**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of a facility self-reported incident (SRI), review of an emergency medical services (EMS) report, review of a 911 call and dispatch log, interviews with facility staff, Physician #31, Physician #35, Emergency Medical Services (EMS) Chief #86, Paramedic #87, facility policy and procedure review and review of the American Red Cross Basic Life Support manual, the facility failed to initiate effective cardiopulmonary resuscitation (CPR) and immediately contact emergency medical services (EMS) for Resident #201. This resulted in Immediate Jeopardy on [DATE] at 2:50 A.M. when Resident #201, who had advance directives for a Full Code status was found unresponsive, without a pulse or respirations, and was not properly provided CPR. Life threatening harm and death occurred when Resident #201 did not receive immediate effective CPR and EMS was not immediately contacted by staff. The resident subsequently expired. This affected one resident (#201) of three residents reviewed for an emergent change in condition and death. The facility census was 40. On [DATE] at 4:12 P.M., the Administrator, Regional Director of Operations #91, Registered Nurse (RN) #85 and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 2:50 A.M. when the facility failed to immediately initiate effective cardiopulmonary resuscitation (CPR) and immediately contact emergency medical services (EMS) for Resident #201 who was found unresponsive, without a pulse or respirations, and who was identified as a Full Code status. The resident subsequently expired. The Immediate Jeopardy was removed and deficiency corrected on [DATE] when the facility implemented the following corrective actions. • On [DATE] at 3:01 A.M., the DON immediately educated Licensed Practical Nurse (LPN) #33 on the CPR policy, initiation of CPR, Ohio Revised Code 4723.36 on determination of death and the Centers for Medicare and Medicaid Services (CMS) regulation on CPR in nursing homes. • On [DATE] at 9:00 A.M., the Administrator notified Licensed Practical Nurse (LPN) #33 and LPN #34 (the two nurses on duty at the time of the incident) they were suspended pending investigation. • On [DATE] at 9:30 A.M., the DON audited all hard copies of advanced directives in current resident's medical records to ensure they were present, appropriately signed and had a physician's order in place. • On [DATE] at 10:15 A.M., Business Office Manager (BOM) #36 audited employee files for all licensed nurses to ensure they had valid active CPR certification. This was completed [DATE] at 2:00 P.M. • On [DATE] at 11:45 A.M., the DON audited the advanced directive care plans for all current facility residents to ensure they reflected the hard copy and physician order. This was completed on [DATE] at 12:45 P.M. • On [DATE] from 12:00 P.M. to 1:00 P.M., the Administrator and LPN #04 educated all department heads including Dietary Manager #24, Registered Nurse (RN) #45, Business Office Manager (BOM) #36, Maintenance Director #15, Marketing Director #50, Housekeeping Supervisor #03, Social Services #43 and Therapy Director #41 on the facility CPR policy including but not limited to calling 911 as directed by the licensed nurse. • On [DATE] from 1:00 P.M. to 5:15 P.M., LPN #04, the Administrator, Business Office Manager (BOM) #36, Housekeeping Supervisor #03, Social Services #43 and Therapy Director #41 educated all 44 staff excluding licensed nurses on the CPR policy including but not limited to calling 911 as directed by the licensed nurse. • On [DATE] from 1:00 P.M. to 2:15 P.M., LPN #04 educated all 12 licensed nursing staff on the facility CPR policy, advanced directive policy, Ohio Revised Code 4723.36 on determination of death and the CMS regulation on CPR in nursing homes. • On [DATE] at 2:30 P.M., LPN #04 held a mock code blue, and the response was immediate and appropriate. • On [DATE] at 2:30 P.M., the Administrator updated new hire orientation packets to include the CPR policy, advanced directive policy, Ohio Revised Code 4723.36 on determination of death and the CMS regulation on CPR in nursing homes. • On [DATE] at 2:50 P.M., the facility completed an ad hoc Quality Assurance and Performance Improvement (QAPI) plan related to the abatement. The Administrator, Maintenance Director #15, BOM #36, Marketing Director #50, Physician #88, LPN #04, the DON, and RN #85 were in attendance. The plan was approved by the committee including ongoing compliance. • For ongoing compliance, the facility implemented a plan for nursing administration and designee to review all progress notes and new orders related to code status in the daily clinical operations meeting five times weekly for four weeks to ensure all advanced directives have an appropriate physician signature, order in place and are appropriately care planned. All variances