**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of established guidelines for Cardiopulmonary Resuscitation (CPR), the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of five residents reviewed (Resident 288), creating a situation in which the residents were placed in Immediate Jeopardy related to failing to perform cardiopulmonary resuscitation. Findings include: Review of facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation with a revised date of February 2018; revealed under section titled General Guidelines and Number Six indicated If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death ( e.g., rigor mortis). Further review of facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation revealed Number Seven under General Guidelines indicating; If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. Review of clinical record of Resident 288 revealed the resident was admitted to the facility on [DATE], as a short-term respite admission on hospice service with diagnoses including but not limited to Essential Hypertension, Cardiomyopathy, Heart Failure, and Aortic Stenosis (severe). Review of Resident 288's clinical record revealed Resident 288 had a physician's order for full life sustaining interventions of Cardiopulmonary Resuscitation dated [DATE]. Review of Resident 288's progress note completed by RN Supervisor, dated [DATE], at 2:08 a.m. indicated This RN was called by nurse that the resident had stopped breathing. Resident unresponsive to external stimuli, no pulmonary activity was noted. Not responding to sternal rub. Apical and Radial pulse not absent for 60 seconds. Pupils were fixed and Dilated. Resident was pronounced CTB at 2230 on [DATE]. Daughter [Name Withheld] made aware. [Name withheld] hospice and [name withheld] geriatrics made aware of death. Body released to [identified] funeral home. Interview conducted via telephone on [DATE] at 12:35 p.m. with RN Supervisor, Employee E3 revealed that due to resident's hospice status and full code status, CPR was withheld. Further interview with Employee E3 revealed, RN supervisor initiated a telephone conversation with resident's daughter who informed the RN Supervisor the family does not wish to have CPR performed on the resident. Review of Resident 288's clinical record revealed documents faxed to the facility by hospice provider on [DATE], at 10:47 a.m. including Patient Information Report indicated daughter was emergency contact only but an alternative family member was legal representative. Further review of Resident 288's hospice documents including Patient Information Report revealed Resident 288 also diagnosed with Congestive Heart Failure. Further review of hospice documents revealed a progress note dated [DATE] by attending hospice physician who indicated Resident 288 was FULL CODE. Interview with the Nursing Home Administrator and the Director of Nursing on [DATE] revealed that they were aware that staff did not provide CPR to Resident 288 in accordance with the code status, and the facility's policy. On [DATE], at 3:30 p.m. the Nursing Home Administrator was informed that Immediate Jeopardy was identified due to Licensed staff failing to provide CPR in accordance with a resident's physician's order and the facility policy. Nursing Home Administrator was provided the Immediate Jeopardy template at approximately 3:35 p.m. The facility submitted an acceptable immediate action plan on [DATE]:35 p.m. that included the following actions: A facility wide review of all residents' life sustaining code status to ensure each resident's advanced directive and physician-ordered code status was in place. The facility developed an education plan for all licensed nurses regarding the facility's CPR policy including general guidelines, preparation and emergency procedure for all residents; to ensure that CPR will be provided in accordance with each resident's advanced directive and physician orders and further education on where to find the code status of residents. The plan also included to actively hold Code Blue drills (simulated event whereby staff respond to a resident experiencing cardiac arrest) with staff, and to complete ongoing audits. An audit of the eleven hospice residents including nine with Do Not Resuscitate (DNR) and Full life sustaining measures were reviewed. The Immediate Jeopardy was lifted on [DATE], at 10:15 a.m. when it was confirmed that the facility provided licensed nursing staff of 11 LPN's (Licensed Practical Nurses) and 4 RN's (Registered Nurses) with education regarding providing CPR in accordance with residents' advanced directives, physician's orders and the facility's policy and completed a Code Blue drill to ensure that licensed nurses were prepared to respond to situations that required CPR. Staff were able to identify resident's code status is located on the Medication Administration Record (MAR) which is accessible to all licensed staff. Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, and policy and procedures, as well as staff interviews, it was determined that the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent elopement (unauthorized leave from a safe area) of a resident (Resident 27) assessed to be at risk for eloping and who successfully left the building without staff knowledge. This failure placed residents at the facility in an Immediate Jeopardy situation one for nine residents who were identified as at risk for elopement. The incident has been identified as past non-compliance. Findings include: Review of the facility's policy titled Emergency Procedure-Missing Resident, undated, revealed residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. Review of Resident 27's diagnosis list revealed Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life and anxiety disorder. Review of Resident 27's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 9, 2023, revealed the resident had severe cognitive impairment. The same MDS assessment revealed resident was able to ambulate on and off the unit needing one staff supervision. Review of Resident 27's elopement assessment dated [DATE], revealed resident was at risk for wandering and elopement. The assessment revealed resident had verbally expressed desire to go home, packed belongings to go home, or remained near exit doors. Review of the current care plan (initiated on January 27, 2022) revealed Resident 27 is at risk for elopement related to cognitive loss, wandering, exit seeking, packing clothes/personal items in a bag looking to leave, getting on an elevator, and believes personal car is in the parking lot. Interventions include monitoring the resident's location with visual checks and wander guard placement. Review of information dated May 11, 2023 submitted by the facility revealed, approximately 4:30 a.m., the nurse was notified by the nursing assistant (NA) that Resident 27 was not able to be located during the hydration pass. The missing resident protocol was initiated, and the police department was notified. At 6:15 a.m., the resident was observed walking adjacent to the facility along the side of the road and was returned to the facility by the police. The resident interview revealed no recollection of the incident. Review of the nursing progress notes dated May 11, 2023, at 6:45 a.m., revealed resident was found outside the facility, and was brought to the unit. The nursing assessment revealed resident did not have injuries or pain, the wandering guard was on the left wrist. The resident was placed on 1:1 supervision, MD and family were notified of the incident. Review of the facility documentation, facility investigation, and staff statements revealed the following: Review of the facility investigation, written statement from N.A, Employee E5 revealed Yes, I heard the alarm but knew nothing about it, I did not do anything because the alarm is always going off. Review of the facility investigation, written statement from N.A, Employee E6 revealed, I saw [resident] around 3:00 a.m., and [resident] was at the nurse's station, I am uncertain about the time I have seen [resident]. The same statement revealed that Employee E6 heard a normal beeping originating the front door but also revealed lack of action taken by Employee E6 upon hearing the alarm. The statement revealed Employee E6 went outside to look around 4:30-5:00 a.m. Review of the facility investigation, revealed a written statement from the licensed nurse, Employee E7 dated May 12, 2023, indicating she/he was working on the first floor. Employee E7 reported hearing an alarm and was told by another staff member that it was because someone was in the bathroom. Employee E7 reported, I looked through the bathroom on my floor and I didn't see a concern, so I disregarded the alarm. Review of the facility investigation, written statement from licensed nurse Employee E8, dated May 11, 2023, revealed Resident 27 was seen near the nursing station around 11:15 p.m., but Employee E8 was transferred to the first floor. Employee E8 further stated, A red box at the nurses' station randomly alarms when no one uses the doors, I heard it last night, but it stopped. The statement failed to reveal that Employee E8 did anything when an alarm was heard. Review of the facility investigation, written statement from N.A, Employee E9, dated May 11, 2023, revealed the employee was working on the first floor. Employee E9 stated, I heard beeping, but I thought it was a bed or chair alarm. The statement failed to reveal any action Employee E9 did upon hearing the alarm sound. Review of the facility investigation, written statement from N.A, Employee E10, dated May 11, 2023, revealed I heard an alarm that I thought was to the front door, but I know people go to Wawa and stuff. The statement revealed that Employee E10 was not assigned to the floor where Resident 27 resided. The statement failed to reveal actions taken by Employee E10 upon hearing the alarm from the front door. Review of the facility investigation, written statement from N.A, Employee E11, dated May 11, 2023, revealed Resident 27 was last seen at 3:00 a.m., and was seated by the front of the nursing station. Employee E11 stated, At around 4:45 a.m., while putting ice water in [resident's] room, I noticed that I did not see [resident] there in his/her room, I notified the RN nurse supervisor immediately. Employee E11 denied hearing any alarms sounding during the shift. Review of the facility investigation, written statement from the licensed nurse, Employee E12, revealed Resident 27 was seen around 2:00 - 3:00 a.m., walking back and forth in the hallway. Employee E12 stated, I heard an alarm, but I've been hearing the same alarm that I've heard since I started two weeks ago. No one knows how to turn it off, I looked around and didn't see anything, so I stopped looking at exits and elevator doors. Another statement completed by Employee E12 revealed Resident was seen at 3:00 a.m., wandering in the hallway. The resident asked during the night Where do I go? The statement further revealed that there was a sound going off at the nurse's station but does not know what it was. The employee went for a break around 3:00 - 3:40 a.m. Another statement completed by Employee E12 revealed that she/he came back from a break at approximately 3:45 a.m. At around 4:30 p.m., NA reported that Resident 27 had not been seen while passing water, and the missing resident protocol was initiated. Review of facility documentation and interview with