Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to cite for a deficiency discovered during a complaint visit that is unrelated to the complaint allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Administrator Juliane Cruz.

During the unrelated complaint visit, it was determined that Resident 1's (R1) file did not contain a written doctor's order for a medication change. Review of R1’s medication list between November 2022 and May 2023 revealed that R1 was prescribed hydromorphon 2mg as needed every 2 hours and to not exceed 12 doses within 24 hours. Review of R1’s Medication Administration Record (MAR) for hydromorphon revealed that following R1’s surgery on 5/11/2023, R1 was given 2mg hydromorphon on 5/13/2023 at 11:30am and 2:00pm. R1 received additional doses of hydromorphon at 5:00pm, 8:00pm and 11:00pm, however, those doses had a handwritten note next to each dose that the dose given was 3mg. On the following page of R1’s MAR, another handwritten note stated that the doctor changed the dose and frequency to 3mg every 3 hours. The MAR revealed that R1 received 3mg of hydromorphon approximately 3 hours apart. Review of R1’s physician’s orders revealed that R1 did not have any written orders to change the dose and frequency of hydromorphon.

Therefore, a deficiency regarding written doctor's orders is being cited per California Code of Regulations Title 22 and noted on the attached LIC809-D page.

An exit interview was conducted with Administrator Juliane Cruz, whose signature below confirms receipt of a copy of this report, and the Licensee Appeal Rights (LIC9058 3/22).