HospitalInspections.org

Based on interviews and document reviews the hospital failed to ensure the provision of Governing Body as evidenced by:

1. The Governing Body failed to improve contracted security within the hospital. The hospital had identified contracted security problems with the Sheriff 's Department since 2009 and the Governing Body did not improve security which resulted in a patient who went missing for 17 days and was found dead in a hospital emergency stairwell (See A-0084, A-0283, A-0273).



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2. The Governing Boby failed to ensure that Patient Rights were protected and enforced when a safe patient environment was not provided and patient privacy was not ensured. (See A115, A144 and A146)

3. The facility failed to ensure nursing services were provided in accordance with professional standards of practice and in a well-organized manner to ensure patients' safety in the hospital. (See A0385, A0395 and A0396)

The cumulative effects of these systemic problems resulted in the Governing Body's inability to provide services and care in a safe and effective manner in accordance with the statutorily-mandated Conditions of Participation for Governing Body.

Based on interview and document review the Governing Body failed to improve contracted security within the hospital. The hospital had identified contracted security problems with the Sheriff 's Department since 2009 and the Governing Body did not improve security which resulted in a patient who went missing for 17 days and was found dead in a hospital emergency stairwell (stairwell 8).

Findings:

A review of the clinical record indicated Patient 1 was 57 years old and was admitted to the hospital on 09/19/13 with symptoms of confusion, weight loss, and dizziness. She was diagnosed with a bladder infection, sepsis (blood infection) and delirium (confusion).

During an interview on 10/30/13 at 10:00 AM the Director of Regulatory Affairs stated Patient 1 went missing on 09/21/13 and was last seen on the 5th floor nursing station. She was later found dead lying on the 3rd floor cement landing in the emergency stairwell on 10/08/13 by hospital staff. The emergency stairwell (stairwell 8) was accessible and an distance of 99 yards away from Patient 1's room where she was last seen by staff. The Director of Regulatory Affairs said that the stairwell was rarely used and once someone entered the stairwell, the stairwell door locked behind them and could not be opened unless one had a key to the door.

A review of the entitled document Bylaws of the Governing Body For San Francisco General Hospital and Trauma Center in section 3. Duties and Responsibilities of the Governing Body indicated "To provide the resources needed to maintain safe, quality care, treatment, and services." According to the Bylaws the Governing Body had a responsibility to provide resources to the hospital to ensure patient safety.

During an interview on 10/30/13 at 2:23 PM the Chief Executive Officer (CEO) stated that she was not provided the resources needed to maintain safe security services. She also stated that since 2009 there had been several attempts to improve and add security. The CEO said that since 2009 Program Change Requests were submitted to the Board of Supervisors to obtain resources to improve and add security.

A review of the Program Change Request for 2009 to 2010; Program Change Request for 2010 to 2011; and the Program Change Request for 2011 to 2012 indicated requests to reduce the reliance of the San Francisco Sheriff Department and add contracted private security services at San Francisco General Hospital (SFGH). The Program Change Request documents were submitted to the Health Commission and Board of Supervisors in 2009, 2010, and 2011. The documents indicated a request for resources to hire private security.

A review of the 2011 Budget and Finance Committee minutes, during a Board of Supervisors session, indicated minutes discussing the Program Change Request for 2011 to 2012. The Director of Clinical Operations and Chief Medical Officer made comments to the Board of Supervisors. The Director of Clinical Operations stated in the minutes "we are here to urge you to vote yes ...allow the contract out ...of security services ...We believe this presents us ...to integrate security as part of our health care team, rather than an entity solely devoted to law enforcement. Currently, the constraints placed upon the Sheriff 's Department, because they are sworn peace officers, render them unable to support clinical situations ...Deputies ...restrain and attain ...criminal ...behavior ...We envision a model where security is part of the healthcare ...team ...additionally ...operations at the hospital, would have the power and authority to deploy such security where the need arises. Something that is currently lacking under our current ...model ..." The Chief Medical Officer stated in the minutes "This is a patient care and safety issue ...we simply do not have the employees with the training, skills, and most notably, the legal flexibility to manage medical crises in the hospital ...This is a health care issue, not a legal or law enforcement issue. We need trained personnel who can act on behalf of patients, consistent with hospital policy, and integrated into the health care team ...As health-care providers, we have a duty and obligation to provide safe and appropriate care, especially to the most vulnerable patients and those are the folks without capacity to make rational decisions, due to their acute medical illnesses. We must have the tools and resources to provide that care in a safe environment for patients and staff...Supervisors provide us with the personnel and resources to do so."

During an interview on 10/30/13 at 2:23 PM the Chief Executive Officer (CEO) stated
The following events occurred from 2009 to 2013:
2009-2010 Program Change Request to improve security-Denied;
2010-2011 Program Change Request to improve security-Denied;
2011-2012 Program Change Request to improve security-Denied;
2013 Hospital/Sheriff 's Department contract (Letter of Management Agreement) changes to improve security-No changes made

A review of the contract between the Hospital and local Sheriff 's Department (Letter of Management Agreement) page 7 section 10 entitled DPH(hospital) Policies and Procedures indicated "SFSD[San Francisco Sheriff ' s Department] employees assigned to work at sites under DPH control shall be subject to applicable DPH policies and procedures, provided that no such policy or procedure shall be construed to limit the authority of the SFSD to exercise command and control of law enforcement and other public safety operations at such sites ..."

A review of the hospital administrative policy, entitled AMA (Against Medical Advice) , AWOL (leaving without notification-missing) and Elopement indicated: patients Leaving SFGH Prior to Completion of Their Evaluation or Treatment indicated "C. Patient on a Legal Hold and/or without Capacity Found Missing: If a patient, who is on a legal hold [legally held dangerous to self or others] and/or lacks capacity ...is not in his or her room and cannot be found after a reasonable search on the unit, staff will do the following ...The nurse will notify the SFSD Dispatcher ...and provide a description of the patient and ask for their assistance to search the hospital public areas, stairwells, etc. and , if found, to return the patient to the unit."

During an interview on 11/04/13 at 2:00 PM Sheriff 's Department Staff 10 (SDS 10) stated that he interviewed hospital staff on the day Patient 1 went missing on 09/21/13. He also stated that he read the chart and found that Patient 1 was not on a legal hold. He said because Patient 1 was not on a legal hold he did not complete a missing persons report. He reported his findings to his supervisor Sheriff 's Department Staff 2 (SDS 2). He said he never actively searched or received orders to actively search for Patient 1.

During an interview on 11/07/13 at 11:40 AM Sheriff 's Department Staff 1 (SDS 1) stated he supervised SDS 2 and SDS 10. He also stated that patients medically at risk (lacks capacity), patients not safe to be out on their own should be searched for and reported as a missing person irrespective to their legal hold status.

A review of a Missing Persons Report entitled San Francisco Police Department INCIDENT REPORT indicated Patient 1's daughter filed a report with the San Francisco Police Department on 09/21/13 (the same day Patient 1 was found missing). The Missing Persons Report indicated "On 09/21/2013 at 1145 hours ...[Daughter] called to say that her mother ...walked out of SFGH at approximately 1125 hours and has not been heard of ...[Daughter] told me she is worried because her mother is not well and can be confused on where she is and what's going on..."

A review of hospital's dispatch transcripts, transcribed voice recorded telephone communications with Sheriff 's Department Dispatch; entitled SFSD Phone Transcripts indicated the following at the corresponding times on 09/21/13:
*10:25 AM Communications between Nurse/Dispatch
"I'm calling for a [Patient 1]...We tried looking all over the place...I didn't see anything, looked all over the place, we cannot find her..."
*11:12 AM Communications between MD 1/Dispatch
"I am one of the physicians' in the hospital. I just had a patient who AWOL'd ....She was confused and wandered off ...she was very confused ...not safe to be out on her own."
*11:17 AM Communications between Patient 1's Daughter/Dispatch
"She wandered off ...We have her down as 57 years old ... short black hair, 5'2, 115 pounds. Um, we put that out over the air, but since she is not on a legal hold ...You know, there is no report written. We have documented, but we did put it out as far as if we see her, return her to 5D ...I don't think she is realizing what she is doing ...she is really weak, because the fact of that is why she was in there, like she could barely get up and walk to the bathroom ...Okay ...we are searching continuously in the hospital ...since she is not technically on a hold so we have no custody of her ...I don't understand how she is escaped. I don't understand that, like she is in a state to just run out and sneak out, like she is going to very noticeable..."
*11:45 AM Communications between SDS 6/Unknown Caller
"You guys have any walk aways from the hospital. I received a call from an out of state person saying that her mother left the hospital..[Patient 1], she left the ward, but she is not on a hold, so um, so there is nothing we can really do about it..."
*12:25 PM Communications between SDS 6/Patient 1's Daughter
"I am confused because I did contact the police...they said...that nobody was looking for her because she was being discharged...we can't legally force her to go back, since she is not on a hold..."
*12:42 PM Communications between MD 1/Dispatch
"I am the physician taking care of her. Technically, she AWOL'd ...I did not formally discharge her. I didn't even get to meet her today. So had I met her and made an assessment, I may not have discharged her today. The plan was to discharge her today, but ...provided that everything had stayed the same from yesterday...So, I don't know how that has a bearing on you guys looking for her...No...it doesn't change because she is not on a legal hold ...If we find her, we can't like, you know forcibly take her back to the unit, it is just more of a hey, can you please go back, this and that since she is not on hold..."
*8:45 PM Communications between Patient 1's Daughter/Dispatch
"Hi, I was calling up to see if there is any news on my mom...I'm going to transfer you..."
*9:18 PM Communications between Charge Nurse/Dispatcher
"Is there anything stating dementia ...She was here for ...altered mental state ...There is no need for report ..."

A review of the Sheriff Department logs indicated a written record of communications and actions taken daily. The Watch Commander log dated 09/21/13 did not indicate that a search was conducted for Patient 1. The Dispatcher log dated 09/21/13 did not indicate that a search was conducted for Patient 1. The San Francisco Sheriff 's Department-Short Report Form did not indicate that a search was conducted for Patient 1 on 09/21/13.

During individual interviews from 11/04/13 to 11/07/13 the Sheriff Department Staff stated the following on these dates and times:
*11/04/13 at 1:33 PM-SDS 6 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/04/13 at 2:31 PM-SDS 7 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/04/13 at 2:00 PM-SDS 10 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/05/13 at 1:59 PM-SDS 19 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/05/13 at 3:53 PM-SDS 21 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/05/13 at 4:01 PM-SDS 13 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/04/13 at 9:00 AM-SDS 2 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/06/13 at 11:56 AM-SDS 14 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/06/13 at 12:13 PM-SDS 25 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/06/13 at 3:00 PM-SDS 3 (highest acting supervisor when Patient 1 was reported missing) stated he gave orders for a search for a black woman (Patient 1 was Caucasian). He also stated that he did not give orders to search the stairwells on 09/21/13.

