NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: July 29, 2022
Corrected date: September 19, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during an abbreviated survey (Complaint # NY 682), the facility failed to accurately identify each resident's advance directive status and did not initiate Cardiopulmonary Resuscitation (CPR) when a resident was found unresponsive and with no pulse. This was identified for one (Resident #1) of eight residents reviewed for advance directives. Specifically, on [DATE], at approximately 11:00 AM, when Certified Nursing Assistant (CNA) #1 was providing morning care to Resident #1 the resident became unresponsive. CNA #1 alerted Registered Nurse (RN) #1 who evaluated the resident and noted that the resident was unresponsive and had no pulse or respiration. Resident #1 had a physician's orders [REDACTED]. The facility's Do Not Resuscitate (DNR) identifier is a red armband. RN #1 did not initiate CPR as Resident #1 had a red armband in place from the hospital which was not removed upon admission to the facility on [DATE]. The resident was pronounced dead by RN #1. This resulted in actual harm to Resident #1 with potential for serious harm to 83 residents with full code status that is Immediate Jeopardy and Substandard Quality of Care. The finding is: The facility's policy titled, Advance Directives, revised on [DATE] documented that at the time of admission, an inquiry will be made as to the existence of any prior Advance Health Care Directives such as Health Care Proxy (HCP), Do Not Resuscitate (DNR) orders, Living wills, and Medical Orders for Life-sustaining Treatment (MOLST) forms. Any valid directives will be entered into the resident's medical record. If there is not a pre-existing DNR/MOLST the admitting nurse must ask the resident, and/or the HCP, and/or the designated representative about the existence of any Advance Directives. Based upon the response, the nurse will document if the resident is a DNR or full code. This conversation must be witnessed by the nurse and another clinician and documented in the (resident's) chart. An order from the Medical Doctor (MD) must be obtained to support the resident's and/or HCP or designated representative's request. The facility's policy titled, Admission Policy and Procedure, revised on [DATE] documented that the admission nurse or the charge nurse is responsible for ascertaining that each new admission is properly tagged with an identification (ID) bracelet provided by the Admission Department and any indicated colored armbands. The facility's policy titled, Arm Bands, revised ,[DATE] documented the facility utilizes armbands as identifiers for the resident's status and certain conditions where a point of service identification will help prevent untoward events. All residents are provided with a name identification band on admission. Residents receive an arm band printed by the admission department. All residents have additional colored armbands applied for the following conditions: red for DNR, blue for no Blood Pressure (BP) or blood draw from the extremity, and green for Aspiration Precaution/Swallow alert for residents with modified consistency diets. The arm band policy did not document who is responsible to ensure that arm bands from other facilities will be removed upon admission. The facility's policy titled Resuscitation Measures: Procedures for implementing Basic Life support measures for airway obstruction, respiratory arrest, and or [MEDICAL CONDITION], revised on [DATE] documented that Licensed nursing staff are responsible to implement Basic Life Support measures as warranted by the resident's condition: If a resident demonstrates signs and symptoms of respiratory arrest, the nurse will initiate rescue breathing using an Ambu bag (a hand held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) . If a resident demonstrates signs and symptoms of respiratory and [MEDICAL CONDITION], the nurse will initiate CPR procedures. The staff member discovering the victim is to call out Stat Supervisor and give the location. Supervisor STAT, room ___ is paged. The first nurse to discover the victim or arrive at the scene is to assess the resident to determine the need for Basic Life Support measures. The nurse will check the name and Sigma (Electronic Medical Record (EMR)) orders to determine which resuscitation measures are needed. Once the status of the advance directives is known and they indicate full code, the nurse will initiate CPR and direct other staff to assist as needed. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED].#1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The physician's orders [REDACTED].