**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews during the recertification survey conducted [DATE]- [DATE], the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding advance directives to the staff responsible for the resident's care for 1 of 24 residents (Resident #87) reviewed. Specifically, Resident #87 updated their Medical Orders for Life Sustaining Treatment (MOLST) during a hospitalization to reflect a change from wanting cardiopulmonary resuscitation (CPR) to do-not-resuscitate (DNR) code status. When the resident was readmitted to the facility their medical record and code status indicators were not revised to reflect the resident's advance directive wishes and the facility continued with cardiopulmonary resuscitation orders. Subsequently, the facility's failure to have a system to ensure code status changes were properly identified and implemented, placed all 117 residents in the facility who had advance directives in place, at risk. This resulted in Immediate Jeopardy to resident health and safety. Findings included: The facility policy, Advance Directives reviewed [DATE], documented all properly executed advance directives are honored including do-not-resuscitate orders, living wills, health care proxies, and electronic Medical Orders for Life-Sustaining Treatment. The Admissions department, social worker, Nurse Manager, and physician are all responsible to assess advance directives and electronic medical orders for life sustaining treatment to assure that the advance directives have been expressed in a clear and convincing manner. The facility policy, Cardiopulmonary Resuscitation: Skilled Nursing Home revised [DATE], documented all residents who have a valid do-not-resuscitate order will have a purple dot placed on their name band and in the electronic medical record program. Any changes to a resident's cardiopulmonary resuscitation or do not resuscitate status will be communicated to staff immediately upon the change. When a resident changed status from cardiopulmonary resuscitation or do not resuscitate the staff were to update the medical record and print/apply a new name band. Resident #87 was readmitted to the facility with diagnoses including syncope (loss of consciousness) and collapse, chronic kidney disease, and hypothyroidism (underactive thyroid). The [DATE] Minimum Data Set documented the resident had intact cognition and participated in the assessment and goal setting. Resident #87's comprehensive care plan effective [DATE] documented the resident had advance directives of cardiopulmonary resuscitation per their wishes and an electronic Medical Orders for Life Sustaining Treatment. Resident #87's Medical Orders for Life Sustaining Treatment in effect prior to their hospitalization on [DATE], was signed by the resident on [DATE] and documented attempt cardiopulmonary resuscitation when they had no pulse and/or was not breathing. A hospital discharge summary documented the resident was hospitalized [DATE]-[DATE] for syncope after blacking out during a shower at the nursing facility. The resident's code status at discharge was do not resuscitate/do not intubate (placement of a breathing tube). The electronic Medical Orders for Life Sustaining Treatment electronically signed by the resident on [DATE] at 6:16 PM and by the hospital physician on [DATE] at 8:59 PM documented the resident's wishes included do not attempt resuscitation (allow natural death). The section for review and renewal of the medical orders for life sustaining treatment included a review by the hospital physician on [DATE] at 8:59 PM and documented the previous form was voided and a new form was completed. The resident's medical record face sheet with a last admission date of [DATE] at 1:30 PM, documented the resident had advance directives of full cardiopulmonary resuscitation (CPR), refer to the electronic Medical Orders for Life Sustaining treatment. The [DATE] at 11:08 AM medical readmission order by nurse practitioner #20 documented advance directives, full cardiopulmonary resuscitation. Refer to electronic Medical Orders for Life Sustaining Treatment. The electronic Medical Orders for Life Sustaining Treatment section for review and renewal was signed on [DATE] at 8:25 PM by facility physician #6 and documented the outcome of the review was no change. The resident's comprehensive care plan revised on [DATE] by social worker #9 documented the resident had advance directives of cardiopulmonary resuscitation per their wishes and an electronic Medical Orders for Life Sustaining Treatment. There was a cardiopulmonary resuscitation order in place. During observations on [DATE] at 3:17 PM and [DATE] at 9:54 AM, Resident #87's identification bracelet on their right wrist did not have a purple dot to indicate do-not-resuscitate. The electronic medical record documented the code status indicator for Resident #87 as full cardiopulmonary resuscitation and the resident had an electronic medical order for life sustaining treatment. During an interview on [DATE] at 12:06 PM, Resident #87 stated they had signed a do-not-resuscitate order and that was what they wished to remain. During observations on [DATE] at 4:08 PM and [DATE] at 9:55 AM, there was a list of residents with their code status posted in the Tulip Court (third floor) open breakroom. The list documented Resident #87 was a full code, meaning the resident wished to receive cardiopulmonary resuscitation. During an interview on [DATE] at 2:50 PM, licensed practical nurse #1 stated they would check resident's chart for their code status. A resident would have a purple dot next to their name in the chart if they had a do-not-resuscitate order. The resident's medical orders also indicated their code status. The licensed practical nurse stated they would also check the resident's identification bracelet as they would have a purple dot on the bracelet if they had a do-not-resuscitate order. During an interview on [DATE] at 4:08 PM, Registered Nurse Unit Manager #2 stated they posted a listing of what residents were to receive cardiopulmonary resuscitation and what residents had do-not-resuscitate orders, so staff had a visual of what the code status was for the residents on the unit. The listing was updated weekly and as needed if a code status changed. They stated in the event of an emergency, the nursing staff would respond to the resident and check the resident's identification bracelet. If the resident had a purple dot on their identification bracelet it meant they had a do-not-resuscitate order. During an interview on [DATE] at 10:06 AM, certified nurse aide #10 stated they would look in the electronic medical record and on a resident's identification bracelet for code status. The purple dot on the resident's identification bracelet meant the resident was a full code (cardiopulmonary resuscitation). During an interview on [DATE] at 10:10 AM, certified nurse aide #7 stated they would look at a resident's identification bracelet for their code status. If there was a purple dot, the resident was a full code (cardiopulmonary resuscitation). During an interview on [DATE] 10:16 AM, certified nurse aide #11 stated they would look at the resident's identification bracelet for code status. If the resident had a green or red dot that meant they were a full code. During an interview on [DATE] at 10:16 AM, certified nurse aide #8 stated they would look at a resident's wrist band for code status. A purple dot meant the resident wanted cardiopulmonary resuscitation. During an interview on [DATE] at 10:19 AM, licensed practical nurse #15 stated if a resident was found unresponsive, they would check the resident's identification band for a purple dot as that meant the resident was a do-not-resuscitate. They would also look in the resident's orders in the electronic medical record. They would not check the resident's electronic Medical Order for Life Sustaining Treatment as they did not have access to the system where it was located. Their access expired. During an interview on [DATE] at 10:23 AM, certified nurse aide #12 stated they would look at the resident's identification bracelet for code status. A blue dot meant the resident was a full code. If there was no dot, the resident had a do-not-resuscitate order. During an interview on [DATE] at 10:26 AM, physician #6 stated when a resident was admitted to the facility, part of the initial discussion was about what their current advance directives were and if the resident wanted to keep their current advance directives or make changes. If the resident wanted their advance directives changed, the social worker completed a new electronic Medical Orders for Life Sustaining Treatment form, and the physician would sign off once completed. For a readmission, the nurse that took report reviewed the electronic Medical Orders for Life Sustaining Treatment at the time of admission and the social worker reviewed the resident's advance directives with the resident within 24 hours of admission. The advance directives were not always reviewed by the physician immediately upon readmission. Physician #6 stated they expected staff to check the patient lists on the unit or the resident's identification bracelet for their code status. A resident's identification band was marked if the resident had a do-not-resuscitate order. It was important that the electronic Medical Orders for Life Sustaining Treatment matched the physician order in the computer, so the wrong directive was not provided during an emergency. At 11:42 AM, Physician #6 stated if cardiopulmonary resuscitation was provided against the resident's wishes, it could prolong life when the resident did not want it prolonged. It also had the potential to cause suffering as ribs could be broken during cardiopulmonary resuscitation and possibly lead to hospitalization and intubation. If a resident was not provided cardiopulmonary resuscitation when they requested, the person could pass away. During an interview on [DATE] 10:42 AM, Director of Nursing stated the nursing staff checked the resident's identification bracelet to determine code status; a purple dot meant the resident was do-not-resuscitate and no dot meant cardiopulmonary resuscitation. The code status was also listed in the resident's orders. When a resident was admitted or readmitted , the admitting nurse received a nurse-to-nurse report in addition to the hospital records. The admitting nurse entered the advanced directive orders. The unit secretary doubled checked the resident's identification band against the advance directive order in the