Tiffany Revelle — Record-Bee staff
LAKEPORT — The 44-year-old woman who died last year at Evergreen Lakeport Healthcare Center was identified by the Lake County Coroner”s Office as Tania Deborah Gottfried. She had been a Lakeport resident, and a resident of the center for three days before she died June 2 during a seizure.
The California Department of Health Services cited the facility for failing to assess her for and prevent her aspiration, failing to ensure staff were trained in emergency response procedures and CPR, and failing to make sure emergency airway equipment was stocked and available to nursing staff when it was ultimately needed.
Gottfried reportedly was diagnosed with seizure disorder, which along with aspiration was listed as her cause of death.
Her mother, Carol Gottfried, said a stroke in March 2006 had worsened her daughter”s already disabled condition and left her in need of fulltime care. It was Gottfried”s second stroke, the first leaving her unable to swallow and partially paralyzed on her left side. The second stroke affected her balance, which in combination with her inability to use her left hand in operating a walker, took away her ability to walk on her own.
That left Gottfried”s mother looking for another living situation for her daughter, as the Caring Home facility in Willits where Gottfried was living was not licensed to provide care for her new condition.
Carol Gottfried, a Ukiah resident, explained that Evergreen Lakeport Healthcare was the only facility that would take her daughter, and that it took her on the condition that she would need round-the-clock care. She was admitted May 30, and Carol Gottfried said a contagious respiratory infection prohibited her from visiting her daughter at the time.
Three days later, as stated in the report from CDHS, Gottfried had a seizure and aspirated material into her lungs. When facility staff responded, suction equipment needed to clear her airway was unavailable in the woman”s room and an emergency cart was not stocked with equipment to set up emergency suction to clear her airway.
The report further states that CPR was initiated, but was stopped before paramedics arrived on scene.
A Lake County Coroner”s report narrative written by Deputy E. Keener states, “CPR was continued until the paramedics arrived.”
A Form 2567, which documents the findings of CDHS” investigation, states that responding staff noted that “there was no documentation that staff attempted to clear (Gottfried”s) airway or that CPR continued until the paramedics arrived.”
When Carol Gottfried learned from facility staff what had happened, she reported it to the state. “All I want is to make sure this doesn”t happen to someone else,” she said.
A CDHS report reveals that Evergreen was cited on a total of nine occasions between July 2003 and June 8 of this year, most of those for reasons having to do with “patient care.” Two of those reports were for “abuse/facility not self reported,” both in November of 2005. All except the June 8 complaint were class B. A CDHS press release explained that class B is the least severe penalty category, for which fines of $100 to $1,000 can be imposed. All but one of the class B fines were $1,000, one was for $750.
The June 8 citation, in connection with the circumstances surrounding Gottfried”s death, was classified as AA, and carried the stiffest fines the state could impose, ranging between $25,000 and $100,000. The fine imposed was $80,000, the CDHS clarified Friday, and not $100,000 as previously reported.
Facility Administrator Steve Hendrickson would not comment on the matter Friday, but said no litigation was under way.
Carol Gottfried described her daughter Tania as “a really brave, gallant spirit.”
Although mentally disabled and deaf, “she had such dignity and pride, and everything she did she did well,” said Gottfried. Until her second stroke in March 2006, Tania Gottfried had lived and worked in Willits, and had looked forward to recovering and being even more independent.
Carol Gottfried said because of the timing of her daughter”s seizure last year, she was only looking for a temporary living situation until her daughter would be in an apartment close to her own home, with a roommate in an assisted-living situation.
“No matter where she was, she would introduce herself and set up relationships,” said Gottfried, who remembered how even as a baby, Tania Gottfried would crawl to other people”s blankets in the park, smile and make friends.
Contact Tiffany Revelle at trevelle@record-bee.com.
