**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow physician orders and the resident's advance directives for 1 of 24 Residents (Resident #76) whose records were reviewed for DNR code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #76, who had a DNR in place, CPR, after the resident choked and became unresponsive, according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on 05/26/2023. While the IJ was removed on 05/27/2023, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. These deficient practices could contribute to a resident's decline in emotional, physical and psychological health and result in serious injury and or death. Review of Resident #76's admission record, dated 5/23/23, revealed she was admitted to the facility on [DATE] with diagnoses to include Dementia (is a progressive brain condition that can cause issues with thinking, behavior, and memory) in other Diseases Classified Elsewhere, Moderate with Agitation, Parkinson's Disease (A chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and Dysphagia, Oropharyngeal Phase (A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing). Review of Resident #76's admission MDS assessment, dated 3/10/23, revealed her BIMS was 01 of 15 reflecting severe cognitive impairment and she required extensive assistance by 1 or 2 persons for ADL's including eating. Review of Resident #76's Care Plan, revised on 3/10/23, revealed she had a diet alteration related to Resident and family wishes. Resident and family wish for Regular diet, regular texture. The interventions included: Educate patient on nutrient restriction in relation to medical condition/Dx, Diet as ordered, Monitor lab data as available, Monitor meal consumption daily, Notify physician and family/responsible party of weight change, Obtain and update food/beverage preferences. Resident also had an advance Directive as evidenced by DNR. Interventions included: Follow facility protocol for identification of code status. Follow Living Will. Obtain Advance Directive with physician order and resident/responsible party signature. Review of Resident #76's of physician orders for May 2023 revealed she had an order for regular diet, thin regular consistency, dated 3/6/23; and an order for DNR, dated 4/13/23. Review of Resident #76's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) revealed it was signed on 4/21/21. Review of a cheat sheet with resident's code status observed in rooms 1 to 13 revealed Resident #76's code status was not included. Review of progress note, dated 5/25/23, at 18:51 (6:51) PM, read as follows: Event Type: Pt choked on chicken and rice at lunch time and then went into cardiac arrest requiring CPR to be performed. Date of Event: 5/25/2023 Time of event: 1215 Detailed description of event (how, when, where, vitals, symptoms): Pt assessed choking on food at lunch time in dining room. Pt not moving air at all and not coughing just showing signs of a blocked airway. Had CNA and LVN try to pull patient out of chair to attempt to do Heimlich maneuver and 3-4 thrusts given but pt could not stay upright so we lowered pt to ground. 911 called. LVN gave 4-5 Heimlich maneuver thrusts which did move food a little bit but pt was still choking. At this time pt became unresponsive, carotid pulse palpated with no pulse detected and pt with no respirations. Then CPR was initiated. 2-3 compressions given per [name], LVN, which caused a big inspiratory gasp and pt opened her eyes then. Pt having shallow respiration but is moving air. Placed pt on right side in the rescue position and continued to attempt to remove what was in her airway. Some chicken and rice were removed. EMS arrives and takes over code. Pt leaves building on stretcher at 1245 with EMS. Patients' description of event: Pt unable to describe event due to dementia. Full Range of Motion Assessment findings (i.e. wnl for resident, or describe abnormal findings): wnl for resident. MD Notification (Date, Time, Method of communication): 5/25/23 at 1300 (1:00 PM) Responsible Party Notification (Date, Time): [LVN B] notified at 1300 (1:00 PM) Interventions (should address any abnormal assessment findings): Pt transferred to [hospital] ER per EMS. If Fall note-injury, how patient was found, environment, footwear, last toileted, FSBS if diabetic: NA. Review of progress note, dated 5/25/23 at 18:16 PM (6:16 PM), revealed Resident #76 was admitted to the ICU at a local hospital. Observation at 05/25/23 in the dining room, on hall B at 12:22 PM, revealed multiple staff (RN A, LVN B and CNA C) with Resident #76. LVN B and CNA C were holding Resident #76 up and she was slumped forward. It looked like the Resident was going to throw up. RN A conducted multiple abdominal thrusts