During an interview on 11/07/13 at 3:15 PM the Director of Regulatory Affairs stated the following events occurred from 09/21/13 to 10/08/13:
*09/21/13 Nurse search for Patient 1 and request assistance with Sheriff 's Department. Sheriff's Department did not search for Patient 1.
*09/30/13 Nine days after being first reported missing Hospital Administration requests for search for Patient 1. Search conducted by Sheriff 's Department but does not include stairwell number 8.
*10/01/13 Search conducted by Sheriff 's Department but does not include stairwell number 8.
*10/04/13 Someone reports to nurse that somebody is lying on the landing in stairwell number 8. Sheriff 's Department does not search stairwell number 8.
*10/08/13 Patient 1 found dead by hospital staff on the landing in stairwell number 8.
The Director of Regulatory Affairs stated that there were no other searches for Patient 1 done by the hospital or Sheriff 's Department between the dates mentioned above.

During an interview on 11/01/13 at 11:15 AM the Director of Clinical Operations stated she saw Patient 1's dead body in the stairwell. She also stated that Patient 1 was lying on her back on the cement landing with her right hand above her head, her left hand on her torso, and her head turned to the left. She said she was properly dressed fully clothed with the clothing she had at the hospital, and there was a canvas tote bag sitting upright next to her with all the contents inside the bag. There was no blood visible around the body or near her head. The Director of Clinical Operations said it did not look like she fell. She said it looked like she was just lying there.

The Sheriff 's Department first conducted an active search 9 days after Patient 1 was found missing. The search was incomplete and did not include the stairwell where Patient 1 was found dead. Patient 1 was found dead by hospital staff 17 days after she was first reported missing.

The Condition of Participation for Patient Rights was not met when the cumulative effect of the deficiencies identified resulted in actual harm to Patient 1 and potential harm for all patients within the facility as evidenced by the following:

1. The hospital failed to provide a safe environment for a vulnerable patient when Patient 1 wandered off her nursing unit and was not located in the building until after her death(A144);

2. The hospital and its contracted security services did not have a coordinated search plan for missing persons (A144);

3. The hospital failed to ensure the confidentiality of Patient 1's medical information when four staff members accessed Patient 1's Lifetime Care Record (LCR) without need and without authorization (A146);

4. The hospital failed to ensure the confidentiality of Patient 1's protected health information (PHI) when a contracted employee discussed Patient 1's PHI over the telephone with persons with no need and no authorization to receive such information (A146);

5. The hospital failed to ensure that all contracted employees received annual training on their roles and responsibilities with regard to confidentiality, privacy and HIPPA (Health Information Privacy and Portability Act) (A146); and,

6. The hospital failed to ensure the safety of their patients when there was no coordinated plan for fire and disaster response which included the contracted security personnel (A144).

Based on observation, interview, and record review, the hospital failed to provide a safe environment for care when:

1. Patient 1, a confused woman, was not assigned a one-to-one personal assistant (1:1 Coach) as ordered by the physician, which enabled Patient 1 to wander off her nursing unit without staff awareness for forty minutes. Patient 1 was able to walk through an alarmed fire escape door without anyone hearing the alarm, and Patient 1 was able to remain in a rarely used stairwell from 9/21/13 through 10/8/13 without anyone finding and assisting her before Patient 1 died in the stairwell.

2. Hospital security did not have a coordinated plan on how to search for any missing patients whether they were classified as AWOL (Absent Without Leave), missing persons, medically at risk persons, or 5150/5250 (Legally Detained) On Hold. The hospital security staff did not follow the hospital policy and procedure titled AMA (Against Medical Advice), AWOL and Elopement: Patients Leaving (Hospital Name) Prior to Completion of their Evaluation or Treatment which stated that if nursing staff were unable to locate a patient who lacked mental capacity, with or without a 5156/5250 Involuntary Hold, the Deputies would assist with searching hospital public areas and stairwells. This failure to perform an organized search which included all of the ten stairwells at the hospital was directly responsible for the failed rescue of Patient 1 from stairway #8. This lack of a coordinated search plan also had the potential for other confused patients to become lost within the hospital buildings and grounds for excessive periods of time.

3. The hospital and its contracted security service did not have a coordinated plan for their combined response to fires and other disasters such as an earthquake. This had the potential for a chaotic and ineffective response during actual emergencies which could potentially result in harm to patients, visitors, and staff.

Findings:

1. Patient 1 was admitted to the facility on 9/19/13 after her daughter brought Patient 1 to the Emergency Room for treatment of confusion over more than the past month, weight loss and dizziness. The physician's diagnoses included bladder infection, sepsis (severe infection in the bloodstream) and delirium (confusion and disorientation).

Patient 1 had a physician's order for a 1:1 coach/sitter but this order was not implemented on 9/21/13. Patient 1 dressed herself and left the nursing unit without authorization and without staff awareness of her departure until approximately forty minutes after her departure. Staff notified Security to locate Patient 1 but the nursing staff gave an incorrect description. Since Patient 1 was not on a 5150, Involuntary Hold, the Security personnel only listed her as a "Be On the Look Out" and they did not actively search for Patient 1 despite two telephone calls from the attending physician stating that Patient 1 was not safe to leave the hospital, and one telephone call from Patient 1's daughter asking for assistance. The Administrator on Duty (AOD 2) on the evening shift contacted the evening Watch Commander (SDS 2) directly to request that he file a Missing Persons report for a "Medically at Risk" person..
SDS 2 sent a Deputy (SDS 10) to the nursing unit to gather additional information but SDS 10 reported that Patient 1 was not "On Hold" so the case had "No Merit." The security department did not file a Missing Persons report with the local Police Department. Patient 1's daughter did file a Missing Persons report with the local Police Department at 11:21 AM on 9/21/13.

See Nursing Services A0395 for details of this first day of Patient 1's disappearance.

2. Patient 1 was not located between 9/21/13 and 9/30/13. Patient 1's daughter had filed a Missing Persons Report with the local Police Department on

In an interview on 111/6/13 at 3:28 PM, the Administrative Sergeant (SDS 4) stated that on 9/30/13 ay approximately 12:45 PM he met with the Chief of Nursing and she asked SDS 4 to have his Deputies conduct another complete search of the buildings and the grounds, including all ten stairwells in the main hospital building.

SDS 4 stated that at approximately 1:30 PM, he went to the Watch Commander (SDS 2) and requested another search. SDS 4 stated that he used a Visitors' Guide map and he numbered all ten of the stairwells in the main hospital building and he gave the map to SDS 2.

During an interview on 11/4/13 at 9:25 AM, SDS 2 stated that on 9/30/13 he instructed the two cadets SDS 19 and SDS 20 to search the 80/90 Building (not the main hospital building) and the tunnels which connected buildings below grounds, and he assigned two Deputies (SDS 11 and SDS 12) to search the main Hospital building including all of the ten stairwells.

During an interview on 10/31/13 at 1:50 PM, SDS 12 stated that the contracted security services had no master plan for a systematic search so when SDS 2 asked him to do another search, it was a generic "search the campus" type of order. SDS 12 said he conferred with SDS 1 and they agreed that SDS 11 would search the main Hospital and SDS 1 would search the external perimeter and the grounds of the campus. SDS 12 was unable to provide a description of the woman he was searching for, nor did he know if she was wearing street clothes or a hospital gown. SDS 12 stated that he reported back that he had not seen the missing Patient 1 on the hospital grounds.

During an interview on 11/4/13 at 3:50 PM, SDS 11 stated that he had not conferred with SDS 12 on a planned search route. SDS 11 confirmed that the security department did not have a coordinated search plan. SDS 11 stated that he searched two public stairwells, stairwell 7 and the stairwell leading to Outpatient Pharmacy which he thought was stairwell 5.

In his interview on 11/6/13 at 3:28 PM, the Administrative Sergeant (SDS 4) stated that on 10/1/13 he learned from their reports that SDS 11 had searched stairwell 7 only, and SDS 12 did not report his search area. SDS 4 stated that, after morning muster, he told the day shift Watch Commander (SDS 3) to complete the search of all ten stairwells. SDS 4 said he did not follow up with SDS 3 to see if his orders had been carried out.

During his interview on 11/4/13 at 9:25 AM, SDS 2 stated that on 10/1/13 he was the evening Watch Commander and he asked two deputies (SDS 9 and SDS 10) to search all the stairwells. SDS 2 stated that later in the evening shift the two deputies reported back to SDS 2 that they had searched all the stairwells.

In an interview on 11/4/13 at 2:00 PM, SDS 10 stated that on 10/1/13, he understood SDS 2's order to search the stairwells as a generic order, meaning that if you have free time search the hospital stairwells. SDS 10 said the security department did not have a coordinated systematic search plan for missing persons.

In an interview on 11/4/13 at 3:00 PM, SDS 9 stated he searched two public stairwells, stairwell 7 and stairwell 2 to the Emergency Department. SDS 9 said he never went in the fire exit stairwells because he had never received orientation on how to operate the fire door alarms.

During an interview on 10/31/13 at 10:55 AM, the Intensive Care Unit Director (RN 1) stated that on 10/4/12 at approximately 7:15 AM, she was walking past fire stairwell 8 on the fifth floor, when she noticed a man standing outside on the stairwell knocking on the door to be let into the hospital. RN 1 stated this fire alarm door allowed exit only and a soft beeping noise was audible for the period of time while the door was actually opened. RN 1 said the man showed her an ID badge from an associated hospital so she opened the door for him. The man relayed to her that there was a person lying on the landing between levels three and four of the stairway. RN 1 said it was not uncommon for homeless persons to gain admittance to the fire stairwells so she did not give it too much thought. RN 1 called security and told the dispatcher that there was a person lying on the landing between levels three and four in stairwell 8.

The tape recording of the dispatcher calls for 10/4/13 confirmed that RN 1 had given this information to the dispatcher, SDS 18, at 7:17 AM.

During an interview on 11/6/13 at 11:50 AM, SDS 18 stated she was on duty 10/4/13 during the day shift but she did not remember receiving the call from RN 1. SDS 18 said she was supposed to log every call that came in on the dispatch line. SDS 18 reviewed her log and stated that was the only call to come in between 7:14 AM and 7:47 AM so she wasn't too busy. SDS 18 said that if she didn't log the call then she didn't assign any deputies to investigate RN 1's report.

After 10/1/13 no additional searches of the hospital were conducted and on 10/8/13, Patient 1's body was discovered in stairwell 8 of the main Hospital building. A hospital engineer doing routine quarterly maintenance discovered the body.

Based on interviews with twenty-one deputies, officers, cadets, and dispatchers, it became apparent that only three public stairwells were searched and none of the other seven fire alarmed stairwells, including stairwell 8, were searched.

Based on these twenty-one interview, only SDS 1 was aware that a Missing Person who was medically at risk, even if he/she was not on a 5150 Hold, could be physically detained for "Investigatory Detention" and could be returned to their nursing unit for further evaluation. The Deputies and Sergeants thought that if a missing person was not on a 5150 Hold, then the security forces had no ability to detain them and could only "Be on the Look Out" for the missing person.

Throughout the interviews, the security personnel were very clear that the department did not have a coordinated systematic approach to searching for missing persons. Each deputy independently determined the most likely escape route and was "on the look out" in that area.

