complaint·June 19, 2025

Review of R1’s medication list for May 2023 revealed that R1 had been prescribed numerous medications, including one routine pain medication and five as needed (PRN) medications for pain relief, one of which was the pain medication hydromorphon 2mg. Review of R1’s medication list between November 2022 and May 2023 revealed that R1 was prescribed hydromorphon 2mg as needed every 2 hours. Interviews with staff revealed that the facility did not keep a Medication Administration Record (MAR) for routine medications, but did maintain a MAR for PRN medications, including R1’s hydromorphon. Interviews with staff and review of R1’s death certificate revealed that R1 had a surgical operation to correct a complication from R1’s tracheostomy on 5/11/2023. Review of R1’s 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. Interviews with staff revealed that R1 was very aware of R1’s medication schedule and routine, and would frequently ask for their prescribed medications, including pain medications more often than the medication was allowed by the doctor’s order. Review of R1’s death certificate revealed that R1’s cause of death was listed as tongue cancer, and did not list any conditions related to medications contributing to R1’s death. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. 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).