**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the American Heart Association (AHA) Guidelines, clinical records, facility policies, and staff interviews it was determined that the facility failed to ensure consistent care by initiating Cardio Pulmonary Resuscitation (CPR) to an unresponsive resident for one of eighty-seven residents (Resident R1), resulting in immediate jeopardy. Findings include: The Pennsylvania Code Title 49, Professional and Vocational Standards through the Department of State indicates under Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all the following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals. Review of AHA Guidelines dated 2024, indicated if a person is unresponsive with no breathing and has no pulse for more than 10 seconds, start CPR. The facility's CPR policy titled. Cardiac and/or Respiratory Arrest reviewed [DATE], indicated the following guidelines are available and are to be utilized in the event of a resident emergency. If a witnessed or unwitnessed arrest for patients without a Do Not Resuscitate (DNR) First, the licensed nurse will evaluate the patient for obvious clinical signs of irreversible death unless not permitted by state regulation. If at least ONE obvious clinical sign of irreversible death is present, do not initiate CPR (Obvious clinical signs of irreversible death include: lividity or pooling of blood in dependent body parts, hardening of muscles or rigidity (rigor mortis) or injuries incompatible with life). If there are no obvious clinical signs of irreversible death, initiate CPR/AED, call 911 and notify primary physician, designate an individual to record events, continue CPR until EMS arrives, notify family health care decision maker of patient's status. Review of Resident R1's clinical record indicated an admission date of [DATE], with diagnoses that included high blood pressure, muscle weakness, atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (a group of diseases that block airflow and make it difficult to breathe, emphysema and chronic bronchitis are most common conditions). Review of Resident R1's Minimum Data Set (MDS-a periodic assessment of care needs) dated [DATE], indicated the diagnoses were current. Review of Resident R1's physician order dated [DATE], current through [DATE], indicated Resident R1 was a full code (allows for all interventions needed to restore breathing or heart functioning). Resident R1 ceased to breathe on [DATE] at 12:22 p.m. Review of Resident R1's closed record revealed a Physician Order for Life Sustaining Treatment (POLST) form dated [DATE], indicated if the resident has no pulse and is not breathing, attempt resuscitation. The form was signed by Nurse Practitioner E5 and it was indicated a verbal consent was provided from Resident R1's daughter who was listed as emergency contact. Review of Resident R1's care plan dated [DATE], indicated the resident was a full code. Interventions indicated CPR will be performed as ordered. Review of Resident R1's Task list dated [DATE], indicated the resident was a full code. Review of Resident R1's progress note dated [DATE], at 12:37 p.m. entered by Licensed Practical Nurse (LPN) Employee E3, indicated resident ceased to breathe (CTB) at 12:22 p.m. There was no documentation that CPR was administered as ordered. During an interview on [DATE] at approximately 9:00 a.m. the Nursing Home Administrator (NHA) and Registered Nurse (RN) Employee E2 confirmed CPR was not initiated for Resident R1 on [DATE]. RN Employee E2 indicated that the family had arrived at 12:20 p.m. on [DATE], asked for her to evaluate the resident since they found him with his head bent, [employee] ran out of the room to grab her stethoscope to obtain vital signs (apical pulse-pulse point on your chest at the bottom of the heart) and grabbed RN Supervisor Employee E4. LPN Employee E3 also in the room acknowledged that Resident R1 was a full code. RN Employee E2 revealed she did not start CPR because the daughter was too upset and they did not want to start in front of her. RN Employee E2 pronounced Resident R1 CTB at 12:22 p.m. The resident's POLST form was for a Full Code as found in the resident's chart and on the electronic record, placing all residents at risk if they become unresponsive and pulseless, which resulted in an Immediate Jeopardy situation. On [DATE], at 3:32 p.m. the Nursing Home Administrator and the Director of Nursing was notified that an immediate jeopardy was identified and was provided a copy of the completed IJ template. On [DATE], at 6:26 p.m. and Immediate Action Plan was accepted with the following actions: Immediate Action: -Whole house audit was conducted and completed on [DATE], on all code status