Christina Kyler
Sep 2026
PROTECT YOUR LOVED ONES<br><br>Patient Rights, Surrogate Decision-Making, Consent, Communication, and Documentation<br><br>I am submitting a complaint regarding care, communication, and decision-making processes involving Michael at Oak River Rehab in Anderson, California.<br><br>Our concern is not primarily the medication itself, but whether Michael’s wishes were respected, whether proper process was followed when he was considered unable to make decisions, and how another family member became involved in decision-making.<br><br>Michael had recently been hospitalized. While there, he expressed that he wanted his son, T, involved in making medical decisions. A POLST was completed in the hospital with family present. We understood that Michael wanted to make his own decisions while able to do so, and that T was the person he wanted involved if he could no longer make decisions himself. C was present when this was discussed.<br><br>Michael was then transferred to Oak River Rehab. Shortly before his death, Michael told T that staff were trying to increase his morphine and that he did not want more morphine at that time. T attempted to speak with a nurse that day but could not locate one. He also attempted to arrange communication with the physician and left his telephone number requesting an appointment or follow-up. No one contacted him.<br><br>T had been visiting Michael regularly and speaking with him. The day before Michael’s condition deteriorated, T spoke with him and Michael said he was feeling better. We therefore had no reason to understand that Michael had changed his wishes or believed he was actively choosing to end treatment.<br><br>We subsequently learned that C had been involved in authorizing a medication increase. We were shown documentation where C’s name was written, and she signed medication-related paperwork in our presence. Staff told us C was not “in charge,” yet simultaneously told us to contact her if we disagreed with what was happening. This was never adequately explained.<br><br>We also observed that C’s name had been written on the facility face sheet/emergency contact information and on a purple POLST-type form at the top of Michael’s chart, though there was no signature on the purple form. We do not know who entered her name, when it was entered, or what authority was relied upon.<br><br>The nursing supervisor told us she could not discuss Michael’s care with us because we were not listed on the emergency contact information. However, C was listed there. We do not know who placed C on the list or whether Michael provided that information, as he did not appear to complete all admission paperwork himself.<br><br>We are concerned staff accepted C’s account that T and family were not involved without independently verifying it. C did not contact T regarding Michael’s deterioration, despite T being his son who regularly visited and communicated with him.<br><br>There were significant difficulties reaching staff outside normal business hours and on weekends. When T attempted to address Michael’s expressed wishes, he could not locate a nurse or physician.<br><br>A feeding tube was also discussed despite Michael’s POLST indicating he did not want artificial nutrition. Although not placed, this raised concerns about whether his documented wishes were being reviewed and followed.<br><br>A staff member told us that morphine would “shut his system down.” We understand morphine may be used for pain or respiratory distress; our concern is whether Michael’s own wishes and proper decision-making processes were respected.<br><br>We request investigation of:<br>How and when Michael’s capacity was assessed.<br>What procedure was followed to identify a surrogate and whether Michael’s stated preference for T was considered.<br>Who entered C’s name on the face sheet and POLST-type form, why she signed medication paperwork, and whether she had legal authority.<br>What efforts were made to contact T after he left his phone number, and whether appropriate after-hours/weekend communication procedures were available.<br>Whether Michael’s POLST and other documented wishes were reviewed and followed.
