Manhattanville Health Care Center
May 14, 2018 Complaint Survey

Standard Health Citations

FF11 483.70:ADMINISTRATION

REGULATION: §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: May 14, 2018
Corrected date: July 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated and partial extended survey (NY 421), the facility administration failed to ensure that the facility is operated in a manner in which basic life support, including Cardiopulmonary Resuscitation (CPR) is provided in a timely manner to a resident requiring such emergency care. In addition, the administration failed to have a system in place to distinguish [MEDICAL CONDITION] emergency from other types of emergencies. This was evident in 1 out of 20 residents sampled (Resident #1). Specifically, Resident #1 was observed unresponsive and not breathing on [DATE] at approximately 10:30AM. Approximately ,[DATE] minutes had passed before CPR was initiated and approximately 5 minutes before 911 was activated. This practice resulted in actual harm and the potential for serious harm to the health and safety of all residents in the facility that is Immediate Jeopardy. The findings are: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15 indicating an intact cognition (,[DATE] Severe Impairment, ,[DATE] Moderate Impairment, & ,[DATE] Cognitively Intact). The resident has a pacemaker implanted in the right upper chest. The resident had no Advance Directive or Health Care Proxy (HCP). The facility policy and procedure titled STAT (EMERGENCY) with a review date of ,[DATE] documented that if a resident is noted unresponsive, the staff who responds must check the resident's pulse/breathing and advance directive, if any (order and/or name band). A STAT code must be paged for a Full Code resident, initiate CPR if there is no pulse, and call 911. After the incident occurred, the facility developed a new policy on [DATE] changing STAT for Full Code to CODE BLUE. The Medical Director was interviewed on [DATE] at 12:30 PM and stated that he does not remember when was the last time he reviewed the policy and procedure on STAT/CPR. He was made aware that STAT was changed to CODE BLUE the day after it had been changed. He was not involved in formulating or reviewing of the new policy. The Director of Nursing Service (DNS) was interviewed on [DATE] at 3:20 PM and stated that on [DATE], Resident #1 returned from [MEDICAL TREATMENT] after 10:00AM and he was observed unresponsive and not breathing in the ambulette. The resident's code status was not immediately identified because the resident was not wearing a wrist band. She stated that the staff who initially responded to the STAT code arrived on the scene without any emergency equipment because they were confused. The staff was not aware that the STAT code was for a resident in [MEDICAL CONDITION]. The DNS explained that STAT code is used for both a regular emergency (i.e. falls) and for [MEDICAL CONDITION]. The Administrator was interviewed on [DATE] at 4:08PM and stated that he was not aware that there was a problem related to the [DATE] incident. The Director of Nursing Service (DNS) gave him a copy of a revised policy on CODE BLUE. The policy was revised to change STAT, used to identify Full Code resident, to CODE BLUE. The Administrator stated that the DNS explained that she made the change so it would be clearer for the staff to know the difference between a Full Code and other emergencies. The Administrator stated that he was not asked to review the policy before it was changed. Immediate Jeopardy was removed prior to survey exit of [DATE] based on the following corrective actions taken. The facility: -Implemented a new policy titled Policy and Procedure on Emergency Care for Full Code Residents / Code Blue. The policy documented that in the absence of physician order [REDACTED]. The policy also documented that when a resident has no DNR order and has no pulse or respirations or if the resident is in acute distress with labored breathing and faint pulse, the nurse will instruct a staff member to call CODE BLUE by announcing on overhead page CODE BLUE UNIT (Area) ____ three times. In instances when CODE BLUE is announced off unit i.e. lobby, the crash cart will be brought to the lobby. -A CODE BLUE drill guideline and audit tool were also developed by the facility on [DATE]. -Developed and implemented education associated with the Policy and Procedure on Emergency Care for Full Code Residents / Code Blue that was provided to staff of all discipline. The staff that are not in-serviced (i.e. per diem, on leave of absence, on vacation) will be given a copy of the policy via mail. Upon return to the facility, the staff will be in-serviced by the DNS/ADNS and or the Registered Nurse Supervisor prior to working on the unit. -Emergency equipment (AED, ambu bag, oxygen, cardiac board) was made available in the nursing office on the first floor. 415.26

Plan of Correction: ApprovedJune 7, 2018

DP(NAME)
F835
Immediate Correction:
1) On 5/29/18 the Administrator contracted the services of GNYHCFA to implement a directed plan of correction with directed In-service education.
