Health inspection·April 24, 2025

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, policy review, and surveillance camera review, the facility failed to ensure a resident's advance directive choices were honored for a resident's expressed wishes for a Do Not Resuscitate (DNR) order for 1 of 4 sampled residents reviewed for DNR status (Resident #1). The deficient practice caused Resident #1 to have likely suffered serious psychological harm by the facility's attempt to be resuscitated against his wishes. Resident #1 could not express his reaction to this event; therefore, the reasonable person concept was applied. Additionally, there was a likelihood that Resident #1 experienced severe physical pain; broken ribs; broken sternum and bleeding in the chest area from the resuscitation efforts (https://pubmed.ncbi.nlm.nih.gov/38206442/). The facility staff did not follow their procedure to verify code status prior to initiating CPR. These actions resulted in the identification of Immediate Jeopardy. The facility administrator was informed of the Immediate Jeopardy on [DATE] at 9:45 AM. The Immediate Jeopardy was removed after verification of the facility's removal plan on [DATE], with an effective date of [DATE]. The scope and severity was reduced to D, no actual harm with potential for more than minimum harm. At the time of the investigation, there were 63 residents who were identified as DNR status. The findings included: A review of the facility's policy titled Advanced Directives and Code Status, dated [DATE] and [DATE], revealed the code status order will be documented in the electronic record and will serve as the primary source of validation of code status by a licensed nurse should a resident be found unresponsive. If the electronic record has an order for DNR, then CPR will not be initiated. If the electronic record is down, the code status must be verified by a licensed nurse using the backup code status notebook. The State of Florida DNR form will be used to communicate a resident's DNR code status wishes to 911/Emergency Medical Services (EMS) should the resident be found unresponsive. Record review revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the prostate (prostate cancer), Type 2 Diabetes Mellitus, Hypertension, and Muscle weakness. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/maximum assistance with activities of daily living. Resident #1 was care planned for a DNR on [DATE]. An intervention included to verify the presence of physician order for a DNR. Page 1 of 6 105607 105607 04/24/2025 Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401

F 0578 The resident had an order for DNR date [DATE]. Level of Harm - Immediate jeopardy to resident health or safety Resident #1's DNR form/document was signed on [DATE] by the resident. The document was signed by the physician, but not dated. Residents Affected - Few A review of Resident #1's progress notes, written by Staff Nurse A, a Licensed Practical Nurse (LPN), dated [DATE] at 5:30 AM, revealed Resident #1 became unresponsive while care was being provided by Staff B, a Certified Nursing Assistant (CNA) and Staff C, a Certified Nursing Assistant (CNA). Staff Nurse A went to the room and the resident was difficult to arouse. Staff Nurse A, checked the computer for the code status, which was a DNR. Staff A then proceeded to check the DNR status binder for a signed yellow DNR document, which was not in the binder. Staff Nurse A returned to the room, tried to arouse the resident again without success, and called 911. There was no documentation in the progress note on whether or not the nurse assessed the resident for a pulse or respirations, or that she had initiated CPR. The progress note stated the resident was transferred to the hospital for further evaluation and treatment. During an interview with the Director of Nursing (DON) on [DATE] at 11:30 AM. The DON acknowledged Resident #1 had a Do Not Resuscitate Order (DNRO) and a signed DNR document. During an interview with the Unit Manager (UM) on [DATE] at 1:20 PM. The UM stated she received a call on [DATE] at approximately 5:55 AM from Staff A, who stated Resident #1 was being dressed for dialysis and stopped talking. The resident was not responding. The UM asked for the code status of the resident, and was told the resident was a DNR and had been sent out. The UM stated she called the nurse back and asked if she did CPR, and nurse stated yes. Then the UM called the Director of Nursing (DON) to inform her of the incident. The UM stated when she came in the facility, Resident #1 did not have a DNR form/document in the Red book/DNR status binder. The UM stated, she printed out the form and placed it in the binder. The UM stated, residents should have a DNR form in the binder for when residents transfer out, or in the case of a power outage. A telephone interview was conducted with the Risk Manager (RM) via telephone on [DATE] at 2:30 PM. The RM stated, he was notified via telephone that Resident #1 was sent out via 911 on [DATE]. The RM stated, he started a chart review and spoke to staff about what occurred. The RM reviewed the surveillance cameras, and interviewed Staff A, Staff B, and Staff C, who all provided written statements. The RM stated, the root cause analysis was human error. The RM stated, Staff A knew Resident #1 had an order for a DNR in the electronic records, but second guessed herself and looked in the DNR status binder. The RM further stated that Staff A stated she did CPR on the resident. During an interview on [DATE] at 4:00 PM with Staff Nurse A, LPN, Staff Nurse A explained that 10 minutes prior to the incident, Resident #1 was getting ready for dialysis and being helped by two CNAs, Staff B and Staff C. When she got notified of the resident being unresponsive, she was shocked, ran to the room, shook him and called his name, and there was no response. Staff A stated she went back to the nursing station, checked the DNR Status binder and did not find the DNR document. Staff A stated she called 911 and the operator said to start CPR. Staff A stated she got the crash cart and went to the resident's room, a few seconds later EMS arrived. Staff A stated, there was no time for me to perform CPR. CPR was started by EMS. Staff A stated that in the 8 years that she had been working in this facility, she was always told that the confirmation of a DNR status relied on the yellow DNR document in the binder on each unit. If no DNR document was found in the binder, the resident should be treated like a full code. But they changed management so many times. Staff A stated she did not tell the 911 operator or EMS that the resident had a DNR order because they did not ask. 105607 Page 2 of 6 105607 04/24/2025 Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few There was conflicting information from Staff Nurse A's interview with the surveyors. Staff A stated to the surveyors that she did not initiate CPR prior to EMS arriving. However, a review of the EMS report, dated [DATE] 05:24 AM, stated upon their arrival Rescue found the patient lying supine in a hospital bed with CPR in progress. On [DATE], the DON provided a copy of the Advance Directive Acknowledgment form signed by Staff Nurse A, dated [DATE], which demonstrated Staff Nurse A had read and understood the facility's Advance Directive policy, which stated that the primary source to verify code status is the order in the electronic health record in PCC (Point Click Care). During an interview with the Social Service Director (SSD) on [DATE] at 5:00 PM. The SSD stated her department is responsible for placing DNR documents in the chart and binder. Before the DNR document is placed in the DNR status binder, it has to be signed and dated by resident/representative and physician. The document is placed in the binder and scanned into the electronic medical record (EMR) within the same day. The SSD stated she probably took the resident's DNR document from the binder, scanned it into EMR, and did not replace it back into the binder. The SSD stated it is an expectation that every resident that has a DNR order has a DNR document in the DNR status binder. On [DATE] the surveyors reviewed the [DATE] surveillance footage which showed the paramedics wheeling Resident #1 down the hallway of the facility with the chest compression machine operating and ambu bag for oxygenation (the full form of AMBU is Artificial Manual Breathing Unit. This device is used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately). A review of the hospital emergency department admission record, dated [DATE] at 5:47 AM, revealed Resident #1 was admitted while receiving CPR. The hospital emergency department notes documented EMS was called for patient unresponsiveness, the call was placed approximately 10 minutes prior to their arrival. There was no pulse on their arrival. At the time of the patient arrival in the Emergency Department, there had been no pulse for at least 30 minutes. IJ Removal: On [DATE] the facility provided an acceptable plan to remove the Immediate Jeopardy. The plan included the following immediate actions which were verified as implemented before the survey exit to prevent this event from reoccurring: 1. [DATE] Resident pronounced deceased at 5:51 AM by hospital personnel. 2. [DATE] MD was notified that the resident was transported to the hospital. 3. [DATE] Notification to unit manager. 4. [DATE] Notification of event to DCS (Director of Clinical Services). 105607 Page 3 of 6 105607 04/24/2025 Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401

