Woodbury Heights Nursing and Rehabilitation Center
May 9, 2022 Complaint Survey

Standard Health Citations

FF11 483.24(a)(3), 483.24(a)(3), 483.24(a)(3):CARDIO-PULMONARY RESUSCITATION (CPR)

REGULATION: § 483. 24(a)(3) Personnel 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.

Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: May 9, 2022
Corrected date: N/A

Citation Details

None

Plan of Correction: ApprovedJune 13, 2022

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A plan of correction is not required for Past Non-Compliance deficiencies. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. As indicated in the SOD, No Plan of Correction is required.??ÿ Further, the SOD states that Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey: The facility implemented the following: -On [DATE] the facility conducted a facility wide audit of residents' armbands to ensure placement, alert accuracy, EMR match and DNR status. -Mandatory Inservice-Emergency Response was started on [DATE] for all licensed staff. As of [DATE] they have 299 out 350 which is 85% of licensed staff received in-service. The remaining 15% percent are not on the schedule to work and will be in-serviced prior to commencing work. Interviews conducted on [DATE] at [DATE] with all staff (4 CNAs, 1 LPN, 2 RNs, and 2 RNS), RN Risk Manager, DON and Administrator to ascertain the post incident in-service training/education regarding facility's procedures on identifying resident's code status. -Termination of RN Supervisor & LPN on ,[DATE]/ 22. Reported both nurses to Office of Professions on ,[DATE]/ 22. -Facility Wide Care Plan Audit-of all advanced directive care plans. -Reviewed polices on advanced directives, facility codes and identifiers with revision to ID band policy to include licensed personnel to check for accuracy. -Facility Wide EMR Audit-checked all residents for CPR and DNR orders for accuracy. The facility checked all the residents' physicians' orders for CPR and DNR. -CPR certification- all licensed staff will have updated certification by ,[DATE]/ 2022. ??ÿ