2) On 6/4/18 the Administrator participated in the QA Meeting convened by the GNYHCFA Consultants to examine causative factors resulting in Immediate Jeopardy and subsequent SOD and to identify interventions to correct causative factors.
II. Identification of Others:
1) The facility respectfully states that all residents were potentially affected.
III.Systemic Changes:
1) On 6/4/2018 GNYHCFA Consultants in conjunction with facility Leadership developed a system for Administration to oversee Policy and Procedure review and development in accordance with the Facility Assessment and any system issues reported in Morning meeting and quarterly QA meeting
2) The Administrator, Medical Director and DNS will meet weekly x 4 weeks followed by monthly x 12 months to review all newly revised/developed P/Ps as well as any identified facility issues. The objectives of the meeting will include:
? Review of current Policies and Procedures to identify any areas that need revision
? Review newly established guidelines and recommendations for long term care facilities
? Identify areas that need to have Policy and Procedures developed based on new or revised regulatory requirements and current standards of practice.
? Utilize root cause analysis to investigate instances when facility staff failed to follow established Policy and Procedures
? Identify areas that require Staff Education and/or Competency training based on Facility Assessment.
? The Administrator will monitor compliance the facility P(NAME) outlined under each F-tag.
IV. Quality Assurance:
1) The GNYHCFA consultant developed an audit tool to monitor the facility?s compliance with ensuring effective Administration to ensure that Policy and Procedures are reviewed and revised in accordance with regulatory standards. This audit will be done monthly by the Administrator/designee x 12 months. All findings will be provided to QA Committee and Governing Body for input and follow up as indicated.
V. Person Responsible for this FTag:
Administrator, DNS

FF11 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 14, 2018
Corrected date: July 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review conducted during an abbreviated and partial extended survey (NY 421), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) in a timely manner to an unresponsive resident who had Full Code status with no Advance Directive in place. This was evident in 1 out of 20 residents sampled (Resident #1). Specifically, on [DATE] at approximately 10:30 AM, Resident #1 was observed unresponsive in the ambulette after arriving from [MEDICAL TREATMENT] appointment. The staff responded without any emergency equipment. Approximately ,[DATE] minutes had passed before CPR was initiated and approximately five minutes before 911 was activated. This practice resulted in actual harm and the potential for serious harm to the health and safety of all residents in the facility that is Immediate Jeopardy and Substandard Quality of Care. The findings are: The facility policy and procedure titled STAT (EMERGENCY) with a review date of ,[DATE] documented that if a resident is noted unresponsive, the staff who responds must check the resident's pulse/breathing and advance directive, if any (order and/or name band). A STAT code must be paged for a Full Code resident, initiate CPR if there is no pulse, and call 911. After the incident occurred, the facility developed a new policy on [DATE] changing the code for [MEDICAL CONDITION] from STAT to CODE BLUE. Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15 indicating an intact cognition (,[DATE] Severe Impairment, ,[DATE] Moderate Impairment, & ,[DATE] Cognitively Intact). The resident had a pacemaker implanted in the right upper chest. The resident had no Advance Directive or Health Care Proxy (HCP). The resident had a [MEDICAL TREATMENT] schedule 3 times a week on Tuesdays, Thursdays, and Saturdays. On [DATE] at 11:02AM, surveillance camera was reviewed with the Administrator. The time stamped in the camera's live feed was 11:08AM (actual time was 11:02 AM, the camera was six minutes fast) At 10:36 AM (actual time 10:30 AM) - Certified Nursing Assistant #1 (CNA #1) was waiting outside At 10:37 AM (actual time 10:31 AM) - CNA #1 walked towards the street/ambulette At 10:38 AM (actual time 10:32 AM) - CNA #1 went inside the building At 10:39 AM (actual time 10:33 AM) - escort and Registered Nurse Supervisor (RNS) went outside the building