F 0578 5. Level of Harm - Immediate jeopardy to resident health or safety [DATE] Notification to ED (Executive Director) Residents Affected - Few [DATE] - [DATE] Education on code status, DNR policy, abuse and neglect policy initiated for current license staff. With post quiz and attestation. 6. 7. [DATE]- New hired licensed nurses will be educated on the advanced directive DNR policy with post quiz and attestation. Ongoing. 8. [DATE] Resident's chart review completed. 9. [DATE] Audit of medical records of current residents to validate DNR/CPR orders. 10. [DATE] Federal immediate report submitted with the notification to DCF and law enforcement. 11. [DATE] Code books reviewed for accuracy. Books located at each nursing station. 12. [DATE] The nurse involved in the incident was removed from the schedule pending investigation. 13. [DATE] Code blue drills to be performed as follows: every shift times 7 days, then every other day on different shift times 7 days, then weekly times 7 days, then monthly to include weekends and holidays starting on [DATE] until all nurses have attended a code blue drill with no deficiencies, alternating different scenarios of code status to increase staff understanding. 14. [DATE] Medical director notified of events and interventions. 15. [DATE] Crash carts audited. 105607 Page 4 of 6 105607 04/24/2025 Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401

F 0578 16. Level of Harm - Immediate jeopardy to resident health or safety [DATE] - [DATE] CPR cards audited for validation. Residents Affected - Few [DATE] Ad hoc meeting with Interdisciplinary Team (IDT) and medical. director. 17. 18. [DATE] - [DATE] Quiz presented to licensed nurses to validate knowledge on code status and procedures competency as needed. 19. [DATE] Licensed nurse hires to be educated on current advanced directive policy attestation and competency and post quiz. Ongoing. 20. [DATE] New admissions/readmissions records to be reviewed daily Monday through Friday and AM clinical meeting on weekends by the nursing supervisor for accurate cold status. Ongoing. 21. [DATE] Reeducate SSD, UM, DCS, DQA on DNR policy and obtaining form DH1896 (DNR document) with physician and resident representative signature as soon as an order is received for DNR. 22. [DATE] - ongoing SSD/designee will do audit daily Monday through Friday during clinical meeting of binders kept at the nurses' station to ensure that form 1896 is in place for those residents with an order for DNR. 23. [DATE] - ongoing Results and outcome of audits of binders for Form 1896 to be presented monthly. 24. [DATE]- 04/14 audit results and outcome of drills to be presented weekly times 3 at ad hoc meeting. Then monthly times three months or until compliance to determine the effectiveness of the plan. Plan to be revised as necessary. 25. [DATE] Federal five day report submitted. 26. 105607 Page 5 of 6 105607 04/24/2025 Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401

F 0578 [DATE] Report to the board of nursing. Level of Harm - Immediate jeopardy to resident health or safety 27. Residents Affected - Few IJ Removal date [DATE]. [DATE] - [DATE] Physician to be re educated on signing and dating Form 1896. Review of the in-service attendance sheets validated the participation of licensed staff education on the above topics. 100% of the nurses were in-serviced. Review of the code blue audits revealed no concerns. On [DATE] and [DATE], interviews were conducted with licensed staff that represented all three shifts. All staff interviewed confirmed they were made aware of the incident that involve a resident with a DNR status that received CPR. They verbalized understanding the education provided and verified participation in at least one mock Code Blue drill. SSD acknowledged education on ensuring resident's DNR document was signed and dated by resident/representative, and placed in the DNR status binder on each unit, and continued audits. A telephone interview was conducted with the Medical Director on [DATE] at 11:00 AM. He acknowledged the above information. 105607 Page 6 of 6