the Nursing Home Administrator (NHA) were conducted on June 13, 2023, at 1:00 p.m. The NHA reported that the camera surveillance captured Resident 27 exiting the ground exit door (front building) at 2:35 a.m. At 2:38 a.m., camera #7 captured Resident 27 by the front entrance trying to reenter the facility. The resident was found by the police in the back parking lot at 6:15 a.m. At 6:23 a.m., camera #8 captured the resident brought back to the facility by the nursing supervisor. Observation conducted on June 13, 2023, at 1:00 p.m., in the presence of the NHA and maintenance director, Employee E15 revealed Resident 27 resides on the second-floor unit. An exit door with an alarm was observed on the second-floor front side of the building, including two levels of stairs to reach the ground floor exit door (where a resident was captured by the camera exiting). Additional observation revealed an alarm sounded when the ground floor exit door was opened. Observation and interview conducted with the NHA and Director of Nursing on May 14, 2023, at 8:30 a.m. revealed Resident 27 walking in the hallway, and a wander guard was observed on the resident's left wrist. When resident 27 stood by the exit door, an alarm went off. The Director of Nursing (DON) and the NHA explained that an alarm will go off if someone wearing a wander guard was near the exit door but would automatically turn off if the resident walks away. The exit door on the second-floor front side of the building was locked but will automatically open when someone leans on it for 15 seconds, an alarm will go off when the door opens and would require someone to manually enter a code to the panel to turn off the alarm. The NHA also explained that the exit door on the ground floor front side of the building will alarm when the door was opened but would automatically shut off at approximately 20 seconds. Interview with the DON on May 14, 2023, at 8:40 a.m., revealed that the facility investigation did not reveal who/how the second-floor exit door alarm stopped. The DON confirmed that based on the facility investigation, and staff statements multiple employees that worked during the time of the incident heard an alarm but did not do anything about it. Resident 27 was assessed as an elopement risk, with episodes of exit-seeking behaviors. On May 11, 2023, facility documentation review revealed that from around 2:00 a.m., until 4:30 a.m., Resident 27, who was last seen wandering in the hallway was not sufficiently monitored. An alarm/door alarm was heard by multiple staff but was disregarded resulting in an elopement of a confused resident, climbing down two flights of stairs, walking out of the building at 2:35 in the morning, and wandering on an area with a two-lane highway nearby with the potential to experience negative outcomes. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator (NHA) on June 14, 2023, at 2:45 p.m., and the IJ template was presented to the NHA, regarding the elopment of Resident 27 from the facility. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure the implementation of supervision and safety measures to prevent elopement for residents in the facility and an immediate action plan was requested. The facility identified the jeopardy at the time of the incident, May 11, 2023. The facility submitted and completed an immediate action on June 14, 2023, which included: Placing Resident 27 on 1:1 monitoring upon return to the facility; Audited current residents at risk for elopement, wander guard orders, care plan reviewed for accuracy; All doors/exit doors audited for functioning; Installation of additional auditory and visual alarm system as well as additional screamer alarm placed at the nursing station placed on May 17, 2023; Review of the elopement risk evaluation for all new admission, and re-admission; Elopement drills completed and will continue to be conducted on each shift monthly; Weekly audits for four weeks to validate wander guard system is being audited by maintenance department; Random audits of ten resident records weekly to assure compliance with the implemented process; and bringing findings to the Quality Assurance and Process Improvement committee meetings monthly for review until sustained compliance is achieved. Facility staff was educated on the following: elopement prevention; search of facility and grounds during elopement; notification of appropriate parties during elopement; supervision of exit seeking residents: and timely response to alarms. The administration educated 181 facility staff, six dialysis staff and eight agency staff. On June 15, 2023, a review of audits, and documentation of conducted to verify the employee education was completed. Licensed Employee E21 and E25 and non licensed employees E16, E17, E 22, E23, E24, Activity Director Employee E19, and Housekeeping Employee E20 were interviewed regarding supervision of residents and education provided. The staff members interviewed, confirmed receiving above education and verbalized knowledge of the education provided, facility had completed the interventions developed for the action plan on May 11, 2023. The Immediate Jeopardy was lifted on June 15, 2023, at 1:20 p.m., after confirmation that the action plan was implemented and completed. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer considered to be in immediate jeopardy. 28 Pa. Code 201.18 (b)(1)(e)(1) Management Previously cited 6/17/22, 3/3/22, 10/22/21, 5/6/21 28 Pa. Code 211.5(h)Clinical records Previously cited 6/17/22, 5/6/21 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 6/17/22, 5/6/21 28 Pa. Code 211.12(d)(1)(3) Nursing Services Previously cited 6/17/22, 5/6/21 28 Pa. Code 211.12(c) Nursing Services Previously cited 6/17/22