Record review indicated that there was very little detailed information in the "Red Book" kept by the Watch Commanders in their shift-to-shift report for the oncoming shift. For example, on 10/1/13, SDS 3 summed up his deputies stairwell search as "General Activity."

Record review of the dispatcher end-of-shift logs and their "LAB" reports (interim summaries of calls received, deputy assigned, deputy on scene, and deputy case resolution) had missing information for many shifts and many calls. The dispatchers stated these gaps occurred when Deputies did not radio back to them the results of their assignments. This was accurate but the dispatchers also forgot to log calls as was demonstrated on 9/21/13 and 10/4/13.

3. Based on interviews from 10/31/13 through 11/6/13, Hospital Leadership and the contracted security personnel stated that there was no coordinated plan between the hospital and the contracted security department which specified the roles and responsibilities of each during a fire or other disaster at the facility.

The Hospital conducted annual training sessions for "Emergency Response" and "National Patient Safety Goals - non Clinical." Record review of the document titled Training Report, dated 10/31/13, indicated that of the 38 contracted security staff assigned at the hospital only three had completed this training during the preceding year.

Without a coordinated and well rehearsed emergency response plan, the facility places all patients at risk if there was a chaotic and poorly coordinated response to fire and or other disasters.

Based on interview, tape recordings, and record review, the hospital failed to maintain the confidentiality of Patient 1's protected health information (PHI - personal identifiers [name, medical record number, etc.], health status, care received, payment of services, demographics [age, gender, zip codes, etc.]) when:

1. One staff member and three contracted Billing employees accessed Patient 1's Lifetime Care Record (LCR - medical record/electronic chart) without need or authorization and they reviewed confidential information in the LCR;

2. One contracted security person (SDS 16) discussed Patient 1's protected health information over the telephone with persons who had no need and no authorization to receive this information; and,

3. The contracted security personnel had not participated in annual training on their roles and responsibilities with regard to confidentiality, privacy and HIPPA (Health Information Privacy and Portability Act).

Findings:

1. Patient 1 was a 57 year old woman admitted to the hospital on 9/19/13. Patient 1, who had periods of confusion, wandered off the nursing unit and was not located within the hospital or at home. This triggered a Missing Persons search by the local Police Department which was broadcast in newspaper and television reports. Patient 1's dead body was found in a stairwell of the hospital on 10/8/13 and this started more media coverage. This made Patient 1 a high-profile case.

During an interview on 10/28/13 at 8:00 AM, the hospital's Privacy Officer (PO) stated that the hospital automatically does weekly computer audits on high-profile cases to identify potentially unauthorized access to the high profile individual's Lifetime Care Record (LCR). The PO went on to say that the audits identified four individuals who had accessed Patient 1's LCR without an obvious need to review Patient 1's clinical information.

The PO went on to say that on 10/21/13 the audit report identified that on 10/18/13 a Registered Nurse (RN 6), who worked in the ICU (Intensive Care Unit), had accessed clinical notes and reports in Patient 1's LCR. The PO stated she spoke with RN 6 by telephone on 10/21/13, and RN 6 admitted that she had accessed Patient 1's LCR without need and without authorization because she (RN 6) "was curious."

The PO continued her report and stated the audit indicated that on 10/10/13, a contracted Billing Manager, working for the Department of Anesthesia, had accessed Patient 1's LCR two times to review Patient 1's report notes and discharge summary. During her interview with the PO, the Billing Manager admitted that she had improperly accessed Patient 1's record because she "was curious."

The PO went on to say that a contracted Billing Clerk, working for the Department of Anesthesia, accessed Patient 1's LCR reports and clinical notes on 10/10/13. The Billing Clerk told the PO that she was checking the LCR to see if there was a need to bill for Anesthesia Services. Patient 1 had never had any Anesthesia Services. The PO and the Billing Manager stated there was no need and no authorization for this Billing Clerk to access Patient 1's LCR.

The PO continued that a contracted Billing Analyst, working for the Department of Neurosurgery, viewed Patient 1's clinical notes and discharge summary on 10/10/13. The Billing Analyst acknowledged that there was no need and no authorization for this access and stated that she (Billing Analyst) "was curious."

Record review of the reports "Display Audit Log", dated 10/21/13, showed the dates and the areas of Patient 1's LCR which each of these four individuals had accessed.

Record review of the hospital's Policy and Procedure titled "Health Information Services: Confidentiality, Security, and Release of Protected Health Information" dated 6/11, stated "It is the policy of (Hospital Name) to protect every patient's right to privacy. As a general guideline, all observations and/or communications regarding a patient's medical history, mental or physical conditions, and treatments are considered confidential. Protected health information may be released only for approved purposes, with proper authorization from the patient when required, and as permissible or required by federal or state law."

Record review of documentation titled "Transcripts" indicated all four individuals had completed Compliance (HIPPA) and Patient Privacy and Information Security training modules - RN 6 on 5/22/13, Billing Manager on 5/15/13, Billing Clerk on 6/3/13, and Billing Analyst on 6/6/13.

2. During an interview on 10/30/13 at 2:15 PM, the hospital's Risk Manager told the Survey Team that all calls to and from the contracted security dispatcher's telephone dispatch line were recorded. The Risk Manager said that this had been approved by senior officials at the security service but the information may not have been transmitted to all of the dispatchers. The Risk Manager reported that during the recordings on 10/8/13, the dispatcher on duty (SDS 16) made several calls to his wife and brother relaying protected health information about Patient 1. The Risk Manager stated that it was not clear if SDS 16 also telephoned other individuals and disclosed similar confidential information.

On 10/30/13 at approximately 2:30 PM, the Survey Team listened to a tape recording of conversations to and from the dispatcher. On 10/8/13 during the evening shift (3:00 PM to 11:00 PM, the dispatcher (SDS 16) had multiple calls with persons who were not involved in Patient 1's care. During these calls SDS 16 discussed Patient 1's PHI with unauthorized persons.

As examples, on 10/8/13 at 9:34 PM, SDS 16 was recorded saying "18 days later. Yep, she (Patient 1) had no eyeballs. We don't know where they went seriously...I saw a picture of her, she wasn't looking too good. Yeah, still in the same clothes they said she was in so that's how we know it was her. The media doesn't know that yet so keep that under your hat."

On 10/8/13 at 10:03 PM SDS 16 was recorded saying to another individual "this lady (Patient 1) has dementia, she's all f__ up on meds, and she's even potentially suicidal."

At the completion of the tape recordings, both the Risk Manager and the Director of Regulatory Affairs acknowledged that SDS 16 had disclosed Patient 1's protected health information to persons who had no need and no authorization to receive it.

During an interview on 11/5/13 at 3:50 PM, SDS 16 was made aware that his dispatch calls on 10/8/13 had been recorded; SDS 16 said he was unaware that dispatch line was being recorded. SDS 16 said that he only talked with his wife and some relatives but he never told them anything that wasn't on television. SDS 16 stated the he had received confidentiality and HIPPA training but that it was more than one year past.

During an interview on 11/6/13 at 3:28 PM, the Administrative Sergeant (SDS 44) for security staff stated that he was aware that the dispatch telephone line was recorded. SDS 4 stated this had been agreed upon by the hospital and the security services "years ago."

The hospital was asked to provide the documentation indicating when SDS 16 had taken Confidentiality, Privacy, and HIPPA training. On 11/7/13, the Director of Regulatory Affairs stated SDS 16 had never participated in the hospital's training for Confidentiality, Privacy, and HIPPA.

3. During an interview on 11/7/13 at 11:40 AM, the Lieutenant in charge of contracted security at the hospital (SDS 1) stated that when he assumed command of the security department in April 2012, he ordered the Sergeants to ensure that all Deputies and Dispatchers participated in the hospital's annual training.

During an interview on 11/6/13 at 3:28 PM, the Administrative Sergeant (SDS 44) for security staff stated that he was aware of the hospital's requirement's for annual training for all contracted staff. SDS 4 stated that he was notified by the hospital of all security staff who were overdue with their training. SDS 4 stated the he e-mailed this list of overdue staff members to the Watch Commanders (Sergeants in charge of a specific 8-hour shift).

During an interview on 11/6/13 at 1:45 PM, a contracted security Sergeant (SDS 3), routinely the Watch Commander on day shift, stated that he was responsible to ensure that all of the Deputy security staff and Dispatcher staff received annual hospital training for Confidentiality and Privacy, including a HIPPA review. SDS 3 stated he had completed his training in late 2012. SDS 3 stated he received regular reports from SDS 4 which showed which Deputies and Dispatchers were overdue for this training and he required them to attend.

During interviews from 10/31/13 through 11/7/13, five contracted security personnel, SDS 9, SDS 10, SDS 11, SDS 15, and SDS 19, stated they were not aware of any hospital training requirements. Two other contracted security staff, SDS 8 and SDS 13, stated they received Privacy training from the Security Contractor but not from the hospital.

In addition to SDS 1, SDS 3, and SDS 4, two other contracted security staff, SDS 6 and SDS 14, stated they participated in annual hospital training.

Record review of the documents titled "Transcripts" dated 10/31/13, indicated that of the 38 contracted security personnel assigned to the hospital, only four had current completion dates for the training modules Compliance (HIPPA), Patient Privacy and Information Security. Of the 21 security personnel interviewed, only SDS 4 and SDS 20 had current completion dates.

Review of an undated hospital's Staff Education Policy, (Policy Number 5.13) indicated, "The Department of Education and Training shall...2. Develop and implement an annual competency program that addresses identified needs in collaboration with the Performance Improvement and Safety Committee and is approved by the SFGH Executive Staff..."

The Management Agreement between the Hospital and the Contracted Security Services, dated 10/16/02, stated all (security) personnel assigned to work at sites under (Hospital) control shall be subject to applicable (Hospital) policies and procedures, provided no such policy or procedure shall be construed to limit the authority of (Security) to exercise command and control of law enforcement and other public safety operations at such sites."

Both SDS 1 and SDS 4 acknowledged that security personnel should participate in the Hospital's annual training activities.

Based on interviews and document reviews, the hospital failed to ensure the provision of Quality Assessment and Performance Improvement as evidenced by:

1. The hospital Quality Assessment Performance Improvement (QAPI) program failed to set priorities for it performance improvement activities that focused on improving security for patients that go missing. The QAPI program had identified issues with missing persons since 2010 and the contracted security, Sheriff 's Department, did not participate in improving hospital performance which resulted in a patient who went missing for 17 days and was found dead in a hospital emergency stairwell (See A-0283, A-0273, A-0084).

2. The hospital Quality Assessment Performance Improvement (QAPI) program failed to track missing persons as a quality indicator to improve contracted security services. The QAPI program had identified issues with missing persons since 2010 and did not include contracted security, Sheriff 's Department, in improving hospital performance which resulted in a patient who went missing for 17 days and was found dead in a hospital emergency stairwell (See A-0273, A-0283, A-0084).


