Bria Of Woodriver

whose name she cannot remember came and told her R2 was unresponsive. R2's nurse was on break

jeopardy to resident health or trach, so they just placed the respiratory bag over his face and turned the oxygen up.

The (Local Fire safety Department) Incident Report dated [DATE] at 5:15 PM documents, FD (Fire Department) units arrived on scene and found staff bagging the patients mouth and performing CPR on the patient while he was

secretions coming from the tube while CPR was being performed. FD crew marked the patient was cold to the touch while attempting to find a femoral pulse, no pulse was found. FD crews moved the patient to the floor, continued CPR and ventilation.

The BVM (Bag Valve Mask) was taken off the patients mouth, mask was removed, and the BVM was connected to the patients trach tube.

Staff left the room and came back a few minutes later with paper work for the patient, showing the patients extensive medical history.

The [NAME] and the defib pads were placed on the patient, showing an initial rhythm of asystole. FD crew gained IO access in the left tibial tuberosity. IO drew and flushed.

First epi at 1723 (5:23 PM). ACLS protocols were followed with pulse checks every 2 minutes and Epi every 3-5.

Initial end tidal reading was an 11. AMA crew arrived on scene and briefed on patient.

Patient remained in asystole for the duration of the resuscitation attempt. AMA medic called medical control for directions.

Medical control advised crews to terminate resuscitation efforts, per DM 153.

FD gathered restock from the ambulance and returned to service.On [DATE] at 2:37 PM, V22, (Local Fire Department) Chief, stated when his staff arrived to the facility on [DATE], Facility staff were bagging R2 with the BVM over the naso-oral pharynx which is not the standard place for the BVM when a resident has a tracheostomy.

The BVM should have been via tracheostomy. On [DATE] at 3:15 PM, V35, Assistant Director of Nursing (ADON), stated there is a bag that goes over the tracheostomy when you provide CPR. On [DATE] at 3:20 PM, V2, Director of Nursing (DON), stated there is a bag that goes on the trach, and those BVMs should be at bedside.

She was not previously informed of any issues with staff getting the BVMs on the tracheostomy. On [DATE] at 3:33 PM, V1, Administrator, stated standard CPR protocol should be followed for residents with tracheostomies, but the respiratory bag should go over the tracheostomy site or the residents would not be getting air.

On [DATE] at 3:50 PM, V33, Medical Director, stated he would expect staff to know how to perform CPR on residents with tracheostomies and would expect the Facility to have the necessary equipment and supplies for both maintenance and emergent situations.

The Facility's Tracheostomy Care Policy reviewed 10/2024 documents, It is the policy of this facility that residents with tracheostomies receive care to maintain a patent airway.The Facility's Code Blue Policy reviewed 10/2024 documents, Breathing: provide 2 breaths via ambu or manually if ambu is not available.

Continue CPR per BLS guidelines until EMS arrives and takes over CPR.The Facility provided CPR Certificates for Nursing Staff which document V19, V54, and V55, CNAs, did not have CPR certification from the American Red Cross or American Heart Association with hands on, in person training.The Facility's CPR Certification Policy revised [DATE] documents, Staff will have CPR certification from the American Red Cross or the American Heart Association The CPR Certification will be the CPR/BLS for Healthcare Providers level and include in-person training, hands on training.The Immediate Jeopardy and deficiency practice that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Clinical and agency staff were inserviced on performing CPR on residents with tracheostomies, CPR Policy was reviewed, CPR equipment was verified as available in the Facility, CPR audits were initiated, and QAPI Meeting was held.

The abatement was validated by review of CPR policy and audits, observation of CPR/tracheostomy equipment and supplies, review of purchase orders for equipment and supplies, and interviews from V2, V6, V10, V13, V24, V25, V34, V39, V42, V44, V45, V47, V49, V51, V52, and V53.

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Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095

expect staff to report any changes in condition to the nurse on duty. On [DATE] at 1:40 PM, V2,

jeopardy to resident health or to the nurse. If the resident's nurse is not available, they should report it to another nurse that is safety available. R2's change of condition was not reported to her, and she had no idea why they would not have reported those changes to the nurse on duty.The Facility's Change In Resident Condition Policy

the resident, resident's physician and resident's responsible party of a change in condition.

The policy does not contain documentation pertaining to communication between nurse aids and licensed nurse staff.The Immediate Jeopardy that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Clinical and agency staff were in-serviced on timely assessments, Notification of Change Policy was reviewed, QAPI meeting was held on [DATE], 24 hour reports were reviewed for change in condition.

The abatement was validated through review of 24 hour nursing reports and Notification of Change Policy and interviews with V2, V6, V10, V13, V24, V25, V34, V39, V42, V44, V45, V47, V49, V51, V52, and V53.

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Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095

V2, Director of Nursing (DON), stated she expects nursing staff to be proficient in providing routine

jeopardy to resident health or emergency.The Facility's Tracheostomy Care Policy revised 10/2024 documents, It is the policy of safety this facility that residents with tracheostomies receive routine care to maintain a patent airway.

Suction as needed.

Cleanse stoma site.

Document appropriately.The Facility's Facility Assessment

disease, and respiratory failure.

Specialized Rehabilitation Services include Respiratory.

Special Care Needs include tracheostomy care and ventilator care.The Immediate Jeopardy and deficiency practice that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Tracheostomy in-service was completed on [DATE], and all nurses, including agency nurses, were educated prior to the start of their next scheduled shift.

The abatement was validated with interviews with V15, V25, V48, V50, V56, and V57.