of all residents' to ensure all orders are out in medical record, care planned and POLST forms are to be uploaded into the medical record and the original form placed in the physical chart. -Any POLST forms not uploaded into the chart will be uploaded to the electronic record on [DATE]. -All primary staff will be educated by end of day [DATE], on code status and recognition of signs of death and proper procedure of notification to nursing staff if there is an occurrence. All agency and PRN staff will be instructed to complete education prior to the start of their next shift. -All primary Nurses prior to the start of their next shift, or by [DATE], will be educated on signs of irreversible death, proper documentation in medical records of the occurrence and Policy NSG208 Cardiopulmonary Resuscitation (CPR) and Procedure: Cardiac and/or Respiratory Arrest. All agency and PRN staff will be instructed to complete education prior to starting next shift. -Primary Licensed staff will be educated to facilitate CPR on residents who have elected such services until EMS arrives and assumes responsibility for the residents by [DATE]. All agency and PRN staff will be instructed to complete education prior to their next scheduled shift. -All new admissions will be audited to ensure code status orders are entered into the medical record accurately, care planned, and uploaded into the medical chart. They will also ensure the physical copy of the advance directive is placed in the physical chart weekly x 4. -Mock codes will be conducted every shift x2 days then randomly daily x1 week, then weekly x 4. -QAPI completed on [DATE]. -Audit completed for nurses CPR cards on [DATE]. -AED/Crash carts verified with stocked and expiration dates of PADS on [DATE]. -Education related to change in condition and notifications NSG122 will be completed by end of day [DATE]. Entering Advance Directives orders are put in the medical record, care planned and Advance Directives are to be uploaded in the medical record and he original form placed in the physical chart by end of day [DATE]. The facility's CPR policy titled Cardiac and/or Respiratory Arrest was revised on [DATE] and reviewed on [DATE], and indicated the center will support the right of every patient to accept or decline cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The center will perform CPR on all patients, except in certain limited circumstances, unless there is a written physician's order agreed to by the patient or health care team representative, in accordance with state regulation/law. The facility's Procedure: Cardiac and/or Respiratory Arrest was revised on [DATE], and reviewed on [DATE], and indicated upon discovery of a patient in cardiopulmonary arrest to first call for assistance, alert licensed nurse and CPR/automated external defibrillator (AED) certified staff, prepare patient for CPR/AED while determining the code status, call 911 and notify primary physician, designate an individual to record events on the CPR/AED flow sheet. Continue CPR until EMS arrives, restoration is effective, rescuer is unable to continue because of exhaustion, and state regulation allows licensed nurse to pronounce/certify death, reliable and valid criteria indicating irreversible death are met or criteria for termination of resuscitation are met. 114 of 139 residents code status, including orders, POLST and care plan were reviewed and accurate as of [DATE]. On [DATE], at 10:07 a.m. 90 of 92 nursing staff (1-Maternity Leave of Absence, 1-Vacation out of country) verified they were educated prior to start of their shift via signature sheet. All nursing staff in facility on [DATE], were interviewed and confirmed training and understanding. All nursing staff were educated on what to do in an event of an emergency. Staff must determine unresponsiveness, notify a licensed nurse immediately, verify resident's code status. If an emergency response is required to activate in-house emergency communication system, and call 911. If necessary, initiate cardiopulmonary resuscitation (CPR) and chart completely all events up to the situation, what transpired during situation, and the events that followed. The physician and healthcare decision maker must be notified. The facility will continue to educate nursing staff prior to the start of the shift. The Director of Nursing (DON) or designee will conduct audits to ensure policy is being followed and findings will be reported in upcoming QAPI meetings. On [DATE], the Immediate Jeopardy was lifted at 2:05 p.m. after ensuring the Immediate Plan of Correction had been implemented. During an interview on [DATE], at 3:47 p.m. RN Unit Manager, Employee E6 stated that they conduct training on CPR, they