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3. The hospital failed to develop performance improvement projects to identify and reduce medical errors related to the implementation of physician's orders, the use and monitoring of coach/sitters (Patient Care Assistant assigned to monitor one patient on a continuous basis),and patient care planning. This had the potential for harm especially to the most vulnerable patients who required coaches for safety. (See A286)


The cumulative effects of these systemic problems resulted in the Quality Assessment and Performance Improvement Program's inability to provide services and care in a safe and effective manner in accordance with the statutorily-mandated Conditions of Participation for Quality Assessment and Performance Improvement.

Based on interview and document review the hospital Quality Assessment Performance Improvement (QAPI) program failed to track missing persons as a quality indicator to improve contracted security services. The QAPI program had identified issues with missing persons since 2010 and did not include contracted security, Sheriff 's Department, in improving hospital performance which resulted in a patient who went missing for 17 days and was found dead in a hospital emergency stairwell.

Findings:

During an interview on 10/30/13 at 2:23 PM the Chief Executive Officer (CEO) stated that from 2009-2012 there had been several attempts to improve and add security. The CEO said that since 2009 Program Change Requests were submitted to the Board of Supervisors to obtain resources to improve security and had been denied.

A review of the 2011 Budget and Finance Committee minutes, during a Board of Supervisors session, indicated minutes discussing the Program Change Request for 2011 to 2012. The Director of Clinical Operations and Chief Medical Officer made comments to the Board of Supervisors. The Director of Clinical Operations stated in the minutes "we are here to urge you to vote yes ...allow the contract out ...of security services ...We believe this presents us ...to integrate security as part of our health care team, rather than an entity solely devoted to law enforcement. Currently, the constraints placed upon the Sheriff 's Department, because they are sworn peace officers, render them unable to support clinical situations ...Deputies ...restrain and attain ...criminal ...behavior ...We envision a model where security is part of the healthcare ...team ...additionally ...operations at the hospital, would have the power and authority to deploy such security where the need arises. Something that is currently lacking under our current ...model ..." The Chief Medical Officer stated in the minutes "This is a patient care and safety issue ...we simply do not have the employees with the training, skills, and most notably, the legal flexibility to manage medical crises in the hospital ...This is a health care issue, not a legal or law enforcement issue. We need trained personnel who can act on behalf of patients, consistent with hospital policy, and integrated into the health care team ...As health-care providers, we have a duty and obligation to provide safe and appropriate care, especially to the most vulnerable patients and those are the folks without capacity to make rational decisions, due to their acute medical illnesses. We must have the tools and resources to provide that care in a safe environment for patients and staff...Supervisors provide us with the personnel and resources to do so."

During an interview on 11/01/13 at 4:00 PM the Director of Regulatory Affairs stated there was an AWOL (leaving without notification-missing) performance improvement (PI) project. He also stated that there were several patient safety issues with AWOL patients that were of concern and the PI project was started in 2010. When patients go missing they become unavailable for treatments, monitoring, exams, etc. The Director of Regulatory Affairs said the project's purpose was to improve patient safety. He said that contracted security (Sheriff's Department) was not included in the project in 2010.

A review of an AWOL 2010-2013 PI project documents did not indicate that the Sheriff 's Department was included in the project. The PI Project also indicated that between August 2010 and September 2013 there were a total of 412 AWOL incidents.

The hospital had a missing patient one of every 2.8 days (1,157 divided by 412).

During an interview on 11/06/13 at 10:15 AM the Sheriff 's Department Staff 4 (SDS 4) stated he was a member of the Environment of Care (EOC) Committee. The EOC Committee was a quality committee which was responsible for tracking quality indicator data to improve security quality and ensure safety. SDS 4 stated that there had been no data that had been tracked for missing persons (AWOL). He acknowledged issues with patients going missing since 2010 as indicated by the 2010-2013 AWOL PI project.

During an interview on 11/07/13 at 10:35 AM the Emergency Preparedness Acting Administrator and Chair of the EOC Committee stated the EOC Committee was not tracking missing person quality indicator data. She acknowledged that importance of tracking the data and developing action plans to improve security quality and to ensure safety.

The missing person quality indicator data was not tracked by the quality security committee (EOC Committee). The hospital QAPI program missed an opportunity to improve security quality and to ensure safety for missing patients. As a result of the lost opportunity to improve security Patient 1 was not found for 17 days.

During an interview on 10/30/13 at 10:00 AM the Director of Regulatory Affairs stated Patient 1 was admitted on 09/19/13 with symptoms of confusion, weight loss, and dizziness. She was diagnosed with a bladder infection, sepsis (blood infection) and delirium (confusion). He also stated that Patient 1 went missing on 09/21/13 and was last seen on the 5th floor nursing station. She was later found dead lying on the 3rd floor cement landing in the emergency stairwell on 10/08/13 by hospital staff. The emergency stairwell (stairwell 8) was accessible and an distance of 99 yards away from Patient 1's room where she was last seen by staff. The Director of Regulatory Affairs said that the stairwell was rarely used and once someone entered the stairwell, the stairwell door locked behind them and could not be opened unless one had a key to the door.

A review of the hospital administrative policy, entitled AMA (Against Medical Advice) , AWOL (leaving without notification-missing) and Elopement indicated: patients Leaving SFGH Prior to Completion of Their Evaluation or Treatment in section C. Patient on a Legal Hold and/or without Capacity Found Missing: indicated "If a patient, who is on a legal hold [legally held dangerous to self or others] and/or lacks capacity...is not in his or her room and cannot be found after a reasonable search on the unit, staff will do the following...The nurse will notify the SFSD Dispatcher...and provide a description of the patient and ask for their assistance to search the hospital public areas, stairwells, etc. and , if found, to return the patient to the unit."

During an interview on 11/04/13 at 2:00 PM Sheriff 's Department Staff 10 (SDS 10) stated that he interviewed hospital staff on the day Patient 1 went missing on 09/21/13. He also stated that he read the chart and found that Patient 1 was not on a legal hold. He said because Patient 1 was not on a legal hold he did not complete a missing persons report. He reported his findings to his supervisor Sheriff ' s Department Staff 2 (SDS 2). He said he never actively searched or received orders to actively search for Patient 1.

During an interview on 11/07/13 at 11:40 AM Sheriff 's Department Staff 1 (SDS 1) stated he supervised SDS 2 and SDS 10. He also stated that patients medically at risk (lacks capacity), patients not safe to be out on their own should be searched for and reported as a missing person irrespective to their legal hold status.

A review of a Missing Persons Report entitled San Francisco Police Department INCIDENT REPORT indicated Patient 1's daughter filed a report with the San Francisco Police Department on 09/21/13 (the same day Patient 1 was found missing). The Missing Persons Report indicated "On 09/21/2013 at 1145 hours ...[Daughter] called to say that her mother...walked out of SFGH at approximately 1125 hours and has not been heard of ...[Daughter] told me she is worried because her mother is not well and can be confused on where she is and what's going on..."

A review of hospital's dispatch transcripts, transcribed voice recorded telephone communications with Sheriff 's Department Dispatch; entitled SFSD Phone Transcripts indicated the following at the corresponding times on 09/21/13:
*10:25 AM Communications between Nurse/Dispatch
" I'm calling for a [Patient 1] ...We tried looking all over the place ...I didn't see anything, looked all over the place, we cannot find her..."
*11:12 AM Communications between MD 1/Dispatch
" I am one of the physicians' in the hospital. I just had a patient who AWOL'd ....She was confused and wandered off ...she was very confused ...not safe to be out on her own."
*11:17 AM Communications between Patient 1's Daughter/Dispatch
"She wandered off ...We have her down as 57 years old ... short black hair, 5'2, 115 pounds. Um, we put that out over the air, but since she is not on a legal hold...You know, there is no report written. We have documented, but we did put it out as far as if we see her, return her to 5D...I don't think she is realizing what she is doing...she is really weak, because the fact of that is why she was in there, like she could barely get up and walk to the bathroom ...Okay...we are searching continuously in the hospital...since she is not technically on a hold so we have no custody of her...I don't understand how she is escaped. I don't understand that, like she is in a state to just run out and sneak out, like she is going to very noticeable..."
*11:45 AM Communications between SDS 6/Unknown Caller
"You guys have any walk aways from the hospital. I received a call from an out of state person saying that her mother left the hospital..[Patient 1], she left the ward, but she is not on a hold, so um, so there is nothing we can really do about it..."
*12:25 PM Communications between SDS 6/Patient 1's Daughter
"I am confused because I did contact the police...they said...that nobody was looking for her because she was being discharged...we can't legally force her to go back, since she is not on a hold..."
*12:42 PM Communications between MD 1/Dispatch
"I am the physician taking care of her. Technically, she AWOL'd ...I did not formally discharge her. I didn't even get to meet her today. So had I met her and made an assessment, I may not have discharged her today. The plan was to discharge her today, but ...provided that everything had stayed the same from yesterday ...So, I don't know how that has a bearing on you guys looking for her...No...it doesn't change because she is not on a legal hold ...If we find her, we can't like, you know forcibly take her back to the unit, it is just more of a hey, can you please go back, this and that since she is not on hold..."
*8:45 PM Communications between Patient 1's Daughter/Dispatch
"Hi, I was calling up to see if there is any news on my mom...I'm going to transfer you..."
*9:18 PM Communications between Charge Nurse/Dispatcher
"Is there anything stating dementia...She was here for...altered mental state...There is no need for report..."

A review of the Sheriff Department logs indicated a written record of communications and actions taken daily. The Watch Commander log dated 09/21/13 did not indicate that a search was conducted for Patient 1. The Dispatcher log dated 09/21/13 did not indicate that a search was conducted for Patient 1. The San Francisco Sheriff 's Department-Short Report Form did not indicate that a search was conducted for Patient 1 on 09/21/13.

During individual interviews from 11/04/13 to 11/07/13 the Sheriff Department Staff stated the following on these dates and times:
*11/04/13 at 1:33 PM-SDS 6 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/04/13 at 2:31 PM-SDS 7 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/04/13 at 2:00 PM-SDS 10 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/05/13 at 1:59 PM-SDS 19 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/05/13 at 3:53 PM-SDS 21 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/05/13 at 4:01 PM-SDS 13 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/04/13 at 9:00 AM-SDS 2 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/06/13 at 11:56 AM-SDS 14 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/06/13 at 12:13 PM-SDS 25 stated there was no active search or orders for an active search for Patient 1 on 09/21/13.
*11/06/13 at 3:00 PM-SDS 3 (highest acting supervisor when Patient 1 was reported missing) stated he gave orders for a search for a black woman (Patient 1 was Caucasian). He also stated that he did not give orders to search the stairwells on 09/21/13.

