**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of video/audio camera recordings, review of a fire department cardiopulmonary resuscitation (CPR) report, review of a facility Self-Reported Incident (SRI), review of the facility policy for call lights, review of the facility policy for resident condition change, review of the redcross.org Adult Cardiopulmonary Resuscitation (CPR) Steps reference, and interviews, the facility failed to timely and appropriately respond to Resident #118's calls for assistance and failed to provide adequate assistance/intervention as the resident was experiencing a change in condition/respiratory distress. This resulted in Immediate Jeopardy and serious life-threatening harm/subsequently death beginning on [DATE] at 6:59 A.M. when staff failed to provide timely and appropriate care after Resident #118 pushed her call light and began yelling out for the nurse. Video/audio recording of the resident on [DATE] between 7:13 A.M. and 10:30 A.M. demonstrated a continued lack of adequate and necessary care by multiple staff. This included at 7:13 A.M. when an unidentified staff member entered Resident #118's room, turned off the call light and turned and exited the room stating to Resident #118, You will be fine (Resident #118's name), as she walked away. As the unidentified staff member was walking away, Resident #118 stated she had to pull for air and the unidentified staff member continued to exit the room without addressing Resident #118's concern. At 7:33 A.M. State Tested Nurse Aide (STNA) #274 entered Resident #118's room, shut off the call light and said he had to get report then he would be back to help her. There was no further video recording until 9:14 A.M. when Resident #118 began pushing her call light again. (Video footage is recorded following the movement detected by the camera). Between 9:14 A.M. and 9:57 A.M. Resident #118 pushed her call light an additional 11 times and yelled out multiple times for help, with no response from staff. At 9:57 A.M. STNA #274 entered Resident #118's room and asked, What is going on? Resident #118 stated she could not breathe and asked for help sitting up. STNA #274 stated the resident could not sit on the edge of the bed as requested and exited the room. At 9:58 A.M. Licensed Practical Nurse (LPN) #221 and STNA #274 entered Resident #118's room, Resident #118 said she was choking. LPN #221 attempted to suction Resident #118's oral secretions but did not complete an assessment, including vital signs of Resident #118. At 10:01 A.M. LPN #221 called emergency medical services (EMS) via 911. At 10:03 A.M. Resident #118 went unresponsive and at 10:06 A.M. chest compressions were initiated while Resident #118 was lying on an inflated low air loss mattress. A backboard was not used. At 10:08 A.M. an automated external defibrillator (AED) (device that analyzes heart rhythm and delivers shock, if needed, to restore normal heath rhythm) was brought into Resident #118's. However, the AED battery was low and there were no pads to connect the device to Resident #118 to enable detection of heart rhythm and deliver a shock if needed. At 10:10 A.M. staff indicated there was no backboard under the resident, a backboard was not provided for increased effectiveness of CPR. At 10:12 A.M. Emergency Medical Services (EMS) personnel took over care of the resident (a backboard was placed under the resident at that time). Resident #118 was unable to be resuscitated and was pronounced deceased at 10:30 A.M. This affected one resident (#118) of two residents reviewed for death. The facility census was 112. On [DATE] at 12:05 P.M. the Administrator and Administrator in Training (AIT) #401 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide adequate, necessary care and treatment and timely intervention to Resident #118, who was a full code status, for an acute change in condition resulting in Resident #118's death. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions. • On [DATE] after Resident #118 expired, the identified AED machine was taken out of service and removed from the facility (at 12:00 P.M.) • On [DATE] LPN #221 completed Cardiopulmonary Resuscitation (CPR) training and provided the facility a current CPR certification card. • On [DATE] the Director of Nursing (DON) reviewed all current resident charts to ensure residents experiencing a change in condition were assessed immediately by the licensed nurse, CPR was performed using a back board appropriately if needed, and the call lights were answered timely. • On [DATE] the DON completed training for all facility licensed nurses which included residents with a change in condition were fully assessed and follow up was completed. Additional training was completed for licensed nursing staff to ensure a backboard was used when performing CPR, and that per the facility policy was followed and that the AED was not to be used. Licensed nurses were also educated to check and assure a back board was available for use on the facility crash carts. • On [DATE] the DON completed training for all nursing staff to ensure resident call lights were answered timely and care was