Based on closed medical record review, staff interviews, Nurse Practitioner (NP) interview, review of the emergency medical services (EMS) report, review of a death certificate, review of the facility investigation, review of the facility's policy for cardiopulmonary resuscitation (CPR) [an emergency life-saving procedure performed when someone's breathing or heartbeat has stopped] and review of the American Heart Association Journal, the facility failed to timely implement life-saving measures for one resident (Resident #90) found outside, unresponsive, without a pulse or respirations, and was identified as a Full Code Status (medical term that indicates a patient/resident's wish to receive all possible life-saving measures in the event of a cardiac or respiratory arrest). This resulted in Real and Present Danger and serious life-threatening harm and ultimate death, when Resident #90 did not receive CPR by staff after he was discovered facedown, outside the facility, unresponsive, with no pulse or respirations on 02/05/25 at 9:49 P.M. and EMS was contacted. This affected one (#90) of one resident who expired unexpectedly at the facility with a Full Code Status. The facility identified a total of 50 residents with a Full Code Status. The facility census was 88. On 05/28/25 at 12:03 P.M., the Chief Executive Officer/Executive Director (CEO/ED), Clinical Operations Officer (COO) #30, and Corporate Nurse (CN) #80 were notified Real and Present Danger began on 02/05/25 at approximately 9:49 P.M., when Resident #90, who was a Full Code resuscitation status, was outside the facility, found face down and unresponsive by Hospitality Aide (HA) #10. HA #10 notified Licensed Practical Nurse (LPN) #20 of Resident #90 being found outside and unresponsive. LPN #20 did not initiate CPR upon discovering Resident #90 had no respirations or pulse and called nine-one-one (911). When EMS arrived, CPR was initiated for Resident #90, and the resident was transported to the local hospital where he subsequently expired in the Emergency Room (ER). The Real and Present Danger was abated on 05/29/25, when the facility implemented the following corrective actions: On 02/05/25, LPN #20 was notified by HA #10 that Resident #90 was lying in the outside doorway. LPN #20 responded and attempted to arouse the resident. When LPN #20 found him to be unresponsive, she dialed 911. LPN #20 stated the resident was lying face down and she was unable to move him to his back for CPR. EMS arrived, assessed Resident #90 and began CPR. LPN #20 failed to initiate CPR in accordance with the Resident #90's full code status. Resident #90 is now deceased. On 02/05/25, NP #100 was notified of the event by COO #30. On 02/06/25, notification was made to Area on Aging Representative #70 by the CEO/ED. On 02/06/25, the CEO/ED and COO #30 conducted interviews with LPN #20 and HA #10 who discovered Resident #90 unresponsive. On 05/27/25 to 05/28/25, COO #30 audited all residents' Code Status to validate those residents with advance directives in place, and matching the advance directive orders in the medical record. There were no identified concerns. On 05/28/25, LPN #20 who failed to initiate CPR, was provided with a Performance Correction by COO #30. On 05/28/25, COO #30 audited former resident stays that ended in death from 01/01/25 to present, to identify others who may have requested full code status but were not provided CPR. None were identified. On 05/28/25, the CPR policy was revised to clearly state that any resident who is found unresponsive, will be assessed, and if found to be without a pulse, and if the resident does not have a Do Not Resuscitate order, CPR will be initiated. The policy was revised by the CEO/ED and CN #80. On 05/28/25, education was initiated with the direct care staff and will be provided to oncoming staff, prior to working their next shift, regarding unresponsive residents with Full Code Status and the need to initiate CPR. This education was provided by the CEO/ED, COO #30, Assistant Clinical Operations Officer (ACOO) #31, and CN #80. No employee will be permitted to work without receiving this education. Post-tests were administered following the education regarding the process for finding an unresponsive resident to validate comprehension of the education