LAKEPORT — A rehabilitation and long-term care nursing facility in Lakeport received the harshest penalty allowed under state law for an incident nearly two years ago during which a female patient reportedly died after being given the wrong medication, state officials said last week.
Evergreen Lakeport Healthcare was issued a Class “AA” citation and a $100,000 fine for a pair of violations that investigators allege directly contributed to the woman”s death in August 2011.
Dr. Ron Chapman, director and state health officer for the California Department of Public Health (CDPH), announced the penalty Friday.
“By providing nursing facilities it licenses with consequences for substantiated violations, CDPH strives to protect the health and safety of vulnerable individuals,” according to the department statement.
Attorney Kippy L. Wroten, who represents Evergreen Lakeport Healthcare, said company officials plan to challenge the state-imposed penalty.
“We don”t believe the citation and fine are consistent with what we know the facts to be,” Wroten, of Irvine-based Wroten & Associates Inc., said by phone Monday. “We”re disappointed with that, especially two years down the road.”
The 99-bed, 24/7 care facility was sanctioned after CDPH investigators determined a female patient received pain medication actually intended for another patient and then was not transferred to a hospital for evaluation and treatment after Evergreen officials discovered the mix-up.
Wroten did not address many facts about the incident, citing privacy laws, but she did say the incident involved one third-party professional and at least one person who no longer works at the facility.
State officials did not release the name of the deceased woman, who died Aug. 8, 2011 from what the Lake County Coroner”s Office deemed “acute methadone toxicity.”
Around 1:30 a.m. that day, a licensed nurse reported that her colleague said a patient needed pain medication, according to a CDPH investigation report completed May 16.
The nurse prepared 30 milligrams of methadone and used a photograph from medication administration records to identify which patient was set to receive the oral dose, according to the report.
The unnamed woman was admitted to the Craig Avenue facility with diagnoses including atrial fibrillation, coronary artery bypass graft and a pacemaker for sick sinus syndrome, according to the report. There was no history of a doctor prescribing her methadone.
The nurse reportedly looked at a picture of the unnamed woman instead of the patient actually in need of the methadone and proceeded to give the medication to the wrong person, according to the CDPH.
The nurse discovered her mistake 15 minutes later when the colleague again inquired about pain medication for the aching patient, state investigators said.
Evergreen nursing supervisors were immediately informed, and the nurse practitioner ordered facility reps to monitor the woman”s vital signs and check hourly for indications of respiratory depression, according to the CDPH report.
The patient “remained at the facility for eight hours and exhibited signs and symptoms of decreased oxygen saturations and increased sedation and was not treated with a reversal agent to prevent adverse effects of methadone,” the CDPH investigators alleged.
By 10:30 a.m. on Aug. 8, 2011, the woman had a severe drop in blood pressure and a spell of apnea, according to the CDPH. Evergreen staff reportedly called 9-1-1, with the woman in need of resuscitation, but she died at 10:45 a.m.
The woman”s doctor”s orders called for “full treatment transfer to hospital if indicated, includes intensive care,” according to the CDPH.
The unnamed Evergreen nurse practitioner reportedly gave a statement to the county coroner two days after the death, admitting the woman should have been transferred to a hospital.
“I should have sent (the patient) to the hospital immediately but decided to watch and take her vitals to see how she would progress,” the employee said, according to the CDPH report. “I see so many advanced age residents here all year long that are sent to the hospital and sent right back by them, as the patients are at our facility for comfort care.”
Additionally, Evergreen”s director of nurses at the time indicated, “The facility does not have a specific policy for resident identification staff is to use the picture of the resident that is kept with the resident”s records or the identification bracelet,” the CDPH report stated.
Wroten said Evergreen officials reviewed the 2011 death to look for ways to improve its operations and employee decision-making, just as they would with any “unexpected incident.”
“The facility is proud of its services to the community and its dedication to patient care,” she added.
Jeremy Walsh is a staff reporter for Lake County Publishing. Reach him at 263-5636, ext. 37 or jwalsh@record-bee.com. Follow his coverage on Twitter, @JeremyDWalsh.
