- Elizabeth Larson
- Posted On
State fines Evergreen Lakeport Healthcare $100,000 for 2011 death of patient
LAKE COUNTY, Calif. – A Lakeport skilled nursing facility has received the most severe penalty and highest fine under state law for the 2011 death of a woman who was given the wrong medication and not transported to the hospital for acute care.
Dr. Ron Chapman, director and state health officer of the California Department of Public Health, said Evergreen Lakeport Healthcare received a Class “AA” citation and a $100,000 fine from the state of California.
Chapman said a CDPH investigation found facility deficiencies resulted in the death of the resident, whose name was not released in the report.
Evergreen Lakeport Healthcare – part of Evergreen California Healthcare and EmpRes Healthcare – is a 99-bed skilled nursing facility located on Craig Avenue that offers both short- and long-term care.
Neither Evergreen Lakeport nor any of its associated entities have so far issued a statement in response to the penalty.
The citation packet – including corrective action items to prevent similar occurrences in the future was delivered to the facility's executive director on May 16, state documents showed.
The woman whose death resulted in the penalty was admitted to Evergreen with a coronary artery bypass graft, pacemaker for sick sinus syndrome and atrial fibrillation, the report said. She lived with her daughter and was said to be alert, independent and spry.
According to the investigation, at around 1:30 a.m. Aug. 8, 2011, a nurse incorrectly administered an oral dose of 30 milligrams of methodone for pain to the female resident in question instead of another patient.
The state investigation said that methodone was not in the physician's orders for the woman.
In addition, the state faulted Evergreen for not transporting the patient to a hospital for treatment.
The investigation found that a physician's order for life-sustaining treatment dated Aug. 1, 2011, which the woman had signed, called for full treatment and transfer to a hospital if indicated, including intensive care.
Evergreen's medical staff also didn't administer a reversal agent, Narcan, to the patient, according to the report.
“These failures resulted in delay in treatment of acute methadone toxicity,” and resulted in the woman's death, the investigation report stated.
After giving the woman the dose of methadone, Evergreen staff kept her at the facility, giving her oxygen and monitoring her vital signs, according to the investigation.
Her oxygen saturation levels went down; eight hours later, her blood pressure dropped and she stopped breathing. The report said staff called 911 and cardiopulmonary resuscitation was performed on the woman, who was pronounced dead shortly thereafter.
According to the Lake County Coroner's report, dated Aug. 10, 2011, the nurse practitioner told officials that she did not give the reversal agent for methadone “as we usually don't do that.”
The nurse practitioner went on to tell officials that she should have sent the woman to the hospital immediately but decided to watch her and take her vitals to see how she would progress.
She told coroner's staff that she sees many advanced age residents at the facility all year around that are sent to the hospital and then sent right back to Evergreen, which offers comfort care.
The coroner's office determined the woman's cause of death to be acute methadone toxicity, based on the autopsy and toxicological investigation, the state reported.
State officials concluded that Evergreen's protocol violations “presented an imminent danger to the Resident and were a direct proximate cause of the death of the Resident.”
CDPH said 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 quality of care.
California has the statutory authority to impose fines against nursing facilities it licenses as part of enforcement remedies for poor care, CDPH officials reported.
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 $2,000 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, CDPH said it strives to protect the health and safety of vulnerable individuals.
The citation process is part of CDPH’s ongoing enforcement efforts in improving the quality of care provided to residents of the state’s approximately 1,400 skilled nursing facilities.
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