#1's ID band every shift. The Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. The Nurse's Progress Notes (NPN) dated [DATE] by RN #2 documented that Resident #1 was in stable condition and was alert and oriented. The resident's Advanced Directives were documented as full code (CPR). The Physician's Progress Note (PPN) dated [DATE] documented that Resident #1 was a new admission, was alert and oriented, and had Advance Directives orders as of [DATE] at 9:29 AM for a full code (CPR). A progress note dated [DATE] at 11:11 AM written by Social Worker (SW) #1 documented that they (SW #1) met with Resident#1 this morning. Resident #1 was alert and oriented with a mild short-term memory deficit. Resident #1's family member told SW #1 that advance directives were discussed in the hospital at great lengths with Resident#1 and with the family member present. Resident #1 stated they (Resident #1) wanted CPR. The Nurse's Progress Note (NPN) correction note (with no preceding note) written by RN #1, dated [DATE] at 2:28 PM documented this morning Resident #1 was alert, able to follow commands, and their vital signs were stable. The resident was maintained on oxygen as the oxygen saturation rate was 91%. Resident #1 had no respiratory distress. RN#1 documented that at approximately 11:40 AM they (RN #1) were called to Resident #1's room by CNA #1 and that Resident #1 presented with no signs of life. RN#1 documented that Resident #1 had no pulse detected and no rising of the chest was noted. RN #1 notified Resident#1's Physician and family member. RN#1 documented Resident #1's time of death as 11:40 AM. The facility's investigative summary report dated [DATE] and revised on [DATE] documented that on [DATE] at approximately 11:40 AM Resident #1 was observed with agonal breathing (gasping for air) by Registered Nurse (RN) #1. The resident was wearing a red armband. RN #1 informed the Physician (MD) (of the resident's condition). RN #1 went back to the resident and observed the resident had ceased to breathe. Resident #1 was pronounced dead by RN #1. CPR was not initiated. RN #1 noted that Resident #1 had a full code order in the Electronic Medical Record (EMR) after Resident #1 was pronounced dead. RN #1 went to the Director of Social Work (DSW) and questioned the presence of the red arm band on Resident #1. The DSW confirmed that Resident #1 was a full code. The investigation revealed that Resident #1 was wearing an (red) arm band that was applied by the hospital during their hospital stay prior to the resident's admission to the facility. The red arm band resembled the facility's Do Not Resuscitate (DNR) indicator. RN #1 informed the MD (the resident was a full code). RN #1 did not initiate CPR due to the resident's lividity. RN (#2), who admitted the resident on [DATE], documented that they (RN #2) were about to cut the hospital's red armband off the resident's wrist, but the red arm band was tangled in the resident's chain and the resident was eating at that time. RN #2 intended to return to cut the red arm band off of the resident's wrist but got caught up with other emergencies. RN #2 informed the night shift nurse to remove the red arm band. The facility concluded that RN #1 did not initiate CPR due to the presence of the red armband. Abuse, Neglect, and Mistreatment were ruled out. SW #1 was interviewed on [DATE] at 1:45 PM and stated they (SW #1) met with Resident #1 on [DATE] at approximately 8:,[DATE]:30 AM to complete the admission assessment. Resident #1 was alert and oriented to person, place, and time with mild short term memory impairment. Resident #1's family member told SW#1 that the hospital was very thorough in explaining the advance directives to Resident#1 and them and resident wished to be a full code (CPR). SW #1 stated Resident #1's had a physician's orders [REDACTED]. SW#1 stated they did not discuss advance directives with Resident #1. SW #1 stated that if a resident requested DNR, they (SW #1) are responsible to check the resident's wrist for the presence of a red bracelet, a red dot in the EMR, and a physician's orders [REDACTED].#1 stated they did not check Resident #1's arm band because the resident was a full code. RN #2 was interviewed on [DATE] at 2:18 PM and stated they admitted Resident #1 on [DATE]. RN #2 stated during their conversation with Resident #1 the resident stated they wished to be resuscitated. RN #2 stated they (RN #2) wrote an order for [REDACTED].