towards the ambulette At 10:40 AM (actual time 10:34 AM) - RNS went back inside the building At 10:42 AM (actual time 10:36 AM) - Ambulette driver and CNA #1 wheeled Resident #1 inside the building At 10:42 AM (actual time 10:36 AM) - Ambulette driver and CNA #1 wheeled Resident #1 to the dining room, staff observed coming into the lobby At 10:43 AM (actual time 10:37 AM) - RN #1 and Director of Nursing Service (DNS) wheeled Resident #1 out of the dining room towards the elevator. After that the resident was no longer visible on camera. At 10:45 AM (actual time 10:39 AM) - The Nurse Practitioner (NP) was observed walking towards the elevator At 10:49 AM (actual time 10:43 AM) - Emergency Medical Service (EMS) was onsite At 11:00 AM (actual time 10:54 AM) - EMS left the facility A Comprehensive Care Plan (CCP) on Advance Directive dated [DATE] documented that Resident #1 had no Advance Directive or Health Care Proxy (HCP) in place. A nurse's note dated [DATE] at 7:28 AM that was written by Registered Nurse #1 (RN #1) documented that Resident #1 went out to [MEDICAL TREATMENT] with an escort at 5:45 AM. A nurse's note dated [DATE] at 5:34 PM, written by the RNS, documented that CNA #1 came to the first floor and informed her that Resident #1 was in the ambulette (in front of the nursing home) and that the escort reported that something was wrong, Resident #1 needed help. The RNS went to check Resident #1 and observed him to be unresponsive to verbal and tactile stimuli. There was no chest movement observed. The resident's eyes were open and he had a palpable carotid pulse. The resident had no Advance Directive in place. A STAT code was called and at 10:33 AM, the NP was able to assess the resident. There was no spontaneous movement present, no audible breath sound, no palpable carotid pulse and CPR was performed. At 10:40 AM, 911 arrived in the facility. As per EMS, resident will be sent to the hospital. Resident #1 was transferred to the Hospital at 11:06 AM. The Prehospital Care Summary Report by the Fire Department New York (FDNY) dated [DATE] documented that 911 received a call from the facility at 10:38 (AM), FDNY arrived at 10:44, made contact with the Resident #1 at 10:45. Resident #1 was on the floor in supine position and CPR was in progress. Assessment revealed that Resident #1 was apneic (suspension of breathing), pale, with cold and moist skin, both eyes were not reactive. No blood pressure, no pulse, no respiration. CPR continued, Automated External Defibrillator (AED) applied, an oropharyngeal airway (OPA) inserted, assisted ventilation by Bag Valve Mask (BVM). Another ambulance arrived on the scene and provided Advance Live Support interventions. They left the facility with the resident at 11:06 AM and the resident was pronounced dead in Emergency Department (ED). Resident #1's Escort was interviewed on [DATE] at 2:15 PM and stated that when the ambulette arrived at the facility from [MEDICAL TREATMENT], Resident #1 was not responding and she asked CNA #1 who was standing in front of the facility to call for help. RNS came to the ambulette and checked the resident. The RNS instructed them to take the resident out of the ambulette and bring him into the lobby. CNA #1 was interviewed on [DATE] at 11:34 AM and stated that on [DATE] she was standing outside of the facility when she observed the ambulette pulled up in front of the building sometime after 10:00 AM. CNA #1 went to the ambulette and observed Resident #1 in the wheelchair in the back of the ambulette, he looked as though he was dozing off. The escort who was with Resident #1 tried to wake him up, but he was not responding. She stated that she ran inside the building and called the RNS. The RNS checked on Resident #1 and told them to bring Resident #1 inside the building. CNA #1 helped in wheeling Resident #1 to the first-floor dining room as instructed by RN #1, who was in the lobby when they entered the facility. CNA #1 stated that she left the facility after wheeling the resident to the dining room. The RNS was interviewed on [DATE] and [DATE] and stated that on [DATE] at approximately 10:30 AM, CNA #1 told her that there was something wrong with Resident #1 who was in an ambulette outside the facility. The RNS stated that she went to the ambulette and observed Resident #1 unresponsive, no chest movement, his carotid pulse felt weak, and he was not breathing. The RNS stated that Resident #1 had a weak carotid pulse