and then told the other staff, We are going to have to lay her down. LVN B and CNA C laid Resident #76 on the floor on her right side. LVN B opened Resident #76's mouth and stated something was stuck in the back of the Resident's throat. She turned Resident #76 on her back and completed multiple rapid abdominal thrusts. She removed some food particles, but LVN B stated the airway was still obstructed. RN A noted Resident #76 was non-responsive, was not able to find her carotid pulse, then instructed LVN B to start CPR. LVN B started performing chest compressions on Resident #76. Resident #76 took a deep breath after about 3 to 5 minutes. RN A then instructed CNA E to call 911 which he proceeded to do from the nurse's station at 12:30 PM. Further observation revealed EMS arrived about 10 to 15 minutes later. Interview on 05/25/23 at 12:32 PM with a family member revealed she saw Resident #76 choking and told CNA E about it. She stated CNA E walked up to the Resident, asked if she was choking, walked away into room [ROOM NUMBER]. The family member stated it did not have to get this far and the situation could have been prevented had CNA E told someone. Interview on 05/25/23 at 12:33 PM with CNA E revealed he denied a family member spoke with him. He stated he saw Resident #76 was red and had her hands on her chest. She put her hands down and he asked if she was ok, and she said Yes. CNA E stated he walked into room [ROOM NUMBER] and told CNA C something was going on with Resident #76. CNA C went to check on Resident #76. Interview on 05/25/23 at 12:41 PM with CNA C revealed she was walking towards the dining room and saw Resident #76 put her hands on her chest. She looked closer and saw Resident #76 was not breathing and looked like she was choking. She told RN A who was standing by the food cart that Resident #76 was not breathing. Interview on 05/25/23 at 2:15 PM with CNA E stated he was agency staff and had worked at the facility for 10 months. He stated he had been a CNA since 1996. CNA E was asked what was the first thing he should do in an emergency situation. CNA E stated he had been in this situation before and knew what to do. CNA E stated he told CNA C something was going on with Resident #76 because she was the first staff he saw. He stated CNA C looked at Resident #76 and commented Resident #76 was choking and not breathing. CNA E was asked if he reported the incident to a nurse? He changed the subject and said the nurses were passing out trays. He stated they were supposed to stay in the dining room but were not there. CNA E stated CNA C let the nurses know what was going on. He stated he called 911 after RN A told him, but he did not know how to reach the DON because he did not know how to use the phone at the nurse's desk. He stated he started walking down the hall towards the main offices and flagged the DON down when he saw her. Interview on 05/25/23 at 02:25 PM with RN A revealed her and LVN B were normally in the dining room to supervise the residents during mealtime. RN A stated Resident #76 was eating during lunch time. She stated she had her back to the Resident and was cutting another resident's meat. RN A stated CNA C commented Resident #76 was choking and not breathing. She turned around and saw Resident #76 was turning colors. She stated she responded and tried to perform abdominal thrusts while CNA C and LVN B were holding Resident #76. Resident #76 was slumped over, and flopped down. RN A stated she could not get the technique right because the Resident was slumped over so she told the other staff to lie her down. At that point LVN B tried to conduct abdominal thrusts while the Resident was in supine position. LVN B also tried to dislodge the food by doing a finger sweep. She stated LVN B got some rice and a small piece of chicken out but could not clear Resident #76's throat. RN A stated she looked over at Resident #76 and noted she was blue. She checked for the Resident's carotid pulse but could not find one. RN A stated Resident #76 had agonal breathing (labored, gasping breaths that occur because of insufficient oxygen), and she instructed CNA E to call 911. She stated she checked Resident #76 before she left and had a good bounding (heart is beating faster than normal) caranda pulse but staff and the EMT's could not get a reading on the Resident's O2 saturations. Interview on 05/25/23 at 3:05 PM with RN A revealed she should have called 911 right away or had another staff to call 911 upon responding to Resident #76's choking. She stated she did not know Resident #76's code status and did not check before or after responding to Resident #76 choking incident. She stated she found out Resident #76 was a DNR when gathering paperwork