DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
051528 A. BUILDING __________
B. WING ______________ 		09/21/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ELIZABETH HOSPICE 500 LA TERRAZA BLVD SUITE 130, ESCONDIDO, CA, 92025
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0687      
39448 Based on interview and record review, the agency failed to reorder a pain medication before it ran out for one of two sampled residents (1). As a result, the pain medication was not available to Patient 1. Findings: Per the agency's Patient Information, Patient 1 was admitted to the agency on 7/17/21 with diagnosis of malignant neoplasm of ovary (ovarian cancer). On 8/31/21 at 2:33P.M., a telephone interview was conducted with the Case Manager (CM 1). CM 1 stated, Patient 1's caregiver called her on 7/16/21 at 2 P.M. to request a refill for dilaudid (a pain medication). CM 1 further stated, she told the caregiver that a nurse would visit her later that day and would refill the medication at that time. On 8/31/21 at 3:50 P.M., a telephone interview was conducted with the Skilled Nurse (SN 1). SN 1 stated, she visited Patient 1 on 7/16/21, but did not refill the dilaudid and no one asked her to refill the dilaudid. On 9/14/21 at 11:15 A.M., a telephone interview was conducted with the Pharmacist. The Pharmacist stated, the pharmacy sent 20 vials of dilaudid to Patient 1 on 7/13/21, which usually lasted three to four days, but could have been used in as little as one day. The Pharmacist further stated, the pharmacy received the refill order for dilaudid on 7/16/21 at 8:15 P.M. Per the agency's Charts/Clinical Notes, on 7/16/21 at 7:31 A.M., " ...call received from (Patient 1's caregiver) requesting a refill on pts (patient's) dilaudid ... Caller states the only has 3 vials of dilaudid left ... Caller informed that the team would be contacted with request for urgent medication refill ..." Per the agency's Charts/Clinical Notes, on 7/16/21 " ...Routine ... visit ... Collaboration completed with (CM 1) ... signed by (SN 1) ..." The note did not indicate SN 1 checked the remaining amount of dilaudid or refilled the medication. Per the agency's Charts/Clinical Notes, on 7/16/21 at 7:29 P.M., " ...Call received from patient's caregiver ... regarding medication refill ... states she called this morning requesting a refill of patient's dilaudid ... She states patient's case manager was out today and reminded of the request. Medications/Supplies have not yet arrived ... Writer spoke with (the pharmacy) who states an order for the dilaudid was not placed recently... patient is now out of dilaudid ..." Per the agency's Charts/Clinical Notes, on 7/16/21 at 11:04 P.M., " ...(Patient 1's caregiver) returned call at 1028 pm and stated med had not arrived. Upon calling (the pharmacy) they stated med would not arrive until midnight ..."