Report: Nurses didn’t heed orders to watch patient
SAN FRANCISCO — Nurses at a San Francisco hospital did not heed doctors’ orders to maintain a constant watch on a patient who ended up leaving her room and was found dead in a locked stairwell 17 days later, a newspaper reported.
The San Francisco Chronicle cited the results of a Centers for Medicare and Medicaid Services investigation.
After Lynne Spalding was admitted to San Francisco General Hospital for a bladder infection and disorientation on Sept. 19 a doctor had instructed staff there in writing to “NEVER leave patient unattended,” the newspaper reported.
The next day, after Spalding had wandered into a nursing station speaking incoherently, a doctor reminded a nurse that the woman needed around-the-clock observation. The staff’s notes on Spalding, however, simply indicated that she was supposed to be monitored only with “close observation,” and the nurse who had spoken with the doctor acknowledged she never updated the instructions, the Chronicle said.
Spalding, 57, went missing from her bed a day later. A building engineer conducting a quarterly inspection discovered her body in the stairwell located not far from her room on Oct. 8. The San Francisco coroner attributed her death to dehydration and an electrolyte imbalance likely related to chronic alcohol use, but could not pinpoint when she died.
San Francisco Sheriff Ross Mirkarimi, whose department provides security for the public hospital, has conceded that deputies failed to conduct a thorough search for Spalding.
The report obtained by the Chronicle, which California public health inspectors prepared for the federal agency, contradicts statements hospital officials gave after Spalding’s body was found. They said nurses were told to check on Spalding every 15 minutes and did, including right before Spalding left her room.
Instead, the state inspectors found, the patient went unsupervised for 85 minutes before her disappearance because the person assigned to watch her was called away and no one was assigned to replace her, the newspaper said.
A hospital spokeswoman did not respond to an email seeking comment Sunday, but San Francisco General officials reiterated in a statement to the Chronicle that they have worked hard to improve patient safety protocols since Spalding’s death and “we are a safer organization today.”
The federal report provided more details about the approach sheriff’s deputies took to search for Spalding. It states that on Sept. 30, nine days after Spalding was reported missing, four different deputies were all told to search the hospital’s 10 stairwells. One searched the grounds but no stairwells, and another two checked only a pair of stairwells a piece.
A commander said the fourth deputy reported completing the check, but the deputy informed the state investigators he hadn’t because he thought he was supposed to search for Spalding only if he had free time.
Spalding’s family released a statement Sunday responding to the report, which has not yet been made public.
“This report confirms what we have saying since September 21, 2013 when Lynne Spalding disappeared: SF General and the SF Sheriff’s Department never took seriously the safety and welfare of Lynne Spalding,” it said. “Instead they ignored our calls, childishly pointed fingers at each other, and shuffled deck chairs on a waterlogged ship.”
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