Health inspection·March 3, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure POLST (Physician Orders for Life-Sustaining Treatment- a medical order that outlines a patient's preferences for end-of-life care) was correctly documented into Resident 1's medical record. As a result, Resident 1's POLST signed by the physician to a full code status was changed to a Do Not Resuscitate (DNR) status. This failure had the potential for Resident 1 to not receive the full medical treatment in the event of a medical emergency. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included multiple fractures of the pelvis (break of the ring of bones that connect your spine to the hips), per the facility's admission Record Form. On [DATE], an unannounced visit to the facility was conducted related to an alleged complaint that the facility changed the order of the resident's wishes listed in the POLST form from a full resuscitation to do not resuscitate , in case of medical emergency. A review of Resident 1's POLST form indicated, the POLST form was signed by the resident's wife on [DATE], and the physician signed the POLST on [DATE]. The POLST indicated, Resident 1 wished to be resuscitated if the resident had no pulse or was not breathing and full treatment if resident was found to have pulse and/or was breathing. A review of Resident 1's IDT admission Assessment documentation, dated [DATE] indicated, under the Advanced Directive Resident 1 was a Full Code, Full Treatment. A review of Resident 1's Order Summary Report dated [DATE], indicated an order for Full Cardiopulmonary Resuscitation (CPR). A new order was changed to Do Not Resuscitate (DNR) dated [DATE]. During a concurrent record review and interview on [DATE] at 1:16 P.M., with the Licensed Nurse (LN) 1, LN 1 stated Resident 1's Full Code status was ordered on [DATE] according to Resident 1's POLST form. LN 1 further stated the physician signed the POLST form on [DATE]. LN1 acknowledged that the order for [DATE] for DNR was incorrect. During an interview on [DATE] at 3:31 P.M., with LN 3, LN 3 stated Resident 1's DNR code status was entered incorrectly during the audit process. LN 3 acknowledged that she entered Resident 1's code Page 1 of 2 056017 056017 03/03/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0578 status incorrectly. LN 3 further stated that Resident 1's code status should be Full Code and not DNR. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 3:45 P.M., with the Administrator (ADM) and the Director of Nursing (DON), the ADM stated it's important for the staff to enter the code status correctly to ensure residents' wishes were honored. Residents Affected - Few A review of the facility's policy and procedure, titled, Promoting the Right of Self-Determination for Healthcare Decisions and Advanced Healthcare Directives, dated [DATE], indicated . Each resident will receive the necessary care and services to attain or maintain the highest practice physical, mental, and psychosocial wellbeing, in accordance with comprehensive assessments and plan of care. Each resident and/or legal healthcare decision maker will be provided a mechanism for reaching decisions concerning preferred intensity of care, including the right to forego or withdraw life sustaining treatment. 056017 Page 2 of 2