Health inspection·March 11, 2024

F 0678 Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observations, interview and record review, the facility failed to ensure that personnel provide basic life support including CPR, to a resident requiring such emergency care prior to the arrival of medical personnel and subject to related physician orders and the resident advance directive for 1 resident (CR #1) of 13 residents reviewed for quality of life. The facility failed to immediately initiate CPR at 3:41 p.m. on [DATE] when CR#1 was found unresponsive, causing a 3-minute delay. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:49p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective. This failure could place residents that are a full code at risk of not being provided CPR in a timely manner at risk for death. Findings include: Record review of CR#1's face sheet on [DATE] at 10:30 a.m., revealed she was an [AGE] year-old female that was originally admitted on [DATE]. She had diagnoses of Dementia-loss of cognitive functioning, Psychotic Disturbance-loss of contact with reality, Paroxysmal Atrial Fibrillation-a rapid erratic heart rate, Aphasia-a language disorder that affects a person ability to communicate, Contracture-abnormal thickening of the skin. Record review of CR#1's hospital record dated [DATE] revealed that CR#1 was examined in the emergency room and was found to have been in cardiac arrest, PEA, ACLS measures implemented, definitive airway established, patient with PEA and one episode of V-fib status post defibrillation, subsequently with ROSC though patient became bradycardic again and became pulseless, ACLS measures were implemented again, PEA rhythms again encountered. Given period of pulselessness, recurrent PEA, patient with poor prognosis, resuscitative efforts terminated, patient expired at 5:08 p.m. Record review of MDS dated [DATE] revealed, CR #1's BIMS score was not scored because cognitive skills were severely impaired. CR #1's functional status revealed she required supervision in the following areas: bed mobility, ambulation, eating, and extensive assistance with dressing, toilet use, and personal hygiene. Page 1 of 6 676381 676381 03/11/2024 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of CR #1's Care Plan dated [DATE] indicated CR # 1 was care planned for advance directive having a guardianship and full code. Further review revealed that CR #1 was care planned for impaired communication evidence by no speech, rarely/never understood. Record review of CR #1's Physician Orders dated [DATE] revealed CR #1 code status: FULL CODE. Observation of video surveillance from Cr #1's on [DATE] revealed the following on [DATE]: -3:41 p.m. CNA B had a wipe and wiped the side of her face and neck. CNA B left the room in a hurried walking pace, no rise or fall of chest noticeable; -3:42 p.m. LVN B returned, calls CR #1's name and pushed on the side of her head, there was no rise and fall of chest noticeable. LVN B left and said we got a code and told CNA B to stay right there. No one initiated CPR, -3:43 p.m. heard 911 from the hallway, and staff members LVN-C came and wiped resident face with her gown, did not initiate CPR, -3:43 p.m. crash cart and LVN B, ADON, LVN C, can B, and CNA D enter the room, -3:44p.m. staff was getting resident placed on floor, and -3:44 p.m. CPR was initiated. Interview with CNA B on [DATE] at 1:22pm revealed that she was preparing to provide care for CR#1 and she noticed that the resident was having difficulty breathing. She said she told LVN B two or three times that CR#1 was having difficulty breathing and LVN-B finally came into the room and saw CR#1 was having difficulty breathing and LVN B called a Code blue. Interview with LVN B 0n [DATE] at 11:37 a.m., revealed she said CNA B did not tell her several times that CR#1 was having difficulty breathing. LVN B said that CNA B came to her once and said that CR#1 seemed to have difficulty breathing and that is when she went to the room and saw that CR#1 chest was not rising and she immediately called Code blue and ran to get help and she told CNA B to stay with the resident. Interview with the DON on [DATE] at 12:54 p.m., revealed she prefers that in the event of a Code Blue that the Nurse goes and get the crash cart and whatever else may be needed, because the Nurse has access to know if a resident is a full code or DNR. Interview with LVN C on [DATE] at 2:15pm revealed that she entered CR#1's room and did not initiate CPR. Instead, she stood by CR#1's bed and wiped her mouth with a towel. LVN C was asked why she did not initiate CPR. Her answer was that the resident was on an air mattress, and she could not initiate CPR because she could not place CR#1 on the floor. Record review of https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600120/ on [DATE] For every minute without CPR, survival from witnessed VF cardiac arrest decreases by 7-10%.1 When bystander CPR is provided, the decrease in survival is more gradual and averages 3-4% per minute from collapse to defibrillation. Bystander CPR has been shown to double or triple the chances of 676381 Page 2 of 6 676381 03/11/2024 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0678 survival from witnessed cardiac arrest at many different intervals to defibrillation. Level of Harm - Immediate jeopardy to resident health or safety Record review of the NF Policy on Cardiopulmonary Resuscitation revealed in part: Residents Affected - Few The facility will follow current American Heart Association guidelines regarding CPR. If a resident experiences a cardiac arrest , facility staff will provide basic life support , including CPR prior to the arrival of emergency medical services. The Administrator and the DON were informed the Immediate Jeopardy was removed on [DATE] at 2:43 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The Plan of Removal was accepted on [DATE] at 10:47am and indicated the following: Facility Plan to ensure compliance: Plan of Removal Date: [DATE] F- 678 Problem: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. -The facility failed to immediately initiate CPR at 3:41 p.m. when CR#1 was found unresponsive, causing a 3-minute delay CR#1 Was transferred out to the hospital via EMS on [DATE] @ 1616. LVN# B and C were suspended pending investigation on [DATE]. C.N.A.'s B and D were suspended pending investigation on [DATE]. Interventions: 1. On [DATE] The facility conducted a Mock code blue by the DON/Designee and re-reviewed the process to ensure staff have a sense of urgency and are knowledgeable of the appropriate steps to take in an emergency. The facility will