because he had a pacemaker. She stated that she instructed the ambulette driver and the escort to take Resident #1 out of the ambulette and bring him to the lobby. Resident #1 had no wrist band so she had to go to the nursing office to ascertain the resident's code status in the computer, once she found out that the resident was Full Code, she asked the Assistant Director of Nursing (ADNS) to page STAT while she called 911. She stated that it took her approximately two minutes from the time she assessed the resident in the ambulette to the time she was able to figure out Resident #1's code status. The RNS stated that she was CPR certified. RN #1 was interviewed on [DATE] at 11:15 AM and stated that she was the charge nurse on the 2nd floor on [DATE] where Resident #1 resided. She stated that she received a phone call from the RNS stating that Resident #1 was unresponsive and that she was not told that it was a STAT so she only brought a sphygmomanometer (a machine used to measure blood pressure) and a glucometer (a machine used to measure blood sugar level) because Resident #1 was diabetic. When she arrived in the lobby, she observed Resident #1 in the wheelchair slumped over to one side. The resident had a weak carotid pulse and was not breathing. She added that he had the pulse because of his pacemaker. She was unable to take his blood pressure because of how Resident #1 was positioned in the wheelchair. She stated that she wanted to take Resident #1 to the 2nd floor because he was not breathing and there was no emergency equipment in the first-floor nursing office. RN #1 and the DNS put Resident #1 into the elevator to take him to the 2nd floor but instead the elevator went to the basement and back to the first floor. She stated that while the elevator was heading back up from the basement she heard a STAT paged overhead. The elevator door opened at the lobby, they took the resident off the elevator, placed him on the floor, and the NP started CPR. RN #1 stated that she was CPR certified. The NP was interviewed on [DATE] at 12:15 PM and stated that on [DATE] she heard a STAT paged overhead and she called the front desk to inquire about the STAT. She was informed that it was for Resident #1. She reported to the lobby and observed a group of staff standing by Resident #1. She explained that Resident #1 was in the wheelchair slumped over to one side and that he was unresponsive. She assessed the resident with no heartbeat, he was not breathing, and he had a thready pulse that was barely palpable. She further stated that Resident #1 needed CPR so they placed him on the floor and she started compressions. LPN #1 arrived on the scene and started telling staff to get the ambu bag (a self-inflating bag used to provide ventilation on patients who are not breathing or not breathing adequately), mask, and AED while she continued compressions. LPN #1 was interviewed on [DATE] at 1:07 PM and stated that on [DATE] he heard a STAT paged overhead and he went to the lobby where he observed the NP assessing Resident #1. He noted that there was no ambu bag or any other equipment at the scene so he started telling the staff to get the emergency equipment. He stated that the NP initiated CPR. The AED arrived and when it was applied to Resident #1, it verified that CPR was necessary. LPN #1 stated that he was CPR certified. The Rehab Director was interviewed on [DATE] and [DATE] and stated that on [DATE] at approximately 10:00 AM, she was in the conference room on the main floor when she heard a STAT paged. She responded to the lobby and observed RN #1 with Resident #1 who was slumped over in his wheelchair. She stated that RN #1 and the DNS wheeled Resident #1 onto the elevator to take him upstairs. However, the arrow on the elevator light was pointing downwards, she held the elevator door open asking them if they had the override key to direct the elevator straight to the 2nd floor. She stated that she felt someone pushed her hand off the elevator door and the door closed. She observed the elevator door open and the resident was wheeled out of the elevator, placed on the floor, and the NP who was in the lobby started CPR. The Rehab Director stated that in case a resident needed CPR they do not have emergency equipment in rehab department. They would wait for nursing to identify the resident's code status and, if appropriate nursing would initiate CPR. She stated they are allied health and they do not participate