**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 6 residents (Resident #1) whose records were reviewed for code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff provided Resident #1, who had a Full Code in place, CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice. On [DATE] at 4:51 p.m., and Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 4:05 p.m., the facility remained out of compliance due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal (POR). This failure could place residents at risk of not receiving life-saving measures, decline in health resulting in serious injury and or death. The findings included: Record review of Resident #1's face sheet, dated [DATE], reflected she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses to include cerebral infarction (a disruption in the brain's blood flow), dysphagia (inability to speak), hyperlipidemia (high fat levels in the blood) and malignant neoplasm of the colon (tumor). Resident #1's face sheet listed her as a full code. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected her BIMS score was 11 indicating moderate cognitive impairment and was usually able to understand others and be understood by others. She required substantial assistance for ADL's. The MDS did not reflect the code status. Record review of Resident #1's care plan, dated [DATE], reflected Resident/Family are requesting full code status. The goal stated resident/family wishes will be honored through next review and CPR will be initiated as needed through next review. The goal had a date initiated [DATE], revision date [DATE] and target date [DATE]. The care plan interventions included: activate EMS as indicated, if transferred out of the facility notify receiving facility and EMS of full code, initiate CPR as indicated, mark chart per facility policy, observe for changes in condition and notify MDs and RP, resident is a full code, observe for change when assisting with care and notify the nurse, review code status with resident/family quarterly and prn. Interventions had an initiation date of [DATE]. Record review of Resident #1's admission notes, created by the DON on [DATE] with an effective date of [DATE], reflected Resident #1 was a full code resident and stated resident/family reports code status as full code. Record review of Resident #1's active physician orders for [DATE] reflected she had an order for full code with original date [DATE]. In addition, Resident #1's orders reflected an order to admit to hospice with original date [DATE]. Record review of Resident #1's Social Service admission assessment dated [DATE] stated Resident #1 was a full code status and did not have and out of hospital do not resuscitate form, advanced directives or a medical/financial power of attorney. The assessment reflected resident rights were explained to Resident #1. Record review of Resident #1's Social Service quarterly assessment, dated [DATE], reflected Resident #1 was a full code and did not have an out of hospital do not resuscitate form. Record review of Resident #1's [DATE] MAR reflected Advanced Directive: Full Code listed on the top of each page of Resident #1's MAR. Record review of Resident #1's EMR profile reflected Code Status: Full Code listed at top of the profile page directly under resident name, status, physician, and allergies. Record review of Resident #1's paper chart reflected a yellow binder with a green sheet in the front of the chart that stated, Full Code and a copy of Resident #1's face sheet that stated full code. Record review of Resident #1's progress note, dated [DATE] at 10:02 p.m., authored by LVN A read as follows was called to resident room. No breathes assess. No pulse. Call out to [hospice company name]. Awaiting call back. DON informed. Record review of Resident #1's progress note, dated [DATE] at 10:40 p.m., authored by LVN A read as follows upon retrieving residents face sheet out of resident chart, this nurse realized that resident was a full code. Contacted [hospice company name] in regard to code status. They stated they thought she was a DNR and was looking through their paperwork and stated to wait until hospice RN arrived at facility. [10:46 p.m.] Contacted DON in reference to code status. While on phone with DON, [hospice company name] nurse [name]RN entered facility and was informed of code status. She stated she would need to contact her supervisor to see what needed to be done. Hospice Nurse [name] then called 911 per directions of her supervisor and EMS came to the facility. Initiated life saving measures and resident was then pronounced deceased at 12:01 a.mXXX[DATE]. During an interview on [DATE] at 4:54 p.m., the Hospice Executive Director revealed the Hospice Triage RN received a call from LVN A at 10:06 p.m. on [DATE] and was told there was a patient death at the facility. Hospice triage RN told LVN A than an RN would be headed to the facility as soon as she finished another case. The Hospice Executive Director stated the Hospice RN arrived at the facility at 10:58 p.m., spoke to LVN A who was on the phone with the Hospice Triage RN again, and said LVN A told them the patient was a full code, and she did not start CPR and did not know what to do. The Hospice Executive Director said the Hospice RN spoke to the DON who stated she was twenty minutes away and did not know what to do. The Hospice RN called 911 at 11:10 p.m. and then called and reported the incident to the Hospice Executive Director at 11:17 p.m. The Executive Director stated Resident #1 admitted to hospice services on [DATE] and was a full code status from the time of admission. The Hospice Executive Director stated a full code status means a resident should be resuscitated. During an interview, [DATE] at 4:48 p.m., the Law Enforcement Officer stated the police department received a call regarding a deceased female around 11:30 p.m. on [DATE]. The Officer stated when he arrived, he was told by EMS staff that the facility nurse said she thought Resident #1 was a DNR and did not initiate CPR since she was on hospice. The Officer stated the Hospice RN and EMS said no one had initiated CPR at the facility for Resident #1 until the EMS personnel arrived around 11:30 p.m. The Officer stated he was notified by a staff member, Resident #1 had been checked on around 9 p.m. prior to being found unresponsive at 10 p.m. on [DATE]. During an interview, [DATE] at 5:36 p.m., the Hospice RN revealed she received a text from the Hospice Triage RN stating there was a death at this facility. The Hospice RN stated she finished providing care to another patient and then arrived at this facility at 10:58 p.m. on [DATE]. When she arrived, she stated LVN A was on the phone and very distraught and said, I didn't realize the patient was a full code and I called your office again to find out what to do. Hospice RN said she asked LVN A what the facility protocol was, and LVN A said she did not know and the DON was on the way. LVN A called the DON and Hospice RN spoke to the DON and asked her what the protocol was when this happens and Hospice RN said the DON said, I am not sure. The Hospice RN said she told the DON, I am not comfortable with this and I am calling EMS, and the DON said ok. Hospice RN said she called EMS and notified them of the situation and that Resident #1 had been passed away for over an hour. Hospice RN stated EMS arrived at the facility at 11:23 p.m., ran a lead (refers to the process of attaching and monitoring electrocardiogram leads on a patient) on Resident #1 at 11:29 p.m. The result revealed the patient was deceased . Hospice RN stated EMS called their EMS command and were instructed to initiate CPR. Hospice RN said EMS performed CPR for 31 minutes and then the EMS physician pronounced Resident #1 deceased at 12:01 a.m. on [DATE]. Hospice RN stated hospice records reflect Resident #1 was a full code and Resident #1 was listed as a full code at the facility and had a yellow binder with a green sheet in the front indicating Resident #1 was a full code. Hospice RN stated the facility should have initiated CPR for Resident #1. During an interview, [DATE] at 11:49 a.m., CNA D revealed she had checked on Resident #1 around 9:35 p.m. and Resident #1 was lying in bed and CNA D said, she looked ok, and I made sure she was clean and dry. CNA D said she made a final round at 10:00 p.m. and when she entered Resident #1's room, CNA D observed blackish brown liquid emesis on Resident #1's chest and CNA D said Resident #1 looked like she was gone. CNA D stated she yelled for LVN A to come to the room and when LVN A entered the room CNA D said, I gave LVN A space to check on her and I stepped out of the room. CNA D said she did not recall how long LVN A was in the room but said LVN A exited the room and said, she's gone. CNA D said she was aware Resident #1 was a full code and said a resident's code status is located in the EMR chart. CNA D was asked if anyone performed CPR and she said I don't know if anyone did, I went to get items to clean her up. All I know is I was told she was gone and that's it. When asked if she had received any training on code status or been contacted by leadership to discuss the incident she responded no. CNA D said full code status meant that a resident should get CPR if unresponsive. During an interview, [DATE] at 12:12 p.m., the Hospice Triage RN stated she received a call from the answering service at 10:02 p.m. on [DATE] and was notified to contact LVN A. The Hospice Triage RN called LVN A at 10:04 p.m. and LVN A said a resident on hospice services passed away. She said the conversation was very brief and they did not discuss code status because the Hospice Triage Nurse said, we would send a nurse out regardless of code status, so the facility is responsible for following their protocol for code status, and LVN A did not mention code status or CPR. The Hospice Triage RN notified the Hospice RN and the Hospice RN she would go to the facility as soon as she finished care with another patient. The Hospice Triage RN revealed another call came in around 10:48 p.m. to the answering service. The Hospice Triage RN said she called the facility back and spoke to LVN A at 10:55 p.m., at which time, LVN A told the Hospice Triage RN that Resident #1 was a full code, and she did not start CPR or call EMS. The Hospice Triage RN said she told LVN A she needed to follow facility protocol and LVN A said the Hospice RN had arrived and hung up the phone. The Hospice Triage RN revealed that Hospice RN called her at 10:59 p.m. and said Resident #1 was a full code and the Hospice Triage RN said she told her to hang up and call 911 and notify the Hospice Director of the incident and that the facility did not follow their protocol. When asked what a licensed nurse should do if they find a hospice patient unresponsive, the Hospice Triage RN said they should follow their facility protocol for responding to DNR and full code status and stated a full code resident should receive full resuscitation. Record review of the facility active staff roster, dated [DATE], reflected LVN A's name, position, status, hire date and phone number were not listed. During an interview, [DATE] at 12:25 p.m., the Administrator was asked by the surveyor why LVN A's name was not listed on the employee roster. The Administrator stated, that is because she was terminated. The Administrator stated LVN A was terminated on [DATE] and provided the surveyor LVN A's phone number. During an interview on [DATE] at 12:44 p.m., the DON revealed she received a call around 10 p.m. on [DATE] from LVN A who notified her that Resident #1 was deceased , and hospice was on the way to pronounce Resident #1. The DON stated she received another call from LVN A approximately 40 minutes later and LVN A said, I made a mistake. The DON said she asked LVN A what she meant and LVN A revealed Resident #1 was a full code and then hung up the phone stating the Hospice RN had arrived. The DON said she left her home to go to the facility and when she arrived, EMTs were performing CPR on Resident #1 and pronounced her deceased at 12:01 a.m. on [DATE]. The DON stated no one performed CPR for Resident #1 from 10:02 p.m. until the EMT's arrive and started CPR at 11:30 p.m. The DON was asked what the facility protocol was for finding a resident unresponsive and the DON stated the nurse should verify the resident code status, go to the room and assess the resident, and initiate CPR if the resident is a full code, and instruct another person to call 911. When asked if LVN A checked Resident #1's code status at the time she was found unresponsive, the DON said LVN A reported she did not check Resident #1's EMR or chart for the correct code status. The DON stated the resident code status is listed on the resident profile in the EMR, on the face sheet, MAR/TAR, care plan and in the paper binder labeled with a red or green sheet as a code status identifier. When asked why it is important for staff to adhere to a resident's code status preference, the DON stated, because the resident has the right to choose whether we perform CPR or not. The DON was asked about prior code status training for the licensed nurses, and she stated the licensed nurses had received training in February 2024 on code status, how to respond to a code, where to find code status in resident charts and where to input the order so it populates throughout the EMR. The DON stated she suspended LVN A after the incident on [DATE] and terminated LVN A's employment on [DATE] for not performing CPR on a full code resident. The DON was asked if the facility completed an investigation or gathered statements of the incident and the DON said no. Record review of facility document titled Employee Disciplinary Action Form, dated [DATE], reflected LVN A was terminated on [DATE] for failure to follow facility policy regarding code status and to provide full code response for a resident that was found unresponsive. The document was signed by the DON and Administrator. The document stated LVN A refused to sign. Record review of LVN A's CPR certification reflected LVN A had successfully completed the requirements in accordance with American Health Care Academy's curriculum for the course, Healthcare Provider CPR/AED: Adult, Child, Infant and First Aide (BLS). The certification was completed [DATE] and valid until [DATE]. Record review of an in-service training attendance roster, dated [DATE], reflected the topic of the in-services was patient code status and how to enter a code in the EMR. The in-service also included a document that stated every resident's code status is located in the EMR toward the top of the screen under allergies and provided visual references of the EMR. The in-service was signed by LVN A. Record review of facility document titled Cardiopulmonary Resuscitation (CPR), undated, listed steps for licensed nurses that included 1. Determine unresponsiveness by tapping or gently shaking resident and shouting are you ok? If you suspect a neck or spinal injury, do not shake the resident. 