#2 stated they (RN #2) were responsible to complete a body assessment and remove everything from the hospital, including all wrist bands. RN #2 stated that the admission nurse is also responsible to apply the nursing home's ID band(s), the resident's name on the door, and the resident's bed. RN #2 stated Resident #1 had multiple arm bands from the hospital: a red arm band indicating allergies [REDACTED]. RN #2 stated the red band was entangled with a necklace (a religious item that was worn on the wrist by Resident #1). RN #2 explained to Resident #1 and the family member that they (RN #1) have to remove all hospital wrist bands and put on the facility's ID bands. RN #2 stated that Resident #1 was having dinner at that time. RN #2 returned to the resident but they (RN #2) did not have a pair of scissors to remove the hospital wristbands. RN #2 stated they got busy and told the incoming 11:00 PM-7:00 AM shift Licensed Practical Nurse (LPN) #1 to find a pair of scissors, remove the hospital bands, and apply the facility's ID bands. The Director of Social Work (DSW) was interviewed on [DATE] at 2:23 PM and stated the assigned SW #1 did the assessment for Resident #1 and told the DSW that Resident #1 was a full code on [DATE]. The DSW stated that on [DATE], RN #1 came to the DSW's office at approximately 11 AM and told the DSW that Resident #1 just expired. The DSW asked RN #1 if they (RN #1) called 911 and RN #1 replied that 911 was not called because Resident #1 was wearing a red arm band. The DSW stated the resident was a full code and 911 should have been called. The DSW went to Resident #1's room with RN #1 and confirmed that Resident #1 was wearing a red arm band. The DSW reviewed the MD orders and confirmed that Resident #1 was a full code (CPR). The 11 PM-7 AM shift LPN #1 was interviewed on [DATE] at 9:24 AM and stated that they (LPN #1) were assigned to Resident #1 on [DATE]. LPN #1 stated that RN #2 told them (LPN #1) to remove Resident #1's hospital arm bands. LPN #1 stated they were not able to find any scissors, so they manually took off 1 or 2 bands; however, were unable to remove the hospital's red band. LPN#1 stated that Resident #1 already had the facility's ID band on their left wrist. LPN #1 went to look for a pair of scissors but could not find one. LPN #1 could not recall if they (LPN #1) informed the incoming nurse of the need to remove the resident's hospital red arm band. During a subsequent interview with LPN #1 on [DATE] at 4:26 PM, LPN #1 stated that they (LPN #1) only signed the MAR for the green arm band that they (LPN #1) had applied and for the presence of the facility's ID band. Certified Nursing Assistant (CNA) #1 was interviewed on [DATE] at 9:38 AM and stated they (CNA #1) were assigned to Resident #1 on [DATE] on the 7 AM-3 PM shift. CNA#1 stated at approximately 10:30 AM CNA #1 provided morning care to Resident #1. Resident #1 was alert, calm, and talking and had a red bracelet on their right arm. CNA #1 stated that at approximately 11:20 AM, when they (CNA #1) were fixing the resident's incontinent pad on the bed, they (CNA #1) noticed that the resident not responding to their (Resident #1's) name or touch. Resident#1 was warm to the touch and a little pale. CNA#1 did not see the rise and fall of the resident's chest. CNA #1 immediately called RN #1 who came right away. CNA #1 left Resident #1's room. CNA #1 stated when they (CNA #1) returned to Resident #1's room at approximately 11:40 AM, RN #1 told them (CNA #1) that Resident#1 had expired. RN #3, who was the 7 AM-3 PM assigned supervisor, was interviewed on [DATE] at 10:45 AM and stated that at 2:30 PM RN #1 first reported to them (RN #3) that Resident#1 had expired. RN #3 asked RN #1 if they (RN #1) called for an immediate (STAT) code. RN #1 told RN #3 that Resident#1 had a DNR status. RN #1 did not inform RN #3 that Resident #1 was unresponsive. The Primary Care Physician (PMD) was interviewed on [DATE] at 2:30 PM and stated they (PMD) saw Resident #1 on [DATE] and discussed advance directives with the resident. Resident #1 wanted to be resuscitated. The MD stated on [DATE] they (PMD) were contacted via a text message by RN #1 stating Resident #1 was doing poorly and that Resident #1 was a DNR. The MD responded via text to RN #1 k because the MD did not have the resident's records available and could not recall Resident #1's advance directive status. The MD stated about 3 minutes later RN #1 texted the PMD again that Resident #1 had expired. The PMD stated that RN #1 texted the PMD that Resident #1 is not a DNR. The PMD stated they (PMD) expected that RN #1 would have initiated the CPR protocol and called 911 when a resident is unresponsive. The Director of Nursing (DON) was interviewed on [DATE] at 1:20 PM and stated that on Tuesday, [DATE], RN #3 was reviewing the 24-hour nursing report from the EMR and did not see an entry that RN #1 initiated CPR for Resident #1. RN #3 informed the Assistant Director of Nursing (ADON) who then informed the DON. The DON verified in the EMR that Resident #1 was a full code and initiated the investigation. The DON spoke with RN #1 who stated they did not call STAT, 911, or initiate CPR because they (RN #1) saw a red arm band on Resident #1 and thought Resident #1 had a DNR status. Resident #1 exhibited signs of imminent death, the resident's lips were blue, with no pulse or respiration. RN #1 acknowledged that they (RN #1) later checked the EMR and identified Resident #1 as a full code (CPR). The DON stated they (DON) expected RN #1 to confirm the advance directive of the resident by checking the physician's orders [REDACTED]. The DON stated that they (DON) concluded that RN #1 did not follow the resident's advance directive wishes. The admission nurse did not remove the hospital bands that were in place upon the resident's admission to the facility. The nurses who signed the MAR indicated [REDACTED]. The DON did not believe abuse or neglect occurred. LPN #2, LPN #3, and LPN #4 were interviewed separately on [DATE] between 4:13 PM to 4:25 PM and they stated that they documented and signed the MAR indicated [REDACTED]. The Administrator was interviewed on [DATE] at 4:35 PM and stated that RN #1 saw the red band and thought Resident #1 was a DNR. RN #1 did not verify the physician's orders [REDACTED].