with all clinical staff by CEO/ED, COO #30, ACOO #31, and CN #80. Re-education regarding the process for finding an unresponsive resident, followed by a comprehensive post-test, will be completed in one month, six months and with the annual training thereafter. On 05/28/25, the CEO/ED added new education regarding the process for finding an unresponsive resident to the orientation materials for the facility staff including a post-test to be administered by the CEO/ED, COO #30, ACOO #31, or Human Resource Director (HRD) #90 upon hire, and prior to the employee performing direct resident care. On 05/28/25, a Quality Assurance (QA) meeting was held with the Interdisciplinary Team (IDT) to review the abatement plan. Additionally, QA meetings will be held weekly for four weeks to monitor compliance and effectiveness of the plan. The IDT includes the following: CEO/ED, COO #30, ACOO #31, Plant Director (PD) #125, Activity Director (AD) #40, Business Office Manager (BOM) #115, HRD #90, and Dietary Manager (DM) #120. Beginning on 05/28/25, to monitor ongoing compliance, the CEO/ED and/or COO #30 will audit admissions and readmissions daily Monday through Friday to ensure proper code status is recorded in the medical records with the appropriate validation for four weeks then monthly for three months, then ongoing as needed. All findings will be reviewed in QA meetings presented by CEO/ED. Beginning on 05/28/25, to monitor ongoing compliance, the CEO/ED and/or COO #30 will audit in-house resident deaths or discharges to ensure resident deaths were not a direct result of non- compliance with the CPR policy. This audit will be performed daily Monday through Friday for four weeks, then monthly for three months, then ongoing as needed. All findings will be reviewed in QA meetings presented by the CEO/ED. Although the Real and Present Danger was abated on 05/29/25, the facility remained out of compliance, as the facility is still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance. Findings include: Review of the closed medical record for Resident # 90 revealed an admission date of 08/31/21 and discharged on 02/05/25. Diagnoses included Type II Diabetes Mellitus (DM II), chronic obstructive pulmonary disease (COPD), and major depressive disorder. Review of the physician order dated 08/31/21, revealed Resident #90 was a full code. Review of the Service Plan dated 09/13/21, revealed Resident #90 chose to be a full code status. Interventions included CPR would be initiated in the event of cardiac arrest. Review of the EMS report dated 02/05/25, revealed 911 was called at 9:49 P.M. and EMS arrived at the facility at 9:58 P.M. Staff relayed that Resident #90 went outside to smoke and was found ten minutes later face down and unresponsive. Resident #90 was covered with a sheet by staff, and EMS moved the resident into the dining room and initiated CPR. Resident #90 had an abrasion to the left forehead/eye area, and his skin was cold, dry, and pale. The Lucas Device (a mechanical chest compression system designed to deliver consistent and continuous chest compressions during cardiac arrest) was put into place, and the resident was intubated (a process where a breathing tube is inserted through a person's mouth or nose, then down into their trachea [airway]. Resident #90 remained in asystole (a medical term referring to the absence of electrical activity and mechanical contractions in the heart) and was transferred to the hospital. Review of the Facility Incident Report dated 02/05/25 at 11:00 P.M., revealed HA #10 exited out the back of the cottage and found Resident #90 face down on the ground. HA #10 notified LPN #20. Resident #90 was found unresponsive to verbal stimuli with no pulse. Nine-one-one (911) was called to initiate CPR and further evaluation. The CEO/ED and NP #100 were notified of the incident. Review of the Death Certificate revealed Resident #90 was pronounced dead on 02/05/25 at 11:04 P.M. related to acute cardiopulmonary arrest. Review of a progress note dated 02/05/25 at 11:43 P.M., authored by LPN #20, revealed Resident #90 was on the ground out back. Resident #90 was found face down, unresponsive and EMS was notified. EMS arrived and transported Resident #90 to the hospital. Review of a progress note dated 02/06/25 at 10:44 A.M., authored