provided as necessary. • On [DATE] the facility held mock CPR code drills during the 7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M., and 11:00 P.M. to 7:00 A.M. shifts for licensed nurses to ensure appropriate procedures were followed. • On [DATE] the DON trained Human Resource (HR) #262 to ensure upon hire and monthly thereafter, all licensed nurses had an active CPR card. An audit of licensed nurses was also completed to ensure all CPR cards were current. • The facility implemented a plan for weekly audits to be completed for four weeks by the HR #262 to ensure active CPR cards were in personnel files for all licensed nurses. • The facility implemented a plan for weekly audits for four weeks by the DON or Assistant Director of Nursing (ADON) to monitor all changes in resident condition and to ensure call lights were answered timely, care was provided as necessary, a full assessment was completed by the licensed nurse, an AED machine was not used, and a backboard was used when CPR was performed. All audits will be submitted to the Quality Assurance (QA) committee weekly for trending, tracking and recommendations. • Interviews on [DATE] between 11:30 A.M. and 12:06 P.M. with STNA #204, #233, #271, #232, LPN #235, #311, and #236 confirmed staff were educated by the DON. LPN #311 confirmed she had a mock code completed on [DATE]. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #118's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. Resident #118 had diagnoses including dysphagia (difficulty swallowing), muscle weakness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic congestive heart failure, hypertension, and obstructive sleep apnea. Record review of the care plan for Resident #118 dated [DATE] revealed the resident's advance directives were for a full code status. Record review revealed the resident also had a care plan for impaired respiratory status related to asthma, sleep apnea, and chronic respiratory failure. Interventions included administering medications as ordered, assist with activities of daily living, encourage rest periods, and elevate the head of the bed. Review of a Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #118 was rarely or never understood, required extensive assistance from two staff for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene, and total dependence (from staff) for eating. The MDS also reflected the resident had medically complex conditions which included cancer, heart failure, and renal failure. Review of Resident #118's physician orders revealed an order dated [DATE] indicating Resident #118 was to have nothing by mouth (NPO). An order dated [DATE] indicated Resident #118 was a full code. Review of Resident #18's (re-admission) admission Evaluation dated [DATE] timed 12:03 A.M. revealed on [DATE] at 12:00 A.M. Resident #118 was admitted from the hospital, alert and oriented to person and place, on oxygen therapy, and was a full code status. Review of a nurse's note, dated [DATE] timed 12:00 P.M. and completed by LPN #221 revealed during morning medication pass Resident #118 verbalized she felt short of breath and felt that she needed to go to the emergency room. The resident's oxygen saturation level was documented to be 89 % (normal 92-100%), blood pressure (BP) was 144/62 and pulse 62 beats per minute (bpm). The note indicated Resident #118 coded after vital signs with lack of respiration and lack of heartbeat. LPN #221 documented in the note she initiated a Code Blue and EMS was activated. In house staff-initiated CPR, EMS arrived and took over CPR. EMS was in contact with the emergency room physician. Code continued for 20 more minutes. Resident #118 continued to have lack of vitals and was asystole (no heart rhythm) on the heart monitor. The physician discontinued CPR and the resident was pronounced deceased at 10:30 A.M. Family was notified and came in to view the body and staff performed postmortem care. The funeral home was contacted at 11:15 A.M. The note revealed the Nurse Practitioner was also notified. The resident's family provided video/audio footage recording taken from Resident #118's room via a video/audio monitoring camera that was placed in the room that the family had access to and could view dated [DATE] which revealed the following: • At 6:59 A.M., Resident #118 pushed her call light and yelled out Nurse. Resident #118 attempted to clear her throat and again yelled out while continuing to push her call light with no response. • At 7:13 A.M., an unidentified female staff member entered Resident #118's room, walked directly over to the call light switch located on the wall. Resident #118 spoke to the staff member, the staff did not stop walking, shut off the call light switch on the wall, turned, and as she was walking away from Resident #118, she told her she was fine. Resident #118 stated, I have to pull for air. The staff member continued to walk away and exited the room. • At 7:33 A.M., Resident #118 again pushed her call light. STNA #274 entered the room, shut off the call light switch located on the wall and approached Resident #118 asking if she needed something. Resident #118 requested