for the EMT's. She stated they should not have performed CPR with a DNR in place. However, she stated she believed they did what they had to do in responding to the emergency situation. She stated they moved from performing the Heimlich Maneuver to providing CPR because Resident #76 had no pulse. RN A identified at the point she could not find a pulse might have been the deciding factor not to pursue CPR. She stated she was not sure about it. RN A stated she would have to talk with the DON and maybe the physician for clarification. RN A stated staff had to look in PCC to get Resident #76's code status and was not sure if the resident's charts were color coded to alert staff about their code status. She stated she tried calling the DON while LVN B was performing abdominal thrusts, but the DON did not answer her phone. RN A stated once LVN B resuscitated Resident #76, she used the phone at the nurse's desk and paged the DON STAT to hall B. Interview on 05/25/2023 at 3:47 PM with the DON revealed she stated RN A and LVN B did not perform CPR after responding to Resident #76 choking. She stated they only performed the Heimlich Maneuver. Surveyor clarified, per observation, nursing staff performed CPR when RN A and LVN B were not able to clear Resident #76's airway. The DON stated if the Resident was choking, My position is for them to perform CPR, because that's a horrible death. The DON was asked if staff knew Resident #76 had a DNR should they have performed CPR. The DON stated, that would be something we have to look into because I don't agree that anyone should have to die like that. The DON stated in an emergency situation staff should assess the resident and call 911 after establishing it was an emergency. The DON stated staff carried a sheet of paper with the resident's code status and other care needs so they should know when to call 911. The DON stated the resident's DNR status was also on a report sheet at the nurse's station and in PCC. Interview on 05/25/23 at 4:51 PM with the DON revealed she interpreted the policy as I still would have done it. (DON read policy that stated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect.) The DON was informed the Heimlich was unsuccessful and RN A was unable to find a carotid pulse. The DON stated I'm aware that she coded and had no pulse. I see it, she was still choking. I see the chicken in her throat as affecting her having no pulse. I consider someone dead when they have no apical pulse. The DON further stated staff was to check for a DNR right away in the resident's electronic medical record that is my expectation. Interview on 05/25/23 at 04:52 PM with LVN B revealed she did not know Resident #76's code status when she started CPR. She stated she should not perform CPR when a DNR was in place, and she should have checked Resident 76's code status prior to performing CPR. LVN B stated she did not check. She stated she was not sure about whether or not she should have performed CPR because initially she responded to Resident #76 choking. She performed CPR when she was not able to dislodge the food from the Resident's throat and after RN A could not find a pulse. LVN B stated she thought about the fact she did not know Resident #76's code status when performing CPR. She sated everything happened so fast and she was focused on helping Resident #76. LVN B became tearful during the conversation. LVN B stated would have to look in PCC for the resident's code status. LVN B was not aware of anywhere else she could find a resident's code status during an emergency situation. Interview on 05/25/23 at 5:15 PM with CNA C revealed she was walking towards the dining room and noticed Resident #76's color was off. She stated CNA E approached her and said he did not know if Resident #76 was having a problem breathing. She stated she walked up to Resident #76, looked at her closer and it looked like she was choking and could not breath. She stated RN A was standing by the food cart and responded right away. CNA C stated LVN B walked around the corner. Then she and LVN B were holding Resident #76 up from her arms because she was not bearing weight. She stated RN A performed some abdominal thrusts, but the Resident was slumped over, so RN A asked them to lie the Resident down. CNA C stated LVN B then tried to do the abdominal thrust again and could not get the food out. LVN B then started CPR when RN A could not find Resident #76's pulse. CNA C stated she did not know Resident #76 code status and could find it in the red book at the nurses station. She stated it was their emergency book. CNA C walked to the nurses station and could not find the red book. She one of the nurse's on assignment and the nurse told CNA C she did