also stated if a resident is not breathing, she would check the POLST located in the front of the resident's hard chart or in the electronic record and if a full code would begin CPR as per the resident's wishes. During an interview on [DATE], at 3:49 p.m. LPN, Employee E7 stated if a resident ceases to breathe, the resident's code status is checked in the resident's paper chart. During an interview of [DATE], at 3:53 p.m. RN Employee E8 stated she would check the paper chart for the most up to date POLST. During an interview on [DATE], at 4:08 p.m. LPN Employee E9 stated if no respirations or pulse she would check in either the paper chart or electronic record for a code status and if a full code would start CPR. During an interview on [DATE], at 4:11 p.m. Transitional Nurse-RN Employee E10 stated that they would check in the front of the paper chart for the pink paper for the code status. During an interview on [DATE], at 4:13 p.m. Certified Nursing Assistant (CNA) Employee E11 stated that if they walked into a room and the resident was unresponsive they would grab a nurse or the nurse supervisor and then go to the paper chart to obtain the POLST for the nurse for code status. During an interview on [DATE], at 4:15 p.m. CNA Employee E12 stated that if they walked into a room and a resident was unresponsive they would yell for help, get a nurse, call a code, get crash cart if needed and can assist with writing things down. During an interview on [DATE], at 4:17 p.m. RN Unit Manager Employee E13 stated that they educate CNA's on where to find the POLST and about bringing it to the nurse in emergency situations. During an interview on [DATE], at 10:07 a.m. LPN Employee E14 stated that they received education before the start of their shift and know that the POLST is located on the paper chart and in the electronic record. During an interview on [DATE], at 10:09 a.m. LPN Employee E15 stated that they received education before the start of their shift and know that the POLST is located on the paper chart or in the electronic record. Stated she would call for help and if not a DNR would start CPR. During an interview on [DATE], at 10:10 a.m. RN Employee E16 stated if they walked into a resident's room and resident appeared unresponsive would do a sternal rub, check extremities, start CPR and have someone call 911. Employee E16 stated education was reviewed before the start of her shift regarding POLST. During an interview on [DATE], at 10:13 a.m. CNA Employee E17 stated they received training before the start of their shift and if they walked into a room with an unresponsive resident would seek help immediately and obtain the POLST from the paper chart for the nurse. During an interview on [DATE], at 10:16 a.m. LPN Employee E18 stated they received training before the start of their shift and would locate code status by either checking the chart, report sheet, or electronic record. During an interview on [DATE], at 10:19 a.m. LPN stated they received training before the start of their shift and would locate code status in the paper chart. During an interview on [DATE], at 10:22 a.m. CNA Employee E20 stated they received training before the start of their shift and would follow the steps if they are a full code or a DNR. During an interview on [DATE], at 10:26 a.m. CNA Employee E21 stated they received training before the start of their shift and would obtain the POLST from the paper chart for the nurse. During an interview on [DATE], at 10:28 a.m. RN Employee E22 stated they received training before the start of their shift and would obtain the POLST from the paper chart or the electronic record and would start CPR. During an interview on [DATE], at 10:30 a.m. RN Employee E23 stated they received training before the start of their shift. They stated that the POLST is located on the paper chart and the electronic record, If the resident is unresponsive and known Full Code would start CPR and yell for help. During an interview on [DATE], at 10:46 a.m. RN Employee E24 stated they received training before the start of their shift and would obtain the POLST from the paper chart, would also write it on their resident report sheets for quick reference and to know if they needed to start CPR immediately. During an interview on [DATE], at 10:48 LPN Employee E25 stated that they received training before the start of their shift and know that the POLST is located in the paper chart and the electronic record. During an interview on [DATE], at 12:15 p.m. the NHA and DON confirmed that staff failed to follow policy and procedure and failed to administer CPR to Resident R1 as per the POLST and physician order. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.29(d)(j) Resident rights. 