to be pulled up in bed. STNA #274 said he had to get report first then he would come and take care of her, he would be right back. • There was no further video recording until 9:14 A.M. when Resident #118 began pushing her call light again. • At 9:14 A.M., Resident #118 pushed her call light, coughing and clearing her throat. • At 9:16 A.M., Resident #118 pushed her call light with no response from staff. • At 9:28 A.M., Resident #118 pushed her call light with no response from staff. • At 9:31 A.M., Resident #118 pushed her call light with no response from staff. • At 9:43 A.M., Resident #118 pushed her call light with no response from staff. • At 9:47 A.M., Resident #118 pushed her call light with no response from staff. Resident #118 began yelling for help. • At 9:48 A.M., Resident #118 pushed her call light with no response from staff. Resident #118 was attempting to clear her airway. • At 9:49 A.M., Resident #118 pushed her call light with no response from staff. • At 9:52 A.M., Resident #118 pushed her call light with no response from staff. Resident #118 was yelling out, Nurse I am sick Resident #118 picked up her phone and attempted to make a phone call unsuccessfully, calling out, Nurse, help. • At 9:54 A.M., Resident #118 was observed dropping the phone and heard continuing to call nurse, help. • At 9:55 A.M., Resident #118 continued to attempt to use the phone unsuccessfully and continued to yell out repeatedly, Nurse help me, help me, help me while pushing her call light repeatedly without a response. • At 9:57 A.M., STNA #274 entered and asked, What's going on? Resident #118 stated, I can't breathe. Resident #118 requested STNA #274 to help her sit up. STNA #274 stated the resident could not sit up on the side of the bed, she had to stay in bed. Resident #118 requested to go to the hospital. At this point Resident #118 was struggling to breathe while making grunting sounds with each breath. Resident #274 left the room at 9:58:23. Resident #118 was observed to continue struggling and called, Nurse. • At 9:58 A.M., LPN #221 entered the room with STNA #274. Resident #118, while struggling to speak stated again help me, I am choking. LPN #221 asked what's the matter, are you having a hard time. Resident #118 repeated, I am choking. LPN #221 asked STNA #274 is that thing hooked up (referring to the suction machine). LPN #221 put the tip of the tonsil tip suction device in Resident #118's mouth briefly. Resident #118 indicated there was nothing there. LPN #221 asked Resident #118 if she needed some water. LPN #221 moved from the camera view and stated, Let me see if I can get her some water then asked, Is she NPO? STNA #274 confirmed Resident #118 was NPO. • At 10:01 A.M., LPN #221 placed a call on a cell phone while in Resident #118's room to 911 and said Resident #118 was having trouble breathing. A female voice could be heard coming from the video/audio recording camera asking, What's happening? (the voice was confirmed to be Resident #118's daughter). LPN #221 stated Resident #118 was having a hard time, she called 911, the squad was on the way, she could not give her anything to drink because she was NPO, so she was going to have to send her (the resident) out. • At 10:03 A.M , another unidentified staff member entered the resident's room. Resident #118 had hand movements toward her chest but offered no response to staff. • At 10:03 A.M., Human Resource (HR) #262 (manager on duty) was observed to enter the resident's room and applied gloves. Resident #118 was unresponsive. HR #262 completed a sternal rub and was observed to check the resident for a radial pulse. • At 10:04 A.M., LPN #221 placed an automatic wrist blood pressure cuff on Resident #118's left wrist. • At 10:05 A.M., STNA #274 was observed attempting to obtain a response from Resident #118 who was unresponsive. No other staff were observed in the room. • At 10:06 A.M., Resident #118's bed was positioned flat and manual administration of an ambu bag (for ventilation) was initiated per HR #262. • At 10:06:10 A.M., LPN #221 motioned to staff to cover the camera in the resident's room. STNA #204 and #274 were observed to stand in front of the video camera at this time. • At 10:06:30 A.M., chest compressions were initiated. No backboard was placed under Resident #118 who was lying on a low air loss mattress. Two staff members were noted to be covering the camera view with their backsides. A crash cart was partially in view. Counting of compressions could be heard. • At 10:08:52 A.M., LPN #221 brought an AED into the room and placed it at the foot of Resident #118's bed. • At 10:08:56 A.M., audible from the AED could be heard; Battery Low, Check Pads Several staff asked, Where are the pads? The AED repeated, Check Pads as staff looked through the crash cart drawers, pads were not located. Chest compressions continued. The camera view was intermittently blocked. • At 10:10:03 A.M. a male voice was heard asking, Where is the back board? A female voice stated, There should be one on there. Three staff members (STNA #274, LPN #221, and LPN #207) went to the crash cart and confirmed a backboard was not on the crash