During an interview on 11/07/13 at 3:15 PM the Director of Regulatory Affairs stated the following events occurred from 09/21/13 to 10/08/13:
*09/21/13 Nurse search for Patient 1 and request assistance with Sheriff 's Department. Sheriff ' s Department did not search for Patient 1.
*09/30/13 Nine days after being first reported missing Hospital Administration requests for search for Patient 1. Search conducted by Sheriff 's Department but does not include stairwell number 8.
*10/01/13 Search conducted by Sheriff 's Department but does not include stairwell number 8.
*10/04/13 Someone reports to nurse that somebody is lying on the landing in stairwell number 8. Sheriff 's Department does not search stairwell number 8.
*10/08/13 Patient 1 found dead by hospital staff on the landing in stairwell number 8.
The Director of Regulatory Affairs stated that there were no other searches for Patient 1 done by the hospital or Sheriff 's Department between the dates mentioned above.

During an interview on 11/01/13 at 11:15 AM the Director of Clinical Operations stated she saw Patient 1's dead body in the stairwell. She also stated that Patient 1 was lying on her back on the cement landing with her right hand above her head, her left hand on her torso, and her head turned to the left. She said she was properly dressed fully clothed with the clothing she had at the hospital, and there was a canvas tote bag sitting upright next to her with all the contents inside the bag. There was no blood visible around the body or near her head. The Director of Clinical Operations said it did not look like she fell. She said it looked like she was just lying there.

The Sheriff 's Department first conducted an active search 9 days after Patient 1 was found missing. The search was incomplete and did not include the stairwell where Patient 1 was found dead. Patient 1 was found dead by hospital staff 17 days after she was first reported missing.

Based on interview and document review the hospital Quality Assessment Performance Improvement (QAPI) program failed to set priorities for it performance improvement activities that focused on improving security for patients that go missing. The QAPI program had identified issues with missing persons since 2010 and the contracted security, Sheriff 's Department, did not participate in improving hospital performance which resulted in a patient who went missing for 17 days and was found dead in a hospital emergency stairwell (Cross-ref. A273)

Findings:

During an interview on 10/30/13 at 2:23 PM the Chief Executive Officer (CEO) stated that from 2009-2012 there had been several attempts to improve and add security. The CEO said that since 2009 Program Change Requests were submitted to the Board of Supervisors to obtain resources to improve security and had been denied.

A review of the 2011 Budget and Finance Committee minutes, during a Board of Supervisors session, indicated minutes discussing the Program Change Request for 2011 to 2012. The Director of Clinical Operations and Chief Medical Officer made comments to the Board of Supervisors. The Director of Clinical Operations stated in the minutes "we are here to urge you to vote yes ...allow the contract out ...of security services ...We believe this presents us ...to integrate security as part of our health care team, rather than an entity solely devoted to law enforcement. Currently, the constraints placed upon the Sheriff 's Department, because they are sworn peace officers, render them unable to support clinical situations ...Deputies ...restrain and attain ...criminal ...behavior ...We envision a model where security is part of the healthcare ...team ...additionally ...operations at the hospital, would have the power and authority to deploy such security where the need arises. Something that is currently lacking under our current ...model ..." The Chief Medical Officer stated in the minutes "This is a patient care and safety issue ...we simply do not have the employees with the training, skills, and most notably, the legal flexibility to manage medical crises in the hospital ...This is a health care issue, not a legal or law enforcement issue. We need trained personnel who can act on behalf of patients, consistent with hospital policy, and integrated into the health care team ...As health-care providers, we have a duty and obligation to provide safe and appropriate care, especially to the most vulnerable patients and those are the folks without capacity to make rational decisions, due to their acute medical illnesses. We must have the tools and resources to provide that care in a safe environment for patients and staff...Supervisors provide us with the personnel and resources to do so."

During an interview on 11/01/13 at 4:00 PM the Director of Regulatory Affairs stated there was an AWOL (leaving without notification-missing) performance improvement (PI) project. He also stated that there were several patient safety issues with AWOL patients that were of concern and the PI project was started in 2010. When patients go missing they become unavailable for treatments, monitoring, exams, etc. The Director of Regulatory Affairs said the project's purpose was to improve patient safety. He said that contracted security (Sheriff's Department) was not included in the project in 2010.

A review of an AWOL 2010-2013 PI project documents did not indicate that the Sheriff 's Department was included in the project. The PI Project also indicated that between August 2010 and September 2013 there were a total of 412 AWOL incidents.

The hospital had a missing patient one of every 2.8 days (1,157 divided by 412).

During an interview on 11/06/13 at 10:15 AM the Sheriff 's Department Staff 4 (SDS 4) stated he was a member of the Environment of Care (EOC) Committee. The EOC Committee was a quality committee in which members were responsible for improving security and ensuring patient safety. SDS 4 stated that they had not focused on improving security for missing patients. He acknowledged that there were issues with patients going AWOL since 2010 as indicated by the 2010-2013 AWOL PI project.

During an interview on 11/07/13 at 10:35 AM the Emergency Preparedness Acting Administrator and Chair of the EOC Committee stated the EOC Committee had not focused on improving security for missing patients. She acknowledged the importance of having someone with knowledge and the expertise in hospital security (Sherriff 's Department) to ensure patient safety. She said that the Sherriff 's Department did not actively attend the EOC Committee meetings.

A review of the EOC Committee attendance record in the entitled document Environment of Care Safety Committee Attendance 2013 indicated that the EOC Committee meeting met monthly. The document also revealed that the Sherriff 's Department attended 1 out of 9 months. The Sherriff 's Department representative attended one meeting in July for 2013.

The hospital Sherriff 's Department did not actively participate in the EOC Committee and failed to set priorities for it performance improvement activities that focused on improving security for patients that go missing. As a result of the lost opportunity to improve security Patient 1 was not found for 17 days.

Based on interview, observation, and record review, the hospital failed to develop performance improvement projects to identify and reduce medical errs related to the implementation of physician's orders, the use and monitoring of coach/sitters (Patient Care Assistant assigned to monitor one patient on a continuous basis),and patient care planning. This had the potential for harm especially to the most vulnerable patients who required coaches for safety.

Findings:

During the complaint validation survey of 10/30/13 through 11/8/13, it was noted that physician orders for 1:1 coaches were not being implemented as ordered for two of the eight sampled patients (Patients 1 and 8), and nursing orders for 1:1 coaches were not implemented on three of three random patients (Random Patients 9, 10 and 11). In addition, Nursing Care Plans were missing or incomplete on three of the eight sampled patients (Patients 1, 7, and 8).

Patient 1 had a physician order for a coach written on 9/20/13. A coach was assigned with instruction from the Registered Nurse (RN 2) to monitor Patient 1 on a one-to-one basis because Patient 1 was an elopement risk and was at risk for falling. This order was inadvertently discontinued by nursing staff on 9/21/13 allowing Patient 1 the opportunity to elope from the unit. Patient 1's elopement was not noted for approximately 40 minutes. The immediate searches for Patient 1 were unsuccessful and Patient 1 was eventually found dead in a hospital stairwell on 10/8/13. See A0395 #1 for details.

Patient 8 was admitted to Unit 4D on 10/26/13 with diagnoses which included dementia, brain mass, and cerebral edema. Patient 8 was also blind in both eyes. He had a physician's order for a 1:1 coach written on 11/1/13.

During an interview on 11/5/13 at 9:45 AM, the Registered Nurse (RN 7) caring for Patient 8 stated that he was confused and spoke minimal English. RN 6 said Patient 8 was not an elopement risk but because of his dementia, he had poor safety judgement and that, coupled with his blindness, made Patient 8 a high fall risk.

In an observation on 11/5/13 at 9:45 AM, it was noted that Patient 8 was in a fully occupied four bed room and there was a law enforcement officer seated across from the doorway.

RN 7 stated that Patient 8 was in a four bed room and Patient 8's 1:1 coach (PCA 5) was responsible for watching the other three patients in the room as well. RN 7 said the other three patients in Room 2 also required 1:1 coaches.

During an interview on 11/5/13 at 9:55 AM, PCA 5 said he was responsible for 1:1 monitoring of all four men in Room 2. PCA 5 said that if he has a problem such as two patients trying to get up unassisted at once, he (PCA 5) sets off the bed alarm as a signal to nurses that he needs more help.

Review of PCA 5's assignment sheet for 11/4/13 titled Medical-Surgical Coach Assignment Form for Close Observation indicated the following:

Resident 8 was listed as needing 1:1 Observation because he was pulling necessary tubes, had poor safety awareness, was a high fall risk, and was assaultive.

Random Patient 9 (RP 9) had multiple fractures following a motor vehicle crash. RP 9 was listed as needing 1:1 Observation because he was pulling necessary tubes, had poor safety awareness, was a high fall risk, and he was in the custody of law enforcement. There was a law endorsement officer for RP 9 seated in the hallway across from the door to Room 2.

Random Patient 10 (RP 10) had fractures following a bicycle accident. RP 10 was listed as needing Observation because he had poor safety awareness and was a high fall risk. RP 10's level of Observation was listed as "NEVER leave patient unattended, NO clothing in room, NO sharps or harmful objects (matches. lighter, solution) in room, Search patient area every shift and after visitors or nurses exit."

Random Patient 11 (RP 11) had multiple injuries following a "Jump." RP 11 was listed as needing 1:1 Observation because he needed suicide precautions. RP 11 was also on fall precautions.

During an interview on 11/5/13 at 10:00 AM, the Nurse Manager (RN 9) acknowledged that PCA 5 was caring for patients at a 1:4 ratio rather that the 1;1 ratio which was ordered. RN 9 stated that each of the four patients in Room 2 had a different primary nurse so there always extra people in the room to help PCA 5.

Since the 1:1 coach for Patient 8 was also caring for three other 1:1 patients, the physician's order was not being implemented. Since the 1:1 coach for each of the Random Patients was also caring for three other patients, the nursing order for 1:1 was not being implemented.

Nursing Care Plans were not done, or were incomplete on three of the eight sampled patients Patients 1, 7 and 8. See A0396 for additional details.

During an interview on 11/7/13 at 3:20 PM, the Director of Performances Improvement stated that the hospital was reviewing physician orders to study if they were timed, dated, and signed, but there were no Performance Improvement PI) Projects to ensure that physician orders were implemented. The Director of PI said that there were spot checks of orders looking at verbal orders but the focus was not on the implementation of the physicians' orders.

During this interview, a Registered Nurse (RN 8) stated that he assisted with Nursing PI and he confirmed there were no PI Projects to evaluate the implementation of physician orders. RN 8 said that he had been involved in a Fall Reduction PI Project in approximately 2009. During that project the use of coaches was reviewed as a method for reducing falls. RN 8 said that the results of that project were to decrease the use of 1:1 coaches for fall reduction and to increase the use of roaming Patient Care Assistants who would anticipate patient needs better, respond faster, and, therefore, decrease their attempts to get out of bed independently. RN 8 stated there had not been any PI Projects involving the use of coaches since this Fall Reduction project.

Both the Director of Performance Improvement and RN 8 stated there were no Nursing Care Planning Quality Improvement Projects currently being performed.