2. If the resident does not respond, call out for help. 3. Delegate a specific individual to check the resident's orders and care plan for CPR or no CPR order, have individual call paramedics, attending physician and administrative personnel per facility procedure and report back to you as soon as possible. 4. Do not start cardiopulmonary resuscitation (CPR) if the resident is breathing and has a pulse. 5. Place the resident on his or her back, supporting head and neck, on a hard surface. Perform CPR if the resident is unresponsive and not breathing or no normal breathing (i.e., only gasping). This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:51 p.m. The Administrator was notified at 4:51 p.m. and was provided with the IJ template on [DATE]. During an interview, [DATE] at 6:15 p.m., LVN A verified she was the charge nurse for Resident #1 on [DATE]. LVN A said the last time she observed Resident #1 was around 8 p.m. when she administered a medication and said Resident #1 spoke to her and her vitals were within normal limits. LVN A said CNA D came to her at 10 p.m. and said she needed to go check on Resident #1 and CNA D said she did not think Resident #1 was breathing. LVN A said she entered the room and observed the patient with no pulse and no breath. LVN A said she thought Resident #1 was a DNR and did not go and check her code status. LVN A said she called the DON and hospice and proceeded with doing an end of shift report. LVN A said about 40 minutes later, she went to Resident #1 chart to document and realized Resident #1 was a full code and that I never started CPR. LVN A said she called hospice and was told to wait for the RN to arrive. LVN A said the Hospice RN arrived and LVN A told her what happened, and Hospice RN called 911. LVN A said she called the DON again and was informed that the DON was on her way to the facility. LVN A said, I don't know why I did not do anything, when I realized it, it was too late. LVN A was asked what the facility protocol was for finding a resident unresponsive and/or without a pulse and she said, we are supposed to look at the chart and the computer to verify code status. LVN A said she received training on code status around February or March. LVN A was asked what the facility protocol was if a resident is found unresponsive and is a full code and she said I should of verified the code status and I should have started CPR but it had already been 40 minutes by that time. I was pulling out her face sheet to make a copy and that is when I noticed the error I made LVN A stated she was CPR certified and just renewed my certification last week. LVN A said she was suspended on [DATE] and quit on [DATE]. LVN A stated she was aware that a patient can be on hospice and be a full code. The following Plan of Removal (POR) was accepted on [DATE] at 12:20 p.m. and indicated the following: Events Leading to the Alleged Deficient Practice (narrative format): On [DATE], State Surveyor entered [Facility name] at 8:22am on a Complaint investigation. IJ was called at 4:51pm for the following as quoted on the IJ template: F678 Quality of Life The facility failed to provide a full code resident (Resident #1) with CPR when resident was observed without a pulse from 10:02pm till EMS arrived at 11:23pm. The alleged failure is as follows (summary format, bullet points) 1. Failed to initiate Full Code procedures timely when Nurse found resident unresponsive. The Medical Director, [Physician name] was notified at 12:02pm on [DATE]. No additional instructions or plans obtained. Facilities response was discussed. What action was taken for the staff directly involved in the failure? Nurse was terminated. Staff will be educated/trained in regard to Resident Code Status and Hospice Services and initiating CPR timely for resident who are a Full Code. A 100% audit of Resident Code Status for all residents was completed by [name], Director of Nursing in which Code status on Resident Face Sheet was verified by order for code status and if code status is a DNR the executed OOHDNR document was verified in Miscellaneous section in [EMR name] and copy verified in Resident hard chart. An audit will be completed monthly by the Director of Nursing. Alleged Failure #1 - Failed to follow facility policy regarding code status and initiate CPR/Full Code procedures timely when resident was found unresponsive. In-servicing/education provided in response (bullet point narrative): Start/stop time and date: On [DATE] at 12:30pm education began for Nurses (LVN and RN) staff in regards to Resident Code Status and Hospice Services and initiating CPR timely for resident who are a Full Code. Education Code Status and Hospice: Hospice residents can elect to be a Full Code. Resident with no pulse or respirations: Nurse will check code status in, [EMR name] call the Code Blue, initiate CPR and have another staff call 911. Flow chart of How to respond when a resident has no pulse or is unresponsive is posted at the nurses station as a reminder. When to provide CPR. When resident has no pulse or no respirations, Nurses are to check code status in [EMR name] which will determine how to respond appropriately. What will you do for staff not present? Nurses that aren't present will be in-serviced before the start of their next regularly scheduled shift What will you do with newly hired staff? The education/in-service of facility policy regarding Code Status and Hospice Services and initiating CPR timely for resident who are a Full Code. Who did the education/in-servicing? The education will be completed by [name] Director of Nursing What time did the education/in-servicing complete? All the education on this topic will be complete [DATE] by 5:00pm for Nurse staff present. A 4 question post-test will be given to verify retention of knowledge related Hospice Services and Code Status and initiating CPR timely for resident who are a Full Code. How will you monitor for effectiveness of the Plan of Removal? Administrator will randomly issue post test regarding education/in-service on Hospice Services and Code Status and initiating CPR timely for resident who are a Full Code for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. Director of Nursing will randomly request a Nurse to communicate Code Status on a resident on Hospice and initiating CPR timely for resident who are a Full Code for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. Nurse responses will be documented on a Response LOG that will identify staff name, date, shift, answer/response and if correct, resident name. The facility's POR verification was as follows: During an interview with the DON, [DATE] at 2:19 p.m., the DON stated LVN A was terminated from the facility on [DATE]. The DON stated the Medical Director was notified of the incident on [DATE] at 12:02 p.m. and the Medical Director did not give any additional instructions. The DON stated staff training was initiated on [DATE] and was completed on the morning of [DATE]. The training was provided to 100% of licensed nurses and covered the topics of where to find resident code status in the resident chart, importance of verifying code status if a resident is found unresponsive, what actions to take if a resident is a full code or DNR and hospice resident's right to be full code. During an interview with the Administrator, [DATE] at 2:28 pm, the Administrator stated LVN A was terminated on [DATE]. The Administrator stated the Medical Director was notified of the incident at [DATE] at 12:02 pm and provided no further guidance. The Administrator stated training for licensed nurses was initiated on [DATE] and was completed on the early morning on [DATE] and the training was completed by the DON. Record review of document labeled, Employee Disciplinary Action Form, dated [DATE], revealed the name of LVN A, type of offense is listed as violation of company policy. The document revealed LVN A as suspended on [DATE] at 11 pm and was terminated due to the result of the event on [DATE]. Record review of staff roster dated [DATE] reflected 13 licensed nurses (11 full time nurses and 2 prn nurses). Record review of an in-service training attendance roster, dated [DATE], reflected the in-service topics included hospice resident and code status, resident rights and where to find code status. The instructor was facility DON and roster was signed by 16 nurses (3 agency employees). Documents attached to the in-service included an action tree describing how to respond when a resident is found with no pulse or unresponsive and listed the first action as go to [EMR name] and check code status. Record review of a document titled Hospice Residents/Code Status/Resident Rights Post Test listed 4 questions which included 1. What do you immediately check when a patient is found unresponsive? 2. Can you be on hospice and still be a full code? 3. Where do you find the code status? 4. Resident has the right to decide their code status True or False?. There are 18 (13 facility nurses and 5 agency nurses) completed posttests by nurses. Record review of a Hospice list, dated [DATE], reflected 10 resident names. 3 residents are listed as full code. Record Review of a document labeled [facility name] Ordering Listing Report, dated [DATE] at 8:03am, reflected a list of all facility residents and their code status. The document revealed there are 28 residents with orders for DNR and 31 residents with Full code orders. Record review of resident roster, dated [DATE], reflected 59 resident names. Record review of 59 resident face sheets, dated [DATE], reflected code status on the resident face sheets matched the resident physician order for code status. Interviews conducted with 10 of 11 full time licensed nurse employees (5 -6 a.m.-2p.m., 1- 2 p.m.-10 p.m., 1 - 10 p.m.-6 a.m., 3- double weekends 6 a.m.-10 p.m.). Interviews conducted with 2 agency LVNs (1- 6 a.m.-2 p.m. and 1- 2 p.m.-10 p.m.). 2 PRN employees were unable to be reached by phone and were not on the schedule. The employees interviewed revealed they had received training from the DON regarding where a resident's code status is located in the chart, when to verify code status, what to do if a resident is a full code or DNR and hospice patients can be a full code. The licenses nurses were all able to answer the questions correctly, validating understanding of the in-service topic. During an interview with the Administrator, [DATE] at 2:28 p.m., the Administrator stated the DON would provide training to new hires during the orientation process and would provide training to agency employees prior to their assigned shift. The Administrator stated random post tests would be given to licensed nurses, weekly for 4 weeks, starting on [DATE] by the Administrator. The test would include questions regarding code status and initiating CPR timely for residents that are a full code. During an interview with the DON, [DATE] at 2:19 p.m., the DON stated new hires would receive training on code status, hospice and full code, and what to do when a resident is DNR or full code, during the orientation process and the DON would provide the education. DON stated agency staff would be educated on code status prior to beginning their shift and the DON would be providing the education. DON stated she had created an audit log and would conduct random audits with the licensed nurses. The audit would include asking the nurse to identify the residents code status, identify if the patient is on hospice, identify if the resident is a full code and how the nurse would respond to the code status. Record review of a document titled Monitoring for Knowledge Retention, undated, listed the names of all facility nurses and had a section for agency staff. There are 4 forms listed as week 1, 2, 3, and 4 and stated it will be conducted by the Administrator. Record review of audit logs labeled Week 1, undated, listed date, shift, nurse, resident, code status, hospice y/n, correctly identified code status y/n and correct response of what to do if full code y/n. There were 5 blank audit lines per sheet. There are 3 additional correlating documents labeled Week 2, Week 3 and Week 4. The audit would be completed by the DON. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and/or completed. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 4:05 p.m. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to provide adequate supervision, for 1 of 4 residents (Resident #3) reviewed for accidents, hazards, and supervision. Resident #3 walked out of the facility through an alarming door without staff responding. This deficient practice placed residents at risk for being unsupervised, accidents, and injury. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/8/2024 at 2:05 PM. While the immediacy was removed on 4/9/2024, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not an Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal. The findings included: Record review of Resident #3's admission record, dated 03/09/2024, reflected an [AGE] year-old resident with an admission date of 05/26/2020, and diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #3's Annual MDS, dated [DATE], reflected Resident #3 had not exhibited behaviors of wandering, and that the residents BIMS score was a 4, indicating the resident was severely cognitively impaired. Record review of Resident #3's Wandering Risk Assessment History of Outcomes, dated 03/09/2024, reflected that Resident #3 had consistently scored in the category of being a Moderate Risk of wandering on Resident #3's Wandering Risk Assessments completed on the following dates: 11/26/2020, 03/11/2021, 03/11/2022, 03/10/2023, 06/13/2023, 09/18/2023, 12/19/2023, and 03/07/2024. Record review of Resident #3's Comprehensive Person-Centered Care Plan, dated 03/09/2024, reflected Resident loves to wander around facility with/without purpose d/t her cognitive impairment and 3/7/24 Resident to utilize wander guard with interventions that included if wandering increases and place resident at risk for injury, or leaving facility, Notify MD, RP, ADMIN, DON, SS and assess, discuss possible need for secure unit. In an interview on 03/09/2024 at 4:03 PM, [NAME] C stated that she was taking a break in the smoking area outside when she heard banging and the alarm going off at the fire exit door. [NAME] C stated that when she looked up after a while, she noticed Resident #3 was standing next to her. [NAME] C stated that at this point, the Maintenance Director came over and proceeded to redirect the resident, and that the alarm had been going off for probably 3 or 4 minutes before she or the Maintenance Director noticed. [NAME] C then went on to state they had not had an elopement training at this facility. In an interview on 03/09/2024 at 4:12 PM, Maintenance Director stated that while walking up to the facility building from his workshop, which was not connected to the main building of the facility he noticed Resident #3 was standing outside pushing her wheelchair and using it as a walker. The Maintenance Director stated that this is when he realized he heard the door alarm going off, he proceeded to help the resident sit back in her wheelchair and brought her back inside. The Maintenance Director then stated that he brought the resident to the nurses' station and asked the nurses if they heard the alarm, to which they responded no. The Maintenance Director stated that the alarm was easy to hear at the nurses' station, and he was not sure why the nurses did not respond to it. The maintenance director stated he believed the staff may have chosen to ignore the alarm, as it goes off at times while staff members take residents out for smoking break. In an interview on 03/09/2024 at 4:37 PM, CNA D stated that on the date Resident #3 walked out of the facility, she was providing a shower to a resident in a closed shower room down the 100 hallway and heard the alarm going off but did not feel comfortable leaving the resident alone in the shower room to respond to the alarm. CNA D stated that the alarm was loud and easy to hear, and it should be easily heard at the nurse's station. CNA D stated that Resident #3 walked around a lot, but that she has not observed exit seeking behavior from the resident. In an interview on 03/09/2024 at 4:40 PM, CNA E stated that while Resident #3 walked out of the facility, he was with a resident when he heard the alarm going off and was unable to respond to it. CNA E stated the alarm was loud, and you could hear it well from most common areas as it was near the dining room and nurse's station. CNA E stated that Resident #3 walked around a lot and they sometimes had to bring her wheelchair to her because she would walk to another area of the building without it. Otherwise, she has never seen her try to exit the facility. CNA E stated that usually someone was always near Resident #3, so they were able to help her if necessary. Observation on 03/09/2024 at 4:50 PM revealed Resident #3 resting in her bedroom wearing a wander guard. In an interview on 03/10/2024 at 11:06 AM, LVN F stated she was at the nurse's station when Resident #3 walked out of the door, looked at the doors in and out of the facility when the alarm went off until the maintenance director brought Resident #3 inside. LVN F stated she heard the alarm, and that Resident #3 had not tried to exit seek before but would walk around the facility a lot. In an interview on 03/10/2024 at 1:09 PM, the DON stated that the expectation was that if staff heard the door alarm, they need to investigate why the alarm went off. The DON stated they have not had an in-service training relating to elopement since the event. She then stated that RN I was unavailable for interview and that RN I would call as soon as she was available for an interview. The DON stated that they did not treat this as a true elopement. She stated they did not notify the physician or the resident's representative as the resident did not leave the property, and thus did not create an incident report. The DON stated a true elopement was when the resident leaves the property entirely. The DON stated they assessed the resident when she returned inside the facility, and this was when the wander guard was placed. In an interview on 03/10/2024 at 1:18 PM, the Administrator stated that the expectation was that all staff who heard the door alarm were to respond to it and investigate as to why it went off. The administrator stated they did not treat this as a true elopement and did not notify the physician or the resident's representative as the resident did not get very far outside. The administrator stated there was no incident report made. In an interview on 03/10/2024 at 1:40 PM, RN I stated she was at the nurses' station when Resident #3 walked out of the door. RN I stated that she and LVN F were documenting in residents charts and realized they had been hearing a beeping. RN I stated this was when she began to look around for a moment and saw the maintenance director bring in Resident #3. RN I stated that she and LVN F were caught up in report and talking that by the time they realized the alarm was going off, the maintenance director was bringing Resident #3 back inside. RN I stated it was the expectation that when any beeping or any kind of alarm was going off you were to answer it. Record review of a policy titled, Elopement, undated, reflected Nursing personnel must report and investigate all reports of missing residents. This was determined to be an Immediate Jeopardy (IJ) on 4/8/2024 at 2:05 PM The facility Administrator and the DON were notified. The Adminsitrator was provided with the IJ template on 4/8/2024 at 2:05 PM. The following Plan of Removal submitted by the facility was accepted on [4/9/2024 at 5:09 PM ]: Plan of Removal Guidelines Events Leading to the Alleged Deficient Practice: On 04/08/2024, Surveyor entered the facility to change an IJ issued on 3/22/24 to a current IJ. IJ was called at 2:05pm for the following as quoted on the IJ template: F689 The facility failed to ensure Resident #3 was as free of accident hazards as was possible and received adequate supervision to prevent accidents in that Resident #3 walked out of the facility through an alarming door without staff responding. The alleged failure is as follows (summary format, bullet points) 1. Staff failed to respond to a door alarm when a resident was exiting out the door. The Medical Director, was notified at 2:20pm on 4/8/2024. No additional instructions or plans obtained. Facilities response was discussed. Medical Director was notified of the incident regarding Resident#3 on March 9th, 2024. What action was taken for the staff directly involved in the failure? Staff will be educated/trained on door alarm response. Alleged Failure #1 - Staff failed to respond to a door alarm that was activated by a resident. In-servicing/education provided in response (bullet point narrative): - Start/stop time and date: - On 3/11/2024 at 9:00am education began for all staff in regards to responding to a door alarm. - What will you do for staff not present? o Staff that aren't present will be in-serviced before the start of their next regularly scheduled shift - What will you do with newly hired staff? o The education/in-service for Door Alarm Response will be included in the new hire process for all staff. - Who did the education/in-servicing? o The education will be completed by Administrator. - What time did the education/in-servicing complete? o All the education on this topic was completed by 3/22/2024. How will you monitor for effectiveness of the Plan of Removal? - Administrator will randomly perform door alarm testing for staff response. o Start date March 11, 2024, Weekly on various shifts for 6 weeks, ending April 20th, 2024. What will be the procedure in the event the door alarm is activated? o Staff will respond by going to the door in which the alarm is activated. Who will be the point of contact to report door alarm activity. o The staff member(s) that respond to the alarmed door and they will notify the Administrator or the Director of Nursing. Verification of Plan: Observations: Observations on 3/22/2024 at 3:30 PM and 5:09 PM revealed no door alarms were sounding and no residents were outside in front or side of the building. Observations on 4/8/2024 at 1 PM revealed no door alarms were sounding and no residents were outside in front or side of the building. Observations on 4/9/2024 at 9 AM revealed no door alarms were sounding and no residents were outside in front or side of the building. Observation on 4/9/2024 at 10:51 AM revealed a mock door alarm was opened in the dining area by the Administrator and 5 staff immediately responded and went towards the door. Records: Resident #3 was discharged on 3/14/2024 to a facility with a secure unit. Record review of Resident #3's consolidated physician orders and care plan for wander guard was dated 3/7/2024. In-service sheets with staff signature. In service dated 3/11/2024 Door Alarm Response, Elopement (nursing personnel must report and investigate all reports of missing residents). Record review of In-services signed by staff: 73 out of 74 of their staff were in-serviced. (part-time and full time). One staff person was out on FMLA and when they return to work, they will be in-serviced. 8 out of 11 therapy staff have been in-serviced. The other 3 staff had not been to work. 5 out of 6 agency staff that had worked had been in-serviced. One agency staff that normally worked has not been into work. Staff interviews: Interview on 4/9/2024 at 4:07 PM with MD stated the facility did notify her of the current IJ and when Resident #3 had left out a door in the facility. MD stated she was not sure why it was a an IJ. MD she had nothing else to say. Interviewed a total of 18 out of 74 regular staff. Interviewed all 3 shifts, including 2 CMA, 7 CNA's, 4 LVNS, 1 RN, 2 dietary aide, 1 housekeeper, and 1 staffing coordinator, 3 therapy staff, and 2 agency staff. Interviewed a total of 23 staff on all 3 shifts, prn, weekends, therapy, and agency staff that have been on the schedule since 3/7/ 2024. In an interview on 3/22/2024 at 5:28 PM with CNA A (6-2 PM, 2-10 PM) he stated he was in-serviced on door alarms, immediate check if alarm doors sounded, and make sure residents were not trying to go out. If resident does go out, staff were to bring back the resident. Staff were to guide the resident back safely and notify the Administrator or charge nurse. In an interview on 3/22/2024 at 5:34 PM with dietary aide B (6-2 PM) stated she was in-serviced on the door alarm and if a resident leaves the facility via the door. Dietary aide B stated if she heard the alarm sound, she would go check the door, and look to see if the resident left the facility. Dietary aide B stated she would bring the resident back in the facility and notify the nurse or DON. In an interview on 3/22/2024 at 5:36 PM with housekeeper C (3-8 PM, prn) stated she was in-serviced when she started her shift at the facility. Housekeeper C stated the in-service was about making sure no residents go out the door and they did a demonstration of the process. She was to notify the DON/nurse/manager of any residents leaving through the doors. In an interview on 3/22/2022 at 5:43 PM with RN D (6-2 PM) stated she did receive the in-service for checking the door if it alarms, immediately go see if a resident was nearby or had left the facility. If they did see a resident, bring back the resident inside the SNF and notify the Administrator. The nurses have a daily reminder to check for residents that were trying to go out the door. In an interview on 3/22/2022 at 5:47 PM with LVN E (2-10 PM) he stated he had been in-serviced on checking the door alarm if a resident had gone out, go over to resident, and re-direct the resident if the resident did not want to come into the facility. LVN E stated he would notify the Administrator, RP, and MD and document event. In an interview on 3/22/2022 at 6 PM with CNA F (2-10 PM) she stated she was in-serviced on if an alarm door sounds, she will go see which door it was, see if resident had gone out of the facility, and bring them back in the facility. CNA F stated if the resident did not want to come back in, CAN F would re-direct the resident back inside, stay with the resident to make sure they don' t go back outside, and notify the nurse. In an interview on 3/22/2022 at 6:06 PM with CMA G (2-10PM) she stated she was in-serviced on the door alarm. If she heard the alarm, she would locate the door, and see if a resident went outside. If she did see that a resident was outside, or near the door, she would re-direct the resident back inside into a safe place. CMA G stated she would notify the nurse. In an interview on 3/22/2022 at 6:09 PM with LVN H (agency) (6-2 PM, 2-10 PM) she stated she was in-serviced when she first started her shift on the door alarms. LVN H stated she would go see where the sound was coming from, she would immediately see if resident went out, and if a resident did re-direct them. LVN H stated she would assess the resident for an injury, if no injury re-direct them back to the SNF. If the resident had an injury, she would call 911, notify the charge nurse that resident left out the door and document. In an interview on 3/22/2022 at 6:16 PM with CNA I (2-10 PM) she stated she was in-serviced on the door alarm, if it alarms, she would walk towards the door to see if the resident went outside or not. If the resident did bring them back in, give them something to eat or drink and notify the nurse. In an interview on 3/22/2022 at 6:20 PM with MA J (2-10 PM) she stated she was in-serviced on the door alarm. MA J stated if she heard the door alarm, go see if resident went outside, and if so bring them back in. If resident refused, let the nurse know and stay with resident. In an interview on 3/22/2022 at 6:34 PM with CNA K (2-10 PM) he stated he was in-serviced on the door alarm. CNA K stated he would go outside immediately to door that was alarming, to see if the resident went outside. If the resident did go outside, he would bring the resident back inside. He would make sure the resident was safe and notify the nurse. In an interview on 3/22/2022 at 6:37 PM with HR coordinator L (8-5 PM) she stated she was in-serviced on door alarms. If a door alarm were heard she would go towards the door, to see if the resident went outside the facility. If the resident did go outside the facility, she would bring them back, and notify the nurse and/or the DON/Administrator. In an interview on 3/22/2022 at 7:30 PM with LVN M (2-10 PM) she stated she was in-serviced for door alarms. LVN M would immediately go to door to see if the resident was outside, bring the resident back in, she would notify the Administrator, the MD/family, and document. In an interview on 3/22/2022 at 7:31 PM with Staffing Coordinator N (8:30-5:30 PM) she stated she was in-serviced on door alarms, exit doors alarms (15 minutes egress alarm), and to go to door to see if resident was outside of the door. If resident was outside, go out immediately and secure the resident, bring the resident back in, and notify the DON. In an interview on 3/22/2022 at 7:35 PM with ADON O (7-4 PM) she stated she had an in-service training on door alarms. Staff should get up immediately if they heard the