Feds Investigate Laguna Honda Hospital
Police: Patient Falls To Her Death
KGO By Dan Noyes
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Mar. 19 – KGO – State regulators have slapped San Francisco’s Laguna Honda Hospital with the most severe penalty following the death of an elderly patient five months ago. It’s just the latest in a long list of problems for the hospital, which is supposed to serve as the safety net for the city’s low-income seniors and disabled.
The family of the 82-year-old patient asked us not to use her name or picture. They are having a terrible time with what happened. This case is now part of a federal investigation into Laguna Honda. We found inspectors from the Department of Justice at the hospital today.
John Kanaley, Laguna Honda administrator: “I’d really like to convey our sympathy to the family.”
The I-Team spoke with Laguna Honda’s administrator today about the death of the 82-year-old woman.
The state Department of Health and Human Services has fined the hospital $100,000 dollars in a class AA citation — the most severe — for failing to provide adequate supervision for the patient.
John Kanaley: “They cited us for the care that we provide and the failure to supervise, and we don’t agree. So, therefore, we’ve appealed the citation.”
But records obtained by the I-Team today show the patient had dementia and a history of leaving the hospital. She was trying to get out that day in October. She struggled with the staff, they sedated her, and two hours later, she was missing from her bed. Police investigators concluded she fell from a third story window.
John Kanaley: “What we found was that the patient was clearly supervised, we continued to monitor the individual, as I stated.”
ABC7’s Dan Noyes: “Oh, come on, John. She was supervised to the point she went out a third floor window, I mean, how do those two things jive?”
John Kanaley: “Again, I’m not stating that the individual went out the third floor window.”
John Kanaley questioned the conclusion by police that the patient fell from the top floor, but a medical examiner’s report says inspectors found pieces of the woman’s jade bracelet on the ground near her body and on the ledge of the second story window.
Ed Jew, San Francisco supervisor: “They have no answers to it, and this is under supervision of Laguna Honda? This is not supervision, there’s no supervision.”
Supervisor Ed Jew says this latest case is an example of the crisis at Laguna Honda.
We spotted Department of Justice investigators starting their three-day inspection of the hospital, and the I-Team’s obtained five pages of questions they have for Laguna Honda officials, including “a computerized list of significant incidents (including, but not limited to, abuse and neglect) and serious injuries.”
Ed Jew, San Francisco supervisor: “This is pretty serious when a senior falls out of a three story building. I think this is very, very serious. I think the children should be devastated from what we’ve discussed.”
Administrator John Kanaley says the hospital performed its own investigation into the incident. He wouldn’t share the findings, but he says he has plans for improving patient care.
John Kanaley: “I think you improve staffing, you look at your processes, you look at your quality measures and you stay focused on those. You try not to get distracted by external factors.”
He’s referring to the controversy over the Newsom administration’s plan that sent the homeless — many with criminal records — to the hospital, endangering the frail and the elderly.
The patient’s family gave us a statement today: “Our family is still grieving over the loss of our loved one, and we hope that Laguna Honda will not allow something like this to happen to anyone else.”
Have a tip on this or another investigation? E-mail the ABC7 I-Team or call 1-888-40-I-TEAM.
Did Budget Cuts Lead To Patient’s Death?
Doctor Offers Insight
KGO By Dan Noyes
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Mar. 20 – KGO – The ABC7 I-Team has uncovered new details of what lead up to the death of an 82-year-old patient at Laguna Honda Hospital. It appears that the city’s budget crisis played a role.
The hospital got slapped by the state last week with the most severe fine possible — $100,000 dollars — a Class AA citation. And it all comes down to something so simple — the use of a sitter.
Dr. Teresa Palmer was a geriatrician at Laguna Honda for 15 years. She left in November 2004.
From looking at the state’s citation against the hospital, she has insight into how the 82-year-old patient died.
ABC7’s Dan Noyes: “Did budget cuts contribute to this lady’s death, in your opinion?”
Dr. Teresa Palmer: “Yes, and this is a constant thing.”
The state’s citation describes what happened that night at Laguna Honda’s Clarendon Hall.
The patient called “Resident A” is an 82-year-old woman with severe dementia and a history of trying to leave the hospital.
On October 30th, she tries again.
6 p.m.: Resident A “tried to kick and fight” the two nursing assistants who stop her.
6:45 p.m.: A doctor orders an injection of sedative, and nurses place Resident A in bed.
7:55 p.m.: A nurse “had a feeling she would need help if she woke up restless,” so she orders a sitter.
The sitter never came. A half hour later, the staff finds the patient on the ground outside Clarendon Hall, after a three-story fall.
Palmer says current staffers at the hospital have been told they can’t order sitters.
Dr. Teresa Palmer: “This is terrible. It’s terrible. It’s not based on what’s right for the people that are patients at Laguna Honda.”
ABC7’s Dan Noyes: “It seems so basic and so simple, why not use a sitter?”
Dr. Teresa Palmer: “Money.”
A month after Resident A dies, Laguna Honda’s administrator reports to the hospital’s oversight committee they’re running $44 million dollars over budget, the use of sitters being one of the top reasons.
But John Kanaley writes: “What are we doing to get back on track with our budget overage? We’ve decreased our sitter hours per day from 299 hours to 34 hours per day.”
Kanaley has not returned our calls requesting an interview on this issue. Yesterday, he told us despite her plunge from a third-story window, the patient was supervised.
ABC7’s Dan Noyes: “You understand those two things don’t seem to match up.”
John Kanaley: “Um, I understand that there could be additional questions from that, and unfortunately, I can’t comment beyond that.”
We also tried to speak with Mayor Newsom about this today. If you’ve followed I-Team investigations in the past, you know he refuses to sit down for an interview with us on any topic. He insists we catch up to him at public events. We called his office again this afternoon requesting a comment for this story, but no answer.
ABC7’s Dan Noyes (to Newsom): “Any thoughts on the elderly woman who fell from the third floor at Laguna Honda?” (No Response.)
So, we met Newsom after a City Hall news conference on the central subway.
ABC7’s Dan Noyes: “Mayor, there is some evidence that budget cuts played a role in what happened, could I talk to you about that, please?” (No Response.)
Mayor Newsom will be facing more questions from the city’s Asian journalists.
Supervisor Ed Jew told them today about the patient who died, a Chinese-American woman, with family still in the city.
Ed Jew, San Francisco supervisor: “They’re very, very distraught. She was just crying on the phone. I just told her that we’re going to look into it and make sure this doesn’t ever happen again, for any other family.”
We also spoke to the family and are respecting their request not to use their grandmother’s name or picture.
There are so many issues at Laguna Honda and we’ve already been getting calls from current and former workers. If you have a tip, e-mail us through or call 1-888-40-ITEAM.