in an emergency like CPR. She stated that she was CPR certified. The Assistant Director of Nursing Service (ADNS) was interviewed on [DATE] at 11:43 AM and stated that on [DATE] the RNS came and told her to call STAT because Resident #1 was unresponsive. She called STAT to the lobby twice and stayed in the nursing office and prepared the paper work to transfer Resident #1 to the Hospital. She stated that DNR residents have a yellow dot on the wrist band and a yellow dot next to their name in the electronic medical record (EMR). The ADNS stated that when a resident is found unresponsive, the staff should check the resident's pulse, identify the resident's code status, and if full code start CPR right away and call 911. The ADNS further stated that it is better to check the code status in the chart because sometimes wristbands are not updated. The Administrator was interviewed on [DATE] at 4:08 PM and stated that he was not aware that there was a problem related to the [DATE] incident. He stated that he heard a STAT paged on [DATE] and when he went to the lobby he observed CPR in progress. The Receptionist was interviewed on [DATE] at 9:46 AM and stated that she was at the front desk when the ambulette arrived at about 10:32AM. The escort came and said that Resident #1 does not look good. The RNS went to check on Resident #1 and when she came back in she heard the RNS say he is not well I am calling 911. She stated that the escort, the ambulette driver, and CNA #1 brought the resident inside the building. She heard RN #1 tell them to bring the resident into the dining room. The receptionist stated that she announced STAT overhead and the nurses came to the lobby. She added that she observed Resident #1 being pushed onto the elevator, and then he was brought back to the lobby. CNA #3 was interviewed on [DATE] at 11:50 AM and stated that she does not know how to determine a resident's code status. She also stated that she forgot the code for [MEDICAL CONDITION] and that Code Blue is for allergy. LPN #3 was interviewed on [DATE] at 12:00 PM and stated that residents with Do Not Resuscitate (DNR) status have a yellow chart and a yellow dot on the wrist band. However, she was not sure of the code for [MEDICAL CONDITION]. LPN #4 was interviewed on [DATE] at 3:04 PM and stated that she could not remember what to look for on the wrist band to determine a resident's code status. CNA #4 was interviewed on [DATE] at 7:432 AM and stated that she does not know the color of the dot on the wrist band for DNR residents. The Medical Director was interviewed on [DATE] at 12:30 PM and stated that the Administrator informed him on [DATE] that Resident #1 was unresponsive in the ambulette, The Medical Director stated that the resident had a pulse because of the pacemaker and that the staff should have used a stethoscope to check the resident's heartbeat. He stated that I think the delay in initiating CPR was when the staff tried to take the resident upstairs. The DNS was interviewed on [DATE] at 3:20 PM and stated that on [DATE], Resident #1 returned from [MEDICAL TREATMENT] after 10:00AM and he was observed unresponsive in the ambulette. The RNS went to the ambulette and assessed Resident #1 who was unresponsive and not breathing. Resident #1 was not wearing a wrist band and the RNS had to go to the nursing office to find out the resident's code status. She stated that she was in the nursing office when RNS came in to check the resident's code status. She went out to the lobby and noted that RN #1 was in the lobby with Resident #1. RN #1 decided to take Resident #1 to the 2nd floor as there was no emergency equipment in the first floor (lobby level) nursing office. All emergency equipment is kept on the units. She stated that she accompanied RN #1 on the elevator with Resident #1 who was slumped over to one side in the wheelchair. She further stated that the elevator went down to the basement and then back up to the first floor where staff were waiting for the resident. The DNS stated that she did not hear a STAT Code announced and that she did not perform any assessment on Resident #1. The elevator stopped off on the first floor, the resident was taken off the elevator and was laid on the floor. The NP assessed Resident #1 and stated that he needed CPR, which she initiated. She stated that the staff who initially responded to the STAT code arrived on the scene without any emergency equipment because they were