alarm and make sure all the residents were in the building. Check to see if a resident got out, then bring the resident back, re-direct the resident, staff stay out there with the resident, notify Administrator, the nurse, family, the DON, the ADON, the STATE, and the MD. In an interview on 3/22/2022 at 7:39 PM with CNA P (10-6 AM) she stated she was in-serviced on the door alarms. CNA P was to check all exit doors and secure the doors and make sure no residents were outside. If a resident was outside, bring them back in and notify the nurse. In an interview on 3/22/2022 at 7:41PM with CNA Q (10-6 AM) he stated he had training on the door alarms. To make sure residents did not get out of the building, re-direct into building, keep the resident safe, and notify the nurse and management. In an interview on 4/9/2024 at 11:41 AM with LVN R (6-2pm, prn) she stated she worked as needed at the facility. LVN R stated she had training on the door alarm and stated he would go to door and make sure a resident did not exit. LVN R stated all staff should check where the alarm was sounding and watch the exit doors. LVN R stated she would to make sure resident does not go out, and, if resident was outside, she would bring the resident back inside the facility. LVN R stated she would notify the chain of command, the Administrator, DON, family, charge nurse and document. In an interview on 4/9/2024 at 11:51 AM with CNA S (6-2 PM) stated she was in-serviced on the door alarms. CNA S stated she would see which door it was and look to see if a resident went outside. CNA S stated if resident went outside, she would go outside with resident and would bring them back into the facility. CNA S would notify the nurse and the Administer/DON. Interview on 4/9/2024 at 12:06 PM with CNA T (agency) (6-2 Pm, 2-10 PM) stated she was in serviced when she started work on the floor on door alarms. CNA T stated she would go to door that was alarming, see if resident were near the door or outside. CAN T stated if she saw a resident outside, she would bring them back to their room, and notify the nurse. In an interview on 4/9/2024 at 5:01 PM with the DON/Administrator stated the expectations for the door alarms were if it should sound all staff were responsible for immediately going to the door that was alarming. If staff were busy with resident care, there were other staff in the building that could respond to the alarm from the exit doors. When the door alarms alarm, the staff should notify the DON/Administrator about why the door alarm was sounding and what they did. They stated they would notify the resident physician and family if a resident was to elope. The Admin/DON stated they were responsible for ensuring staff were educated/trained on door alarms and ensuring residents were safe. The DON stated the risk of if a resident eloped would be that they would get hurt. The Administrator provided a copy of the Random Door Alarm testing LOG. In an interview on 4/9/2024 at 4:40 PM with the Administrator she stated, education was started for staff on 3/11/2024 responding to the door alarm. The Administrator/DON stated as staff were hired and work on the floor, she would educate the staff and the new hire process would include the door alarm response education/training. The Administrator stated she had a door alarm record log that she kept for the random door alarm checks on staff. The Administrator stated when the door alarm sounds, staff were to go to the door that was sounding off. She stead the egress exits doors have a 15 second delay. The staff were educated on making the response to the door alarm urgent and immediately. The Administrator stated any staff should go to door that was alarming and all staff must respond unless caring for a resident. The Administrator stated all staff were to notify the Administrator/DON if a false alarm or why the alarm sounded and what they did. The Administrator stated she would provide oversight to her staff in regard to the door alarms and responses. The Administrator and the DON were in charge of the training /education of staff. If not here the point of contact was the charge nurse, then the charge nurse would notify the Administrator/DON. The Medical Director would be contacted if the resident was harmed or impacted. The Administrator stated she notified the Medical Director of the IJ. The Administrator was informed the Immediate Jeopardy was removed on 4/9/2024 at 5:09 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate an advance directive for 1(Resident #69) of 24 residents reviewed for advanced directives. The facility failed to honor the rights of Resident #69's wishes to die a dignified death by failing to honor a signed OOH DNR order on [DATE] at 9:30 AM when Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:55 p.m. While the IJ was removed on [DATE] at 2:55 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. This facility failure placed residents at risk of not having their rights honored, to include pain, fractures, psychological and physical harm. The findings included: Record review of Resident #69's electronic face sheet dated [DATE] reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: diabetes mellitus (a disease of inadequate control of blood glucose levels), cognitive communication deficit (difficulty with thinking and how someone uses language), chronic kidney disease (when the kidneys have become damaged over time (for at least 3 months) and have a hard time doing all their functions), CVA (cerebral vascular accident or brain attack) and osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection. Resident #69's electronic face sheet reflected he had Full Code (desired CPR) status. Record review of Resident #69's significant change MDS assessment dated [DATE] reflected he scored a 12/15 on his BIMS which signified he was cognitively intact. He could usually understand others and could usually be understood. He required extensive assistance with his ADL's. Record review of Resident #1's comprehensive care plan revised on [DATE] reflected Focus, the resident/family are requesting DNR status, Goal, resident/family wishes will be honored through next review, Interventions/Tasks, Activate EMS as indicated, if transferred out of facility, notify receiving facility and EMS of DNR status, initiate CPR as indicated. Record review of Resident #69's readmission assessment dated [DATE] reflected resident desired to have DNR status under advanced directives. Record review of Resident #69's Order Details dated [DATE] reflected Admit to .under .Hospice, DX. CVA, Code Status: DNR. Record review of the facility shift change report dated [DATE] from the night shift nurse (LVN B) to the day shift nurse (LVN C) reflected ADMISSIONS: Resident #69 admitted at 01:00 AM to .Hospice, on pleasure feedings, regular diet, multiple breakdowns noted. No mention of Code Status. Record review of Resident #69's progress notes written by LVN E dated [DATE] at 10:45 AM, reflected Resident #69 was found unresponsive without a pulse. PCC checked and resident listed as Full Code status. Crash cart was brought into room, Resident #69 placed on the floor. CPR was initiated at 09:28 AM, no respirations, no pulse, no BP, pupils fixed and dilated, skin cool to touch, non-responsive, EMS arrived at 09:45 AM and took over CPR, artificial airway placed. CPR stopped at 09:53 AM after electronic DNR located and provided to EMT's. Pronounced at 09:59 AM via phone by MD for EMS Fire/EMS, and local police. Record review of Resident #69's progress notes dated [DATE] at 1:21 PM, reflected that during an interview with the local police, LVN A located an OOH DNR for Resident #69 under the miscellaneous tab in PCC. Record review of Resident #69's OOH DNR reflected it was signed and dated on [DATE], prior to his readmission to the facility. Interview on [DATE] at 10:46 AM with LVN C, she stated she and LVN A initiated the code for Resident #69. LVN C stated that LVN A found him, called for help, and came out of his room and they checked PCC and found Full Code status was noted on his electronic face sheet. LVN C stated she did not check his orders. LVN C stated the police and EMS was notified and they arrived within 5 minutes. LVN C stated she was trained on how to put a resident's code status and orders into PCC. LVN C stated she did not recall being told Resident #69 was admitted with DNR status from LVN B. LVN C stated it was important to honor a resident's wishes for advanced directives otherwise their rights would be violated. Interview on [DATE] at 10:58 AM with LVN A, she stated she found Resident #69 and called for help. LVN A stated she and LVN C checked his EMR and found he was full code status in PCC. LVN A stated she did not check his admission orders. LVN A stated when a police officer asked her about his medications, she looked under his miscellaneous tab in PCC and saw the OOH DNR. LVN A stated she felt bad when that happened and immediately took the OOH DNR to show to the EMT responders and they stopped CPR. LVN A stated Resident #69 was pronounced deceased by the MD. Interview on [DATE] at 11:44 AM with LVN B, she stated she was the nurse that did the admission assessment for Resident #69. LVN B stated she put his information into PCC, to include his code status, and she did not know why it was not reflected on Resident #69's face sheet because she felt like she did everything right. LVN B stated his code status was reflected in his admission orders and she communicated it to the night shift nurse LVN C. LVN B stated it was important for the resident's rights and advanced directive desires to be noted and communicated to the nursing staff because if he had a cardiac event, he did not want to be resuscitated. Interview on [DATE] at 12:00 PM with the DON, she stated she was called by LVN A, and she told her to check Resident #69's chart. The DON stated she did not realize that Resident #69 received a full course of CPR, and when she realized what had happened, she knew she needed to in-service the nurses on the PCC order entry process. The DON stated LVN B must have failed to discontinue the previous full code order, and this resulted in the change of code status not populating onto the face sheet. Interview on [DATE] at 12:15 PM with the Administrator, she stated she reported Resident #69's death as required under long term care death notifications for a death within 24 hours of transfer, however she did not realize the issue with Resident #69's advanced directives not being honored, or she would have reported it to HHSC right away. Record review of the facility policy and procedure titled Resident Rights (undated) reflected Purpose, to ensure the resident rights are respected and protected. Further review of the policy and procedure reflected, The resident has a right: To a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Record review of the facility pamphlet (undated) titled Treatment Choices reflected Code Status Policy. Purpose, to provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel. The Administrator was notified of an IJ on [DATE] at 5:55 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] at 2:55 p.m. and included the following: Alleged Failure #1 - Failed to properly input code status in the Point Click Care (PCC) Electronic Medical Record (EMAR) upon admission. Alleged Failure #2 - Failed to honor the rights of Resident # 1's wishes to die a dignified death by failing to honor a signed out of hospital do not resuscitate (DNR). Director of Nursing completed an audit of all resident code statuses on [DATE], 8:00pm, and all were found to be accurate. In-servicing/education provided in response (bullet point narrative): -Start/stop time and date: -On [DATE] at 6:30pm education began for Nurses (LVN and RN) staff in regards to properly complete Order Entry of code status in the PCC/EMAR of a resident. Nurses will reference PCC in the event of an emergency situation. -o Nurses that aren't present will be in-serviced by the DON before the start of their next regularly scheduled shift, utilizing a staff roster to ensure training and ensure a passing score on Post Test. -o The education/in-service of Order Entry of Code Status in a Resident PCC/EMAR will be included in the new hire process for all Nurses. o The education will be completed by the DON -o All the education on this topic will be complete [DATE] by 10:00pm for Nurse staff present. o A 4 question post-test will be given to verify retention of knowledge related Order Entry of code status into resident PCC/EMAR. -Administrator will randomly issue post test regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. Record reviews of sampled residents #9, #14, #22, #23, #26, #33, #35, #36, #38, #43, #44 and #56 EMR's and face sheets reflected code status was accurate. Verification of the POR Record review of facilities incident response binder revealed the facility completed the in-service with nursing staff on topics where to find the resident's code, how to enter resident's code status for new admissions and status changes, the purpose of code status, and resident's rights-choosing their code status. -Record review of facilities incident response binder revealed the facility conducted a post test for each nursing staff that received the in-service. Facility has documented 100% of their nursing (all 19 nurses) staff have completed the posttest and received a 100% on the post test. Interview on [DATE] at 1:05 p.m. with the DON revealed she in-serviced 100% (all 19 nurses) staff were on [DATE] after 6 PM and the remainder were in serviced on [DATE]. OUT OF 19 TOTAL NURSES-16 WERE INTERVIEWED FOR VERIFICATION (84%) Phone interview with RN N at 9:40 AM on [DATE]. She stated she received training on [DATE] on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Administrator will randomly issue posttest regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -5 DAY SHIFT NURSES -Interview with LVN D on [DATE] at 12:21 p.m. revealed she had training on code status, how to put in the code status and to respect their rights. -Interview with the DON, RN at 9:51 AM on [DATE]. RN conducted the training with all nursing staff. RN started training on [DATE] and completed training on [DATE]. RN had all staff complete a posttest to ensure they understood the in-service. -Interview with MDS Nurse at 10:42 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN E ADON, at 11:02 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN F on [DATE] at 11:52 AM revealed she just had training on DNR and how to put in the code status into PCC. We also check the chart. It is important because it is the resident rights. -4 EVENING SHIFT NURSES -Interview with LVN G, on [DATE] at 11:39 AM, and I went in this am and had training. The training was