conduct the mock code blue with all employees and all departments. This includes but is not limited to employees performing a Code response return demonstration, acknowledgment of training. The training also includes placing residents on a hard surface before CPR is initiated regardless of whether they are on an air mattress, Wheelchair or Geri-chair. During the mock code the response and understanding of the role is being evaluated along with the skill and acknowledgement that the response and the skill will be performed timely and appropriately 676381 Page 3 of 6 676381 03/11/2024 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0678 Level of Harm - Immediate jeopardy to resident health or safety during a code. The trainer utilizes a check list to ensure the course of events takes place appropriately and provides feedback. Any nurse not present or in serviced on [DATE] and [DATE], will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Completion projected [DATE]. Residents Affected - Few 2. On [DATE] the DON/Designee immediately initiated an in-service with the facility staff on the importance of immediately initiating CPR, including but not limited to the consequences of delaying emergency care. Projected completion [DATE]. Monitoring notes Record review of 'In-service Training Report dated [DATE] revealed all facility staff were educated by the facilities DON/Designee. Staff were educated on the importance of initiating CPR as soon as possible and the consequences of what can happened when CPR is delayed. 3. On [DATE] The facility immediately initiated an in-service regarding the CPR process. When a resident is noted to have a life-threatening change in condition, such as gasping for air, without a pulse, or unresponsive, the employee will immediately shout for code blue. They will get the crash cart, AED and check the residents advance directive status. If the resident wishes to be a full code the staff will immediately initiate CPR. Projected completion [DATE]. 4. On [DATE] A study on recent advances and controversies in adult cardiopulmonary resuscitation, by Wanis H [NAME], was reviewed with facility managers, C.N.A's, Med Aides, and licensed nurses. The study will be reviewed via in-service with the staff to give them perspective about CPR and how important it is to perform it and why is it important to initiate promptly. Projected completion [DATE]. 5. On [DATE] the DON/Designee initiated an in-service with the facility nursing staff on Changes of condition/Code Status/CPR Process, focusing on the sequence of events of a code. [DATE]. 6. On [DATE] the DON/Designee did in-service with all staff on the location of the residents' code status binder and or where in the electronic medication record that is information is also located. [DATE] 7. On [DATE] The Social Worker/designee completed the audit to verify all code status were correct and in place for staff to identify. No issues noted. 676381 Page 4 of 6 676381 03/11/2024 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0678 8. Level of Harm - Immediate jeopardy to resident health or safety On [DATE] the DON/Designee educated on practicing within the scope of their license/certification during a code. Staff were educated during a mock code with return demonstration and acknowledgement. Monitoring notes Residents Affected - Few 9. On [DATE] The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with nursing staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion [DATE]. Record review of the facility's training questionnaire dated [DATE] revealed that all facility staff were able to answer the questions listed on the questionnaire in a satisfactory manner. 10. An impromptu QAPI meeting was conducted with the facility's Medical Director, on [DATE] to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on [DATE]. Monitoring Notes Interviews were conducted on [DATE] from 3:00 p.m. until 3:30 p.m. with staff on 2pm to 10pm shift LVN-F, LVN G, and CNA E to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. Interviews were conducted on [DATE] from 12:00 a.m. until 12:30 a.m. with staff on 10 pm to 6 am shift RN-M, LVN-O, LVN-P, CNA-Q, CNA-R, and CNA-S to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. Interviews were conducted on [DATE] from 1:00 p.m. until 1:30 p.m. with staff on 6am to 2pm shift CNA-F, House Keeper, Physical Therapy Assistant to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. Record review of in-service revealed Any nurse not present or in serviced on [DATE] and [DATE], will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Completion projected [DATE]. Record review of 'In-service Training Report dated [DATE] revealed that staff had been trained on their roles regarding mock code. Record review of check list sheet used during this mock code revealed that staff were able to answer questions in a satisfactory manner. 676381 Page 5 of 6 676381 03/11/2024 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of 'In-service Training Report dated [DATE] revealed all facility staff were educated on the CPR process. Staff were educated on resident change in condition, call code blue, they were educated on the location of the crash cart, and were the residents advance directive book is located. Record review of 'In-service Training Report dated [DATE] revealed all facility managers, C.N.A's, Med Aides, and licensed nurses were educated on the components of CPR. Components discussed were emergency services, chest compressions, rescue breaths, and associated components discussed were Heimlich maneuver, and Automatic external defibrillators. Record review of 'In-service Training Report dated [DATE] revealed that the DON/Designee in serviced nursing staff on changes of condition/Code status/and CPR process. Record review of 'In-service Training Report dated [DATE] revealed that the facility's DON/Designee did in-service with all staff on the location of the residents' code status binder and or where in the electronic medication. Record review of facility's audit sheets dated [DATE] revealed that all code status were correct and in place for staff to identify. Record review of 'In-service Training Report dated [DATE] revealed that staff were educated during a mock code on what their roles are. Record review of the sign in sheet dated [DATE] for the QAPI meeting revealed that all department managers, the administrator, the director of nursing, and medical director attended the meeting. The IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolation. as the facility continued to monitor the implementation and effectiveness of their plan of removal. 676381 Page 6 of 6