The facility failed to ensure nursing services were provided in a well-organized manner to ensure patients' safety in the hospital as evidenced by:

The facility failed to ensure all staff followed physician's order when Patient 1 had an order for coach/sitter on 9/20/13 but was discontinued by a licensed nurse without discussing it with the physician. (A-395)

The facility failed to ensure physician's order was carried out as ordered when Patient 8 had an order for 1:1 (one to one) coach/sitter but Patient 8 was put in a room with one facility staff coaching 3 (three) other patients who also had an order for 1:1 coach/sitter. (A-395)

The facility failed to ensure nursing staff followed the instructions of the nursing administrator. On 9/21/13, the Nurse Administrator On Duty directed Charge Nurse 1 to report Patient 1 as a missing person on 9/21/13 but this information was not relayed to the Sheriff's Department Dispatcher. (A-395)

The facility failed to ensure all staff follow policy and procedure on reporting a missing patient when Charge Nurse 1 did not give an accurate description of Patient 1 when patient was described as an African-American woman and wearing a hospital gown. Patient 1 was Caucasian and was wearing her own clothes when her body was found on the hospital's stairwell, 17 days after she was reported missing from her ward. (A-395)

The facility failed to develop an individualized plan of care for falls, altered mental status and elopement risks for Patient 1, 7 and 8. (A-396)

The cumulative effect of these systemic failure resulted in the facility's inability to provide quality nursing care to patients.

Based on observation, interview and record review, the facility failed to ensure nursing care was supervised and evaluated for 2 of eight sampled patients (Patient 1 and 8) when:

1. Patient 1 had an order for coach/sitter on 9/20/13 but was discontinued by a licensed nurse without discussing it with the physician.

Licensed staff did not follow policy and procedure on reporting a missing patient when Charge Nurse 1 did not give an accurate description of Patient 1 when patient was described as an African-American woman, wearing a hospital gown. Patient 1 was Caucasian and was wearing her own clothes when her body was found on the hospital's stairwell, 17 days after she was reported missing from her ward.

Licensed staff did not follow the instruction from a nursing administrator. On 9/21/13, the Nursing Administrator On Duty directed Charge Nurse (CN1) to report Patient 1 as a missing person on 9/21/13 because the patient had an altered mental status (confused and disoriented) but this information was not relayed to the Sheriff's Department Dispatcher.

2. Patient 8 had a physician's order for 1:1 (one to one) coach/sitter and was not carried out as ordered when Patient 8 was put in a room with one facility staff coaching 3 (three) other patients who also had an order for 1:1 coach/sitter.

Findings:

1. Patient 1 was admitted to the facility on 9/19/13 brought in by daughter for confusion of more than a month, weight loss and dizziness. The diagnoses included bladder infection, sepsis (severe infection in the bloodstream) and delirium (confusion and disorientation).

Review of the Nursing Notes on 9/19/13 (night shift 7 PM to 7 AM) indicated, Patient 1 had weakness on both legs, had an unsteady gait, on falls precautions and had a "coach/sitter" at bedside.

Review of the 9/19/13 (night shift) Assignment Form for FREQUENT OBSERVATION indicated the reason for constant observation was Patient 1 was confused, an elopement risk and on fall precautions. It also indicated, "NEVER leave patient unattended."

Review of the medical record indicated on 9/20/13 at 6:28 AM, MD 2 ordered a "COACH/SITTER" for Patient 1. Further review of the medical record had no documentation MD 2 examined and evaluated Patient 1's condition for any changes in mental status and level of care. There was no progress notes written by MD 2 on 9/20/13.

In an interview on 10/30/13 at 1:25 PM, MD 2 stated licensed nurse from 5D (RN 4) called him in the morning of 9/20/13 and was told that Patient 1 was acting strangely. The licensed nurse (RN 4) told him that Patient 1 thought she was working in an airport, was not aware of where she was and why she was in the hospital. He stated that after he got the call from the licensed nurse (RN 4), he went to a computer and wrote an order for coach/sitter. When asked if wrote a progress notes, he said, "No".

In an interview on 10/31/13 at 7:51 AM, RN 4 stated she was on duty on 9/19/13 night shift. She stated Patient 1 was accompanied by daughter and the patient was thin and a little unsteady on her feet. She stated Patient 1 was oriented to person, place and time. She stated she put Patient 1 in a "coach room" just to anticipate if patient needed coach/sitter for fall risks. She stated that on the morning of 9/20/13 at around 6:30 AM, Patient 1 was anxious, restless and disoriented so she called the physician (MD 2) and the physician wrote an order for "coach/sitter." She stated she did not get a chance to write the physician's for coach/sitter order on the Kardex (a form with patient's health information used to pass on to oncoming licensed staff).

Review of the 9/20/13 (7 AM to 7 PM - day shift) Assignment Form for FREQUENT OBSERVATION indicated, reason for constant observation was Patient 1 was an elopement risk and fall precautions.

Review of the Nursing Notes on 9/20/13 (7 AM to 11 PM) indicated, Patient 1 was disoriented to date and time and had periodic confusion but redirectable. It indicated Patient 1 had slight unsteady gait and walks with standby assist. It also indicated safety precautions were maintained and Patient 1 was on "close observation". There was no documentation Patient 1 had a coach/sitter on bedside.

Review of the Nursing Notes on 9/20/13 (7 PM to 7 AM) indicated, Patient 1 had periodic confusion, was easily redirectable and frequent orientation was performed. It also indicated Patient 1 was able to ambulate in the hallway independently but standby assist was provided. It indicated, "frequent rounding done". There was no documentation Patient 1 had a coach/sitter on bedside.

In an interview on 10/30/13 at 4:12 PM, RN (Registered Nurse) 2 stated she was on duty on 9/20/13 from 7 AM to 7 PM. She stated Patient 1 had a physician's order for coach/sitter because the patient was confused and didn't know time and date.

In an interview on 10/31/13 at 8:35 AM, RN 5 stated she was on duty on 9/20/13 from 7 PM to 7 AM. She stated Patient 1 had periodic confusion and was slightly off on date. She stated Patient 1 also expressed that she had to be transferred to another location in the hospital. She stated Patient 1 walked to the nursing station and was redirected to go back to bed. She stated Patient 1 did not have a coach/sitter that night. When asked if she was aware that there was an order for coach/sitter, she stated, "No." She also stated, she could not recall if coach/sitter order was on the Kardex.

In an interview on 11/1/13 at 10:00 AM, PCA 1 was on duty on 9/20/13 7 AM to 7 PM. She stated she was the coach/sitter for Patient 1 and her roommate. She stated that in the afternoon of 9/20/13, Patient 1's roommate was moved to another room so she no longer sat inside the room with Patient 1. She stated she was instructed to check Patient 1 every 15 minutes. She was also assigned to do other tasks like answering call lights, taking blood pressure of other four patients and help other staff when needed.

In an interview on 11/1/13 at 2:38 PM, CN 2 was on duty on 9/20/13 from 7 PM to 7 AM. He stated charge nurse (CN 1) from day shift did not tell him that Patient 1 had an order for "coach/sitter". He stated the report he got from day shift charge nurse (CN 1) was Patient 1 was alert and oriented and a stable patient. He stated that he did the staff schedule for 9/21/13 day shift but did not assign a coach/sitter for Patient 1 because he was not aware of the physician's order.

Review of the Nursing Notes on 9/21/13 from 7 AM to 7 PM indicated, Patient was unsure why she was in hospital and patient was reoriented as needed. It also indicated that at 9:55 AM, the nurse did a "frequent round on patient", and she noted Patient 1 was missing and not anywhere to be found in the unit. It indicated a nursing assistant was sent off the unit to look for Patient 1. It also indicated the physician and Patient 1's daughter were informed.

In an interview on 10/30/13 at 1:51 PM, MD 1 stated she called the Sheriff Department Staff (SDS 6) on 9/21/13 after she was informed Patient 1 was missing. She stated that she told the Sheriff (SDS 6) Patient 1 was confused and not safe to be out on her own. She stated she also gave the Sheriff (SDS 6) Patient 1's daughter phone number. She stated that she made a second phone call to the Sheriff's Department on the same day because the daughter was upset that somebody told her that Patient 1 was discharged, and she wanted to clarify with the Sheriff (SDS 6) that Patient 1 was not discharged but AWOL.

In an interview on 10/30/13 at 4:33 PM, RN 3 stated she was on duty on 9/21/13 from 7 AM to 7 PM. She stated Patient 1 did not have a coach/sitter on bedside on the morning of her shift but Patient 1 was put on every 15 minutes check. When asked if she was aware of the physician's order for coach/sitter, she stated that she was never made aware of the order by the night shift nurse (RN 5). She stated Patient 1 had periods of confusion but redirectable. She stated Patient 1 walked down the hallway and was steady on her feet. She added on the morning of 9/21/13, Patient 1 was looking for her boots. She stated the last time she saw Patient 1 was in the room when Patient 1 had a blanket over her shoulder and she could not see what Patient 1 was wearing. She stated she did not see if Patient 1 was wearing her own clothes or a hospital gown and if the patient was also wearing her boots. She stated she noticed at 9:55 AM, Patient 1 was missing so she notified the charge nurse and sent staff (PCA 3 - Patient Care Technician) to search for the patient.

In an interview on 11/4/13 at 7:55 AM, PCA 3 stated he was on duty on the morning of 9/21/13. He stated he was doing a 15 minutes round on Patient 1. He stated at 8:30 AM, a licensed nurse asked him to pick-up belongings of another patient on Ground Floor. He stated when he came back, he attended the Charge Nurse report and when he came out from the report, Patient 1 was already missing.

In an interview on 11/4/13 at 8:20 AM, CN 1 was on duty on 9/20/13 and 9/21/13 day shift. He stated at the start of his shift on 9/20/13, Patient 1 had a coach/sitter in the room but when Patient 1's roommate was transferred to another room, Patient 1 was put on a rounder (every 15 minutes check). He stated that if he was aware of the physician's order, he would let the coach/sitter stay in the room with Patient 1. He stated he saw Patient 1 during his room to room rounds and Patient 1 was wearing a hospital gown, was on bed and waiting for breakfast. He stated at around 10 AM of 9/21/13, the primary nurse (RN 3) told him Patient 1 was missing but patient left her cellphone. He stated he called the supervisor and Sheriff Department and described Patient 1 as confused, Caucasian female wearing a hospital gown. When asked why he was the one who called the Sheriff Department to give Patient 1's description, he stated, "Because I was already on the phone talking to the supervisor." He acknowledged that the best person to give an accurate description of Patient 1 was the primary nurse (RN 3) who knew the patient and gave direct nursing care. He stated he sent PCA 3 to look for Patient 1 in cafeteria, lobby and other common places in the hospital. When asked if PCA 3 checked stairwells, he stated, "It was not a common practice to look for patient in stairwells." When asked if he told the Sheriff Department staff where to look for Patient 1 like stairwells, he stated, "No".

The San Francisco Sheriff Department (SFSD) Phone Transcripts (recorded calls to the dispatcher) on 9/21/13 at 10:25 AM indicated that CN 1 description of Patient 1 was "patient was confused, an African-American female, wearing a hospital gown". Patient 1 was Caucasian.

Review of the hospital policy and procedure entitled AMA (Against Medical Advice), AWOL and Elopement: Patients Leaving SFGH Prior to Completion of their Evaluation or Treatment indicated, "III Elopement, C. Patient on Legal Hold and/or without Capacity Found Missing: If a patient, who is on a legal hold and/or lacks capacity... is not on his or her room and cannot be found after a reasonable search on the unit, staff will do the following: ...4. The nurse will notify the SFSD Dispatcher at extension 4911 and provide a description of the patient and ask for their assistance to search the hospital public areas, stairwells, etc...."

In an interview on 11/7/13 at 9:08 AM, AOD 1 stated he got a call from CN 1 on the morning of 9/21/13 that Patient 1 went AWOL. He stated he went to 5D and spoke to CN 1 who told him that Patient 1 was admitted for infection and altered mental status. He stated that he told CN 1 to notify the Sheriff Department and to tell the Sheriff Department that Patient 1 was a missing person so the Sheriff Department can make a report to San Francisco police. He also stated he told CN 1 to tell the Sheriff to search the campus. When asked if he verify with CN 1 if his nursing orders were conveyed to the Sheriff Department Dispatcher, he stated that he did not verify with CN 1.

Review of the San Francisco Sheriff Department Phone Transcripts (recorded calls to the dispatcher on duty) indicated Sheriff Dispatchers received 9 (nine) phone calls about Patient 1 on 9/21/13:

1. At 10:25 AM from the charge nurse (CN 1) who gave the wrong description of Patient 1.
2. At 11:12 AM from MD 1 who told SDS 6 (dispatcher), "She (Patient 1) is confused and not safe to be out on her own."
3. At 11:17 AM from Patient 1's Daughter who told SDS 6 that she was worried about her mother and was bothered that her mother would just leave the hospital. She also told SDS 6 that Patient 1 was weak and could barely walk to the bathroom and does not realize what she (Patient 1) was doing that's why she brought her to the hospital.
4. At 11:45 AM from the San Francisco police who clarified if Patient 1 was a missing person or not and SDS 6 told the police that Patient 1 was about to be discharged before she went AWOL.
5. At 12:25 PM from Patient 1's Daughter (2nd phone call)who was following up with her mother and SDS 6 told her, "We have been looking for her, I don't know her status."
6. At 12:42 from MD 1 who clarified with SDS 6 that Patient 1 was not discharged but AWOL'd.
7. At 8:30 PM from another Sheriff Department Staff who talked about Patient 1 was missing since morning and SDS 7 (Dispatcher) stated, "the daughter made a stink about it."
8. At 8:45 PM from Patient 1's Daughter (3rd phone call) who was following up about her mother but she was transferred to 5D Unit. Patient 1's Daughter was not given any update by SDS 7 if search was done to look for Patient 1.
9. At 9:18 PM from SDS 10 (Deputy) who told SDS 7 (Dispatcher) that Patient 1 was not on a hold (involuntary hold if a person is a danger to self or others) based on the medical record so no report was necessary.

Review of the Sheriff Department Log (written record of phone calls to the dispatcher) on 9/21/13 indicated there was only one written record out of 9 phone calls to the dispatcher. The written log was for the call at 9:18 PM (actual written record was 9:20 PM.)

In concurrent review of Patient 1's medical record, there was no documentation that licensed nurses on 5D made a follow-up on 9/21/13 with the Sheriff's Department if search of the hospital was done to look for Patient 1, who was confused and not safe to be out on her own according to the physician (MD 1). There was no documentation licensed nurses had further interaction with Patient 1's daughter after the daughter was informed on the morning of 9/21/13 that Patient 1 was missing from 5D.

Review of the San Francisco Sheriff's Department - Short Report Form (form was filled by dispatcher on duty for every phone calls the dispatcher receives) indicated an undated form with Patient 1's name, Patient 1's daughter telephone number, height of 5'2" and weight of 115 pounds and hospital gown. Another form dated 9/21/13 indicated, "Possible missing person. Spoke to CN 2, no hold paperwork...altered mental state per SDS 10."

Review of the Watch Commander Log dated 9/21/13 indicated, from 7 AM to 7 PM there was "General Activity". It also indicated from 3 PM to 11 PM, "Missing person 5D, Patient 1, older Asian female (BOLO - Be On The Look Out) no other description available."

In an interview on 11/4/13 at 9:49 AM, SDS 2 stated he was the Sheriff in Charge on 9/21/13 from 3 PM to 11 PM. He stated AOD 2 asked if he received a missing person report from 5D. He stated he ordered SDS 10 to go to 5D and review the chart. He stated SDS 10 reported back to him that Patient 1 was not on a hold so there was no reason to take missing person report. He stated SDS 10 got a description from 5D was an Asian female elderly and that's what he wrote on the log. He stated that after he got that information, he informed Sheriff Staff on duty about Patient 1 and just be on the look out. He stated he did not order a search on 9/21/13.

In an interview on 11/4/13 at 1:09 PM, SDS 6 stated he was a Dispatcher on 9/21/13 from 7 AM to 3 PM, and after he got the call from CN 1, he relayed Patient 1's information over the radio to all Sheriffs on duty including SDS 3 (Sheriff in Charge). He stated he told on the radio to all the Sheriffs to be on the look out for black female in her 50's, wearing hospital clothing. He stated no one was dispatch specifically for Patient 1's case because the patient was not on a hold. When asked why he did not put urgency on the information he relayed to the Sheriffs on duty even after the physician (MD 1) told him (SDS 6) the patient was confused and not safe to be out on her own, he stated, because Patient 1 was not on a hold and if she wanted to leave, she's free to go.

In an interview on 11/4/13 at 2:00 PM, SDS 10 stated he was on duty on 9/21/13 from 3 PM to 11 PM. He stated he was dispatched to 5D to review Patient 1's chart. He stated Patient 1's information on the chart was that the patient was not on a hold and not at risk and told that information to SDS 7 (Dispatcher) and SDS 2 (Sheriff in Charge). When asked if he did actively search for Patient 1, he stated, "There was no order to search from SDS 2."

In an interview on 11/4/13 at 2;32 PM, SDS 7 stated he was on duty on 9/21/13 from 3 PM to 11 PM as Dispatcher. He stated the Administrator on Duty (AOD 2) talked to SDS 2 (Sheriff in Charge) about the missing Patient 1 and directed SDS 10 to go to 5D and review the chart. He stated SDS 10 called him and stated Patient 1 had no merit for hold and was not risk. He stated SDS 10 advised SDS 2 (Sheriff in Charge) and AOD 2 what happened when he reviewed Patient 1's chart. He also stated he did not receive an order to dispatch Sheriff Department Staff to search for Patient 1. When asked if he was aware MD 1 called and told SDS 6 that Patient 1 was confused and not safe to be out on her own, he stated, "No". He stated he did not see the record of phone calls in the Log by SDS 6.

In an interview on 11/6/13 at 1:54 PM, SDS 3 stated he was on duty on 9/21/13 from 7 AM to 3 PM as the Sheriff in Charge. He stated he got the information from SDS 6 (Dispatcher)about a missing person who was a black female. He stated the information he got was Patient 1 went AWOL and not medically at risk. He stated he ordered the Sheriffs on duty to look around and see if they could locate Patient 1. When asked if he knew Patient 1's Daughter and MD 1 called SDS 6 (Dispatcher) and told him that Patient 1 was confused and not safe to be out on her own, he stated, he did not get that information. He stated that if Patient 1 was medically at risk, a more extensive search will be done and a missing person report will be forwarded to the police. When asked if the physician told him that Patient 1 was confused and not safe to be out on her own, would he consider that patient medically at risk, he stated, "I would need additional information."

Review of the email print-out from Administrator on Duty 2 (AOD) dated 10/29/13 at 3:47AM to the Director of Regulatory Affairs indicated, "AOD 1 further informed me (AOD 2) that the patient (Patient 1) was altered (sic) and a missing person report had been filed. During the 2000 (8 PM) bed huddle I asked officer SDS 2 if there was any word on the patient that had been reported missing... his response was something like I don't know about a missing person/patient. I then told officer SDS 2 (Sheriff in Charge) that the day shift AOD informed me that a patient was missing from 5D and that was a missing persons report had been filed earlier that same day Saturday September 21, 2013. Officer SDS 2 advised me that he would check on it and get back to me... SDS 2 contacted me and advised me that he found out the (2) officers had been 'on standby' on 5D earlier that day (9/21/13) and the patient was not on a hold. He also told me that he followed up with the night shift charge nurse CN 2 who also advised him that the patient that was missing was not on a hold. Officer SDS 2 then asked me, should we do a missing persons report? I answered yes we should because I was told it had been done earlier. I told officer SDS 2 and also soon followed up with the 5D charge CN 2, at the 2300 discharge meeting that the patient did not have to be on hold for a missing person report to be filed and that it had been reported to me by AOD 1 that the patient was altered... I remember trying to explain to both SDS 2 and CN 2 that the person (Patient 1) could be wandering outside and could easily be victimized; it was not necessary for the patient to be on a hold for us to be concerned about the patient whereabouts..."

In concurrent review of Patient 1's medical record, phone transcripts (calls to dispatcher) and ALL documents provided by the Sheriff Department including logs of activities by the Sheriff Department staff and report forms filled out by the Sheriff Department staff, had no documentation that a missing persons report was filed by any of the hospital staff or any of the Sheriff Department Staff on 9/21/13 after Patient 1 went missing.

Review of the San Francisco Police Department INCIDENT REPORT form indicated Patient 1's daughter filed a missing person report on 9/21/13 at 2:28 PM. Patient 1's description on the report were 57 years old white female, black hair, height of 5'5", weight of 115 pounds. It also stated, "LAST SEEN AT SAN FRANCISCO GENERAL HOSPITAL...JEANS, BOOTS, ZIP-UP SWEATER WITH STRIPES ON ARM WITH THE WORDS 'SAN FRANCISCO POW WOW' ON FRONT. PATIENT 1 SPEAKS WITH BRITISH ACCENT."

In an interview on 11/6/13 at 3:28 PM, SDS 4 stated he was on duty on 9/30/13 from 7 AM to 3 PM as Supervisor. He stated a log has to be done and Watch Commanders are responsible for checking these logs. He stated he never heard that Patient 1 went AWOL until he got a request from Administration to do a search on 9/30/13. He stated that on 9/30/13 (9 days after Patient 1 went missing), he went directly to SDS 2 (Sheriff in Charge) and advised him that Administration made a request to search hospital buildings including 10 (ten) stairwells in Building 5 (main hospital) and assumed SDS 2 understood the extent of the search.

In an interview on 11/7/13 at 9:30 AM, the Chief of Nursing stated from 9/21/13 to 9/29/13, she was not aware that Patient 1 was missing. She stated that on 9/30/13, she saw on the news that Patient 1 was missing from the hospital. She stated that she requested SDS 4 (Supervisor) to do a search of the hospital campus. She stated she told SDS 4 to "search all stairwells because it will be the worst case scenario if she (Patient 1) was here and we missed it."