not know anything about a red book. Interview on 5/26/23 at 12:40 PM with Resident #76's family member revealed she talked with facility staff about Resident #76's choking incident which ended up with staff performing CPR. The family member stated she was ok with staff providing CPR because she did not want Resident #76 to choke. The family member did not understand Resident #76 lost consciousness and nursing staff could not find her pulse and then staff performed CPR. The family member did not know facility policy read that nursing staff could not perform CPR once a resident lost consciousness and or could not find a pulse. In addition, the facility CPR policy provided options when addressing other emergency situations for residents who had a DNR in place. The family member stated nursing staff had not discussed any options with her. She stated Resident #76 was placed on what looked like a puree diet when she was initially admitted to the facility and remained on it for a couple of days. Then she asked the facility to put Resident #76 back on a regular diet because she was refusing to eat the puree food. The family member stated facility staff had not talked with her about the results of a completed ST evaluation. She stated it would have helped her in determining the best diet plan for Resident #76 and wondered if Resident #76 would benefit from eating chopped foods. She stated another family member questioned why staff performed CPR because Resident #76 had a DNR in place. The family member stated she was not sure how she would feel if the Resident was in a coma as a result of having CPR. She stated she would be talking to the other family member about Resident #76's DNR code status and would call the facility. Interview on 05/26/23 at 03:10 PM with Dr. T (MD who signed the DNR), stated Resident #76 had been with their care team since 05/2021 and the last note was entered by an NP, one of the team members. He stated Resident #76 had lost 10% of her body weight and was at end stage Parkinson's, and end stage Dementia. Dr. T stated the team was planning on placing her on hospice soon. He stated the incident with Resident #76 choking and then staff performing CPR was an odd situation and staff could potentially get a resident back if the food was dislodged. He stated he would not start CPR with someone with end stage disease. Dr. T commented, Me personally I wouldn't have started CPR. I can see why the facility started it because she was choking, but she did not have a good quality of life. He stated he would have stated CPR on a patient who was robust. Dr. T wondered how well staff knew Resident #76 and stated it was a tough question; whether or not to perform CPR after a choking incident. He stated almost universally all the patients and families who they talked with and had a DNR did not want CPR even if the patient was choking. Interview on 05/26/2023 at 10:00 AM with the ADM and Regional RN revealed they audited all nursing staff's CPR status and discovered that many of the staff did not have a CPR certification including RN A, LVN B and CNA C. Review of CPR certification status for RN A, LVN B and CNA C revealed they did not have a CPR certification at the time LVN B performed CPR on Resident #76. Review of facility policy, Do Not Resuscitate Order, revised March 2021), read in part; Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a (Do Not Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident medical record. 3. In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include: c. Medical Orders for Life-Sustaining Treatment. e. Clinical Orders for Life Sustaining Treatment. 5. Do Not Resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. Review of a facility policy, Emergency Procedure-Cardiopulmonary Resuscitation, revised February 2018, read in part: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. This was determined to be an Immediate Jeopardy (IJ) on 05/26/2023 at 12:34 PM and the Administrator was notified at 12:34 PM. The Administrator was provided with the IJ template on 05/26/2023. The following Plan of Removal was accepted on 05/26/2023 at 6:48 p.m. POR LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws Verification Plan of Removal: 1. Director of Nursing/designee completed immediate education with RN A, LVN B and CNA C, who were in attendance to emergency on proper response to emergency situation, when to initiate CPR on a resident and include the following steps for emergency response. 1. Staff was trained on 05/25/2023 at 2:15 p.m.; copy of in-service report and sign in sheet provided. 2. Administrator/designee verified status of Resident #76 and was determined by the hospital to be stable and returning to facility on 05/26/2023. 