by COO #30, revealed a follow-up call was completed with the Fire Department in regard to the status of Resident #90. CPR was performed on Resident #90 during the transfer to the hospital and the hospital staff took over care but were unsuccessful. Resident #90 passed away at the hospital. Review of a progress note dated 02/06/25 at 3:26 P.M., authored by COO #30, revealed Resident #90 complained of shortness of breath (SOB) prior to the incident. HA #10 advised Resident #90 to wait in his room until LPN #20 could assess him. Resident #90 did not listen and went outside to smoke. Resident #90 was found outside face down, not breathing, without a pulse and EMS was notified. EMS arrived and initiated CPR then transferred Resident #90 to the hospital. Interview on 05/27/25 at 10:29 A.M. with LPN #20, revealed she was notified Resident #90 was having SOB by HA #10. LPN #20 reported another resident told her Resident #90 was outside faced down. LPN #20 stated the resident had a t-shirt and pants on with no jacket. LPN #20 immediately called 911. LPN #20 stated he was unresponsive, but he was a larger man and weighed 300 pounds, and she didn't attempt to move him. LPN #20 voiced she did not initiate CPR, assess his vital signs or complete an assessment. LPN #20 reported EMS arrived and initiated CPR. Interview on 05/27/25 at 11:58 A.M. with HA #10, revealed Resident #90 reported he was SOB, and she advised him to wait on the nurse and not go outside. HA #10 explained when she was passing out water, she saw Resident #90 heading towards the back door. HA #10 stated she gave another resident water and saw Resident #90 on the ground in the doorway. HA #10 yelled for the nurse, who responded and then HA #10 continued helping other residents. Interview on 05/28/25 at 2:49 P.M. with NP #100, revealed she was notified of the incident that occurred on 02/05/25 with Resident #90. NP #100 was also made aware on 05/28/25 of the Real and Present Danger. Review of the personnel file for LPN #20, revealed on 05/28/25, LPN #20 received a written reprimand for neglecting to provide Resident #20 with CPR measures. LPN #20 had an active CPR certification. Review of the undated facility policy titled, Cardiopulmonary Resuscitation (CPR)Based on closed medical record review, staff interviews, Nurse Practitioner (NP) interview, review of the emergency medical services (EMS) report, review of a death certificate, review of the facility investigation, review of the facility's policy for cardiopulmonary resuscitation (CPR) [an emergency life-saving procedure performed when someone's breathing or heartbeat has stopped] and review of the American Heart Association Journal, the facility failed to timely implement life-saving measures for one resident (Resident #90) found outside, unresponsive, without a pulse or respirations, and was identified as a Full Code Status (medical term that indicates a patient/resident's wish to receive all possible life-saving measures in the event of a cardiac or respiratory arrest). This resulted in Real and Present Danger and serious life-threatening harm and ultimate death, when Resident #90 did not receive CPR by staff after he was discovered facedown, outside the facility, unresponsive, with no pulse or respirations on 02/05/25 at 9:49 P.M. and EMS was contacted. This affected one (#90) of one resident who expired unexpectedly at the facility with a Full Code Status. The facility identified a total of 50 residents with a Full Code Status. The facility census was 88.
On 05/28/25 at 12:03 P.M., the Chief Executive Officer/Executive Director (CEO/ED), Clinical Operations Officer (COO) #30, and Corporate Nurse (CN) #80 were notified Real and Present Danger began on 02/05/25 at approximately 9:49 P.M., when Resident #90, who was a Full Code resuscitation status, was outside the facility, found face down and unresponsive by Hospitality Aide (HA) #10. HA #10 notified Licensed Practical Nurse (LPN) #20 of Resident #90 being found outside and unresponsive. LPN #20 did not initiate CPR upon discovering Resident #90 had no respirations or pulse and called nine-one-one (911). When EMS arrived, CPR was initiated for Resident #90, and the resident was transported to the local hospital where he subsequently expired in the Emergency Room (ER).