28 Pa. Code 211.10(c) Resident care policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for a resident resulting in elopement (resident leaves the premises or a safe area without the facility's knowledge). This failure created an immediate jeopardy situation for one of 12 residents (Resident R340). Findings include: A review of the facility policy Elopement of Resident reviewed 2/7/23, stated that the facility will identify patient's elopement risk upon admission, re-admission, quarterly, or with a significant change in condition. It is indicated for patients identified as a risk; an interdisciplinary elopement prevention patient-centered care plan will be developed. An Elopement Risk Identification form for all patients at risk of elopement is to be completed. It is also indicated if staff witness a confused patient or an identified elopement risk patient attempting to leave the unit, staff will intervene as appropriate to redirect the patient to a safe area and prevent elopement. A review of the facility policy Dementia reviewed 2/7/23, stated if the assessment shows cognitive loss or dementia then the resident will be monitored for elopement risk. A review of the facility policy Accidents/Incidents reviewed 2/7/23, stated if an employee witnesses a patient accident or incident, the employee will provide immediate assistance and remove the individual from immediate harm, if needed. It is also indicated the Administrator, Director of Nursing (DON), or designee will review all accidents and incidents to determine if the accidents or incidents have been appropriately and timely reported, required documentation has been completed, and the accident or incident has been investigated, and interventions to eliminate if possible, and if not, reduce the risk of the accident or incident form reoccurring have been identified and implemented. A review of the admission Record indicated Resident R340 was admitted to the facility on [DATE], with diagnoses that included nicotine dependence, depression, and high blood pressure. A review of Resident R340's clinical record failed to include an elopement risk assessment that was completed upon admission. A review of the Speech Therapy SLP Evaluation form dated 4/20/23, indicated that Resident R340 had a mild cognitive impairment (MCI) and required minimum to close supervision. A Brief Cognitive Assessment Tool (BCAT-provides objective measures to determine cognitive abilities and the impact on function) was completed and Resident R340 scored a 35/50, consistent with mild cognitive impairment (44-50 normal cognitive functioning: independent living, 34-43 MCI: functional decline in instrumental activities of daily living (IADL), 25-33 mild dementia: IADL deficits, memory and cognitive decline, 0-24 moderate to severe dementia: functional deficits, marked decline in memory and executive functions, behavioral and psychological symptoms common; requires complex care). It is indicated MCI is a serious health condition that can have far reaching implications for independence and everyday functioning. Patients with MCI are at risk for developing dementia, especially Alzheimer's disease. A progress note dated 4/18/23, entered by Registered Nurse (RN) Employee E11 indicated that Resident R340 states he has some short-term memory loss and has fallen at home a few times. A progress note dated 4/18/23, entered by RN Employee E12 indicated Resident R340 is awake, alert, forgetful. A progress note dated 4/19/23, entered by Nurse Practitioner, Employee E13, indicated Resident R340 was being seen for alcohol withdrawal and Resident R340 stated he normally drinks approximately six large glasses of wine every day, seven days a week. A progress note dated 4/19/23, entered by Licensed Practical Nurse (LPN) Employee E14, stated wife informed facility that resident drinks 20 out of 24 hours in a day. A progress note dated 4/20/23, entered by Physician Employee E15 indicated Resident R340 was alert and oriented x2 and confused. A progress note dated 4/22/23, entered by Physician Assistant Employee E10 indicated Resident R340 admits to short term memory loss. A review of Resident R340's care plan dated 4/20/23, indicated Resident R340 has cognitive and communitive deficits, interventions included speech therapy and speech therapy group treatment. The baseline care plan failed to show documented risks, goals or interventions related to the risk of elopement or wandering. A review of Resident R340's physician order dated 4/18/23 through the elopement date of 4/23/23, failed to show any documented orders or protocols to follow for Resident R340 in case of elopement or wandering behaviors. A progress note dated 4/23/23, entered