confused. The staff was not aware that the STAT code was for a resident in [MEDICAL CONDITION]. The DNS explained that STAT code is used for both a regular emergency (i.e. falls) and for [MEDICAL CONDITION]. Immediate Jeopardy was removed prior to survey exit of [DATE] based on the following corrective actions taken. The facility: -Implemented a new policy titled Policy and Procedure on Emergency Care for Full Code Residents / Code Blue. The policy documented that in the absence of physician order [REDACTED]. The policy also documented that when a resident has no DNR order and has no pulse or respirations or if the resident is in acute distress with labored breathing and faint pulse, the nurse will instruct a staff member to call CODE BLUE by announcing on overhead page CODE BLUE UNIT (Area) ____ three times. In instances when CODE BLUE is announced off unit i.e. lobby, the crash cart will be brought to the lobby. -A CODE BLUE drill guideline and audit tool were also developed by the facility on [DATE]. -Developed and implemented education associated with the Policy and Procedure on Emergency Care for Full Code Residents / Code Blue that was provided to staff of all discipline. The staff that are not in-serviced (i.e. per diem, on leave of absence, on vacation) will be given a copy of the policy via mail. Upon return to the facility, the staff will be in-serviced by the DNS/ADNS and or the Registered Nurse Supervisor prior to working on the unit. -Emergency equipment (AED, ambu bag, oxygen, cardiac board) was made available in the nursing office on the first floor. 415.3(e)(2)(iii)

Plan of Correction: ApprovedJune 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DP(NAME)
F678 I) Immediate Corrective Actions

1) As of [DATE] the DNS completed In-service and Code Blue drill competencies for all licensed nurses
2) A house-wide re-certification for licensed nurses was conducted by an AHA Instructor on [DATE].
3) A tool has been developed to track the certification dates for all licensed nurses.
4) The DNS issued an educational counseling to the RNS failure to properly assess resident # 1 and institute appropriate emergency measures.
5) The DNS issued educational counseling to the RN who arrived on the scene for failure to properly assess resident # 1 and institute appropriate emergency measures
6) On [DATE] the facility contracted the services Of Greater New York Health Care Association to assist with directing the Plan of Correction and Directed Inservice.
7) On [DATE] the GNYHCFA consultants convened the facility QA Committee to assess the causative factors that may have contributed to the deficiencies cited, to identify and correct causative factors, identify routine triggers to alert facility of any evolving issues and develop audit tools to monitor facility compliance with the plan of correction.
II) Identification of other Residents
1) The facility respectfully states that all residents were potentially affected
2) An in house audit was conducted to identify any resident that was not wearing a facility ID band
3) Any missing ID bands were replaced including DNR identifier as needed .A list of residents that refuse to wear ID band was generated for each unit.
F 678 III) Systemic changes
1) On [DATE] The GNYHCFA Consultants in conjunction with the DNS and Medical Director reviewed the policy and Procedure on Emergency Care for Full Code Residents/Code Blue implemented during the abbreviated survey and found same to be compliant.
2) On [DATE] The GNYHCFA consultants in conjunction with the DNS and Medical Director reviewed Code Blue Drill Guidelines and found same to be compliant.
3) On [DATE] The GNYHCFA consultants in conjunction with the DNS and Medical Director reviewed the Emergency Cart containing ambu bag, oxygen, and cardiac board was made available on the first floor in the nursing office that was implemented during the abbreviated survey.
4) The ADNS initiated a tracking system was put into place to ensure that CPR recertification would be done on a timely basis for all Licensed Nurses.
5) The GNYHCFA Consultants implemented staff inservice education on the Updated Policy and Procedure for Emergency Care for Full Code Residents/Code Blue.
6) The GNYHCFA Consultants will Inservice all nursing staff on the Emergency Care for Full Code Residents/ Code Blue.
7) The GNYHCFA will Inservice all ancillary staff on action to take when encountering a resident with a change in condition.