#1 noticed the resident was full code it was too late. The Administrator stated RN #1 should have called a STAT, started CPR, and called 911. The Administrator stated the admission nurse should have removed the hospital's arm bands and placed the facility's arm bands on Resident #1. The Medical Director (MD) was interviewed on [DATE] at 6:00 PM and stated that when they (MD) looked at the facility and hospital bracelets, the similarities were troublesome. The MD stated the staff needed to follow the policies and procedures. The MD stated they do not expect the physician to know the code status of the resident; the PMDs rely on the nurses to guide them (PMDs) because the nurses have access to the resident's medical record. The MD stated they expect the nurse to confirm the code status when a resident has trouble breathing. The MD stated that when the nurse saw that Resident #1 was not DNR and was full code, RN #1 should have initiated CPR. If there is a serious event, like this incident, the MD expected the nurse to call the PMD. RN #1 was interviewed on [DATE] at 6:38 PM and stated they were assigned to Resident #1 on [DATE]. At approximately 9:25 AM during the medication pass, RN #1 took the resident's vital signs, and the vital signs were within normal limits. At approximately 11 AM, CNA #1 called RN #1 to the resident's room to see the resident. When RN #1 entered Resident #1's room, they (RN #1) observed Resident #1 was having agonal (gasping for air) breathing, RN #1 raised the resident's head and saw a red band on the resident's right arm. RN #1 stated the facility's policy for red arm band means DNR therefore, RN #1 did not perform CPR. RN #1 left the room to get the family member's phone number. RN #1 used their personal cellphone and sent a text message to the PMD. RN #1 read their text message to the PMD which revealed at 11:37 AM Dr. (Resident #1) looks dying, (the resident) is DNR and can I keep (resident) here and call the family. The PMD texted back at 11:38 AM k. RN #1 came back to Resident #1's room at 11:39 AM and saw that Resident #1 was not breathing. RN #1 texted the PMD again, I think (resident) took (their) last breath, and I am calling the (family member) now. RN #1 stated in a span of two minutes, the resident took their last breath. The resident's time of death was 11:40 AM. RN #1 stated they did not get the chance to check the resident's advance directive orders prior to the resident's death and should have. When RN #1 checked the EMR they saw that Resident #1 was a full code. RN #1 stated that they (RN #1) should have confirmed the resident's advance directive status in the EMR, but RN #1 did not get a chance to do that because they were busy doing something else and was pulled in many directions. RN #1 stated they (RN #1) were focused on the fact that the resident was wearing a red arm band, and they needed to call the resident's family. When RN #1 noticed the discrepancy between the red arm band and the physician's orders [REDACTED].#1) went to the DSW and questioned the resident's advance directive status and the DSW to witness the red arm band on the resident. RN #1 did not recall if the DSW instructed them (RN #1) to call 911. RN #1 stated when cutting the red arm band, they noticed that the arm band was the hospital's red arm band and not the facility's. Because the red color was the same RN #1 assumed the red arm band was the facility's DNR red arm band. RN #1 stated that at 11:57 AM they (RN #1) texted the PMD Sorry Dr. but resident is not DNR, but (resident) is clearly gone, the patient is full code per (their) wishes. At 11:58 AM the PMD responded via text yes (resident) is full code. RN #1 stated the PMD did not compel' RN #1 to do CPR. RN #1 stated if that red arm band was not present on the resident then, they would have started CPR. Once they (RN #1) identified that Resident #1 was a full code (CPR) RN #1 felt there is no reason for them (RN #1) to start CPR and believed that Resident #1 was clinically gone and it was too late. 415.3(d)(iii) | Plan of Correction: ApprovedAugust 29, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-678 Directed Plan of Correction was done by consultant: CMS