cart nor in the room. No backboard was brought to the resident's room. • At 10:10:05 A.M., Environmental Services #239 was providing rescue breaths to Resident #118 using an ambu bag while LPN #280 was doing chest compressions. The low air loss mattress was inflated and Resident #118's body was moving up and down on the mattress during compressions. • At 10:11:08 A.M., EMS arrived. • At 10:11:32 A.M., LPN #287 took over chest compressions. Environmental Services #239 continued providing respirations/ventilation with the ambu bag. • At 10:11:56 A.M., EMS staff can be heard saying they responded for shortness of breath. The team was grabbing what they needed (getting supplies needed to care for a resident requiring cardiopulmonary resuscitation) • At 10:12:13 A.M., LPN #221 relieved LPN #287 and continued chest compressions. • At 10:12:50 A.M. EMS took over and continued resuscitation efforts through 10:30:57 A.M. Review of the local Fire Department Treatment/CPR report dated [DATE] on page three revealed Resident #118's date and time of death was [DATE] at 10:31 A.M. pronounced per Physician #501. Interview on [DATE] at 3:23 P.M. with HR #262 revealed he was the Manager on Duty on [DATE]. When he walked in the building at 10:00 A.M. he heard a Code Blue. HR #262 was informed Resident #118 was having trouble breathing and went unresponsive. HR #262 stated he was an emergency medical technician (EMT) prior to his employment with the facility in HR and when he entered Resident #118's room, the resident was having agonal (gasping) breathing. HR #262 stated he did a sternal rub, checked for alertness, used a pen to check capillary refill, then tried to obtain a pulse and could not find one. LPN #280 asked for an AED. LPN #221 retrieved the AED which was kept by the receptionist's office on the wall. LPN #280 opened the AED; it said low power and staff could not find the pads. Once the fire department arrived, they brought a [NAME] (provides mechanical chest compressions) device and a cardiac monitor. HR #262 was unaware of the low air loss mattress (on the resident's bed), and the ability to deflate the mattress. HR #262 confirmed the backboard was not in place while staff did CPR on Resident #118. HR #262 revealed the AED was tossed out the next day, the battery was not good enough. The cost of the battery was almost as much as the AED and the reason why the facility had not replaced the battery. On [DATE] at 4:24 P.M. a telephone interview with STNA #274 revealed Resident #118 frequently pushed her call light on (sometimes about 50 times per eight-hour shift) and the majority of the time it was to request to be suctioned. The STNA revealed the resident often needed suctioned (maybe about 10 times per shift) because she had a lot of mucous. Review of employee files and interview with HR #262 on [DATE] at 4:50 P.M. revealed LPN #221 (the nurse assigned to care for Resident #118 on [DATE]) had a hire date of [DATE]. The CPR card on file for LPN #221 was dated [DATE] (following the incident with Resident #118 on [DATE]). There was no evidence the facility had checked or verified LPN #221's CPR certification status at the time of hire. On [DATE] at 5:17 P.M. telephone interview with LPN #221 revealed (on [DATE]) she was outside of Resident #118's door when Resident #118 said nurse can you help me (unable to recall time) but stated this was the first time that morning Resident #118 had called out. LPN #221 stated she went into the room and asked Resident #118 what she needed. Resident #118 said she needed help, she was having a little trouble, but she did not say what kind of trouble. LPN #221 stated she sat Resident #118 up to get her vital signs. Resident #118 had oxygen on, and LPN #221 obtained her vital signs. LPN #118 stated as soon as she got the vital signs, Resident #118 went unresponsive, and LPN #221 called a Code Blue. LPN #221 said STNA #274 was with her, and CPR was initiated. LPN #221 said all equipment was available on the crash cart and 911 was called by another staff member. The squad showed up and took over. LPN #221 said when she assessed Resident #118 that morning (time not provided) she was fine, there were no concerns or complaints expressed by Resident #118. LPN #221 did not recall if there was a suction machine in Resident #118's room but said she did check Resident #118's mouth and there was nothing in her mouth. LPN #221 said there was no AED in Resident #118's room during CPR. On [DATE] at 5:37 P.M. telephone interview with Resident #118's granddaughter revealed the family had placed a camera in the resident's room (date note provided) after the resident reported concerns with care/abuse. The camera was motion detected, the facility was aware of the camera and Resident #118's children would often speak with staff through the camera while the staff would provide care to Resident #118. The granddaughter stated she watched the video from [DATE] and documented the concerns she had from the video, including the resident asking for help and the staff not assisting her, the resident yelling for help and no one coming to check on her, the resident ringing her call light