would be corrected upon discovery and education and follow up will be provided as deemed necessary. • The facility implemented a plan for the DON or designee to audit each new readmission five times weekly for four weeks to ensure advanced directives were ordered, care planned and were present with the physician's signature in the medical record. All variances would be corrected upon discovery and education and follow up would be provided as deemed necessary. • The facility implemented a plan for the DON or designee to conduct code blue drills weekly for four weeks on shift to ensure staff respond accordingly with the first one being conducted on [DATE]. All variances would be corrected upon discovery and any additional education and follow up would be provided as deemed necessary. • The facility implemented a plan for the DON or designee to reeducate the licensed nursing staff on the CPR policy, advanced directive policy, Ohio Revised Code 4723.36 on determination of death and the CMS regulation on CPR in nursing homes for four weeks to ensure all staff were competent and informed of the facility policy. All variances would be corrected upon discovery and additional education and follow up would be provided as deemed necessary. Results would be reported to the quality assurance committee and further continued ongoing compliance would be maintained through audits as dictated by the facility quality assurance committee. • On [DATE] between 2:00 P.M. and 3:00 P.M. interviews with LPN #47, LPN #67, STNA #08, and STNA #10 verified they were educated on the facility CPR policy, advanced directive policy, Ohio Revised Code 4723.36 on determination of death and the CMS regulation on CPR in nursing homes. Findings include: Review of Resident #201's closed medical record revealed Resident #201 was admitted to the facility on [DATE] with diagnoses including muscle weakness, gastroesophageal reflux disease without esophagitis, osteoarthritis, anxiety disorder, panlobular emphysema, insomnia due to other mental disorder, fracture of upper end of unspecified tibia subsequent encounter for closed fracture with routine healing, and unspecified kyphosis thoracolumbar region. Resident #201 expired in the facility [DATE]. Review of Resident #201's code status form dated [DATE] revealed Resident #201 was to receive full measures (Full Code Status). Review of Resident #201's code status physician order dated [DATE] revealed Resident #201 was a Full Code. Review of Resident #201's medical record from [DATE] to [DATE] revealed no documentation Resident #201 or Resident #201's physician changed Resident #201's code status from a Full Code to a Do Not Resuscitate (DNR). Review of Resident #201's code status care plan dated [DATE] revealed Resident #201 had decided she wanted cardiopulmonary resuscitation (CPR) attempted in the event of a code. Interventions included if Resident #201 was in cardiac arrest begin CPR and then call 911. Review of Resident #201's progress note dated [DATE] at 5:16 A.M. by LPN #17 revealed Resident #201 arrived at the facility from the hospital at 11:45 P.M. The note reflected Resident #201 was a Full Code. Review of Resident #201's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #201's was moderately cognitively impaired, required extensive assistance from staff for mobility, transfers, dressing, toileting, and personal hygiene. Resident #201 required supervision from staff for eating. Review of Resident #201's progress note dated [DATE] at 1:01 P.M. by Registered Nurse (RN) #13 revealed Resident #201 was noted with increase work of breathing during a neurological assessment status post fall. Resident #201 stated something isn't right. Vitals were obtained and noted blood pressure 165/57, oxygen 89% (low) saturation with 3.5 liters per nasal cannula and lungs with rhonchi (adventitious breath sounds) noted. The physician was notified and recommend Resident #201 be sent to the emergency room. However, Resident #201 refused the transfer at that time and a new order was given for a chest x-ray and to start antibiotics and the steroid medication, Prednisone. The note indicated the resident's representative was made aware. Review of Resident #201's progress note dated [DATE] at 6:46 P.M. by LPN #47 revealed Resident #201's x-ray results from [DATE] were positive and were sent to Physician #31. The note revealed Resident #201 was currently being treated with the antibiotic, Levaquin. The resident and family were made aware. Review of Resident #201's progress note dated [DATE] at 2:50 A.M. by LPN #33 revealed the State Tested Nursing Assistants (STNAs) came to LPN #33 and stated Resident #201 was non-responsive. The note included LPN #33 and another nurse attempted resuscitation and was ineffective. Resident #201 was pronounced deceased at 2:55 A.M. and Physician #31 and Resident #201's granddaughter were called immediately. The Director of Nursing (DON) and the unit manager were also notified. The note failed to contain any additional information related to the actual physical condition of Resident #201 at the time she was found unresponsive; there were no documented signs of lividity or rigor mortis noted by the nurse on duty and responsible for care at that time. Review of Resident #201's progress note dated [DATE] at 3:50 A.M. by LPN #33 revealed paramedics (who were onsite at this time) declared Resident #201 deceased . The paramedics called the coroner, and the family was there with the resident. The family stated they wanted the resident to be sent to the funeral home. The funeral home was called, and the resident's body was released to the funeral home at 4:55 A.M. Review of Resident #201's physician progress note dated [DATE] and filed [DATE] at 4:53 P.M. by Physician #31 revealed Physician #31 received a phone call on [DATE] at 2:51 A.M. from LPN #33. The note revealed Resident #201 was discovered gray and blue in color. Resident #201 was unresponsive. She was examined by two nurses (identified to be LPN #33 and LPN #34) who noted the resident to be deceased . This physician progress note documented determination of death by this physician was on [DATE] at 2:51 A.M. Review of a facility self-reported incident (SRI) dated [DATE] revealed the facility reported an allegation of neglect/mistreatment to the State agency. A brief description of the allegation/ suspicion revealed Resident (#201) found absent of vital signs. Staff had a potential delay in CPR administration. Resident #201 remained absent of vital sign once EMS arrived. Supporting information in the facility SRI revealed on [DATE] the Director of Nursing (DON) received notification at 2:54 A.M. from LPN #33 that Resident #201 had been found absent of vital signs. The DON returned a phone call to LPN #33 at 3:01 A.M. At that time LPN #33 had communicated Resident #201 was found absent of vital signs and the physician (#31) had been notified. The DON inquired of the resident's code status. LPN #33 informed the DON the resident was a full code. The DON inquired if CPR was in progress, to which the LPN stated no. The DON then instructed LPN #33 to initiate CPR per (facility) policy. Review of the dispatch log dated [DATE] revealed the county 911 number received a call on [DATE] at 3:37 A.M. regarding a deceased person or body being found. The call was assigned at 3:39 A.M., EMS were in route at 3:43 A.M. and arrived at the facility at 3:46 A.M. The 911 call from the facility was reviewed as part of the investigation. The 911 dispatcher could be heard asking for the address of the emergency. The facility caller was noted to be asking someone in the background for the facility's address and the person in the background could be heard laughing. The caller stated the emergency was at the facility. The dispatcher asked what was going on there and the caller stated they just found a resident deceased at 3:00 A.M. and reported they are saying we have to call 911 and the county coroner. The dispatcher stated a squad would be sent to the facility and the age of the resident was asked. The caller stated the resident was [AGE] years old. The dispatcher asked for a call back number and the facility caller was noted asking someone in the background the facility's number. The dispatcher asked if there was anywhere particular they needed to come to, and the caller stated to come to the side door and knock on the door for staff to let them in the facility. Review of an emergency medical services (EMS) report [DATE] revealed EMS were dispatched to the facility on [DATE] at 3:41 A.M. and were in route at 3:43 A.M. EMS was at the scene at 3:46 A.M. Resident #201 was listed as dead at the scene with no resuscitation attempted without transportation. Review of the EMS pre-hospital care report dated [DATE] revealed EMS was dispatched on [DATE] at 3:41 A.M., arrived on the scene on [DATE] at 3:46 A.M. and was with the resident on [DATE] at 3:48 A.M. The report stated Resident #201 was found lying supine in the bed. Per staff, Resident #201 was diagnosed with pneumonia on [DATE] and started on Prednisone and Levaquin. Staff stated Resident #201 was last seen alive at 12:30 A.M. Staff went into check on Resident #201 and found her cold to the touch with no spontaneous breathing or pulse. Staff pronounced Resident #201 at 2:55 A.M. and then they called the DON who told them that they needed to do 30 minutes of CPR and then call 911 to have them pronounce (the resident's death). Staff stated they did as requested but felt that something was not right. EMS staff noted Resident #201 was unconscious and unresponsive, pulseless and apneic with skin that was cold, pale, and dry. Three leads were placed showing asystole in