**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation and clinical record review, the facility staff failed to provide consistent basic life support, including CPR for 1 Resident (Resident #35) in a survey sample of 27 Residents. This resulted in Immediate Jeopardy at Level 4 isolated on [DATE]. After reviewing the facility documentation, Immediate Jeopardy was determined to be removed at past non-compliance on [DATE]. The findings included: 1. For Resident #35, the facility staff failed to continue cardiopulmonary resuscitation (CPR) on [DATE]. Also, the facility staff failed to activate Emergency Medical Services (EMS) when CPR was initiated. Resident #35 was a full code. Resident # 35 was admitted to the facility on [DATE] and expired on [DATE]. Resident # 35's diagnoses included but were not limited to: Parkinson's disease, Orthostatic hypotension and Peripheral Vertigo. Resident # 35's most recent MDS (Minimum Data Set) assessment with an Assessment Review Date of [DATE] was coded as an admission Assessment and coded Resident # 35 as having a BIMS (Brief Interview of Mental Status) score of 2 indicating severe cognitive impairment. Resident # 35 was coded as requiring extensive assistance of one staff person for all aspects of ADL (activities of daily living) care except for bathing which was coded as requiring total assistance of one staff person. Resident # 35 had a Full Code status. On [DATE] at 10:40 a.m., a review of the closed electronic clinical record for Resident # 35 was conducted and revealed Resident # 35 expired in the facility on [DATE]. Review of the Nursing Progress Notes revealed the following entries (in order of writing): Progress Note Clinical Notes [DATE] 11:30 (EST) [DATE] 1:14 (EST) [written by LPN-B name redacted] Late entry. Resident medicated with Tylenol 650 mg for complaint of generalized discomfort all over. Mobile image here for X-ray. Resident alert and oriented to name. Awaiting X-ray results. Nursing Progress Note Clinical Notes [DATE] 3:33 (EST) [DATE] 3:36 (EST) [Written by RN-D name redacted] [name of Doctor of Nursing Practice redacted] in with Residents wife for final view. [name redacted] funeral home called to pick up remains. [name of Funeral Home redacted] arrived and took remains into their care. Nursing Progress Note Death Clinical Notes [DATE] 1:19 (EST) [DATE] 1:26 (EST) [Written by RN-D name redacted] Resident is without Apical pulse, BP, or respirations. Pupil non responsive. At first resident still making some gasping attempts then stopped at 0040. Large amounts of black emesis was expelled from his mouth and nose and PDP [private duty person] described it as projectile. large puddle also on floor. Resident was wet with perspiration. DNP notified at 0045 and Wife at 0114. Nursing Progress Note Clinical Notes [DATE] 0:30 (EST) [DATE] 9:22 (EST) [Written by LPN-B name redacted] Late Entry. Called to room resident covered in dark emesis and unresponsive. Compression given and resident remained on responsive and mouth continued to fill with emesis with each compression. Resident turned to side a more produced. [Sic] Charge RN in and no apical pulse. DNP aware. Nursing Progress Note Clinical Notes [DATE] 19:14 (EST) [DATE] 19:15 (EST) [written by RN-F name redacted] BP-85/55, apical pulse 76, Metoprolol held per orders, MD and RP aware Resident lying in bed this evening with spouse at bedside Resident's abdomen round firm bladder scanned Review of the Physicians Orders revealed an order written by the Nurse Practitioner on [DATE] for FULL Code. Review of the care plan revealed the following entries: ADVANCED DIRECTIVES: Please review my Advanced Directives with me, my representative, and/or my family STATUS: Active (Current) [name redacted] Advanced Directives will be reviewed STATUS: Active (Current) GOAL DATE: [DATE] I desire to remain a Full Code. STATUS: Active (Current) All Disciplines Please review my Advanced Directive/Living Will if I am unable to make decisions for myself and enforce my wishes & desires. RESPIRATORY: Resident had a change in condition. Noted audible gurgling, increased respirations 24/min at times, then slows down when eyes closed, skin warm to touch - temp 97.8 non contact. Dr. [name redacted] notified with new orders. Possible aspiration as he had been coughing during lunch. On [DATE] @ 24:30ish [Sic] resident unresponsive with large amount of dark emesis on him, the floor, etc. CPR started without success. Emesis con't [Sic] to produce during each compression. Pronounced deceased at 24:40. STATUS: Active (Current) Thorough review of the Nurses Progress Notes revealed evidence that CPR was started with compressions but