complaint·April 15, 2024

The investigation revealed the following: Regarding the allegation: "Staff altered resident's record.". It has been alleged that staff has altered resident one's Physican Orders for Life-Sustaining Treatment (POLST). Interviews revealed that all 4 staff and all 4 residents have denied the allegation, while one (1) (W3) out of 2 witnesses informed LPA that R1 had a fall at Los Angeles Downtown Medical Center (LADMC) and one out of 2 witnesses (W1) informed that R1 had made a choice to file his POLST for Do Not Resuscitate and additionally to deny artificial means of nutrition, including feeding tubes, using his own mental capacity. Record reviews revealed that R1 had began to deny one of his medications during May 2023, slowly increasing his refusal of one medication through July 2023. R1 later began to completely refuse this medication in December 2023. Then, January 12, 2024, R1 refused all medications. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was conducted with Jenni Gordon, Administrator (S1), and a copy of this report has been provided.