by RN Supervisor Employee E18, stated she was called to first floor for resident outside the building. It was indicated Resident R340 stated he was going to the road for his wife to pick him up. A review of the Elopement incident report completed by RN Supervisor Employee E18 entered on 4/23/23 indicated the patient stated he was going to meet his wife up by the road, he just got off phone with her. A progress note dated 4/23/23, entered by LPN Employee E19, stated Resident left the unit and went outside, he stated he was going to see his wife. A review of facility provided documents, dated 4/25/23, indicated that on 4/23/23, at 4:16 a.m. Resident R340 eloped from the facility. During an interview on 4/25/23, at 12:02 p.m., the Director of Nursing stated the facility did not consider Resident R340 an elopement risk because he was alert and oriented x3 and an investigation was not completed. During an interview on 4/25/23, at 1:51 p.m., Speech Therapist, Employee E21 stated I evaluated him on 4/20/23, I have not seen him since the evaluation. When I evaluated him, he scored 35 out 50, which means he is mildly cognitively impaired. The test completed was the B-CAT. It's a group task to determine the level of supervision for the resident. As the Nursing Home Administrator (NHA) said, none of the residents should be outside the front door. He would need minimum to close supervision. During a phone interview on 4/25/23, at 2:09 p.m., Nurse Aide (NA) Employee E16 indicated she observed Resident R340 on 4/23/23, walking down the hall and observed him turning the corner towards the exit. NA, Employee E16, stated she answered a resident's call light and when she went to see where Resident R340 went, he was nowhere to be found. NA Employee E16 stated she looked outside and saw that Resident R340 was outside. NA Employee E16 stated before going outside to retrieve the resident, she went back to get her jacket because it was really cold. NA Employee E16 indicated by the time she returned to retrieve Resident R340 from outside another aide, NA Employee E17 seen Resident R340 was outside and both aides went outside to assist the resident. NA Employee E16 stated Resident R340 was not wearing shoes or a jacket, he had on jeans and a t-shirt. NA Employee E16 stated that Resident R340 stated he wanted to go home. NA Employee E16, confirmed Resident R340 had intermittent periods of confusion. NA Employee E16 confirmed the facility failed to provide adequate supervision for Resident R340 resulting in elopement. A review of the weather forecast on 4/23/23 around 4:00 a.m., indicated it was 42 degrees Fahrenheit. No written statements from NA Employee E16, NA Employee E17, RN Employee E18, or LPN Employee E19 were available. The DON did not complete an investigation and did not consider Resident R340 being found outside on 4/23/23 at 4:16 a.m. as an elopement. The facility provided a Witness Interview Record dated 4/25/23 for NA Employee E16 and NA Employee E17 that was not signed. It was indicated the statement was obtained from over the phone and was signed by the DON. A late entry progress note for 4/24/23, dated 4/25/23, entered by the DON, stated During review of incident, interdisciplinary team did not determine it was an elopement. It also indicated after further review of records, interviews, and incident facility concludes it was not an elopement. During an interview on 4/25/23, at 3:32 p.m. the NHA and the DON were made aware that Immediate Jeopardy (IJ) existed due to Resident R340's elopement on 4/23/23. The IJ template was provided to facility administration at that time and a corrective action plan was requested. Notification on 4/25/23 at 9:22 p.m., an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident R340 was assessed after the elopement to determine any injury, none at that time. An alert bracelet was applied to Resident R340, a behavior assessment was completed and care plan for elopement risk was implemented to include redirection of resident, the alert bracelet, and educating family and visitors to notify staff when leaving. Residents: A review of residents currently living in the center using the new Elopement Evaluation was completed by the Director of Nursing/Designee to identify other residents who are at risk for wandering and or exit seeking. The review started on 4/25/23 at 6:00 p.m., and it was indicated it would be completed by 4/26/23 at 8:00 a.m. If a resident is identified as exit seeking, an alert bracelet is to be applied and the resident's care plan is updated at the time of identification to address the risk of elopement to include redirection of resident and education of family and visitors. Whole house audit was conducted by the