The incident at Villa Serena Healthcare Center occurred when Resident 1 developed rapid breathing, low oxygen levels, wheezing sounds during exhalation, and a racing heart rate exceeding 100 beats per minute. Paramedics arrived to find the facility's staff offering a POLST form — a legal document directing end-of-life care — that contained no physician signature.
Unable to reach the resident's family member to clarify treatment preferences, paramedics had no choice but to transfer the patient to a general acute care hospital.
The Director of Nursing acknowledged during a November interview that getting the POLST signed was "important" because paramedics "will follow" the document "with a change of condition." The resident's care preferences had recently changed from comfort measures to selective treatment, making a valid signature even more critical.
Yet the Medical Records Director revealed the signature problem went deeper than simple oversight. She told inspectors she "believed she obtained the signature" for the POLST and that "it was backdated." She acknowledged POLST forms "should be signed by the physician as soon as possible, and no later than 72-hours."
The Social Services Director described speaking with the resident's family member about changing the POLST from comfort measures to selective treatment. The change "should have been signed that day by the physician to be acted upon," she said, "but she was not sure why it was not signed."
The facility's own policy makes clear that POLST forms must carry a physician signature to be valid. The policy states its purpose is "to help ensure the facility honors residents' treatment wishes concerning resuscitation and life-sustaining treatment."
For a POLST form to be legally binding, the policy requires signatures from "a physician, a nurse practitioner, or a physician assistant acting under the supervision of the physician." Licensed nurses or social service staff "must ensure the new POLST form is signed by the physician, and the resident, and the revoked POLST form is voided."
The breakdown meant paramedics faced an impossible situation during a medical emergency. With an unsigned directive and no family member available by phone, they couldn't determine whether the resident wanted selective treatment or comfort measures only.
POLST forms serve as portable medical orders that travel with patients between care settings. Unlike advance directives, they provide specific instructions about CPR, medical interventions, and comfort care that emergency responders can follow immediately.
The timing of the signature failure proved particularly problematic. The resident's family had recently decided to change from comfort-focused care to selective treatment — a decision that could affect whether the patient receives certain medical interventions during a crisis.
The Medical Records Director's admission about backdating the signature raises additional concerns about the facility's documentation practices. Backdating medical documents can obscure when critical decisions were actually made and whether proper procedures were followed.
The Social Services Director's uncertainty about why the physician never signed the updated POLST suggests communication breakdowns between departments responsible for ensuring valid medical directives.
Federal regulations require nursing homes to honor residents' preferences about treatment and end-of-life care. When facilities fail to maintain properly executed POLST forms, residents may receive unwanted medical interventions or be denied treatments they would have chosen.
The incident left Resident 1 transferred to a hospital setting that may not have aligned with their care preferences, all because staff failed to complete basic paperwork requirements their own policies demanded.
Villa Serena's policy acknowledges that honoring treatment wishes requires valid documentation. The facility's failure to ensure physician signatures were obtained within required timeframes meant paramedics couldn't honor those wishes when they mattered most.
The breathing emergency that triggered the 911 call required immediate decisions about medical intervention levels. Without a signed POLST, paramedics defaulted to full treatment and hospital transfer, potentially subjecting the resident to care they or their family may not have wanted.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa Serena Healthcare Center from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Villa Serena Healthcare Center
- Browse all CA nursing home inspections