resident's record for accuracy before it was applied to the resident. The electronic medical order for life sustaining treatment was mostly used when the resident needed to be transferred to the hospital, not for day-to-day or emergency use. The written order and the electronic medical order for life sustaining treatment should match. If a resident who wished to be do-not-resuscitate was resuscitated, they could be injured in the process, and it would be against their wishes. If a resident wanted to be resuscitated and was not, they would die. During an interview on [DATE] at 11:26 AM, Administrator #3 stated when a resident was admitted , they received hospital notes with advance directives and the admission nurse would verify the code status with the electronic Medical Order for Life Sustaining Treatment. The verification would be done by the physician. The unit secretary printed an identification band with the resident's code status. The Administrator was not sure if the dot on the identification band meant cardiopulmonary resuscitation or do-not-resuscitate. They were unaware of how the resident's chart or electronic Medical Order for Life Sustaining Treatment was updated if a resident's wishes changed. At 12:05 PM, Administrator #3 stated they expected the admitting nurse to confirm the paperwork from the hospital matched the facility's regarding advance directives and they should enter the order accurately in accordance with the electronic Medical Orders for Life Sustaining Treatment. During an interview on [DATE] at 12:53 PM, Licensed Practical Nurse Unit Coordinator #14 stated they were responsible for admissions, readmissions, and discharges. Advance directives were a part of admission and readmission. Advance directive orders were entered and were received by the nurse-to-nurse report and through the paperwork provided by the hospital. The social worker also confirmed advance directives. After the advance directive order was entered by nursing, the social worker verified it with the electronic Medical Orders for Life Sustaining Treatment, if the resident had one. Staff would check the resident's orders for code status. They stated they did not check Resident #87's electronic Medical Order for Life Sustaining Treatment when the resident was readmitted . During an interview on [DATE] at 1:44 PM, social worker #9 stated they discussed a resident's advance directives with the resident and/or the resident's family within 24 hours of admission. They checked the paperwork that came from the hospital and the electronic Medical Orders for Life Sustaining Treatment. A resident's advance directives were always reviewed either by nursing or by social work. They did not always document the advance directive was reviewed on readmissions. Both social work and nursing were responsible for a resident's advance directive plan of care and to make sure the facility records were updated if a resident came back from the hospital with a change in their electronic Medical Order for Life Sustaining Treatment. It was important the electronic Medical Orders for Life Sustaining Treatment and the physician's order in the resident's medical record matched so a mistake was not made if the resident had an emergency. _____________________________________________________________________________________________ Immediate Jeopardy was removed on [DATE] at 11:34 AM prior to survey exit based on the following corrective actions taken: -Resident #87's advance directives were reviewed and discussed with the resident who wished to have a do-not-resuscitate order. A do-not-resuscitate order was entered into the electronic medical record and the comprehensive care plan was updated. -The facility would no longer post code status sheets and staff would be required to look in the computer for code status. -100% of residents will be audited to ensure electronic Medical Orders for Life Sustaining Treatment, physician order in electronic medical record, care plan, and header in electronic medical record match. - Policies for advance directives were updated to include a review of any existing electronic Medical Orders for Life Sustaining Treatment and the inclusion of a triple check for all admissions and readmissions. The triple check will be conducted by the Admissions Nurse, social worker, and the medical provider. -Education was provided to the admission Nurse, social worker, and Medical Director regarding the policy change. -All staff will be educated where to access advance directives and will be included in the orientation of new employees. -All staff will be educated on the termination of the use of purple dots on the identification bracelets as an identifier for code status. -An audit tool was developed to compare the electronic Medical Orders for Life Sustaining Treatment and the physician orders match the residents' wishes. -All staff identified for education received education on [DATE] and [DATE]. The staff that did not receive education were to complete the education upon their return, prior to the start of their shift. -Interviews were completed on [DATE] to determine compliance with staff training and education including the Admissions Nurse, social worker, the Medical Director, and various interdisciplinary team members. 10NYCRR 400.21(c)