no evidence of CPR being continued In addition, there was no evidence of Emergency Medical Services being called . Review of the Nurse Practitioner's Discharge Final Progress Note reads the following. [DATE] [Resident # 35's name redacted] Discharge Notified at 1242am that resident had passed. Large amount of dark emesis and rapid death. Breathless, pulseless. Suspect this represents stress ulcer with GI (gastrointestinal) hemorrhage. Patient had complex course with underlying advanced Parkinson's disease, at time of admission had UTI, developed neurogenic bladder with indwelling catheter. Recent clinical change + CXR [Chest x ray] bibasilar pneumonia suspected aspiration with MODS as noted in Dr. [name redacted] notes. Negative urine culture. On [DATE] at 10:50 a.m., an interview was conducted with the Administrator who stated Resident # 35 expired in the facility. The Administrator stated the facility staff did not continue to perform CPR for Resident # 35 and Emergency Medical Services was not called to the facility to assist with the emergency. The Administrator stated the Licensed Practical Nurse (LPN-B) initiated CPR and Registered Nurse (RN-D) called the physician to notify of the resident's death in the facility. The Administrator stated the incident was very upsetting to all involved. The facility staff should have called EMS and continued to perform CPR until EMS arrived. On [DATE] at 11:15 a.m., an interview was conducted with the Director of Nursing who stated her expectation was for the CPR (Cardiopulmonary Resuscitation) policy to be followed by the staff, activated EMS (Emergency Medical Services and continue CPR until EMS arrives. The Director of Nursing stated the incident with Resident # 35 involved two nurses LPN-B (Licensed Practical Nurse-B) and RN-D (Registered Nurse-D) working night shift that night. One of the nurses (LPN-B) usually was assigned to day shift. It was reported that the private duty person working with Resident # 35 came to the nurses stated the resident was vomiting. The nurses, LPN-B (Licensed Practical Nurse-B) and RN-D (Registered Nurse-D), observed excessive vomiting, no pulse and breathless. The nurse (RN-D) called the Nurse Practitioner who was on the phone with them when CPR was determined to be futile and CPR was stopped. The Director of Nursing stated that was where it seemed to be a misunderstanding. The Nurse Practitioner thought the staff was just telling her the resident had expired. The Director of Nursing stated that the Nurse Practitioner did not give an official order to stop CPR. The Director of Nursing stated through the facility's investigation it was determined that the Nurse Practitioner was under the impression that Resident # 35 was already deceased when the call was placed and the call was for notification but not for orders to be obtained. On [DATE] at approximately 2:45 PM, a meeting was held with the Administrator, Director of Nursing and the Corporate Chief Operations Officer. They were made aware of the concerns with staff not following standard CPR/BLS (Basic Life Support) procedures for Resident # 35 and that it constituted Immediate Jeopardy. They were asked to provide any and all documentation regarding the facility's response to this incident. The Administrator stated when she was informed of Resident # 35's death, she immediately asked if EMS had been called. The Administrator stated she and the Director of Nursing came to the facility immediately to address the issue, educated the staff on the CPR Policy and instituted a new policy entitled Medical Emergency Response on [DATE]. The Administrator stated the facility staff should have followed the CPR policy, called 911 to access the Emergency Medical Services and that CPR should have continued until the EMS arrived to take over. The Administrator stated she submitted a FRI (Facility Reported Incident) to the State Agency. The Administrator stated nothing like this incident had ever happened before and they realized the importance of correcting the problem. The Administrator stated both nurses involved in this incident were suspended pending investigation. Both nurses were referred to the Department of Health Professions for review. The Administrator stated LPN-B had been employed over 25 years and Registered Nurse-D for 15 years. Both employees were suspended. Immediate Jeopardy was called on [DATE] at 2:45 PM. Documentation was received and reviewed. The facility's removal plan included: Under Corrective Action Following Event: On [DATE], the CPR (Cardiopulmonary Resuscitation) policy was reviewed, the Emergency Medical Response policy was adapted and both policies in serviced with staff and placed on all shifts to review and acknowledge. [DATE] Both directly involved staff members placed on administrative leave pending investigation. 