1. Cardiopulmonary Resuscitation (CPR)
Facility Leaders and
Supervisor Training
This training is designed to provide facility supervisors and leaders with an overview of the CPR Regulation

2. OBJECTIVES Participants will:
Review the revised Federal regulation at (a)(3) and Guidance to Surveyors for F309
Identify key components of the CPR Program for staff understanding and action
Define appropriate steps necessary for cardiopulmonary resuscitation consistent with best practices and regulatory requirements
CPR-Cardiopulmonary Resuscitation
American Heart Association
American Red Cross

3. Introduction
The nursing home Requirements of Participation (RoP) are the regulations that set minimum standards for nursing homes.
The RoP were rewritten in October 2016.
The changes in regulations go into effect over the next three years, in phases.
For the purposes of this education, we will refer to the regulations related to CPR and our roles and responsibilities as leaders within this organization.
Nursing homes that accept payments from Medicare and Medicaid must meet minimum standards for the quality of the care and services they provide. Today’s training will discuss the updated federal regulations related to abuse.
The federal regulations were rewritten in 2016 for the first time since 1991 – the updates were completed in order to modernize the language and reflect changes that have happened in care, resident populations and quality standards.
The changes are being called the “Mega-Rule” because there are over 700 pages of regulations. There are three phases of implementation: Phase 1 was effective November 28, 2016, phase 2 is effective November 28, 2017 and phase 3 is effective on November 28, 2019.
Today we will review the changes made to the federal regulations about the residents’ visitation rights and access to visitors anytime, any day. . There are changes in the definitions of some words, new access rights added to the overall visitation policy for our facility.

4. Overview of the Regulation
(a)Based on the comprehensive assessment of a resident and consistent with the resident’s needs and choices,
the facility must provide the necessary care and services to ensure that a resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

5. Overview of the Regulation
§483.24(a)(3) (continued)
(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
Residents have the right to choose their care and treatment and CPR is one of the significant choices made with advance directives and advance care planning. We see many residents/patients today that are not end of life—and even if they are—they still can choose the type of care and treatment they would like.

6. Facility Response Understand Inform Limitations Monitor
Our response to these updated regulations includes:
Understand – understanding the new regulations and our CPR Policy. Todays training walked us through the changes and our roles and responsibilities.
Inform – how we will inform residents about advance directives, choices, explanations of CPR and all staff in the IDT on our protocols
Limitations and Concerns – include not having advance directive choices communicated to all care givers, residents without advance directives, etc.
Monitor – we will monitor our policy via our QAPI program as applicable

7. Inform - Definitions
Advance Care Planning – is a process used to identify and update the resident’s preferences regarding care and treatment at a future time including a situation in which the resident subsequently lacks capacity to do so.
For example, when life-sustaining treatments are a potential option for care and the resident is unable to make his or her choices known
It is ideal to document resident preferences on admission, on a regular basis thereafter (such as care conferences) and when there is a significant change in condition to be able to have discussions with the resident/resident representative regarding treatment and care options

8. Inform - Definitions
Advance Directive – means according to 42C.F.R , a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Some States also recognize a documented oral instruction.
When a resident is admitted to the facility, the facility can assist the resident in formulation of an advance directive if they do not have one. They are not required to have an advance directive. If a resident already has an advance directive – outlining preferences-including code status—it is essential to ensure that this is well documented and that it is communicated and easily identified upon a change of condition (Discuss facility process for identification of code status for emergencies)

9. Inform - Definitions
Cardiopulmonary Resuscitation (CPR) – refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased

10. Inform - Definitions
Life-Sustaining Treatment – is treatment that, based on reasonable medical judgment, sustains an individual’s life and without it the individual will die.
The term includes both life-sustaining medication and interventions (e.g., mechanical ventilation, kidney dialysis, and artificial hydration and nutrition).
Life Sustaining Treatment: The term does not include the administration of pain medication or other pain management interventions, the performance of a medical procedure related to enhancing comfort, or any other medical care provided to alleviate a resident’s pain.