Compliance Group, Inc 68 south Service Road, Suite 100 Melville, NY 1.The following actions were accomplished for the residents identified in the sample: Resident #1 expired; therefore, no corrective action could be implemented. RN#1 The identified licensed nurse who did not initiate CPR was suspended [DATE], returned to duty on [DATE] and received additional education specific to identification of a residentÆs advance directives and initiation of resuscitative measures when appropriate. The DNS/designee identified all licensed nurses who signed the MAR indicated [REDACTED]. On [DATE] the facility policy and procedure ôAdmission Policy and Procedureö was reviewed by Administration and revised to include that the admission nurse is responsible for ensuring that admitted residents are wearing the proper CIH armbands and that bands applied by a previous facility are removed. The nursing supervisor is responsible for verifying that all admissions/readmissions are wearing the correct armbands. On [DATE] the facility policy and procedure ôDo Not Resuscitateö (DNR) was reviewed by Administration and revised to include an additional step of including documentation on the MAR indicated [REDACTED]. The above additional order was entered on [DATE] for all resident with current status of DNR. On [DATE] the facility policy and procedure ôArm Bandsö was reviewed by Administration and revised to indicate the admission nurseÆs role in removal of previously placed ID bands and placement of CIH issued bands. New orders were added into the EMR for the assigned nurses to check the presence of name identification bands as well as red colored arm bands indicative of DNR status every shift and document same on the MAR. On [DATE] the facility policy and procedure ôResuscitation Measuresö dated [DATE] was reviewed by the Administration and no revision was indicated. All responsible staff were educated by the Staff Development Educator/designee on the revised policies and procedures starting on [DATE] and 100% compliance has been met with this initial education. 2. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents with an advance directive order have the potential to be affected by the same practices. On [DATE] the facility completed a full house audit to confirm Advance Directive/code status was correctly identified and consistent with physician orders [REDACTED]. The audit was completed daily for one week, as of [DATE] was completed three times a week and as of [DATE] will continue twice a week. The facility form ôDNR/CPR Nursing Responseö will continue to be used for all supervisor STAT events. Effective [DATE], the facility implemented a form to utilize for Supervisor ôStatö Drills. The Staff Educator/Supervisor/designee are responsible for completion of this form and forwarding the completed form to the DNS/designee. All responsible staff have received education on completion of this form. On [DATE] the facility policy ôDo Not Resuscitate (DNR) was reviewed by Administration and was revised to reflect the removal of colored dots DNR identifiers (red dots) from the spine of resident paper charts and the name plate above the bed. The identifiers were removed from both areas on [DATE] for all residents who have a DNR. On [DATE], the DNS/designee reviewed the BLS/CPR certification of all licensed nurses to ensure scheduled licensed nurses are qualified to provide basic life support, including CPR to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the residentÆs advance directives, and physician orders. All licensed nurses will be CPR/BLS certified as of [DATE]. The Staff Educator will continue monitoring the CPR/BLS certification of all nurses. As per the Directed In-service, the Outside Consultant initiated education for all clinical and non-clinical staff on [DATE] related to CPR and this education will continue until all staff, including PT/PD and agency staff, have received the mandatory education on F-678 protocols. Education will emphasize the need to ensure residents are wearing appropriate CIH issued identification bands, initiate a supervisor ôSTATö during emergency situations, the licensed nursesÆ responsibility to verify code status prior to initiating CPR and checking for DNR identifiers (red armband) every shift. 