PACIFIC COAST MANOR
1935 WHARF ROAD, CAPITOLA, CA 95010
Citation Number: 070004430
Citation Date: 11/7/2007
Violation Date: 9/15/2007
Class: AA
Penalty: $ 100000.00

A 71 year old female resident with metastasizing cancer became agitated. The facility implemented a doctor's order for morphine and fentanyl on 9/15/07, despite the resident's noted opioid intolerance. The facility failed to monitor the resident for adverse side effects, despite her rapidly declining condition. She died on 9/16/07. The facility's failures presented an imminent danger to the resident and were a direct proximate cause of her death.