11. Inform - Definitions
Treatment – refers to interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms
Life Sustaining Treatment: The term does not include the administration of pain medication or other pain management interventions, the performance of a medical procedure related to enhancing comfort, or any other medical care provided to alleviate a resident’s pain.

12. Inform - Definitions Durable Power of Attorney for Health Care
Legal Representative
POLST, MOLST
Durable Power of Attorney for Health Care (a.k.a. “Medical Power of Attorney”) is a document delegating authority for an agent to make health care decisions in the case the individual delegating that authority subsequently becomes incapacitated
Legal Representative (e.g., “Agent”, “Attorney in Fact”, “Proxy”, “Substitute Decision-Maker”, “Surrogate Decision-Maker”) – is a person designated and authorized by an advance directive or State law to make a treatment decision for another person in the event the other person becomes unable to make necessary health care decisions
POLST- some states have instituted a POLST which is a form called Physician Orders for Life-Sustaining Treatment
MOLST – some states have a MOLST which is a form called “Medical Orders for Life-Sustaining Treatment

13. Policy - CPR
It is the policy of this facility will provide basic life support, including CPR – Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident’s advance directives.
Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless:
A valid Do Not Resuscitate order is in place
Resident presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) are present
Initiating CPR could cause injury or peril to the rescuer

14. CPR
Facilities must have CPR policies and must provide CPR as indicated to residents
Facilities cannot have a NO CPR or witnessed code policy
§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.

15. CPR Certified Staff
The facility must have CPR Certified Staff on duty at all times, 24/7
Staff will be required to maintain current CPR certification for healthcare providers including hands-on skills practice and in-person assessment and demonstration of skills. Online only classes are not sufficient by regulation

16. Inform - CPR Procedure
The facility staff will provide basic life support, including CPR to a resident who requires such emergency care prior to the arrival of emergency medical services, consistent with
the resident’s advance directives and
physician orders.

17. CPR
The steps for proper CPR include: 1. Employee to verify safety of the scene/environment 2. Check for resident response. Tap or shake shoulder of resident asking, “Are you okay”.
If the environment is unsafe at the scene – do not put yourself in an unsafe situation.
Call for immediate help and activate the EMS by dialing 911

18. CPR
Simultaneously assess the resident for breathing and pulse for 10 seconds.
Shout for nearby help or pull the call button for assistance. Activate emergency response system. Staff immediately instructed to retrieve AED and emergency equipment.
If necessary, open the airway:
Head-tilt/chin-lift technique
If a head, neck or spinal injury is suspected, utilize the modified jaw-thrust maneuver
If collapse was witnessed and staff member alone, leave resident to activate emergency response and retrieve AED-unless another staff member is able to retrieve the device, before beginning CPR

19. CPR
5. Identify code status/advance directive preference
If resident is a DNR (do not resuscitate):
DO NOT PERFORM CPR
**Add facility process for identification of code status i.e. DNR order, POLST/MOLST

20. CPR
6. If no DNR order/advance directive exists or if advance directive does not indicate “Do Not Resuscitate”, begin resuscitation efforts
(Review facility process for code identification in an emergency here)

21. CPR
7. If Resident does not exhibit normal breathing and has a pulse, begin rescue breathing, 1 breath every 5-6 seconds (10-12 per minute) using face mask or Resuscitator Bag. 8. Check pulse about every 2 minutes while performing rescue breathing
If resident is presenting with agonal breaths, continue as if resident is not breathing

22. CPR If no pulse, BEGIN CPR:
Place backboard under resident in bed or assist resident to a firm, flat surface if possible
Compress chest compressions at a rate of per minute (place 2 hands on the lower half of the sternum)
Compress to a depth of at least 2” (inches)
Ensure full recoil following each compression
Minimize any pauses in compressions
Ventilate 2 breaths after 30 compressions, each breath to be delivered over 1 second, causing chest to rise (30:2 Ratio for both 1 or 2 rescuers). Use face mask or resuscitator bag.
(*Please note: if AED is immediately available, use defibrillator as soon as possible when device is ready for use):

