct. During an interview with the surveyor on [DATE] at 2:14 PM, the Social Service Director (SSD) stated Resident #1 was unable to complete the POLST form due to cognitive status. The POLST form was discussed and mailed to the family member/Responsible Party (RP), but the form was never completed. The SS was unable to explain why there was not follow discussion about the POLST form with the RP. She confirmed that Resident #1's code status was a full code since the POLST form was never completed, and there was no PO for DNR. During a telephone interview with the surveyor on [DATE] at 11:20 AM, the Social Worker (SW) confirmed she completed the SSE on [DATE], which indicated full code under AD. She stated that a POLST form is not mandatory, but the resident or RP is encouraged to complete the form. She continued to state that Resident #1 was a full code since the POLST form was blank and there was no PO for DNR. During a telephone interview with the surveyor on [DATE] at 11:33 AM, Resident #1's Physician stated that on [DATE], unknown time, the on-call Physician emailed him that Resident #1 had expired. He explained he was not informed that CPR was not provided, or CPR was delayed. The Physician explained that he expects the nurses to call him or the clinician on call for changes in the resident's condition so they can make clinical decisions based on the nurse's assessment. He stated the nurse should have informed the Physician on a call about the unclear code status of the resident. However, if there was no PO for DNR, the resident was full code. Additionally, the physician confirmed that signs of rigor mortis can occur a couple of hours after death, including stiffness, coldness, and cyanosis (bluish skin discoloration), which were not conveyed to the Physician on-call on [DATE]. Review of a witness statement dated [DATE] signed by the DON, indicated that she received a call from at 12:42 AM LPN #2 who reported that Resident #1 expired during 3PM-11PM shift. LPN #2 went on to say that no there was no funeral home listed on the resident's chart and the RP could not be reached. The RN/NS took the phone and explained that Resident #1 expired at 11PM and explained that the resident was identified as a full code and no code was initiated. The RN/NS went on to ask if he should pronounce Resident #1 or move forward doing the code because the on-call Physician had already been notified of the time the resident expired. The DON instructed that a code be initiated and 911 be called. During a telephone interview with the surveyor on [DATE] at 11:22 AM, The DON explained LPN #2 called and informed her at around 12:20 that Resident #1 had expired and did not have a funeral home listed on the chart. The RN/NS who was also on the phone explain what had transpired and informed her that Resident #1 was full code. She instructed the RN/NS to initiate CPR and call 911 immediately. The DON continued to state that LPN #1 should have conveyed the resident's findings when he notified the Physician because LPNs are not permitted to pronounce the resident's death. The DON acknowledged that LPN #1 should have initiated CPR immediately and activated the ERS upon confirming there was no PO for DNR. During an interview with the Assistant Director of Nursing (ADON) and Administrator on [DATE] at 6:19 PM, they both stated that nurses and CNAs who are CPR certified are expected to immediately start CPR and activate 911 if a resident is a full code and found unresponsive, not breathing and without a pulse. They both confirmed that if there was no PO for DNR or a POLST form indicating DNR, the resident is a full code. The ADON confirmed LPN #1 did not follow the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation and should have initiated CPR and activate 911 immediately. A review of the facility's undated policy titled Emergency Procedure- Cardiopulmonary Resuscitation included but was not limited to the following: Under Guidelines it was indicated that 4. The chances of surviving SCA (sudden cardiac arrest) may be increased if CPR is initiated immediately .5. Early delivery of a shock with a defibrillator plus CPR .can further increase chances of survival. 6. If an individual (resident, visitor .) