Complaint Investigation Report

415600755-10-21-2022-14-AS-CSMH-CLHVSZ-20221125154223

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SF COASTAL AC/SC , 851 TRAEGER AVE., SUITE 360

This is an official report of an unannounced visit/investigation of a complaint received in our office on

07/07/2022 and conducted by Evaluator Audrey Jeung

COMPLAINT CONTROL NUMBER: 14-AS-20220707132155

- Staff provided incorrect POLST paperwork to paramedics

Based on information reported by and obtained from facility staff, San Mateo County Sheriff and Fire Dept. reports, this allegation is substantiated. The preponderance of evidence standard has been met.

Resident #5 passed away on 6/21/22, according to Incident and Death Reports submitted to CCLD on 6/27/22. Additional information was provided by administrator by phone on 6/28/22 and in writing on 7/8/22. When paramedics arrived, staff provided them with the client folder of another resident in error, which included a POLST that specified "Do Not Attempt Resuscitation/DNR (Allow Natural Death)." According to administrator, staff was nervous and uneasy. R5 did not have a DNR on file.

Deficiency of the CA Code of Regulations, Title 22 is cited on a following page.