2. The resident's status at the hospital was verified and a fax from the hospital was provided to the survey team. The fax indicated that the resident was alert and awake and in no acute distress, and was initially on a face mask but was being titrated down. returned to the facility on [DATE]. Her diet order had changed to mechanical soft texture. She was observed by the survey staff on 05/26/2023 between 2:00 p.m. to 3:00 p.m. and also on 05/27/2023 at 3:00 p.m. sitting in her wheelchair by the nursing station. She looked well, her eyes were clear and her pallor was good. Per interview on 05/27/2023 at 3:00 p.m. with the charge nurse, when asked if she had choked on some chicken, her response was, Oh, no, that was my daughter. 3. Director of Nursing/designee validated all resident current Code status was up to date and in EHR, including care planned and on direct care [NAME] on 05/26/2023. 3. Verified; however, the survey team discovered that a total of four (4) OOH-DNR forms were invalid. This was brought to the attention of the Administrator and Regional nurse. They acknowledged the deficiency, and this deficient practice will be cited. 4. The Corporate Clinical Resource completed education with the Director of Nursing regarding requirements on Emergency Response, including following policy titled: Emergency Procedure-Cardiopulmonary Resuscitation on 5/26/2023. 4. Verified via interview on 5/27/2023 and signed in-service roster. 5. The Corporate nurse completed education with nurse management on requirements to follow resident wishes regarding Code status and CPR, regardless of situation or personal feelings. 5. Verified via interviews on 5/27/2023 and signed in-service roster. 6. Administrator/designee completed sweep of all licensed staff to verify CPR certification status is up to date on 5/26/2023. Class scheduled to update all certification needed on 06/03/2023 at facility with certified instructor. 6. Verified via list of all licensed staff and their status, and email from instructor indicating she will be at facility at 9:30 a.m. on 6/03/2023. Also received copy of invoice and proof of payment of $1037.50 for 15 students (two 4-hour sessions) and mileage 7. Identification of all others affected: The DON/designee validated that all residents had up to date code status in EHR, their code is reflected in both care plan and direct care staff [NAME] care record on 5/26/2023. 7. Verified by visually inspecting hard charts, which all had a divider indicating FULL CODE in neon green/yellow or DNR in red, and also checking EHR's. 8. The DON will complete education with all staff on proper procedures to follow in case of Emergency, including initiation of Emergency response system, validating resident code status in EHR, appropriate initiation of CPR, and designating staff in emergent situations to these tasks. Education will specify that any staff responsibility in performing CPR will be delegated to certified personnel, with additional staff to aide in support areas, such as initiating 911, validating code status, etc. Education will be initiated on 5/26/2023 to ensure that staff have a clear understanding of how they should respond during an emergency once they have established a resident's code status prior to performing life sustaining measures to avoid violating the resident's wishes. This education will be ongoing with all staff prior to working their next scheduled shift. 9. DON/designee will complete education regarding initiation of CPR/Emergency response based on resident's code status and wishes, emphasis will be placed on staff understanding of following resident code status indicated in EHR. This education will be ongoing with all staff prior to working their next scheduled shift. 8/9. Verified through record review of sign in sheets of training and also in-person interviews of the following staff members: 1. LVN V 2. HR W 3. CNA X 4. CNA Y 5. CNA Z 6. LVN AA 7. LVN BB 8. CNA CC 9. LVN, ADON DD 10. CNA EE 11. CNA FF 12. LVN GG 13. CNA student HH 14. Dietary Manager 15. LVN R 16. RN II 17. Director of Rehabilitation 18. Maintenance Assistant JJ 19. CNA KK 20. LVN LL 10. Ad hoc QAPI meeting held with IDT team and MD to review policy on Emergency Procedure -Cardiopulmonary resuscitation and Plan of removal/response to Immediate Jeopardy Citation on 5/26/2023 at 3:00 p.m. 10. Verified by record review, signed by administrator, medical director (via telephone), DON, both ADON's, and Director of Clinical Operations. A root cause analysis was conducted by the PIP to determine WHY the event occurred. On 5/27/23 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 05/27/2023 at 10:00 AM. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal.