Health inspection·June 13, 2024

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 observation, interview and record review, the facility failed to honor (Resident 1) choice for the refusal of end-of-life medical treatment. This failure resulted in Resident 1 receiving Cardiopulmonary conversion (chest compressions) and mechanical ventilation (assisted breaths with a medical device) against Resident 1's decision. During a review of Resident 1's medical record, Physician Orders for Life-Sustaining Treatment (POLST) form, dated [DATE], indicated in box A, Do Not Attempt Resuscitation / (DNR) (Allow Natural Death), Box B indicated, Comfort -Focused Treatment – primary goal of maximizing comfort. Relieve pain and suffering with medication by any route as needed, use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments listed in Full treatment (mechanical ventilation and cardioversion) and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. Box D indicated, signature of legally recognized decision maker 1 and MD 2. During a review of Resident 1's medical record, Progress note dated [DATE], signed by Licensed Staff A, indicated, Legally recognized decision maker 1 has changed POLST to DNR (Do not resuscitate) comfort focus. During a review of Resident 1's medical record, Progress note dated [DATE], signed by Licensed Staff B, indicated, MD aware of DNR Comfort Care and an IDT (interdisciplinary meeting for Comfort Care). During a review of Resident 1's medical record, Progress note dated [DATE], signed by Licensed Staff C, indicated, at 4:40 p.m., resident was found with no vital signs and Licensed Staff C started performing CPR (cardiopulmonary conversion) also using AED - Automated Electronic Defibrillator (medical device that shocks the heart with intent to start the heart beating again.) Fire dept arrived and EMT's (Emergency Medical Technicians) took over the CPR using AED and Ambu Bag. (medical device bag that fills with oxygen and then pumps oxygen into the residents nose and mouth). Resident 1 was pronounced dead at 5:21 p.m. Legally recognized decision maker 1 arrived at the facility at 5:30 p.m. During an interview with Licensed Staff C on [DATE] at 1 p.m., Licensed Staff C stated, she was Resident 1 primary nurse on [DATE] and when Resident 1's heart and respirations stopped. Licensed Staff C stated, she immediately checked Resident 1's chart for the POLST but the chart only contained a previously dated POLST from [DATE]. Licensed Staff C stated, she thought that the POLST in the chart was the most up to date. Licensed Staff C stated, she did not realize there was a more recent version of Resident 1's POLST dated after [DATE]. Licensed Staff C stated, the POLST she followed from Page 1 of 3 555836 555836 06/13/2024 Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403

F 0578 Level of Harm - Minimal harm or potential for actual harm [DATE] indicated DNR with Full Treatment (mechanical ventilation and cardioversion). Licensed Staff C stated this is why she performed the CPR on Resident 1. Licensed Staff C queried what the risk to resident safety are if an outdated POLST is left on the front of Resident 1's Chart. Licensed Staff C stated, she thinks that the latest wishes of the resident and / or Resident representative would not be honored as they should. Residents Affected - Few During an observation and record review of Resident 1's medical record, indicated there was a prior POLST dated, [DATE], for Resident 1 that indicated in Box B, DNR with Full Treatment. Box D of the POST was signed by Legally recognized decision maker 1 and MD 1. During an interview with Unlicensed Staff D, on [DATE] at 2:15 p.m., Unlicensed Staff D stated, she is the manager of the facilities Medical Records Department whose job it is to place the resident's POLST form in the front of the hard copy of the chart where it is easily accessible. Unlicensed Staff D stated, she was on vacation at that time and the most recent version of the POLST never made it into Resident 1's chart. Unlicensed Staff D then stated, she was not on vacation, but doesn't understand how the most recent POLST did not make it to Resident's 1 Hard copy of the chart. During an interview with the DSD, on [DATE] at 2:25 p.m., DSD queried if she was aware of the POLST policy. DSD stated, she was aware of the POLST policy. DSD queried for the in-services that she performed for the nursing staff in the last 3 months. No in-services for nurses were completed by the DSD for the facility's POLST Policy, DNR policy or Crash Cart policy and procedures. During an interview with the DON on [DATE] at 2:40 p.m., DON was queried why the latest POLST was not in the front of the chart for Resident 1. DON stated, she knows it is the facility's policy to keep the latest POLST in the front of the hard copy of the chart. DON stated, she is unaware as to how the latest POLST for Resident 1 was not in the front of the hard copy of the chart when Resident 1 expired. During a review of the DSD's job description, titled, Director of Staff Development, updated 2015, indicated, Essential Duties and Responsibilities, 5. Assists in the planning and coordination of training programs for all departments within the facility to respond to identified problem areas, service quality or to teach procedures or methods. 7. Provide-specific orientation to Health Center nursing staff including completion of the clinical skills checklist. 20. Assumes a proactive role in resolving resident issues & concerns related to assigned areas of responsibility. During a review of the facility's policy and procedure titled, Do Not Resuscitate Order Revised [DATE], indicated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a DO NOT Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident' medical record. 6. The Interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. 7. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 8. Inquiries concerning do not resuscitate orders / requests should be referred to the administrator, director of nursing services, or to the social services director. During a review of the facility's policy and procedure titled, Resident Rights Guidelines for All Nursing Procedures Revised 2010, indicated, 1. Prior to having direct-care responsibilities for 555836 Page 2 of 3 555836 06/13/2024 Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents, staff must have appropriate in-service training on resident rights, including: C. Resident notification of rights, services and health/medical condition, F. Resident right of refusal (medication and treatments), H. Resident freedom of choice, I. Resident/Family participation in care planning. During a review of the facility's policy and procedure titled, Advance Directives Revised [DATE], indicated, H. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form-a form designed to improve patient care by creating a portable medical order from that records patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patients current medical condition into consideration. Refusing or Requesting Treatment 1. The resident has the right to refuse medical or surgical treatment, whether or not he or she has an advance directive. A. A resident will not be treated against his or her own wishes. B. Residents who refuse treatment will not be transferred to another facility unless all other criteria for transfer are met. C. The resident's refusal does not absolve facility staff from providing other care that allows him/her to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 2. Depending on the state requirements, the legal representative may also have the right to refuse or forego treatment. 3. If the resident or representative refuses treatment, the facility and care provider will: C. Document specifically what the resident/representative is refusing. 7. The Staff Development Coordinator is responsible for scheduling training regarding advance directives for newly hired staff members as well as scheduling annual advance in-services to ensure that the staff remains informed about the residents' rights to formulate advance directives and facility policy governing such rights. 555836 Page 3 of 3