all leads. Time of death was 3:50 A.M. Physician #35 (from the county coroner's office) was contacted and advised Resident #201 could be signed out to the funeral home, and he would be contacting the facility medical director regarding the direction of 30 minutes of CPR prior to calling 911. Review of STNA #02's undated witness statement revealed STNA #02 noted Resident #201 to be unresponsive and immediately reported Resident #201's condition to LPN #33. Review of RN #85's witness statement dated [DATE] revealed RN #85 interviewed LPN #33. LPN #33 verified Resident #201's code status as a full code. LPN #33 and LPN #34 came to Resident #201's bedside to observe the resident's condition. LPN #33 called Physician #31 and the DON. LPN #34 notified the emergency contact for Resident #201 and EMS was dispatched at 3:41 AM. and called the time of death at 3:50 A.M. A witness statement from RN #85's (dated [DATE]) revealed RN #85 interviewed Physician #31 via telephone on [DATE]. Physician #31 reported she took a phone call from the facility at 2:51 A.M. and the phone call lasted one minute. During the phone call, LPN #33 stated Resident #201 was found expired. Physician #31 reported LPN #33 then stated to her that Resident #201 was gray and blue, her arm was dangling off the bed and was discolored and further stated she had been gone a long time and was cold to touch. When asked about Resident #201's code status, LPN #33 stated to Physician #31 that Resident #201 was a full code, but they did not discuss any resuscitative efforts. Physician #31 declared time of death at that time based upon LPN #33's description of Resident #201's body. LPN #33 brought it to Physician #31's attention that there was no funeral home information available and that she would reach out to family. Physician #31 stated she then thanked LPN #33 for the notification and ended the call. Review of a statement from the Administrator dated [DATE] revealed the Administrator notified LPN #33 and LPN #34 they were suspended pending investigation. Review of LPN #33's suspension form dated [DATE] revealed LPN #33 was suspended pending investigation for failing to follow policy and procedures. Review of LPN #34's suspension form dated [DATE] revealed LPN #34 was suspended pending investigation for failing to follow policy and procedures. On [DATE] at 12:41 P.M. telephone interview with Assistant EMS Chief #86 and Paramedic #87 revealed Paramedic #87 was called to the facility on [DATE] regarding Resident #201 being deceased . Paramedic #87 reported facility staff were not doing any CPR or other resuscitative measures when EMS arrived at the facility. Paramedic #87 stated Resident #201 was laying in her bed on her back with the sheet up to her shoulders. Resident #201 was cold to the touch, and it was evident Resident #201 had been deceased for a while at this time. Paramedic #87 reported staff told her they called the DON, and the DON told the staff to call EMS to pronounce Resident #201 as deceased . Paramedic #87 stated she asked staff what happened, and they stated Resident #201 was found unresponsive over an hour ago and they pronounced her dead with two staff and then they called the DON and the DON stated they had to do at least 30 minutes of CPR. Paramedic #87 stated the staff member used air quotes with her fingers when she said 30 minutes of CPR and she was not sure what that was supposed to mean. Paramedic #87 reported staff told her Resident #201 was pronounced deceased at 2:55 A.M. by the facility and Resident #201 was pronounced deceased at 3:50 A.M. by Physician #35 through EMS communications. Paramedic #87 stated she called Physician #35 and told him what she saw, and he told her that the body could go to the funeral home, but she was later informed that Resident #201 was sent for an autopsy. Paramedic #87 reported staff stated they last saw Resident #201 alive at 12:30 A.M. and when they went to check on her at 2:50 A.M. she was deceased . Paramedic #87 stated upon EMS arrival Resident #201's shirt was still in place, there were no signs that CPR was completed and there was no defibrillator in the resident's room. On [DATE] at 1:00 P.M. interview with Physician #35 revealed he was the physician investigator for the county coroner's office. Physician #35 stated he received a call on [DATE] at what he thought was about 3:00 A.M. (exact time not recalled) from Paramedic #87 stating she was at the facility; staff had told her they went to check on Resident #201 and she was cold to the touch with no spontaneous pulse. Physician #35 stated Paramedic #87 told him staff called the DON and were told to do 30 minutes of CPR and then to call EMS. Paramedic #87 also stated staff were providing her with conflicting stories. Physician #35 stated the body was sent to the funeral home for a hold and then the county coroner's