The Real and Present Danger was abated on 05/29/25, when the facility implemented the following corrective actions:
On 02/05/25, LPN #20 was notified by HA #10 that Resident #90 was lying in the outside doorway. LPN #20 responded and attempted to arouse the resident. When LPN #20 found him to be unresponsive, she dialed 911. LPN #20 stated the resident was lying face down and she was unable to move him to his back for CPR. EMS arrived, assessed Resident #90 and began CPR. LPN #20 failed to initiate CPR in accordance with the Resident #90's full code status. Resident #90 is now deceased.
On 02/05/25, NP #100 was notified of the event by COO #30.
On 02/06/25, notification was made to Area on Aging Representative #70 by the CEO/ED.
On 02/06/25, the CEO/ED and COO #30 conducted interviews with LPN #20 and HA #10 who discovered Resident #90 unresponsive.
On 05/27/25 to 05/28/25, COO #30 audited all residents' Code Status to validate those residents with advance directives in place, and matching the advance directive orders in the medical record. There were no identified concerns.
On 05/28/25, LPN #20 who failed to initiate CPR, was provided with a Performance Correction by COO #30.
On 05/28/25, COO #30 audited former resident stays that ended in death from 01/01/25 to present, to identify others who may have requested full code status but were not provided CPR. None were identified.
On 05/28/25, the CPR policy was revised to clearly state that any resident who is found unresponsive, will be assessed, and if found to be without a pulse, and if the resident does not have a Do Not Resuscitate order, CPR will be initiated. The policy was revised by the CEO/ED and CN #80.
On 05/28/25, education was initiated with the direct care staff and will be provided to oncoming staff, prior to working their next shift, regarding unresponsive residents with Full Code Status and the need to initiate CPR. This education was provided by the CEO/ED, COO #30, Assistant Clinical Operations Officer (ACOO) #31, and CN #80. No employee will be permitted to work without receiving this education. Post-tests were administered following the education regarding the process for finding an unresponsive resident to validate comprehension of the education with all clinical staff by CEO/ED, COO #30, ACOO #31, and CN #80. Re-education regarding the process for finding an unresponsive resident, followed by a comprehensive post-test, will be completed in one month, six months and with the annual training thereafter.
On 05/28/25, the CEO/ED added new education regarding the process for finding an unresponsive resident to the orientation materials for the facility staff including a post-test to be administered by the CEO/ED, COO #30, ACOO #31, or Human Resource Director (HRD) #90 upon hire, and prior to the employee performing direct resident care.
On 05/28/25, a Quality Assurance (QA) meeting was held with the Interdisciplinary Team (IDT) to review the abatement plan. Additionally, QA meetings will be held weekly for four weeks to monitor compliance and effectiveness of the plan. The IDT includes the following: CEO/ED, COO #30, ACOO #31, Plant Director (PD) #125, Activity Director (AD) #40, Business Office Manager (BOM) #115, HRD #90, and Dietary Manager (DM) #120.
Beginning on 05/28/25, to monitor ongoing compliance, the CEO/ED and/or COO #30 will audit admissions and readmissions daily Monday through Friday to ensure proper code status is recorded in the medical records with the appropriate validation for four weeks then monthly for three months, then ongoing as needed. All findings will be reviewed in QA meetings presented by CEO/ED.
Beginning on 05/28/25, to monitor ongoing compliance, the CEO/ED and/or COO #30 will audit in-house resident deaths or discharges to ensure resident deaths were not a direct result of non- compliance with the CPR policy. This audit will be performed daily Monday through Friday for four weeks, then monthly for three months, then ongoing as needed. All findings will be reviewed in QA meetings presented by the CEO/ED.
Although the Real and Present Danger was abated on 05/29/25, the facility remained out of compliance, as the facility is still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance.
Findings include:
Review of the closed medical record for Resident # 90 revealed an admission date of 08/31/21 and discharged on 02/05/25. Diagnoses included Type II Diabetes Mellitus (DM II), chronic obstructive pulmonary disease (COPD), and major depressive disorder.
Review of the physician order dated 08/31/21, revealed Resident #90 was a full code.