numerous times- attempting to reach staff as she was having trouble breathing and using her phone in an attempt to get help but being unsuccessful. The granddaughter also expressed concerns with the suction machine not working when her grandmother asked to be suctioned and the AED not in working order when it was brought into Resident #118's room for use. On [DATE] from 6:16 P.M. to 7:00 P.M. the video footage (with sound) was reviewed with the Administrator, Administrator in Training #401 and the Director of Nursing. The video footage reviewed began on [DATE] at 6:17 A.M. and continued through the resident's death. On [DATE] at 2:55 P.M. during a follow-up interview and observation of the video footage from [DATE] with LPN #221 (with the Administrator and Administer in Training (AIT) #401 present), LPN #221 revealed she did suction Resident #118 stating, you can see she grabbed it; she likes doing it herself. LPN #221 said the suction machine was working, Resident #118 said there was nothing there (in her mouth). LPN #221 said if a resident was NPO they could still have sips of water to wet the tongue. When asked when Resident #118's vital signs were taken or if a backboard was used during CPR, LPN #221 stated, Well you got the video, you can see what happened. (verifying LPN #221 did not assess the resident's vitals as documented and a backboard was not used during CPR for Resident #118). Interview on [DATE] at 5:08 P.M. with Medical Director/Primary Care Physician #348 revealed expectations were for staff to answer a resident's call light within 10-15 minutes. If a resident was calling out - staff should respond immediately. When there was a medical concern, the nurse should get vital signs first, assess the resident, then call the physician. If CPR was required and the resident was in bed, a backboard should be used. On [DATE] at 3:39 P.M. a telephone interview with the DON confirmed the facility had a non-functioning AED. It had been decided by the company the AED would not be used and the batteries and pads would not be replaced. However, the AED was never removed from its original location. The DON stated a staff member must have seen the AED and grabbed it mistakenly. The AED had since been removed. On [DATE] at 9:54 A.M. during a telephone interview with the Administrator regarding viewing the video from [DATE] and the unidentified staff member walking into the room, turning off the call light and not addressing Resident #118's needs, he stated he was unable to hear what the unidentified staff member said to the resident after the call light was turned off and the staff member exited the room but he was looking in to it and would report the information in a facility self-reported incident to the State agency. Review of the facility Self-Reported Incident (SRI), tracking number 240091, created on [DATE] with a date of discovery noted to be [DATE] and authored by the Administrator, revealed the facility reported an allegation of neglect involving Resident #118. Information contained in the SRI noted the State agency surveyor showed me several video clips. One of these video clips showed what appeared to be a staff member in blue clothing walking into Resident #118's room at approximately 7:13 A.M. The unidentified staff member exchanged a few words with Resident #118, I could not understand what was said as I only saw the video once, appears to turn off the call light button in the room and exits the room. The staff member never had any physical interaction with Resident #118. However, per the State agency statement received by me on [DATE] at approximately 3:00 P.M., On [DATE] at 7:13 A.M. an unidentified staff member entered Resident #118's room, shut off the resident's call light and turned to leave when Resident #118 was heard telling the staff member she had to pull for air. The staff member said you will be fine and walked away. This was per the State agency statement received on [DATE]. (However, no written statement was provided to the facility or the Administrator regarding this incident by the State agency surveyor). The facility had not submitted a final report of their investigation to the State agency as of [DATE] at 1:15 P.M. Review of information from redcross.org revealed the following CPR Steps/Giving CPR included but were not limited to: Step 4: Kneel beside the person, place the person on their back on a firm, flat surface. Step 7: Use an AED as soon as one is available. Review of the facility's undated Call Light policy and procedure revealed the purpose was to respond to the resident's request and needs. Turn off the signal light. Identify yourself and call the resident by his or her name. Listen to the resident's request. Do what the resident asks of you, if permitted. If uncertain as to whether a request can be fulfilled or if the request cannot be fulfilled, ask the nurse supervisor for assistance. If you have promised the resident you will return with an item or information, do so promptly. Review of the facility undated policy titled, Change in a Resident's Condition or Status revealed the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00147021.