NHA, DON, and Clinical Leader Employee E1 on elopement risks with updated assessments done on every resident. Residents who were identified to be at risk, care plans were updated to include interventions to address elopement risk. System correction: Education with center staff by the director of Nursing/designee on elopements, exit seeking risks, and possible interventions for risk including redirection, verbal reassurance, reminiscing, offering snack and activities was initiated 4/25/23 at 4:40 p.m. Any staff who are not scheduled will be contacted for education. Education will be completed on or before 4/26/23 at 8:00 a.m. Any staff who has not received education at this time will not be permitted to work until the education has been received. New admissions to the center will be evaluated for exit seeking/wandering risk on admission using the elopement evaluation. The admitting nurse is responsible for completing Elopement Risk Assessments upon admission. This will be implemented with new admissions on 4/25/23. Residents who currently reside in the center were reevaluated for exit seeking risks using the elopement evaluation. The review began on 4/25/23 at 6:00 p.m. and the facility indicated it was to be completed on or before 4/26/23 at 8:00 a.m. Current residents were reevaluated for exit seeking rest using the elopement evaluation with change of behavior where resident displays wandering/exit seeking behavior. This review was initiated on 4/25/23 at 6:00 p.m. and completed by 4/26/23 at 8:00 a.m. Current residents and new admissions will be provided supervision. This was initiated 4/25/23 at 4:40 p.m. Current residents and new admissions who identified as an elopement risk had their care plan updated at the time as identification to address risk of elopement to include redirection of resident, any activities as appropriate, and education of family and visitors. Their picture in Elopement Risk Identification form was placed in the center exit seeking binder located at the front desk. The exit seeking information is available to center staff on duty in this location. Monitoring: New admissions will be reviewed daily for one week, then three times a week for two weeks, then weekly for two weeks to ensure they were evaluated for exit seeking risks by the DON/Designee. The monitoring began on 4/26/23 and is to continue daily through 5/2/23. Monitoring is to be conducted three times a week for the weeks of 5/2/23 and 5/9/23, and then weekly for the weeks of 5/16/23 and 5/23/23. Results of the reviews are to be submitted to the center QAPI Committee for review and development of an action plan as needed. A review of Resident R340's care plan on 4/26/23, indicated the plan of care was updated on 4/25/23, after the incident. Continued review of 12 sampled charts verified the part of the plan that residents were re-evaluated for identifying elopement behaviors. During an interview with RN Employee E20 on 4/28/23 at 10:55 a.m., it was confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During an interview on 4/28/23 at 12:30 p.m., RN Employee E12 confirmed she received education on elopement, potential risk factors, intervention for the resident's care plans, and education on identifying signs and symptoms of a resident's potential for elopement. During an interview on 4/28/23 at 12:45 p.m., RN Employee E7 confirmed she received education on elopement, potential risk factors, intervention for the resident's care plans, and education on identifying signs and symptoms of a resident's potential for elopement. During an interview on 4/28/23 at 1:15 p.m., RN Employee E22 confirmed she received education on elopement, potential risk factors, intervention for the resident's care plans, and education on identifying signs and symptoms of a resident's potential for elopement. During an interview with Registered Nurse Assessment Coordinator (RNAC) Employees E3 and E4, it was confirmed both employees were educated on elopement assessment and determination of risk factors and identification of elopement risks. It was indicated that they were educated and were able to identify how to use the new elopement tool and values associated with risk levels. During interviews on 4/28/23, from 10:55 a.m. through 1:15 p.m. six total staff employees confirmed they had received education on elopement policy, identifying signs and symptoms of residents potential for elopement, and potential risk factors and interventions for residents care plan. Facility provided documentation and sign in sheets verifying 171 out of 172 staff members had received the education via in-person or telephone. The IJ was lifted on 4/28/23, at 1:22 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.