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a DNR order .there are obvious signs of irreversible death (e.g., rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is DNR . It was indicted under Emergency Procedure- Cardiopulmonary Resuscitation, 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. a. Instruct staff member to activate the emergency response system (code) and call 911. b. Instruct staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status .d. Initiate BLS . A review of the facility's undated policy titled Advance Directives included but was not limited to the following: Under Policy Statement it was indicated that Advance directive are honored in accordance with the state law and facility policy. Under Refusing or Requesting Treatment it was indicated that 1. The resident had the right to refuse medical or surgical treatment whether he or she has and advance directive. a. A resident will not be treated against his or her own wishes. On [DATE] at 9:44 PM, the facility provided a copy of the corrective action that was implemented which began on [DATE]. Review of the plan revealed the following: The facility reported the incident to the Ombudsman office and concluded their investigation on [DATE]. The Investigation Report included the timeline of the incident and witness statements obtained from the staff. Review of the statements from TNA #1, CNA #1, LPN #2, RN/NS, and the DON revealed that each staff member provided a signed and dated witness statements. On [DATE], the facility reported LPN #1 to the licensing board and was removed from working at the facility. On [DATE], the SW audited the medical records for all residents to ensure code status was documented using POLST form, matched the PO in the Electronic MR, and will continue this practice with future residents. On [DATE], the DON and ADON educated staff which included nursing, social service, dietary, rehabilitation, housekeeping and maintenance on rapid response (Emergency Procedue-CPR), code status (DNR, POLST), and following physician's orders and would be ongoing. On [DATE], the ADON educated the RN/NS and LPN #2 via telephone on code initiation and CPR policy and procedurea and would be ongoing. On [DATE], the facility audited and validated the facility staff CPR cards and would be ongoing. On [DATE], agency nurse education packets were updated to include facility CPR policy and procedure. All agency nurses were provided the new educations packets. All incoming agency nurses would be povided new education packets. On [DATE], all department heads which included Social Service, Admisssion, Rehabilitation, Housekeeping and Dietary were re-educated on code status and CPR policy and procedure. On [DATE], CPR protocols and mock code drill performed at the facility and would be ongoing. The surveyor reviewed and conducted onsite verification on [DATE] and [DATE] to confirm the facility had implemented all components of the corrective plan of action. After conducting records review and interviews, it was determined the facility implemented their corrective plan and the deficient practice was corrected on [DATE] prior to the survey. Review of the employee education attendance record (EEAR) dated [DATE] revealed that the RN/NS and LPN #2 received education by telephone on facility's policy and procedure for emergency procedure and CPR. Review of the EEAR dated [DATE], [DATE], and [DATE] revealed that nursing staff received education on facility's policy and procedure for emergency procedure and CPR and [DATE] on who can pronounce when a resident expired. Review of the EEAR dated [DATE] revealed that department heads received education on facility's policy and procedure for emergency procedure and CPR. Review of the EEAR dated [DATE] revealed that a mock drill in-service for all facility staff was performed at 2:20 PM and 6:30 PM and an in-service on [DATE] on CPR and code blue drill. Review of the agency nursing staff education packet included CPR certification requirements, information on facility sponsored CPR classes, and emergency response procedures. During the survey, the surveyor verified the validity of nursing staff CPR certifications. During the survey, the surveyor verified that the resident charts were audited and POLST forms (green form) were placed in front of the charts with the resident's code status. The surveyor verified that the RN/NS, LPN #2, CNA #1, and TNA #1 received education on code status and CPR protocols. During a telephone interview with the surveyor on [DATE] at 5:34 PM, LPN #2 confirmed she received education on code status and CPR protocols. During an interview with the surveyor on [DATE] at 3:10 PM, the RN/UM stated that after the incident she was educated on resident code status, emergency procedures, and CPR protocols. During an interview with the surveyor on [DATE] at 3:41 PM, RN #1 explained that she received education and attended a code drill. She explained the process for identifying code status, CPR, and emergency procedures. During an interview with the surveyor on [DATE] at 8:55 PM, LPN #3 and CNA #2 stated they both received in-service on code status, CPR, and emergency procedures. NJAC 8:39-27.1(a) NJAC 8:39-4.1(31) iii NJAC 8:39-9.6 (g)