Evergreen Lakeport Healthcare
1291 Craig Avenue Lakeport, CA 95453
Citation Number: 110008617
Citation Date: 5/16/2013
Violation Date: 8/8/2011
Class: AA
Penalty: $100,000

On 8/8/11, a female resident was given methadone that was not ordered by a physician. The licensed nursed confused the resident for a different resident. The nurse discovered her error about 15 minutes later. Despite the resident's declining functioning, the staff did not call 911 until eight hours later and she died shortly after. The staff had decided to monitor vital signs instead of sending the resident to the hospital or seeking treatment with a reversal agent. The facility was cited for giving the resident the wrong medication and failing to transfer the resident to the hospital after the error was discovered. The violations were a direct proximate cause of the resident's death.