Pacific Coast Manor, in Santa Cruz, has been issued the most severe citation allowed by California law and fined $100,000 after a state investigation concluded inadequate care led to the death of a female resident at the nursing home. The California Department of Public Health concluded the nursing home failed to adequately monitor the woman for adverse consequences from combination of narcotic medications, leading to her death.
The state citation detailed the care of a 71-year-old woman suffering from breast cancer, which had spread to her spine. The resident made it clear she wanted to keep fighting the cancer and would be interested in taking medications. Her cancer specialist noted “she could have years to live” even with her cancer.
Three days after being admitted, a doctor ordered a fentanyl patch, haldol, a morphine sulfate injection for pain, and methadone. On the morning of Sept. 15, the fentanyl patch was placed on the woman, and when she awoke that afternoon, she yelled to the nurses, “I’m dying.” The next day, she was comatose and responsive only to pain. She died the afternoon of Sept. 16, approximately 24 hours after the fentanyl patch was applied.
Pacific Coast Manor is a 99-bed skilled nursing facility. It is owned by Covenant Care of Aliso Viejo, which employs more than 5,000 people who care for more than 4,000 patients at 42 facilities.