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Based on observation, staff interviews, medical record review, review of facility policies and procedures, and review of other related documentation, it was determined that the facility failed to protect and promote the rights of the patients.

Findings include:

1. The facility failed to ensure that patients receive care in a safe setting (Cross refer to Tag A 0144).

A. Based on observation, staff interview, review of two (2) of two (2) personnel files, review of one (1) out of one (1) medical record and a review of facility documents, it was determined that the facility failed to ensure first qualified responders certified in Cardiopulmonary Resuscitation (CPR) assess to make sure the patient is breathing, has a palpable circulation, secures the airway, and if no pulse or respiration can be determined, then they will start CPR.

Findings include:

Reference: Facility policy titled, "Code Blue Emergency" states, "... II: Definitions A. Basic Life Support (BS): is the provision of cardiopulmonary resuscitation and first aid, and may require use of an Automated External Defibrillator (AED) ... C. CPR - Cardiopulmonary resuscitation - The initial care for cardiac arrest until more advanced cardiac life support is available. ... IV. Procedure: Cardio Respiratory arrest. a. The first responder is defined as the person who discovers the victim. The standard order of procedure is for the first qualified responder (one certified in CPR) to make sure the victim is breathing, has a palpable circulation and secures the airway. If no pulse or respiration can be determined, then they will start CPR ..."

1. On 4/27/2021 at 10:15 AM, in the presence of Staff #1, Staff #3, Staff #4, and Staff #10, recorded video surveillance on 4/15/2021 of the Dining Room on the B3 Unit was reviewed by the surveyors and revealed the following:

a. On 4/15/2021 at 2:13:59 PM, Patient #1, while seated in a chair, became unresponsive.

(i) At 2:14:27 PM, Staff #21 responded to the patient and was observed to summon for assistance from Staff #20.

(ii) At 2:14:45 PM, Staff #20 was observed to respond to the patient.

b. It was not identified during the video surveillance review that the first responders (Staff #21 and Staff #20) assessed the patient for breathing, palpable circulation, and secured the airway to determine if CPR needed to be initiated.

2. On 4/27/2021 at 10:30 AM, Staff #1 stated that both Staff #21 and Staff #20 are required by the facility to be certified BLS (Basic Life Support).

a. Review of Staff #21 and Staff #20's personnel files revealed that they both had current BLS certification.

3. Staff #1 confirmed these findings on 4/28/21 at 10:55 AM.


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B. Based on observation, staff interview, review of one (1) of one (1) medical record, and a review of facility documents, it was determined that the facility failed to ensure their policy for Code Blue Emergency is implemented.

Findings include:

Reference: Facility policy titled, "Code Blue Emergency" states, "... 3. An [sic] RN (Registered Nurse) is designated on the Assignment Sheet as the recorder at the start of the shift. This person will fill out: a. Code Blue Record Events b. Sequential Order of Events ... Registered Nurse: ... Monitors the patient's condition, level of consciousness, vital signs, and reports the results to the RN designated as the recorder. ..."

1. On 4/27/2021 at 10:15 AM, Staff #1 indicated that a Code Blue Emergency was initiated on the B3 Unit for Patient #1 on 4/15/2021 at 2:15 PM.

2. On 4/28/2021 at 10:00 AM, Staff #2 provided the following facility forms for review which indicated the following:

a. The "Nurse Directed Care-Day Staff Assignment-Unit B3; Date: 4/15/2021" stated, "Emerg. Med. Record (Emergency Medical Recorder) ... (Staff #9)."

(i) On 4/28/2021 at 2:38 PM, upon interview, Staff #9 confirmed that he/she was designated as the dayshift RN recorder on 4/15/2021 for the B3 unit.

b. The "Department of Nursing Services Medical Emergency Care Recording Form" indicated that the Code Blue was initiated on B3 on 4/15/2021 at 2:15 PM.

(i) Staff #9 confirmed that Staff #13 was the documented RN recorder on the form and that he/she came to the B3 unit from another unit in the facility. Staff #13 stated on the form, "I arrived at 2:24 PM."

(ii) Staff #13 initiated Code Blue Record Events and Sequential Order of Events documentation at 2:24 PM.

(iii) There was no documented evidence on the form that the RN monitored the patient's condition, level of consciousness and vital signs and reported the results to the RN designated as the dayshift RN recorder from when the Code Blue Emergency was initiated at 2:15 PM until Staff #13 arrived at 2:24 PM and began recording.

3. The above findings were confirmed by Staff #1 on 4/28/2021 during the survey exit.