Review of the Service Plan dated 09/13/21, revealed Resident #90 chose to be a full code status. Interventions included CPR would be initiated in the event of cardiac arrest.
Review of the EMS report dated 02/05/25, revealed 911 was called at 9:49 P.M. and EMS arrived at the facility at 9:58 P.M. Staff relayed that Resident #90 went outside to smoke and was found ten minutes later face down and unresponsive. Resident #90 was covered with a sheet by staff, and EMS moved the resident into the dining room and initiated CPR. Resident #90 had an abrasion to the left forehead/eye area, and his skin was cold, dry, and pale. The Lucas Device (a mechanical chest compression system designed to deliver consistent and continuous chest compressions during cardiac arrest) was put into place, and the resident was intubated (a process where a breathing tube is inserted through a person's mouth or nose, then down into their trachea [airway]. Resident #90 remained in asystole (a medical term referring to the absence of electrical activity and mechanical contractions in the heart) and was transferred to the hospital.
Review of the Facility Incident Report dated 02/05/25 at 11:00 P.M., revealed HA #10 exited out the back of the cottage and found Resident #90 face down on the ground. HA #10 notified LPN #20. Resident #90 was found unresponsive to verbal stimuli with no pulse. Nine-one-one (911) was called to initiate CPR and further evaluation. The CEO/ED and NP #100 were notified of the incident.
Review of the Death Certificate revealed Resident #90 was pronounced dead on 02/05/25 at 11:04 P.M. related to acute cardiopulmonary arrest.
Review of a progress note dated 02/05/25 at 11:43 P.M., authored by LPN #20, revealed Resident #90 was on the ground out back. Resident #90 was found face down, unresponsive and EMS was notified. EMS arrived and transported Resident #90 to the hospital.
Review of a progress note dated 02/06/25 at 10:44 A.M., authored by COO #30, revealed a follow-up call was completed with the Fire Department in regard to the status of Resident #90. CPR was performed on Resident #90 during the transfer to the hospital and the hospital staff took over care but were unsuccessful. Resident #90 passed away at the hospital.
Review of a progress note dated 02/06/25 at 3:26 P.M., authored by COO #30, revealed Resident #90 complained of shortness of breath (SOB) prior to the incident. HA #10 advised Resident #90 to wait in his room until LPN #20 could assess him. Resident #90 did not listen and went outside to smoke. Resident #90 was found outside face down, not breathing, without a pulse and EMS was notified. EMS arrived and initiated CPR then transferred Resident #90 to the hospital.
Interview on 05/27/25 at 10:29 A.M. with LPN #20, revealed she was notified Resident #90 was having SOB by HA #10. LPN #20 reported another resident told her Resident #90 was outside faced down. LPN #20 stated the resident had a t-shirt and pants on with no jacket. LPN #20 immediately called 911. LPN #20 stated he was unresponsive, but he was a larger man and weighed 300 pounds, and she didn't attempt to move him. LPN #20 voiced she did not initiate CPR, assess his vital signs or complete an assessment. LPN #20 reported EMS arrived and initiated CPR.
Interview on 05/27/25 at 11:58 A.M. with HA #10, revealed Resident #90 reported he was SOB, and she advised him to wait on the nurse and not go outside. HA #10 explained when she was passing out water, she saw Resident #90 heading towards the back door. HA #10 stated she gave another resident water and saw Resident #90 on the ground in the doorway. HA #10 yelled for the nurse, who responded and then HA #10 continued helping other residents.
Interview on 05/28/25 at 2:49 P.M. with NP #100, revealed she was notified of the incident that occurred on 02/05/25 with Resident #90. NP #100 was also made aware on 05/28/25 of the Real and Present Danger.
Review of the personnel file for LPN #20, revealed on 05/28/25, LPN #20 received a written reprimand for neglecting to provide Resident #20 with CPR measures. LPN #20 had an active CPR certification.
Review of the undated facility policy titled, Cardiopulmonary Resuscitation (CPR)