complaint·September 9, 2025

LPA observed a Directive to Physicians dated March 19, 2008, signed by R1 stating that if R1 at any time is in a terminal condition or should have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will in the opinion of R1s attending physician withhold or withdraw treatment that only prolongs the process of dying and is not necessary for R1s comfort or to alleviate pain. During interviews it was revealed that staff called emergency services twice on August 24, 2025, for R1 due to changes in condition. It was revealed that 3 of 5 staff were present at the time of the incidents. 2 of 5 staff informed LPA that staff were delayed in giving emergency personnel all necessary documentation due to the printer being down. 2 of 5 staff informed LPA that emergency services were given all of the necessary documentation as they were exiting the facility with R1. Staff #3 (S3) informed LPA that emergency services were called again in the evening due to R1 being unresponsive. S3 informed LPA that they started chest compressions until emergency personnel arrived to the facility. S3 informed LPA that emergency personnel informed them that there was a POLST and DNR in place for R1 and S3 stopped compressions once they were made aware of the directives in place. 2 of 5 staff informed LPA that it is the facility policy to provide emergency personnel with necessary documentation upon their arrival and to follow the DNR and POLST directives that are in place. 4 of 5 staff informed LPA that when giving emergency personnel documentation they give the face sheet, insurance documentation, and medication list. Witness #1(W1) informed the Department that they saw staff conducting chest compressions on R1. W1 informed the Department that there was a delay with facility staff giving the necessary documentation upon emergency personnel’s arrival. Based on observation, interviews, record review and information gathered during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC 9099D. An exit interview was conducted with ED Brian Keys and a copy of this report, LIC9099-D and appeal rights were left at the facility.