055798
03/17/2025
Vasona Creek Healthcare Center
16412 Los Gatos Boulevard Los Gatos, CA 95032
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to carry out and implement a physician ' s order in a timely manner for one of three sampled residents (Resident 1). This failure had the potential to compromise Resident 1 ' s health and well-being.
Residents Affected - Few
Findings: Review of Resident 1 ' s medical record indicated he was admitted on [DATE] and had diagnoses including hypothyroidism (a condition in which the thyroid gland does not produce enough hormones which are essential for metabolism and other bodily functions). Review of Resident 1 ' s physician ' s orders indicated he had an order, dated 7/5/24, for levothyroxine sodium (medication used to treat hypothyroidism) 50 micrograms (mcg, unit of dose measurement) by mouth in the morning. Review of Resident 1 ' s Tele Visit Encounter Progress Note, dated 7/10/24, indicated he had a telephone visit with an endocrine clinic (clinic that specializes in conditions of the endocrine system, such as hypothyroidism). The progress note indicated the endocrine clinic doctor gave an order to, Increase levothyroxine to 150mcg one tablet daily. Review of Resident 1 ' s medication administration record (MAR) indicated Resident 1 continued to receive levothyroxine sodium 50 mcg daily until 8/1/24. The MAR indicated Resident 1 received levothyroxine sodium 75 mcg daily from 8/2/24 to 1/14/25. Further review of the MAR indicated Resident 1 ' s levothyroxine sodium was not increased to 150 mcg daily until 1/15/25. During an interview and concurrent record review with licensed nurse A (LN A) on 3/17/25 at 9:30 a.m., LN A reviewed Resident 1 ' s medical record and confirmed that on 7/10/24, the endocrine clinic doctor gave an order to increase levothyroxine to 150 mcg daily. LN A confirmed the facility did not increase Resident 1 ' s levothyroxine sodium to 150 mcg daily until 1/15/25. LN A acknowledged that Resident 1 ' s nurse should have carried out the order when it was given by the endocrine clinic doctor. The facility ' s policy titled Administering Medications, dated 2001, indicated, Medications are administered in accordance with prescriber ' s orders.
Based on interview and record review, the facility failed to carry out and implement a physician's order in a timely manner for one of three sampled residents (Resident 1). This failure had the
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055798
055798
03/17/2025
Vasona Creek Healthcare Center
16412 Los Gatos Boulevard Los Gatos, CA 95032
F 0684
potential to compromise Resident 1's health and well-being.
Level of Harm - Minimal harm or potential for actual harm
Findings:
Residents Affected - Few
Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including hypothyroidism (a condition in which the thyroid gland does not produce enough hormones which are essential for metabolism and other bodily functions). Review of Resident 1's physician's orders indicated he had an order, dated 7/5/24, for levothyroxine sodium (medication used to treat hypothyroidism) 50 micrograms (mcg, unit of dose measurement) by mouth in the morning. Review of Resident 1's Tele Visit Encounter Progress Note, dated 7/10/24, indicated he had a telephone visit with an endocrine clinic (clinic that specializes in conditions of the endocrine system, such as hypothyroidism). The progress note indicated the endocrine clinic doctor gave an order to, Increase levothyroxine to 150mcg one tablet daily. Review of Resident 1's medication administration record (MAR) indicated Resident 1 continued to receive levothyroxine sodium 50 mcg daily until 8/1/24. The MAR indicated Resident 1 received levothyroxine sodium 75 mcg daily from 8/2/24 to 1/14/25. Further review of the MAR indicated Resident 1's levothyroxine sodium was not increased to 150 mcg daily until 1/15/25. During an interview and concurrent record review with licensed nurse A (LN A) on 3/17/25 at 9:30 a.m., LN A reviewed Resident 1's medical record and confirmed that on 7/10/24, the endocrine clinic doctor gave an order to increase levothyroxine to 150 mcg daily. LN A confirmed the facility did not increase Resident 1's levothyroxine sodium to 150 mcg daily until 1/15/25. LN A acknowledged that Resident 1's nurse should have carried out the order when it was given by the endocrine clinic doctor. The facility's policy titled Administering Medications, dated 2001, indicated, Medications are administered in accordance with prescriber's orders.
055798
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