how to find the code status of a resident. Why code status is important because it is their rights. We also were advised to check the chart. -Interview with LVN C, at 10:46 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN H on [DATE] at 11:45 AM, she stated she had code training on updating the code, and we check the orders. We check the paper chart. Respect wishes of resident. -Interview with LVN I at 11:36 AM on [DATE]. She stated she received training yesterday on DNR status and full code. We went over where to find the code status and how to change it in PCC. We would check the chart also. -2 NIGHT SHIFT NURSES -Interview with LVN J at 11:25 AM on [DATE]. Received training today at 08:00 a.m. [DATE]. The training was on DNR and code status, how to enter PCC properly. What the code status means. We were trained to also check the chart. The importance of code status indicates the resident's rights. -Interview with LVN B on [DATE] at 11:47 AM she stated she had code training on updating the code and we check the orders. We check the paper chart. It is important because it is their rights. -Interview with RN K on [DATE] at 11:58 AM revealed she had training on code status. Following the resident wishes. How to change in PCC. It is their rights. -Interview with RN L, at 11:06 AM on [DATE]. She received training on [DATE], of how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN M, at 11:11 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN A, at 10:58 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Phone interview with RN N at 9:40 AM on [DATE]. Received training on [DATE] on how to enter the code status, where to enter the code status and the importance11:36 of ensuring the code status is accurate. Interview on [DATE] at 1:32 PM, with the DON, she stated the auditing for the effectiveness of the Plan of Removal will begin on Monday [DATE]. Nurses will be randomly selected, and observed and evaluated with the post test, and this will continue for 4 weeks. Record Review of facilities incident response binder revealed the facility has implemented a procedure to make random observations with licensed nursing staff by DON for the next 4 weeks starting [DATE]. Post observation the Administrator will administer a posttest to ensure staff understand they understand the training. On [DATE] at 08:48 AM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to monitor the implementation and effectiveness of its plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide basic life support , including CPR, to a resident requiring such emergency care prior to the arrival of medical personnel and subject to related physician orders and the resident's advanced directives for 1(Resident #69) of 24 residents reviewed for advanced directives. The facility failed to provide emergency care subject to physician orders and the resident's advanced directives when Resident #69 was readmitted to the facility. On [DATE] at 09:30 AM Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes when he had an OOH DNR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:55 p.m. While the IJ was removed on [DATE] at 2:55 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. This facility failure placed residents at risk of not having their rights honored, to include pain, fractures, psychological and physical harm. The findings included: Record review of Resident #69's electronic face sheet dated [DATE] reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: diabetes mellitus (a disease of inadequate control of blood glucose levels), cognitive communication deficit (difficulty with thinking and how someone uses language), chronic kidney disease (when the kidneys have become damaged over time (for at least 3 months) and have a hard time doing all their functions), CVA (cerebral vascular accident or brain attack) and osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection. Resident #69's electronic face sheet reflected he had Full Code (desired CPR) status. Record review of Resident #69's significant change MDS assessment dated [DATE] reflected he scored a 12/15 on his BIMS which signified he was cognitively intact. He could usually understand others and could usually be understood. He required extensive assistance with his ADL's. Record review of Resident #1's comprehensive care plan revised on [DATE] reflected Focus, the resident/family are requesting DNR status, Goal, resident/family wishes will be honored through next review, Interventions/Tasks, Activate EMS as indicated, if transferred out of facility, notify receiving facility and EMS of DNR status, initiate CPR as indicated. Record review of Resident #69's readmission assessment dated [DATE] reflected resident desired to have DNR status under advanced directives. Record review of Resident #69's Order Details dated [DATE] reflected Admit to .under .Hospice, DX. CVA, Code Status: DNR. Record review of the facility shift change report dated [DATE] from the night shift nurse (LVN B) to the day shift nurse (LVN C) reflected ADMISSIONS: Resident #69 admitted at 01:00 AM to .Hospice, on pleasure feedings, regular diet, multiple breakdowns noted. No mention of Code Status. Record review of Resident #69's progress notes written by LVN E dated [DATE] at 10:45 AM, reflected Resident #69 was found unresponsive without a pulse. PCC checked and resident listed as Full Code status. Crash cart was brought into room, Resident #69 placed on the floor. CPR was initiated at 09:28 AM, no respirations, no pulse, no BP, pupils fixed and dilated, skin cool to touch, non-responsive, EMS arrived at 09:45 AM and took over CPR, artificial airway placed. CPR stopped at 09:53 AM after electronic DNR located and provided to EMT's. Pronounced at 09:59 AM via phone by MD for EMS Fire/EMS, and local police. Record review of Resident #69's progress notes dated [DATE] at 1:21 PM, reflected that during an interview with the local police, LVN A located an OOH DNR for Resident #69 under the miscellaneous tab in PCC. Record review of Resident #69's OOH DNR reflected it was signed and dated on [DATE], prior to his readmission to the facility. Interview on [DATE] at 10:46 AM with LVN C, she stated she and LVN A initiated the code for Resident #69. LVN C stated that LVN A found him, called for help, and came out of his room and they checked PCC and found Full Code status was noted on his electronic face sheet. LVN C stated she did not check his orders. LVN C stated the police and EMS was notified and they arrived within 5 minutes. LVN C stated she was trained on how to put a resident's code status and orders into PCC. LVN C stated she did not recall being told Resident #69 was admitted with DNR status from LVN B. LVN C stated it was important to honor a resident's wishes for advanced directives otherwise their rights would be violated. Interview on [DATE] at 10:58 AM with LVN A, she stated she found Resident #69 and called for help. LVN A stated she and LVN C checked his EMR and found he was full code status in PCC. LVN A stated she did not check his admission orders. LVN A stated when a police officer asked her about his medications, she looked under his miscellaneous tab in PCC and saw the OOH DNR. LVN A stated she felt bad when that happened and immediately took the OOH DNR to show to the EMT responders and they stopped CPR. LVN A stated Resident #69 was pronounced deceased by the MD. Interview on [DATE] at 11:44 AM with LVN B, she stated she was the nurse that did the admission assessment for Resident #69. LVN B stated she put his information into PCC, to include his code status, and she did not know why it was not reflected on Resident #69's face sheet because she felt like she did everything right. LVN B stated his code status was reflected in his admission orders and she communicated it to the night shift nurse LVN C. LVN B stated it was important for the resident's rights and advanced directive desires to be noted and communicated to the nursing staff because if he had a cardiac event, he did not want to be resuscitated. Interview on [DATE] at 12:00 PM with the DON, she stated she was called by LVN A, and she told her to check Resident #69's chart. The DON stated she did not realize that Resident #69 received a full course of CPR, and when she realized what had happened, she knew she needed to in-service the nurses on the PCC order entry process. The DON stated LVN B must have failed to discontinue the previous full code order, and this resulted in the change of code status not populating onto the face sheet. Interview on [DATE] at 12:15 PM with the Administrator, she stated she reported Resident #69's death as required under long term care death notifications for a death within 24 hours of transfer, however she did not realize the issue with Resident #69's advanced directives not being honored, or she would have reported it to HHSC right away. Record review of the facility policy and procedure titled Resident Rights (undated) reflected Purpose, to ensure the resident rights are respected and protected. Further review of the policy and procedure reflected, The resident has a right: To a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Record review of the facility pamphlet (undated) titled Treatment Choices reflected Code Status Policy. Purpose, to provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel. The Administrator was notified of an IJ on [DATE] at 5:55 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] at 2:55 p.m. and included the following: Alleged Failure #1 - Failed to properly input code status in the Point Click Care (PCC) Electronic Medical Record (EMAR) upon admission. Alleged Failure #2 - Failed to honor the rights of Resident # 1's wishes to die a dignified death by failing to honor a signed out of hospital do not resuscitate (DNR). Director of Nursing completed an audit of all resident code statuses on [DATE], 8:00pm, and all were found to be accurate. In-servicing/education provided in response (bullet point narrative): -Start/stop time and date: -On [DATE] at 6:30pm education began for Nurses (LVN and RN) staff in regards to properly complete Order Entry of code status in the PCC/EMAR of a resident. Nurses will reference PCC in the event of an emergency situation. -o Nurses that aren't present will be in-serviced by the DON before the start of their next regularly scheduled shift, utilizing a staff roster to ensure training and ensure a passing score on Post Test. -o The education/in-service of Order Entry of Code Status in a Resident PCC/EMAR will be included in the new hire process for all Nurses. oThe education will be completed by the DON -o All the education on this topic will be complete [DATE] by 10:00pm for Nurse staff present. oA 4 question post-test will be given to verify retention of knowledge related Order Entry of code status into resident PCC/EMAR. -Administrator will randomly issue post test regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. Record reviews of sampled residents #9, #14, #22, #23, #26, #33, #35, #36, #38, #43, #44 and #56 EMR's and face sheets reflected code status was accurate. Verification of the POR Record review of facilities incident response binder revealed the facility completed the in-service with nursing staff on topics where to find the resident's code, how to enter resident's code status for new admissions and status changes, the purpose of code status, and resident's rights-choosing their code status. -Record review of facilities incident response binder revealed the facility conducted a post test for each nursing staff that received the in-service. Facility has documented 100% of their nursing (all 19 nurses) staff have completed the posttest and received a 100% on the post test. Interview on [DATE] at 1:05 p.m. with the DON revealed she in-serviced 100% (all 19 nurses) staff were on [DATE] after 6 PM and the remainder were in serviced on [DATE]. OUT OF 19 TOTAL NURSES-16 WERE INTERVIEWED FOR VERIFICATION (84%) Phone interview with RN N at 9:40 AM on [DATE]. She stated she received training on [DATE] on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Administrator will randomly issue posttest regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -5 DAY SHIFT NURSES -Interview with LVN D on [DATE] at 12:21 p.m. revealed she had training on code status, how to put in the code status and to respect their rights. -Interview with the DON, RN at 9:51 AM on [DATE]. RN conducted the training with all nursing staff. RN started training on [DATE] and completed training on [DATE]. RN had all staff complete a posttest to ensure they understood the in-service. -Interview with MDS Nurse at 10:42 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN E ADON, at 11:02 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN F on [DATE] at 11:52 AM revealed she just had training on DNR and how to put in the code status into PCC. We also check the chart. It is important because it is the resident rights. -4 EVENING SHIFT NURSES -Interview with LVN G, on [DATE] at 11:39 AM, and I went in this am and had training. The training was how to find the code status of a resident. Why code status is important because it is their rights. We also were advised to check the chart. -Interview with LVN C, at 10:46 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN H on [DATE] at 11:45 AM, she stated she had code training on updating the code, and we check the orders. We check the paper chart. Respect wishes of resident. -Interview with LVN I at 11:36 AM on [DATE]. She stated she received training yesterday on DNR status and full code. We went over where to find the code status and how to change it in PCC. We would check the chart also. -2 NIGHT SHIFT NURSES -Interview with LVN J at 11:25 AM on [DATE]. Received training today at 08:00 a.m. [DATE]. The training was on DNR and code status, how to enter PCC properly. What the code status means. We were trained to also check the chart. The importance of code status indicates the resident's rights. -Interview with LVN B on [DATE] at 11:47 AM she stated she had code training on updating the code and we check the orders. We check the paper chart. It is important because it is their rights. -Interview with RN K on [DATE] at 11:58 AM revealed she had training on code status. Following the resident wishes. How to change in PCC. It is their rights. -Interview with RN L, at 11:06 AM on [DATE]. She received training on [DATE], of how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN M, at 11:11 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN A, at 10:58 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Phone interview with RN N at 9:40 AM on [DATE]. Received training on [DATE] on how to enter the code status, where to enter the code status and the importance11:36 of ensuring the code status is accurate. Interview on [DATE] at 1:32 PM, with the DON, she stated the auditing for the effectiveness of the Plan of Removal will begin on Monday [DATE]. Nurses will be randomly selected, and observed and evaluated with the post test, and this will continue for 4 weeks. Record Review of facilities incident response binder revealed the facility has implemented a procedure to make random observations with licensed nursing staff by DON for the next 4 weeks starting [DATE]. Post observation the Administrator will administer a posttest to ensure staff understand they understand the training. On [DATE] at 08:48 AM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to monitor the implementation and effectiveness of its plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to immediately inform the physician of a significant change of condition to a resident's physical status for 1 of 8 residents (Resident#1) reviewed for change in condition in that: The facility failed to implement their process for ongoing monitoring of residents on oxygen and notify the physician when Resident #1's O2 saturations remained at 81% on oxygen. This change of condition resulted in Resident #1 expiring. This failure resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 12:18 p.m. The IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as an isolated pattern until the facility has completed all in-service and monitoring interventions. This deficient practice place residents with a change in condition at-risk for harm and quality of life. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] and diagnoses that included: morbid (severe) obesity due to excess calories, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen. Record review of Resident #1's Care Plan (start date of [DATE]) for risk of shortness of breath, respiratory distress, and increased anxiety due to a diagnosis of chronic obstructive pulmonary disease revealed interventions which included Resident #1 was known to be non-compliant with wearing oxygen at times and Observe for SOB (shortness of breath), respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD (doctor of medicine) if interventions are not effective. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a Brief Interview for Mental Status (MDS) score of 11, which indicated the resident had moderate cognitive impairment, and the resident required supervision of one staff member physical assistance with transfers, dressing, and hygiene. Review of Resident #1's Clinical Physician Orders, dated [DATE] revealed the resident had order for oxygen at 2-4 liters per minute via nasal cannula as needed to keep O2 saturations above 92%, with a start date of [DATE]. There was another order with a start date of [DATE] to monitor O2 saturations every shift for shortness of breath. Record review of Resident #1's oxygen saturations (O2) for September and [DATE] revealed they ranged between 90-97% on room air or oxygen via nasal cannula. On [DATE] the resident's O2 was at 78% on room air, on [DATE] the resident's O2 was at 88% on room air, on [DATE] the resident's O2 was at 89% on room air, on [DATE] the resident's O2 was at 88% on c-pap, and on [DATE] the resident was at 87% on room air. Additional O2 saturations for Resident #1 during the month of November and [DATE] was 90-97%. Record review of Nurse Practitioner's (NP) progress note, dated [DATE], revealed the resident was wheezing on exam, denied any cough, chest pain or shortness of breath, and continued to be a daily smoker. The progress note revealed the NP ordered chest x-ray, 2 views. Record review of a nurses' progress note dated [DATE] at 10:02 p.m. revealed Resident #1's chest x-ray showed prominent intestinal lung markings which may be due to pulmonary edema or atypical pneumonitis and the physician ordered Prednisone (a steroid used to treat conditions especially associated with inflammation) 40 mg by mouth 2 times a day for 5 days for shortness of breath and abnormal chest x-ray. Review of a nurses' progress note, dated [DATE] at 11:12 p.m., revealed Resident #1's oxygen saturations were at 92% on 2 liters via nasal cannula. Record review of nurses' progress note, dated [DATE] at 5:50 a.m. by LVN A, revealed at 5:20 a.m. she entered resident #1's room to reposition the resident with LVN B's assistance and reapplied her oxygen at 2 liters per nasal cannula for chronic COPD. The nurse further reported she returned to the resident's room at 5:42 a.m. and checked Resident #1's O2 saturations which was at 81%. The nurse documented she left the resident's room to allow privacy while CNA C provided peri-care and that, There were only two nurses and two CNAs in the building this nurse stayed on the floor to continue monitoring the other residents. Record review of nurses' progress note, dated [DATE] at 6:27 a.m. by LVN A, revealed Resident #1 was lying with her neck pressed against the bed. Her face was turning blue and this nurse and the other nurse on duty were able to convince the resident to wear her oxygen and lay with her head sitting up. Review of a nurses' progress note, dated [DATE] at 1:17 p.m. by LVN D, revealed around 7:25-7:30 a.m. the LVN went to check Resident #1's blood sugar and found the resident on her right side, the resident's face noted blueish and when she shook the resident, there was no response, and the resident was not breathing. LVN D called for assistance, Cardiopulmonary resuscitation (CPR) was started, and 911 was called. The LVN documented the automated external defibrillator (AED) pads were placed on the resident's chest and the AED advised no shock. The facility continued CPR until EMS arrived and EMS personnel took over. LVN D documented the resident passed at 8:34 a.m. Record review of Resident #1's Provider Investigative Report, dated [DATE], revealed the resident was found by LVN A at 5:21 a.m. laying on her side with blue lips, pallor, oxygen was off. The LVN requested assistance from LVN B to reposition the resident. The report revealed Resident#1 was somewhat responsive and after she was repositioned up right and oxygen was applied at 2 liters per nasal cannula the resident was responsive and alert. LVN A encouraged the resident to do deep breathing exercises and then left the room. LVN A returned to the resident's room at 5:42 a.m. to assist CNA C with peri-care and at that time LVN A checked Resident #1's oxygen saturations and it was at 81% on two liters per nasal cannula. The nurse indicated she would continue to monitor and left the room. LVN D came on duty for the following shift. LVN D had gone into Resident #1's room at approximately 8:00 a.m. and found the resident unresponsive, not breathing and her oxygen was laying on the floor. CPR was initiated by LVN D, EMS was called, and they continued CPR, however Resident #1 expired at 8:34 a.m. Review of LVN A's progress note dated [DATE] at 5:50 a.m. revealed the LVN applied Resident #1's oxygen at 2 liters per nasal cannula after the resident was sat upright. The LVN documented the resident was non-compliant with her oxygen and her c-pap. The LVN reported she left the room but returned at 5:42 a.m. and checked the resident's O2 saturations and the resident was stating at 81%. LVN A told the resident to take deep breaths and left the room. The LVN documented there were only 2 nurses and 2 CNAs, and she would stay on the floor to continue monitoring the other residents. Review of LVN A's progress note, dated [DATE] at 6:27 a.m., revealed when the LVN had found the resident in bed without oxygen, and the resident's face was turning blue. Review of LVN D's progress note dated[DATE] at 1:17 p.m. revealed when she entered Resident #1's room around 7:25-7:30 a.m. The resident was laying on her side and her face was bluish. The LVN shook the resident, but there was no response, and the resident was not breathing. The LVN called for assistance from other staff began CPR and 911 was called. EMS continued CPR after they arrived on the scene, but the resident was pronounced dead at 8:34 a.m. Review of Resident #1's Record of Death, located in the resident's medical record confirmed the resident passed away on [DATE] at 8:34 a.m. Review of a written statement by CNA D (undated) revealed Resident #1 refused peri-care so she contacted LVN A. The nurse was able to convince the resident to allow the CNA to change her. The CNA's statement revealed the resident was awake and talking the entire time the CNA was in the room and the resident thanked the CNA afterwards. Review of a written statement by CNA E (undated) revealed she went into Resident #1's room at 6:56 a.m. and found the resident sleeping on her side, facing the window and in no distress. During an interview on [DATE] at 9:59 a.m., the Administrator reported Resident #1 had an order to use oxygen and had a history on non-compliance with the oxygen. The Administrator also reported LVN A did not pass on Resident #1's condition during the overnight shift to the oncoming shift, LVN D, on the morning the resident passed away. An interview on [DATE] at 10:58 a.m. with LVN A revealed she had verbally told the oncoming shift LVN, LVN D, about Resident #1's condition during the overnight shift, including that she had found the resident without her oxygen off and she was turning blue. LVN A revealed staff had to frequently reposition Resident #1 to sit up and replace her oxygen, and that the night before the resident passed, was not the first time the LVN found the resident without her oxygen and having some blue color to her and around her lips. LVN A stated when she reported to the oncoming staff how she had found the resident without her oxygen and turning blue, They all agreed this was the resident's normal condition. The LVN reported when they gave report, they wrote some things down but the report she gave to LVN D was mostly verbal because they did not see Resident #1's condition as a change in condition since this was the usual habits of the resident. The LVN reported she was aware Resident #1 recently had an abnormal x-ray of her chest and was started on new medication. LVN A revealed, again, that she and the on-coming nurse, LVN D, did not think anything unusual about what had happened the evening before the resident passed, because that was the resident's usual condition. An interview on [DATE] at 11:07 a.m. with LVN B revealed she worked the overnight shift with LVN A and assisted LVN A with repositioning Resident #1. LVN B reported when she entered the room to assist LVN A to reposition Resident #1 she noted the resident was blue ashen (paleness or gray tint) in color. The LVN stated the resident was initially resistive to rolling over on her back but eventually agreed and they were able to sit her up and place her O2 on that she had removed. The LVN stated when the O2 was placed she noted the resident cognition improved. LVN B stated the resident frequently lay on her side, removed her oxygen, and refused to wear her c-pap. The LVN stated Resident #1 was gaining her color back and responding the last time she saw her. LVN B stated she had never seen Resident #1 with the blue ashen color she was the night before she passed. LVN B stated typically in situations such as this, the LVN would notify her supervisors and the resident's physician about the resident's condition. LVN B stated she thought LVN A had notified Resident #1's physician. The LVN stated the resident frequently removed her oxygen and they kept an eye on her during the overnight shift. LVN B stated they were short of staff that evening but did not think that had anything to do with what was going on with Resident #1. During an interview on [DATE] at 11:36 a.m., LVN D reported when she came on duty on the morning of [DATE], she received report from off-going nurse, LVN A. LVN D reported LVN A stated during the overnight shift, she had found Resident #1 without her oxygen and her face turning blue and LVN A had repositioned her, applied her oxygen and that the resident was doing good. LVN D stated she had never seen Resident #1's face turned blue as LVN A described. LVN D stated she did not check on Resident #1 immediately, because LVN A stated the resident was doing good. LVN D stated the CNAs were on the floor and no CNAs reported any concerns. LVN D stated when she entered Resident #1's room, she found the resident laying on her side, she was blue without her oxygen or c-pap on. The LVN stated Resident #1 removed her oxygen and c-pap. LVN D stated when she entered the resident's room to check her blood sugar level, the resident's face was discolored so she shook her, and the resident did not respond. LVN D stated she called for help from the other staff, and they began CPR and EMS was called. The LVN stated she was not aware Resident #1 had started new medication related to a chest x-ray. LVN D reported LVN A acted as if it was not an emergency and stated Resident #1 was good to go and never in any distress. LVN D stated anyone with their saturations in their 80's, she would place oxygen on the resident, call the primary care physician, and send the resident out to the hospital. An interview on [DATE] at 12:02 p.m. with the DON revealed when a resident had oxygen saturations that were low, staff were instructed to place the oxygen on the resident to get them stabilized with oxygen saturations above 90%. The DON went on to say if the resident's saturations did not increase then the staff should call 911. The DON reported the resident had COPD, was obstinate about taking her O2 off and the resident always had an ill appearance. The DON stated it was hard to say if ashen color meant the resident was in distress because everyone was different, but blue around the lips was concerning and should have been reported to the physician. The DON reported during the overnight shift prior to Resident 1's passing, they were short on nurses' aides but not on nurses. The DON reported she had never had any previous complaints about LVN A. An interview on [DATE] at 2:07 p.m. with CNA E revealed when she came on duty on the morning Resident #1 passed, no one had shared information with her about the resident's condition during the overnight shift. The CNA revealed she had wished the facility shared information about the resident's during the change of shift because she did not know who fell or any other changes during the previous shift. CNA E stated when she checked on Resident #1 around 7:00 a.m. that morning the resident was lying on her side facing the window and thought she was asleep. The CNA revealed she did not see the resident's face, could not confirm if the resident was wearing her oxygen and could not confirm if the resident was still alive and breathing. During an interview on [DATE] at 12:12 p.m. with the Medical