11/22-23/21 Investigation of incident performed; staff statements collected Review of the facility's documentation revealed: Nurses scheduled to work from [DATE] through [DATE] were educated on the facility's CPR policy, the Medical Emergency Response Policy Date implemented [DATE] (to include calling 911, notifying the physician, and performing continuous CPR until care is transferred) prior to the start of their next scheduled shift. There was education provided to staff on Communication Book Information Sheet on [DATE] and [DATE]. Both inservices were repeated for staff scheduled to work on their next scheduled shift. Review of the Facility documentation revealed the following policy: Policy name: Medical Emergency Response, date implemented: [DATE] Policy: It is the policy of this facility to respond to medical emergencies for residents, staff and visitors. Policy Explanation and Compliance Guidelines: 1. The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance. 2. CPR will continue unless: a. There is a DNR order in place b. There are obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection or decomposition. c. Initiating CPR could cause injury or peril to the rescuer 3. A nurse will a. Assess the situation and determine the severity of the emergency. b. Stay with the resident. c. Designate a staff member to announce a Code Blue if necessary, call 911 as needed, notify the physician. 4. A Code Blue will be announced over the intercom system, if necessary. 5. All available staff will respond to the emergency accordingly. 6. The RN supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed. 7. This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS 8. If the resident experiences cardiac arrest, the facility must provide basic lice support, including CPR prior to the arrival of emergency medical services and : a. In accordance with the resident's advance directives, or b. In absence of advance directives or a Do Not Resuscitate order, and c. If the resident does not show obvious signs of clinical death. 9. The RN supervisor or designee will ensure emergency medications and equipment are inventoried and restocked. 10. The facility will ensure that CPR certified staff are available at all times. 11. Current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider whose training includes hands-on skills practice and in-person assessment and demonstration of skills. Online certification is not acceptable. The survey team verified the removal plan by doing the following: Staff at the facility were interviewed for training on the Emergency Response policy and CPR Policy and Mock Codes. Nurses who were not at the facility were called and interviewed. The survey team reviewed copies of the Emergency Policy received by nurses and Certified Nursing Assistants. The survey team reviewed copies of CPR Cards for nursing staff. The survey team confirmed that staff had been educated about CPR, knew to call 911 so that EMS could respond and that CPR would continue uninterrupted until EMS took over after arriving on-site. The survey team reviewed the staff education/training on the CPR Policy and Emergency Response Policy. The survey team reviewed charts of current Residents to ensure the code status was correctly identified in the charts. Review of the facility staff listing revealed that all Nurses had current CPR certification. Therefore, trained staff would be available to provide CPR until EMS arrived in the event of a Resident with a Full Code Status being found unresponsive. The Immediate Jeopardy was determined to be Past Non-compliance and removed on [DATE] at 5:00 PM. On [DATE] at approximately 5:30 PM, the facility Administrator was asked if she had any further information regarding the incident for Resident # 35. The Administrator reported she had no further records or information to provide. The Administrator, Director of Nursing, MDS Coordinator and Chief Operations Officer were informed of the findings that the facility failed to provide CPR to the Resident with a FULL Code order and Advance directive. The facility failed to ensure the staff was familiar with the facility's policies regarding basic life support and CPR and staff failed to confirm Resident # 35's code status in an emergency resulting in Immediate Jeopardy. On [DATE] at 6:45 PM, the facility Administrator, the Director of Nursing and Chief Operation Officer were made aware that Immediate Jeopardy was being cited at Past Non-compliance. No further information was provided.