3.The following measures and / or systemic changes will be implemented to ensure the deficient practice identified does not recur: Effective [DATE], Advance Directives discussion will be included during the daily morning report to identify new admissions/readmission code status as well as changes to residentÆs code status and/or life-sustaining orders. Residents leaving the building for outside appointments will continue to travel with an envelope with information inclusive of code status; escorts are informed of the same. All new staff/agency staff will continue to be educated by Staff Development Educator/designee on the identification of code status during their orientation and the Supervisor STAT procedures. All staff will be re-educated annually as well as on an as needed basis. Follow-up monitoring will be completed by the Staff Development Educator and Nursing Supervisors to ensure staff understands these protocols and their responsibility to adhere to them. The DNS/designee will continue to monitor information shared at Morning Report to identify any issues/concerns related to CPR and Advance Directives. Immediate investigation and implementation of corrective actions will be implemented, such as staff reeducation or review of current protocols for any additional corrective action, as needed. The DNS/designee will continue to monitor daily staffing to ensure that properly trained personnel (and certified in CPR for Healthcare Providers) are available immediately (24 hours per day) to provide basic life support, including CPR, to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the residentÆs advance directives, and physician orders. Nursing management will continue to monitor and maintain a record of licensed nursing staff who are trained and qualified to provide CPR and are able to demonstrate current competency. The DNS/designee will conduct a review of all expirations following a ôSTATö event to assess compliance with all new and revised policies and procedures related to basic life support. Review activities will include confirming code status and staff following advance directives related to CPR, assessing staffÆs timely and appropriate response to a Code, as well as assessing if responsible staff completed the documentation accurately and that expiration notes and other clinical assessment notes are entered in the medical record. 4. The facilityÆs compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan, a Quality Assurance Committee meeting co-chaired by the Outside Consultant was held on [DATE] to discuss and conduct a Root Cause Analysis (RCA) of this deficiency. The facility has developed audit tools to monitor compliance with staff adherence with Admissions/DNR/ Arm bands/Resuscitation Measures policies and procedures. The Director of Nursing/designee will conduct a full audit (100%) of Advanced Directives/physician orders/verification of ID bands weekly for one month, then monthly for three months to determine compliance and consistency with completion of required documentation. Following the initial 100% auditing of Advance Directives, physician orders/ verification of placement of ID bands, the Director of Social Work/designee will audit all residents monthly for six months. The Director of Social Work/designee will report Advance Directives and Physician orders [REDACTED]. Corrective actions, such as staff reeducation, will be implemented as needed. The Director of Social Work/designee will report all Advanced Directive and Physician order [REDACTED]. Following this six-month period, the QAPI Committee will determine the frequency thereafter. The Director of Nursing/designee will audit all ôStatö events to assess compliance with CPR being initiated as per a residentÆs Advance Directives and Physician orders. All Code event audit findings will be reported to the Administrator and Medical Director following completion of the audit. Immediate corrective actions, such as further investigation of the event or staff reeducation, will be implemented as needed. The Director of Nursing/designee will report all ôStatö event audit findings to the QAPI Committee quarterly for evaluation and follow-up corrective action. Ad hoc committee meetings will be convened to conduct an RCA when there is staff failure to adhere to facility protocols related to initiation of CPR. The Staff Educator/designee will utilize the Advance Directives/CPR/Code Status questionnaire to determine staff knowledge of these protocols. Initially all staff will complete the questionnaire following participation in mandatory education. The Staff Educator/designee will then audit 20% of staff monthly for the next three months to determine staffÆs knowledge of the above protocols. Licensed nurses will be included in all audit samples. Reeducation will be provided as needed. The Staff Educator will report Staff Knowledge of Advance Directives/CPR/Code Status to the QAPI Committee quarterly for the next six months for evaluation and follow-up. At the end of the six months, the QAPI Committee will determine the need for ongoing auditing and frequency thereafter. The Staff Educator will conduct ôStatö drills on a quarterly basis for the next six months on all shifts in different locations and utilizing random scenarios to assess the staffÆs compliance and understanding of correct implementation of CPR when indicated. All ôStatö drill findings will be discussed at the QAPI Committee meeting for evaluation and follow-up actions. Person Responsible: Director of Nursing Compliance Date: [DATE] |