SACRAMENTO – Evergreen Lakeport Healthcare skilled nursing facility in Lake County has received a "AA" citation, the most severe under state law, and a $100,000 fine, the highest fine under state law, from the state of California after an investigation by the California Department of Health Services (CDHS) concluded that poor care of a 44-year-old resident led to her death, State Public Health Officer Dr. Mark Horton announced today.

Records show that the resident required total assistance with daily living activities.

On June 2, 2006, three days after admission, the resident suffered a seizure and aspirated material into her lungs. When staff responded, suction equipment was unavailable in the resident’s room. When an emergency cart was found, it was not stocked with the necessary equipment to set up emergency suction to clear the resident’s airway. Cardiopulmonary resuscitation (CPR) was initiated, but was stopped before paramedics arrived. The death certificate indicated "aspiration and seizure disorder" as the cause of death.

CDHS determined that the facility failed to assess for and prevent aspiration, failed to ensure staff were adequately trained in emergency response procedures and CPR techniques and failed to ensure emergency airway equipment was stocked and available to nursing staff during a life-threatening situation.

All nursing facilities in California are required to be in compliance with applicable state and federal laws and regulations governing health care facilities. Facilities are required to comply with these standards to ensure at least a minimal level of quality of care.

California has the statutory authority to impose fines against nursing facilities it licenses as a tool in its arsenal of enforcement remedies for poor care. The "AA" citation process is part of CDHS’ ongoing enforcement efforts in improving the quality of care provided to residents of the state’s approximately 1,400 skilled nursing facilities.

State citations that require a civil monetary penalty be imposed are categorized as Class B, A or AA. The associated fines range from $100 to $1,000 for Class B, $2,000 to 20,000 for Class A and $25,000 to $100,000 for Class AA.

The citation class and amount of the fine depend upon the significance and severity of the substantiated violation, as prescribed and defined in California law. By providing nursing facilities it licenses with consequences for substantiated violations, CDHS strives to protect the health and safety of vulnerable individuals.

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