staff determined an investigation was needed and records were requested the next morning. Physician #35 stated he spoke with Physician #88, the facility medical director the next morning and was told the resident had pneumonia and was being treated 24 hours prior to her death. Physician #35 stated he reviewed Resident #201's treatment of pneumonia and found this treatment was consistent (with standards of practice) but stated there was some confusion on [DATE] regarding CPR being administered with conflicting stories about if facility staff had performed CPR. Physician #35 stated she spoke with Physician Coroner #89 who reported Resident #201 had passed away from necrotic lung tissue and there was no evidence CPR had been provided or completed for Resident #201 at the time she was found unresponsive. Physician #35 shared awareness of the facility terminating the personnel (LPN #33 and LPN #34) who were working at the time of the incident. On [DATE] at 8:20 A.M. telephone interview with Physician Coroner #89 revealed he completed an autopsy on Resident #201 (results pending at the time of this investigation) and reported there was no indication of CPR being provided to the resident. Physician Coroner #89 reported if provided CPR, Resident #201 would have had some physical indication CPR was completed, such as fractured ribs due to her age. On [DATE] at 8:36 A.M. interview with LPN #34 revealed she was working with LPN #33 when she came back from a break and an STNA reported to her she thought Resident #201 was dead. LPN #34 did not know the STNA's name. LPN #34 reported the STNA told her she was in the room at 12:30 A.M. and Resident #201 was alive. LPN #34 stated Resident #201's arm was laying over the side of the bed and all the blood was rushing to the right arm upon entering the room. LPN #34 reported Resident #201 arm was blue and red from above her elbow to her fingertips and the rest of her body was gray. LPN #34 stated she could tell Resident #201 had been deceased for an hour or more, her spine was barely warm, but the rest of her body was cold to the touch. LPN #34 stated she got her stethoscope and listened for breath sounds and a heartbeat, which were absent. LPN #34 stated she then called Resident #201's granddaughter and told her Resident #201 had passed away while LPN #33 was looking for Resident #201's code status in the resident's hard (paper) chart. LPN #34 stated LPN #33 could not find the resident's code status form and had to pull it up on the computer and then informed LPN #34 Resident #201 was a full code. LPN #34 stated LPN #33 had called the DON and the manager on duty and the DON asked if they had done CPR and they stated they did not because they were looking for the code status sheet. The DON told them to call 911. LPN #34 stated she bagged (artificial respiration) Resident #201, LPN #33 did child compressions using two fingertips and Resident #201's chest did not rise. LPN #34 stated she told LPN #33 it was ridiculous and to stop CPR after just a few minutes. The DON called back again and told them to go home until an investigation was completed. LPN #34 stated she called 911 because they could not pronounce a death and reported that LPN #33 had already called the physician and had Resident #201 pronounced deceased , but the DON told them they still had to call 911. EMS arrived and hooked the resident up to a machine where she had no vital signs. LPN #34 stated she told EMS they had to call them because they could not pronounce a death. LPN #34 reported she did not call EMS until after they had completed a few minutes of CPR and they were not doing CPR when EMS arrived. LPN #34 stated they did not use a defibrillator and she stated Resident #201 was in her opinion, clearly deceased and she was not breaking the woman's ribs as she had no color in her lips and her eyes were fixed. However, LPN #34 then reported she would have started CPR immediately and called 911 if they had the code status form and stated it should not have taken that long to find the code status form for Resident #201. On [DATE] at 9:01 A.M. telephone interview with STNA #10 revealed STNA #10 was taking care of Resident #201 on [DATE] when she was told by STNA #02 that Resident #201 was deceased . She stated she went down to Resident #201's room to help the nurses and she an another STNA did postmortem care on Resident #201 per LPN #33's instruction. STNA #10 stated she never saw any staff doing CPR on Resident #201 and there was no indication that CPR was completed on Resident #201 when she did postmortem care. STNA #10 also stated they did postmortem care on Resident #201 prior to EMS arriving at the facility. STNA #10 stated she was outside of Resident #201's room when EMS arrived, and LPN #33 told EMS that they had done an x-ray and Resident #201 had pulmonary edema. STNA #10 reported