Director, she revealed, typically, she was notified when a resident's O2 saturations was less than 91% but the physician was available anytime a nurse had concerns about a resident's condition. When questioned what may have contributed to Resident #1's passing, the Medical Director stated she could not confirm anything at that time as she had not had a chance to review all of Resident #1's medical record. Review of the Order Listing Report, dated [DATE], revealed there were 29 residents with orders for oxygen. Review of the facility policy, Notification to Physician, Family and Others, not dated, revealed, The facility will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative and document in the resident's medical record were applicable, when there is: A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) The Administrator was notified of an IJ on [DATE] at 12:18 p.m. and was given a copy of the IJ Template and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 7:16 p.m. and included the following: Plan of Removal [DATE] Immediate Action #1 - Medical Director was notified on [DATE] at 12:19 p.m. about the incidents surrounding the passing of Resident #1 and the facility response was discussed. - LVN A was terminated [DATE]. - on [DATE] at 1:30 p.m. education began for all LVNs and CNAs in-regards to completing walking rounds and/or bedside rounds at shift change. - LVNs and CNAs not already in-serviced would be in-serviced before the start of their next regularly scheduled shift. - These in-services would be included in the new hire process for LVNs and CNAs. - A post-test would be given to verify retention of knowledge related to walking rounds. - All education on this topic would be completed on [DATE] by 3:00 p.m. for LVNs and CNAs present. Monitoring: - At shift change LVNs and CNAs would sign off on 24-hour report acknowledging they received information regarding each resident on their assignment. - The signed-off 24-hour report would be reviewed by the Director of Nursing or Administrator for 4 weeks until compliance had been achieved. - The Administrator would randomly view video footage and/or be present during shift change 5 times a week to assure walking rounds were completed for 4 weeks until compliance had been achieved and maintained. Immediate Action #2 - On [DATE] at 1:30 p.m. education for LVNs and CNAs began in-regards to notifying the physician/Medical Director for a significant change in a resident's condition and nursing best practice of when to follow up on vital signs out of parameters. - LVNs and CNAs that were not already in-serviced would be in-serviced before the start of their next regular shift. - These in-services would be included in the new hire process for LVNs and CNAs. - A post-test would be given to verify retention of knowledge related to notification of the physician for a significant change in the resident and follow up for vital signs out of parameters. - All the education on this topic would be completed on [DATE] by 3:00 p.m. for LVNs and CNAs. Monitoring: - Director of Nursing would review 10% of resident charts weekly for all significant events for physician notification and would be documented on monitoring log. - Monitoring would continue for 4 weeks until compliance had been achieved and maintained. Verification of the Plan of Removal was as follows: a. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on when to report to the physician for notification of changes of a resident. b. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on nurse-to-nurse-reporting and walking rounds at exchange of shift to assure communication of issues related to care of the residents from previous shift and to always ensure continuity of care. c. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on vital signs and best practice for follow up for vital signs out of parameters. d. Review of the post-tests for 52 nursing staff members, with 3 post tests given to each staff member related to their in-services on notification of physicians, walking rounds at change of shift and vital sign/O2 parameters revealed they had written understanding and knowledge of the in-service teachings. e. Review of the Nurse walking rounds Sign Off Sheet revealed the charge nurses and CNAs were completing rounds with the on-coming shifts on [DATE], [DATE], and [DATE] and the sheets were reviewed and signed by the Administrator. f. Review of the Chart Review Log for week 1 for dates of [DATE]-[DATE], revealed 10 resident charts would be reviewed each week by administrative nursing. g. Review of the Random Video History Review revealed random observations of shift change both in person and viewed on video would be conducted 5 times a week for 4 weeks. h. Observation on [DATE] at shift 2-10 shift change revealed off-going staff were exchanging information on the residents' condition to on-coming staff. i. In an interview between [DATE] at 8:54 a.m. to [DATE] at 10:12 a.m. 2 nurses (LVN F and LVN G) from 6-2 shift, 2 nurses (LVN H and LVN I) from 2-10 shift, 2 nurses (LVN B and LVN J) from 10-6 shift, 3 medication aides (MA K, MA L, and MA M) from 6-2 and 2-10 shifts, 2 CNAs (CNA E and CNA N) from 6-2 shift, 2 CNAs (CNA O and CNA P) from 2-10 shift, 4 CNAs (CNA Q, CNA R, CNA S, and CNA T) from 10-6 shift, 1 prn (as needed) CNA (U) , 1 CNA/van driver (CNA V) 3 administrative staff/LVN (HR W, LVN X, LVN Y) and 3 agency CNA's (CNA Z), CNA AA, and CNA BB) were interviewed (with a total of 25 nursing staff interviewed) regarding the in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of the in-services provided. j. During an interview with the Administrator on [DATE] at 7:56 a.m. the Administrator confirmed the new logging and tracking were being implemented this date. k. During an interview on [DATE] with the Administrator she confirmed the new logging and tracking worksheets for Chart Review and Random Video History Review were being implemented this date. The Administrator reported she had been able to visually monitor staff shift change with exchange of resident information since the incident occurred on [DATE]. l. During an interview on [DATE] at 7:56 a.m. the Administrator reported she believed the incident occurred because LVN A had lack of experience with only 3 years as a nurse. The Administrator reported the LVN had worked only the overnight shift. The Administrator revealed the facility required anybody working the overnight shift had to work the day shift a couple of days first so they could get the training needed. The Administrator reported LVN A had worked for the facility before, left and came back and the Administrator did not think LVN A did the day training when she returned because she had worked at the facility before. The Administrator reported any new nurse hired was shadowed by an experienced nurse for 3 days and if they still felt the nurse was not ready then they would continue training. The Administrator revealed they were starting new training program next week with all the nurses, to include general nurses training, change of condition and a Nurse Educator Toolkit that was provided by Texas Health and Human Services. The Administrator revealed as far as what they could have done different to prevent the incident was to implement nurse training and one-on-one with instructors. The Administrator reported because they did not recognize LVN A's weaknesses and her level of critical thinking skills they were at fault as well. While the IJ was removed on [DATE] the facility remained out of compliance at a level of actual harm with a scope identified as isolated until all staff was in-serviced and showed proficiency on vital sign parameters, notification of physician and change of condition, walking rounds through monitoring of change of shift observations and chart reviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement respiratory care services to prevent residents from respiratory failure for 1 of 8 residents (Residents #1) whose care was reviewed for quality of care, in that: The facility failed to have structures in place to ensure Resident #1 received oxygen to maintain O2 saturations at 92% as per physician orders. This change of condition resulted in Resident #1 expiring. This failure resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 12:18 pm. The IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as an isolated pattern until the facility has completed all in-service and monitoring interventions. This deficient practice place residents requiring oxygen at-risk for harm and quality of life. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] and diagnoses that included: morbid (severe) obesity due to excess calories, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen. Record review of Resident #1's Care Plan (start date of [DATE]) for risk of shortness of breath, respiratory distress, and increased anxiety due to a diagnosis of chronic obstructive pulmonary disease revealed interventions which included Resident #1 was known to be non-compliant with wearing oxygen at times and Observe for SOB (shortness of breath), respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD (doctor of medicine) if interventions are not effective. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a Brief Interview for Mental Status (MDS) score of 11, which indicated the resident had moderate cognitive impairment, and the resident required supervision of one staff member physical assistance with transfers, dressing, and hygiene. Review of Resident #1's Clinical Physician Orders, dated [DATE] revealed the resident had order for oxygen at 2-4 liters per minute via nasal cannula as needed to keep O2 saturations above 92%, with a start date of [DATE]. There was another order with a start date of [DATE] to monitor O2 saturations every shift for shortness of breath. Record review of Resident #1's oxygen saturations (O2) for September and [DATE] revealed they ranged between 90-97% on room air or oxygen via nasal cannula. On [DATE] the resident's O2 was at 78% on room air, on [DATE] the resident's O2 was at 88% on room air, on [DATE] the resident's O2 was at 89% on room air, on [DATE] the resident's O2 was at 88% on c-pap, and on [DATE] the resident was at 87% on room air. Additional O2 saturations for Resident #1 during the month of November and [DATE] was 90-97%. Record review of Nurse Practitioner's (NP) progress note, dated [DATE], revealed the resident was wheezing on exam, denied any cough, chest pain or shortness of breath, and continued to be a daily smoker. The progress note revealed the NP ordered chest x-ray, 2 views. Record review of a nurses' progress note dated [DATE] at 10:02 p.m. revealed Resident #1's chest x-ray showed prominent intestinal lung markings which may be due to pulmonary edema or atypical pneumonitis and the physician ordered Prednisone (a steroid used to treat conditions especially associated with inflammation) 40 mg by mouth 2 times a day for 5 days for shortness of breath and abnormal chest x-ray. Review of a nurses' progress note, dated [DATE] at 11:12 p.m., revealed Resident #1's oxygen saturations were at 92% on 2 liters via nasal cannula. Record review of nurses' progress note, dated [DATE] at 5:50 a.m. by LVN A, revealed at 5:20 a.m. she entered resident #1's room to reposition the resident with LVN B's assistance and reapplied her oxygen at 2 liters per nasal cannula for chronic COPD. The nurse further reported she returned to the resident's room at 5:42 a.m. and checked Resident #1's O2 saturations which was at 81%. The nurse documented she left the resident's room to allow privacy while CNA C provided peri-care and that, There were only two nurses and two CNAs in the building this nurse stayed on the floor to continue monitoring the other residents. Record review of nurses' progress note, dated [DATE] at 6:27 a.m. by LVN A, revealed Resident #1 was lying with her neck pressed against the bed. Her face was turning blue and this nurse and the other nurse on duty were able to convince the resident to wear her oxygen and lay with her head sitting up. Review of a nurses' progress note, dated [DATE] at 1:17 p.m. by LVN D, revealed around 7:25-7:30 a.m. the LVN went to check Resident #1's blood sugar and found the resident on her right side, the resident's face noted blueish and when she shook the resident, there was no response, and the resident was not breathing. LVN D called for assistance, Cardiopulmonary resuscitation (CPR) was started, and 911 was called. The LVN documented the automated external defibrillator (AED) pads were placed on the resident's chest and the AED advised no shock. The facility continued CPR until EMS arrived and EMS personnel took over. LVN D documented the resident passed at 8:34 a.m. Record review of Resident #1's Provider Investigative Report, dated [DATE], revealed the resident was found by LVN A at 5:21 a.m. laying on her side with blue lips, pallor, oxygen was off. The LVN requested assistance from LVN B to reposition the resident. The report revealed Resident#1 was somewhat responsive and after she was repositioned up right and oxygen was applied at 2 liters per nasal cannula the resident was responsive and alert. LVN A encouraged the resident to do deep breathing exercises and then left the room. LVN A returned to the resident's room at 5:42 a.m. to assist CNA C with peri-care and at that time LVN A checked Resident #1's oxygen saturations and it was at 81% on two liters per nasal cannula. The nurse indicated she would continue to monitor and left the room. LVN D came on duty for the following shift. LVN D had gone into Resident #1's room at approximately 8:00 a.m. and found the resident unresponsive, not breathing and her oxygen was laying on the floor. CPR was initiated by LVN D, EMS was called, and they continued CPR, however Resident #1 expired at 8:34 a.m. Review of LVN A's progress note dated [DATE] at 5:50 a.m. revealed the LVN applied Resident #1's oxygen at 2 liters per nasal cannula after the resident was sat upright. The LVN documented the resident was non-compliant with her oxygen and her c-pap. The LVN reported she left the room but returned at 5:42 a.m. and checked the resident's O2 saturations and the resident was stating at 81%. LVN A told the resident to take deep breaths and left the room. The LVN documented there were only 2 nurses and 2 CNAs, and she would stay on the floor to continue monitoring the other residents. Review of LVN A's progress note, dated [DATE] at 6:27 a.m., revealed when the LVN had found the resident in bed without oxygen, and the resident's face was turning blue. Review of LVN D's progress note dated[DATE] at 1:17 p.m. revealed when she entered Resident #1's room around 7:25-7:30 a.m. The resident was laying on her side and her face was