Health inspection·January 14, 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 carry out a resident's wishes for end of life treatment when the facility staff performed cardiopulmonary resuscitation (CPR, an emergency life-saving procedure when breathing or heart beat has stopped ), on one of three sampled residents (Resident 1) that chose not to have CPR not be performed. This resulted in Resident 1 receiving CPR and violated her end of life wishes. Findings: A review of the facility's policy titled, CODE BLUE [means someone is experiencing a life threatening medical emergency where their heart stopped or they are not breathing and staff are to respond immediately] reviewed 5/2021, indicated, Section C: A 'CODE BLUE' will be called on all patients who experience a cardiac and/or respiratory arrest unless a DNR [Do not resuscitate means the same as No CPR] order is written on the patient's chart. Resident 1 was admitted to facility on [DATE] with a diagnosis of high blood pressure and congestive heart failure (CHF, when the heart is unable to pump enough blood to the body and fluid builds up in the lungs). A review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST, a document signed by a resident or their responsible party which specifies their end of life wishes), dated [DATE], indicated that Resident 1 desired No CPR. A review of Resident 1's Physician's Orders dated [DATE], indicated the physician had discussed CPR with Resident 1 and her family member and an order was written for DNR. A review of Resident 1's Progress Notes dated [DATE] at approximately 8:18 PM, indicated Resident 1 was found, unresponsive . without a detected pulse. A Code Blue (means someone is experiencing a life threatening medical emergency and the heart stops or they are not breathing and staff need to respond immediately) was called. Facility staff responded and began doing CPR on Resident 1. On [DATE] at 8:30 AM, an interview was conducted with the Chief Nursiing Officer (CNO). The CNO confirmed that Resident 1 had documented wishes for No CPR on her POLST and on her Physician's Orders, and should not have received CPR. The CNO added that there had been confusion with the verbiage on the POLST form and the facility has since revised the POLST form and implemented a new process. Page 1 of 2 555588 555588 01/14/2025 Vibra Hospital of Northern California D/P Snf 2801 Eureka Way Redding, CA 96001

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 8:00 AM, Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, I was in getting meds for another patient and I heard the code called. I had to finish there and then I was able to go to the patient's [Resident 1] room. I was thinking that it is a DNR patient and I went in and confirmed that. I let everyone know [Resident 1] was a DNR patient. The doctor was there about the same time as me and was on the phone talking to [Resident 1's] family and the family member told us to continue CPR. The doctor told us to continue. I came in after it was started. I told everyone she was a DNR but CPR was already being performed. There was some confusion apparently about what type or level it was. On [DATE] at 8:40 AM the Medical Doctor (MD)1 was interviewed. MD 1 stated, I was in house [in the hospital] and responded to the code. I was told there was a POLST form and was told [Resident 1] was a DNR and I called [a family member]. That [family member] didn't answer so I called [another family member], who said since we were already coding [giving CPR] to continue and transport [Resident 1] to the hospital. 555588 Page 2 of 2