EMS asked if CPR was done, and she thinks LPN #33 told them that they did not do CPR. Attempts to interview LPN #33 on [DATE] were unsuccessful. The LPN's attorney (Attorney #90) contacted the surveyor on [DATE] at 10:08 A.M. on behalf of LPN #33 and stated LPN #33 was not to speak with any type of investigator. On [DATE] at 12:28 P.M. interview with Physician #31 revealed she received notice from the facility on [DATE] regarding a deceased resident at approximately 2:50 A.M. LPN #33 stated Resident #201 was deceased , and she provided a description of the resident. Physician #31 reported LPN #33 never told her if staff performed CPR on Resident #201. Physician #31 stated they told her at the end of the conversation the resident was a full code, but she did not address CPR with LPN #33 and could not remember all the details, but stated she did not get the idea they were doing CPR by the way they were acting. Physician #31 stated LPN #33 had not gotten a hold of the resident's family as of that time. Physician #31 stated she would do adult CPR on a resident that was the age and weight of Resident #201. On [DATE] at 1:07 P.M. interview with the DON revealed she was sent a text on [DATE] regarding Resident #201 and then LPN #33 called her on [DATE] prior to her being able to respond to the text message. The DON stated LPN #33 told her Resident #201 was found without vitals, and she asked about Resident #201's code status. The DON reported LPN #33 stated Resident #201 was a Full Code and the DON asked LPN #33 if they started CPR and then the phone went dead. The DON stated it took a while for her to get back in contact with LPN #33 and when she did get back in contact with LPN #33 the DON asked if they had called 911. The DON reported LPN #33 told her she called the non-emergency number. The DON stated she had sent staff a text and told them to call the coroner if staff could not revive Resident #201. The DON stated LPN #33 then stated she had done CPR, but LPN #33 did not tell her any details on the type of CPR administered, the method CPR was administered or length of time the CPR was provided. The DON reported EMS came to the facility after she instructed LPN #33 to call 911 and they pronounced her deceased . The DON also reported LPN #33 stated she called the physician, but LPN #33 never told her any details about the call or Resident #201 being pronounced deceased over the phone with the physician. The DON reported she was informed the physician was called prior to her instructing LPN #33 to call 911. Review of the facility's Emergency Procedure Cardiopulmonary Resuscitation Policy dated February 2018 revealed licensed health care professionals who were certificated in CPR shall initiate CPR if an individual was found unresponsive and not breathing normally unless it was known that a DNR order that specifically prohibited CPR, or an external defibrillation existed for that individual. If the resident's DNR status was unclear, CPR would be initiated until it was determined that there was a DNR or a physician's order not to administer CPR was given. Review of the facility's Advanced Directives Policy dated [DATE] revealed advanced directives would be respected in accordance with state law and facility policy. Review of the American Red Cross basic life support manual dated 2019 revealed use the same approach and technique for recovery positions as you would for an adult for children. The technique for providing chest compressions were similar for an adult and child. Position one hand on top of the other with your fingers interlaced and off the chest centered on the lower half of the sternum. The manual reported the proper technique was critical when providing chest compressions on an adult and included exposing the patient's chest so you could ensure proper hand placement and visualize chest recoil, place the heel of one hand in the center of the patient's chest on the lower half of the sternum. Place your other hand on top of the first and interlace your fingers or hold them up so that they are not resting on the patient's chest and position yourself, so your shoulders are directly over your hands. For an adult, compress the chest to a depth of at least two inches, provide compressions at a rate of 100 to 120 per minute, allow the chest to fully recoil after each compression and avoid leaning on the patient's chest on the top of a compression. Then continue to provide CPR until you see signs of return of spontaneous circulation (ROSC) such as patient movement or normal breathing, other trained providers take over compression or ventilation responsibilities, you are presented with a valid do not resuscitate order, you are alone or too exhausted to continue to the situation becomes too unsafe. This deficiency represents non-compliance investigated under Complaint Number OH00144142.