bluish. The LVN shook the resident, but there was no response, and the resident was not breathing. The LVN called for assistance from other staff began CPR and 911 was called. EMS continued CPR after they arrived on the scene, but the resident was pronounced dead at 8:34 a.m. Review of Resident #1's Record of Death, located in the resident's medical record confirmed the resident passed away on [DATE] at 8:34 a.m. Review of a written statement by CNA D (undated) revealed Resident #1 refused peri-care so she contacted LVN A. The nurse was able to convince the resident to allow the CNA to change her. The CNA's statement revealed the resident was awake and talking the entire time the CNA was in the room and the resident thanked the CNA afterwards. Review of a written statement by CNA E (undated) revealed she went into Resident #1's room at 6:56 a.m. and found the resident sleeping on her side, facing the window and in no distress. During an interview on [DATE] at 9:59 a.m., the Administrator reported Resident #1 had an order to use oxygen and had a history on non-compliance with the oxygen. The Administrator also reported LVN A did not pass on Resident #1's condition during the overnight shift to the oncoming shift, LVN D, on the morning the resident passed away. An interview on [DATE] at 10:58 a.m. with LVN A revealed she had verbally told the oncoming shift LVN, LVN D, about Resident #1's condition during the overnight shift, including that she had found the resident without her oxygen off and she was turning blue. LVN A revealed staff had to frequently reposition Resident #1 to sit up and replace her oxygen, and that the night before the resident passed, was not the first time the LVN found the resident without her oxygen and having some blue color to her and around her lips. LVN A stated when she reported to the oncoming staff how she had found the resident without her oxygen and turning blue, They all agreed this was the resident's normal condition. The LVN reported when they gave report, they wrote some things down but the report she gave to LVN D was mostly verbal because they did not see Resident #1's condition as a change in condition since this was the usual habits of the resident. The LVN reported she was aware Resident #1 recently had an abnormal x-ray of her chest and was started on new medication. LVN A revealed, again, that she and the on-coming nurse, LVN D, did not think anything unusual about what had happened the evening before the resident passed, because that was the resident's usual condition. An interview on [DATE] at 11:07 a.m. with LVN B revealed she worked the overnight shift with LVN A and assisted LVN A with repositioning Resident #1. LVN B reported when she entered the room to assist LVN A to reposition Resident #1 she noted the resident was blue ashen (paleness or gray tint) in color. The LVN stated the resident was initially resistive to rolling over on her back but eventually agreed and they were able to sit her up and place her O2 on that she had removed. The LVN stated when the O2 was placed she noted the resident cognition improved. LVN B stated the resident frequently lay on her side, removed her oxygen, and refused to wear her c-pap. The LVN stated Resident #1 was gaining her color back and responding the last time she saw her. LVN B stated she had never seen Resident #1 with the blue ashen color she was the night before she passed. LVN B stated typically in situations such as this, the LVN would notify her supervisors and the resident's physician about the resident's condition. LVN B stated she thought LVN A had notified Resident #1's physician. The LVN stated the resident frequently removed her oxygen and they kept an eye on her during the overnight shift. LVN B stated they were short of staff that evening but did not think that had anything to do with what was going on with Resident #1. During an interview on [DATE] at 11:36 a.m., LVN D reported when she came on duty on the morning of [DATE], she received report from off-going nurse, LVN A. LVN D reported LVN A stated during the overnight shift, she had found Resident #1 without her oxygen and her face turning blue and LVN A had repositioned her, applied her oxygen and that the resident was doing good. LVN D stated she had never seen Resident #1's face turned blue as LVN A described. LVN D stated she did not check on Resident #1 immediately, because LVN A stated the resident was doing good. LVN D stated the CNAs were on the floor and no CNAs reported any concerns. LVN D stated when she entered Resident #1's room, she found the resident laying on her side, she was blue without her oxygen or c-pap on. The LVN stated Resident #1 removed her oxygen and c-pap. LVN D stated when she entered the resident's room to check her blood sugar level, the resident's face was discolored so she shook her, and the resident did not respond. LVN D stated she called for help from the other staff, and they began CPR and EMS was called. The LVN stated she was not aware Resident #1 had started new medication related to a chest x-ray. LVN D reported LVN A acted as if it was not an emergency and stated Resident #1 was good to go and never in any distress. LVN D stated anyone with their saturations in their 80's, she would place oxygen on the resident, call the primary care physician, and send the resident out to the hospital. An interview on [DATE] at 12:02 p.m. with the DON revealed when a resident had oxygen saturations that were low, staff were instructed to place the oxygen on the resident to get them stabilized with oxygen saturations above 90%. The DON went on to say if the resident's saturations did not increase then the staff should call 911. The DON reported the resident had COPD, was obstinate about taking her O2 off and the resident always had an ill appearance. The DON stated it was hard to say if ashen color meant the resident was in distress because everyone was different, but blue around the lips was concerning and should have been reported to the physician. The DON reported during the overnight shift prior to Resident 1's passing, they were short on nurses' aides but not on nurses. The DON reported she had never had any previous complaints about LVN A. An interview on [DATE] at 2:07 p.m. with CNA E revealed when she came on duty on the morning Resident #1 passed, no one had shared information with her about the resident's condition during the overnight shift. The CNA revealed she had wished the facility shared information about the resident's during the change of shift because she did not know who fell or any other changes during the previous shift. CNA E stated when she checked on Resident #1 around 7:00 a.m. that morning the resident was lying on her side facing the window and thought she was asleep. The CNA revealed she did not see the resident's face, could not confirm if the resident was wearing her oxygen and could not confirm if the resident was still alive and breathing. During an interview on [DATE] at 12:12 p.m. with the Medical Director, she revealed, typically, she was notified when a resident's O2 saturations was less than 91% but the physician was available anytime a nurse had concerns about a resident's condition. When questioned what may have contributed to Resident #1's passing, the Medical Director stated she could not confirm anything at that time as she had not had a chance to review all of Resident #1's medical record. Review of the Order Listing Report, dated [DATE], revealed there were 29 residents with orders for oxygen. Record review of HHF Safety-Communication with the Physician: Parameters dated [DATE] and provided by the facility revealed, under the heading, Considerations, staff should alert the physician if O2 Saturations are less than 92% and 5. Clinicians are always expected to adhere to professional practice standards and to use sound clinical judgement in assessing patients and making determinations of need to contact the physician. Review under the heading, Procedure, revealed f. Compare patient's measurements against normal parameters and g. If parameters are outside normal parameters (or agency's parameter policy), notify the physician. The Administrator was notified of an IJ on [DATE] at 12:18 p.m. and was given a copy of the IJ Template and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 7:16 p.m. and included the following: Plan of Removal [DATE] Immediate Action #1 - Medical Director was notified on [DATE] at 12:19 p.m. about the incidents surrounding the passing of Resident #1 and the facility response was discussed. - LVN A was terminated [DATE]. - on [DATE] at 1:30 p.m. education began for all LVNs and CNAs in-regards to completing walking rounds and/or bedside rounds at shift change. - LVNs and CNAs not already in-serviced would be in-serviced before the start of their next regularly scheduled shift. - These in-services would be included in the new hire process for LVNs and CNAs. - A post-test would be given to verify retention of knowledge related to walking rounds. - All education on this topic would be completed on [DATE] by 3:00 p.m. for LVNs and CNAs present. Monitoring: - At shift change LVNs and CNAs would sign off on 24-hour report acknowledging they received information regarding each resident on their assignment. - The signed-off 24-hour report would be reviewed by the Director of Nursing or Administrator for 4 weeks until compliance had been achieved. - The Administrator would randomly view video footage and/or be present during shift change 5 times a week to assure walking rounds were completed for 4 weeks until compliance had been achieved and maintained. Immediate Action #2 - On [DATE] at 1:30 p.m. education for LVNs and CNAs began in-regards to when to follow up on vital signs out of parameters. - LVNs and CNAs that were not already in-serviced would be in-serviced before the start of their next regular shift. - These in-services would be included in the new hire process for LVNs and CNAs. - A post-test would be given to verify retention of knowledge related to follow up for vital signs out of parameters. - All the education on this topic would be completed on [DATE] by 3:00 p.m. for LVNs and CNAs. Monitoring: - Director of Nursing would review 10% of resident charts weekly for all significant events for physician notification and would be documented on monitoring log. - Monitoring would continue for 4 weeks until compliance had been achieved and maintained. Verification of the Plan of Removal was as follows: a. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on nurse-to-nurse-reporting and walking rounds at exchange of shift to assure communication of issues related to care of the residents from previous shift and to always ensure continuity of care. b. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on vital signs, oxygen parameters, and best practice for follow up for vital signs out of parameters. c. Review of the post-tests for 52 nursing staff members, with 3 post tests given to each staff member related to walking rounds at change of shift and vital sign/O2 parameters revealed they had written understanding and knowledge of the in-service teachings. d. Review of the Nurse walking rounds Sign Off Sheet revealed the charge nurses and CNAs were completing rounds with the on-coming shifts on [DATE], [DATE], and [DATE] and the sheets were reviewed and signed by the Administrator. e. Review of the Chart Review Log for week 1 for dates of [DATE]-[DATE], revealed 10 resident charts would be reviewed each week by administrative nursing. f. Review of the Random Video History Review revealed random observations of shift change both in person and viewed on video would be conducted 5 times a week for 4 weeks. g. Observation on [DATE] at shift 2-10 shift change revealed off-going staff were exchanging information on the residents' condition to on-coming staff. h. In an interview between [DATE] at 8:54 a.m. to [DATE] at 10:12 a.m. 2 nurses (LVN F and LVN G) from 6-2 shift, 2 nurses (LVN H and LVN I) from 2-10 shift, 2 nurses (LVN B and LVN J) from 10-6 shift, 3 medication aides (MA K, MA L, and MA M) from 6-2 and 2-10 shifts, 2 CNAs (CNA E and CNA N) from 6-2 shift, 2 CNAs (CNA O and CNA P) from 2-10 shift, 4 CNAs (CNA Q, CNA R, CNA S, and CNA T) from 10-6 shift, 1 prn (as needed) CNA (U) , 1 CNA/van driver (CNA V) 3 administrative staff/LVN (HR W, LVN X, LVN Y) and 3 agency CNA's (CNA Z), CNA AA, and CNA BB) were interviewed (with a total of 25 nursing staff interviewed) regarding the in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of the in-services provided. i. During an interview with the Administrator on [DATE] at 7:56 a.m. the Administrator confirmed the new logging and tracking were being implemented this date. j. During an interview on [DATE] with the Administrator she confirmed the new logging and tracking worksheets for Chart Review and Random Video History Review were being implemented this date. The Administrator reported she had been able to visually monitor staff shift change with exchange of resident information since the incident occurred on [DATE]. k. During an interview on [DATE] at 7:56 a.m. the Administrator reported she believed the incident occurred because LVN A had lack of experience with only 3 years as a nurse. The Administrator reported the LVN had worked only the overnight shift. The Administrator revealed the facility required anybody working the overnight shift had to work the day shift a couple of days first so they could get the training needed. The Administrator reported LVN A had worked for the facility before, left and came back and the Administrator did not think LVN A did the day training when she returned because she had worked at the facility before. The Administrator reported any new nurse hired was shadowed by an experienced nurse for 3 days and if they still felt the nurse was not ready then they would continue training. The Administrator revealed they were starting new training program next week with all the nurses, to include general nurses training, change of condition and a Nurse Educator Toolkit that was provided by Texas Health and Human Services. The Administrator revealed as far as what they could have done different to prevent the incident was to implement nurse training and one-on-one with instructors. The Administrator reported because they did not recognize LVN A's weaknesses and her level of critical thinking skills they were at fault as well. While the IJ was removed on [DATE] the facility remained out of compliance at a level of actual harm with a scope identified as isolated until all staff was in-serviced and showed proficiency on vital sign parameters, notification of physician and change of condition, walking rounds through monitoring of change of shift observations and chart reviews.