23. AED Use Follow Manufacturer’s recommendations
Turn on AED and follow prompts
Expose chest area and apply electrode pads
Attach electrode connector to the AED if not already done
Follow message prompts given by the AED
Push Analyze button
If shock indicated announce “ALL CLEAR” and press shock button
If no shock indicated, start CPR
Device will announce prompts to recommend analyzing and shocking instructions
Follow directions until EMS arrives
Dry the chest if wet. (Note: if chest hair prevents contact with skin, shave the area if necessary and avoid cutting skin.)
Do not apply alcohol, tincture of benzoin, antiperspirants or other products to the skin.
Place electrode pads according to manufacturer’s instructions. Check the pads to make sure that the gel has not dried out.
Do not move or touch the resident when the AED is analyzing!
***If cardiac conversion occurs, check for pulse. If pulse present, manage airway appropriately and assist ventilation as necessary. Leave the AED attached. Take vital signs as indicated.
The AED needs to be on a preventative maintenance schedule based on the manufacturer’s recommendation (Identify)

24. CPR
When EMS personnel arrives, care of the resident will be transferred
Notify Physician and resident family/resident representative
Prepare transfer documents to deliver to EMS personnel **Ensure copies of all advance directive forms (i.e. POLST/MOLST, or DNR forms) are available to go with the resident to the hospital
Ensure all documentation is completed in the medical record
Disinfect/replace all resident care equipment
When EMS arrives, continue with CPR until EMS take over
One employee should be documenting the code as it occurs—
When EMS arrives, ensure all transfer forms are being prepared—include advance directive forms!!!

25. Limitations or Obstacles
Individual
Size of resident
Not safe or feasible – backboard or resident to the floor
Other examples
Process
ID of code status not easily obtained
Equip is non functioning (PMP a must)
Discuss potential obstacles or limitations
Individual
Size of resident
Not safe or feasible – backboard or resident to the floor
Other examples
Process
ID of code status not easily obtained
Equip is non functioning (PMP a must)
Resident is in a location that the resident is not easily removed for appropriate treatment

26. Monitor Admission Process Staff interviews Staff Knowledge
Orientation/Education
Medical Record review
RAI Process - Updates
Observations
QAPI
The final step in our process is how we monitor the effectiveness of our CPR P&P and knowledge
Discuss with the team and review roles and responsibilities as well
Admission Process
Staff interviews
Staff Knowledge
Orientation/Education
Medical Record review
RAI Process - Updates
Observations
QAPI

27. Summary Understand Inform Limitations Monitor
In Summary – It is our responsibility to know and understand our P&P as it relates to CPR
Review with the team
Our response to these updated regulations includes:
Understand – understanding the new regulations and our CPR Policy. Todays training walked us through the changes and our roles and responsibilities.
Inform – how we will inform residents about advance directives, choices, explanations of CPR and all staff in the IDT on our protocols
Limitations and Concerns – include not having advance directive choices communicated to all care givers, residents without advance directives, etc.
Monitor – we will monitor our policy via our QAPI program as applicable

28. CONCLUSION
Facilities are required to provide basic life support – including CPR for residents who choose CPR, in accordance with the resident’s advance directive and consistent with professional standards, until EMS arrives
CPR should be initiated unless:
A valid DNR order is in place
Obvious signs of clinical death are present
Initiating CPR could cause injury or peril to the rescuer

29. Questions

30. REFERENCES
References Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities 10/04/16: State Operations Manual Appendix PP – Guidance to Surveyors for Long-Term Care Facilities, 06/10/16: CMS Memo Ref: S&C NH: Advance Copy – Revisions to State Operations Manual (SOM), Appendix PP- Revised Regulations and Tags, 11/09/16:

31. References-continued
American Red Cross, Basic Life Support for Healthcare Providers, Provider Handbook, 2015:
2015 American Heart Association Guidelines for CPR & ECC:
Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC. American Heart Association:
FDA: Strategies for clinical and Biomedical Engineers to Maintain Readiness of External Defibrillators:

32. Thank you for participating in this education session!