8) Highlights of the Lesson Plan include:
? The Assessment to be done when a resident is noted to be unresponsive utilizing the Airway Breathing and Circulation approach as outlined by the American Heart Association.
? The immediate steps that must be taken when a resident is found unresponsive including ascertaining Code status, activation of Code Blue, activation of 911, and positioning of resident for CPR.
? The importance of immediately initiating Chest Compressions and Ventilations on the spot where the resident determined to have cessation of breathing and pulse.
? The Equipment that is needed to be brought onsite for Cardiopulmonary Resuscitation
? The specific responsibilities of the RN, LPN, CNA, and Receptionist during a Code Blue.
? The Documentation of events during the Code Blue.
? The responsibilities of ancillary staff to report when observing a change in resident condition
9) Inservice on of the Skills Competency via a Mock Code Blue include Demonstration of:
? Assessing unresponsiveness
? Assessing airway/breathing
? Assessing pulse
? Safe positioning of resident for CPR
? Announcing Code Blue over the Intercom
? Activation 911
? Location and transport of Emergency Equipment
? Chest Compressions
? Use of the ambu bag and mask with oxygen
? Application of the AED pads

10) The Policy and Procedure for Identification of Residents with a DNR was reviewed and revised to include that all residents are checked for the presence of the ID band which is documented each shift by the CNA the revised P/P will be inserviced by the GNYHCFA Consultants. Highlights of the lesson plan will include:
? Each shift the CNA will check for resident ID band and document same on the Census and Id Band Sheet. The CNA will notify Unit Nurse any residents missing ID band and replace same validating DNR status as indicated.
? Residents that are noncompliant or refuse to wear an ID band will have a care plan developed and reviewed quarterly including a discussion with resident/resident representative by RNS to review need for ID band. The resident will be offered an ID badge with name and yellow DNR identifier as indicated.
? The yellow color identifier on the ID bracelet that indicates residents who are DNR.
? The Policy and Procedure for checking the presence and accuracy of ID bands was revised to include the use of ID badges for residents who refuse to wear ID bands. The ID badge will be clipped to the top layer of the resident?s clothing and must be visible.
? The Unit nurse will be responsible to ensure that all residents going out of facility for [MEDICAL TREATMENT] or other appointments will have Advanced Directive MOLST form sent with them as indicated.
? The Director of SW will update Advanced Directives list as needed for all new/ re- admissions and anytime an Advanced Directive is changed. The Director of SW will provide Advanced Directive list to each unit, reception desk and Nursing office.
11) The Revised Lesson Plan and Competency for Emergency Care for Full Code Residents/ Code Blue will be included in the Orientation for all Newly Hired Employees and included in the Yearly Mandatory In-services for all Staff
12) The Revised Lesson Plan for DNR Identification will be included in the Orientation for all Newly Hired Employees and included in the Yearly Mandatory In-services for all Staff

F678 IV) Quality Assurance Monitoring
1) The Medical Director and Director of Nursing will review all resident expirations that occur in house utilizing the Code Blue Summary Sheet or Resident Expiration Sheet
2) The GNYHCFA Consultants developed an audit tool to monitor Compliance with Emergency Care for Full Code Residents/ Code Blue
This audit will be done by the DNS/Designee for all residents that have a Code Blue in the facility x 12 months.
3) An audit tool will be done to monitor compliance with resident ID bracelet including Identification of DNR status as indicated.
Audits will be done on 10 residents weekly x 4 weeks followed by 10 residents monthly x 12 months.
4) Findings of the Audit will be brought to the Quarterly Quality Assurance Meeting to track compliance and identify any areas for follow up.
F678 V) Responsible Parties
1.) The Administrator, Medical Director, and Director of Nursing are responsible to ensure compliance with facility Policy and Procedure Emergency Care for Full Code Residents/ Code Blue and completion of all audits.
2.) The Social Work Department and ADDNS are responsible to ensure compliance with facility compliance for Identification of Residents that are DNR.