In an interview on 11/7/13 at 10:47 AM, Risk Manager stated on 9/21/13 to 9/24/13, Patient 1's family was calling 5D to follow up. She stated on 9/25/13, she received phone
calls from staff on 5D on how to answer questions from Police Inspectors. She stated she also received phone calls from Patient 1's Daughter and Patient 1's friend who wanted information of what happened to Patient 1. She stated she had several phone conversation with Patient 1's friend but could not get hold of Patient 1's Daughter. She stated on 9/26/13 and 9/27/13 there were a lot of phone calls from the media and also staff were dealing with Police Inspectors. She stated on 9/30/13 (9 days after Patient 1 went missing), a meeting was set up to search for Patient 1.

Interviews were conducted from 10/31/13 to 11/7/13 with several Sheriff Department Staff to gather information if search was done in hospital stairwells especially Stairwell # 8, and all the Sheriff Department Staff interviewed stated they did not search Stairwell # 8.

Review of the San Francisco Sheriff's Department Incident Report indicated the following:

"On Tuesday, October 08, 2013 at 0938 hours, I (SDS 12) was on duty, in uniform and was assigned to Foot Patrol. ... When I arrived, Officer X assigned me to a possible dead body in Stairwell # 8 on the 4th Floor, outside Ward 4B.

Stairwell # 8, is a fire escape stairwell, that is alarmed when the door is opened.

At approximately 0940 hrs (hours), when I arrived, I saw the door to Stairwells # 8 open, however the alarm was not sounding. I also saw a San Francisco General Hospital Engineer (Engineer 2) in the stairwell. I also saw several San Francisco General Hospital environmental Services (porters) employees outside in the hallway in front of 4B.

At about 0941 hrs, I contacted Engineer 2 in Stairwell # 8, he told me, "There's a dead body down there". At that time, the Administrator on Duty (AOD 3) also arrived at Stairwells # 8....

At about 0942 hrs, AOD 3 and I entered Stairwell # 8 and walked down to the stairwells landing on the 3rd floor and saw a white female on the landing lying on her back. The female was wearing a black jacket that was unzipped, blue jeans which were unzipped, but was still on her body and dark color boots.

The female was pale, her eyes were sunken in. In addition, I noticed the skin on her back, where the skin met the ground was reddish purple in color. I also saw what appeared to be a (1) one inch white square tab stuck on her (L) abdomen...

AOD 3, who is also an Registered Nurse, put on a pair of rubber gloves and checked the female's left carotid artery for a pulse. AOD 3 looked at me and shook his head left to right said, "No, she has no pulse...

At 1016 hrs SFPD Officer arrived at Stairwells # 8 and took over the crime scene. He informed me he would write, the dead body report...."



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2. Patient 8 was admitted to Unit 4D on 10/26/13 with diagnoses which included dementia, brain mass, and cerebral edema. Patient 8 was also blind in both eyes. He had a physician's order for a 1:1 coach written on 11/1/13.

During an interview on 11/5/13 at 9:45 AM, the Registered Nurse (RN 7) caring for Patient 8 stated that he was confused and spoke minimal English. RN 6 said Patient 8 was not an elopement risk but because of his dementia, he had poor safety judgement and that, coupled with his blindness, made Patient 8 a high fall risk.

In an observation on 11/5/13 at 9:45 AM, it was noted that Patient 8 was in a fully occupied four bed room and there was a law enforcement officer seated across from the doorway.

RN 7 stated that Patient 8 was in a four bed room and Patient 8's 1:1 coach (PCA 5) was responsible for watching the other three patients in the room as well. RN 7 said the other three patients in Room 2 also required 1:1 coaches.

During an interview on 11/5/13 at 9:55 AM, PCA 5 said he was responsible for 1:1 monitoring of all four men in Room 2. PCA 5 said that if he has a problem such as two patients trying to get up unassisted at once, he (PCA 5) sets off the bed alarm as a signal to nurses that he needs more help.

Review of PCA 5's assignment sheet for 11/4/13 titled Medical-Surgical Coach Assignment Form for Close Observation indicated the following:

Patient 8 was listed as needing 1:1 Observation because he was pulling necessary tubes, had poor safety awareness, was a high fall risk, and was assaultive.

Random Patient 9 (RP 9) had multiple fractures following a motor vehicle crash. RP 9 was listed as needing 1:1 Observation because he was pulling necessary tubes, had poor safety awareness, was a high fall risk, and he was in the custody of law enforcement. There was a law endorsement officer seated in the hallway across from the door to Room 2.

Random Patient 10 (RP 10) had fractures following a bicycle accident. RP 10 was listed as needing Observation because he had poor safety awareness and was a high fall risk. RP 10's level of Observation was listed as "NEVER leave patient unattended, NO clothing in room, NO sharps or harmful objects (matches. lighter, solution) in room, Search patient area every shift and after visitors or nurses exit."

Random Patient 11 (RP 11) had multiple injuries following a "Jump." RP 11 was listed as needing 1:1 Observation because he needed suicide precautions. RP 11 was also on fall precautions.

During an interview on 11/5/13 at 10:00 AM, the Nurse Manager (RN 9) acknowledged that PCA 5 was caring for patients at a 1:4 ratio rather that the 1;1 ratio which was ordered. RN 9 stated that each of the four patients in Room 2 had a different primary nurse so there always extra people in the room to help PCA 5.

Since the 1:1 coach for Patient 8 was also caring for three other 1:1 patients, the physician's order was not being implemented.

Based on observation, interview and record review, the facility failed to develop an individualized nursing care plan for 3 of eight sampled patients (Patient 1, 7 & 8) for fall risks, elopement risks or AWOL (Absent Without Official Leave) and altered mental status.

Findings:

1. Patient 1 was admitted to the facility on 9/19/13 brought in by daughter for confusion of more than a month, weight loss and dizziness. The diagnoses included bladder infection, sepsis (severe infection in the bloodstream) and delirium (confusion and disorientation).

Review of the medical record indicated on 9/20/13 at 6:28 AM, MD 2 ordered a "COACH/SITTER" for Patient 1. Further review of the medical record had no documentation MD 2 examined and evaluated Patient 1's condition for any changes in mental status and level of care. There was no progress notes written by MD 2 on 9/20/13.

Review of the 9/19/13 (11 PM to 7 AM) Assignment Form for FREQUENT OBSERVATION indicated the reason for constant observation was Patient 1 was confused, an elopement risk and on fall precautions. It also indicated, "NEVER leave patient unattended."

Review of the 9/20/13 (7 AM to 7 PM) Assignment Form for FREQUENT OBSERVATION indicated, reason for constant observation was Patient 1 was an elopement risk and fall precautions.

Review of the Nursing Notes on 9/19/13 (7 PM to 7 AM) indicated, Patient 1 had weakness on both legs, had an unsteady gait, on falls precautions and had a "coach/sitter at bedside".

Review of the Nursing Notes on 9/20/13 (7 AM to 11 PM) indicated, Patient 1 was disoriented to date and time and had periodic confusion but redirectable. It indicated Patient 1 had slight unsteady gait and walks with standby assist. It also indicated safety precautions were maintained and Patient 1 was on "close observation". There was no documentation Patient 1 had coach/sitter on bedside.

Review of the Nursing Notes on 9/20/13 (7 PM to 7 AM) indicated, Patient 1 had periodic confusion, was easily redirectable and frequent orientation was performed. It also indicated Patient 1 was able to ambulate in the hallway independently but standby assist was provided. It indicated, "frequent rounding done", but there was no documentation Patient 1 had a coach/sitter on bedside.

Review of the Nursing Notes on 9/21/13 (7 PM to 7 AM) indicated, Patient was unsure why she was in hospital and patient was reoriented as needed. It also indicated that at 9:55 AM, the nurse did a "frequent round on patient", and she noted Patient 1 was missing and not anywhere to be found in the unit. It indicated a nursing assistant was sent off the unit to look for Patient 1. It also indicated the physician and Patient 1's daughter were informed.

Review of the Nursing Plan of Care indicated the generic care plan for Dementia/Delirium was left blank.

Review of the 9/21/13 Discharge Summary indicated, "Patient AWOL (Absent Without Official Leave); wandered off floor without witnesses. Left cellphone behind but took belongings. Patient was confused on AM of AWOL, did not know she was in hospital and was fixated on finding her boots. ... Prior to MD (physician) evaluation patient was noted to be missing from her room. IP (Institutional Police) and SFPD (San Francisco Police Department) alerted. Family aware.

In an interview on 10/30/13 at 4:12 PM, RN 2 stated she was on duty on 9/20/13 at 7 AM to 7 PM. She stated Patient 1 had some confusion but redirectable. She stated Patient 1 had coach/sitter in the room. She stated she missed to develop a care plan for altered mental status. When asked if she developed a care plan for elopement risks/AWOL, she said that she made a mistake checking the elopement risks on the Assignment Form. The Assignment Form signed with her name (RN 2) was shown to her and in the section "Others", AWOL and close observation were written, she did not make further comment.

In an interview on 10/31/13 at 7:51 AM RN 4 stated she was the admitting nurse of Patient 1 on the night of 9/19/13. She stated Patient 1 had periods of confusion but she did not have time to develop a care plan for altered mental status.

2. Patient 7 was admitted to the facility on 10/7/13 from another hospital following surgery on the brain to remove blood clots. Patient 7 was at telemetry (cardiac monitoring unit) then transferred to Medical/Surgical Unit on 10/14/13. He had an order for COACH/SITTER on 10/16/13.

Review of the Nursing Notes on 10/14/13 to 10/18/13 indicated Patient 7 was confused and disoriented but follows commands, impulsive when out of bed and had a coach/sitter on bedside to prevent falls.

Review of the Age Specific Nursing Plan of Care Adult/Geriatric indicated the care plan for Cognition (mental status) was not developed until 10/19/13 although Patient 7 was confused and disoriented.

In an interview on 11/5/13 at 10:16 AM, RN 11 stated she was on duty on 10/16/13 and 10/17/13 from 7 AM to 7 PM. She stated Patient 7 needed frequent reorientation that's why he had a coach/sitter on bedside. When asked if the care plan for cognition was developed, she stated, "I don't think I have activated it before." She added that when she had patient who was confused, she usually activate the care plan for Musculoskeletal/Neurological. When it was showed to her the Neurological care plan did not cover mental status, she did not have further comment.

In an interview on 11/5/13 at 10:30 AM, RN 9 (Charge Nurse) stated that any kind of mental status change with patient, the cognition care plan should be activated.

Review of the facility's Assessment and Reassessment of Patients indicated, "C. Plan of Care 1. Based upon the initial and ongoing assessments of the patient, an appropriate interdisciplinary plan of care and discharge plan is developed collaboratively by the clinical team and is documented in the medical record. This plan of care is communicated to all other disciplines and care providers appropriate. 2. The plan of care is reviewed and updated as necessary, when a change of in patient's status or condition warrants."










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3. Patient 8 was admitted to Unit 4D on 10/26/13 with diagnoses which included dementia, brain mass, and cerebral edema. Patient 8 was also blind in both eyes. He had a physician's order for a 1:1 coach written on 11/1/13.

During an interview on 11/5/13 at 9:45 AM, the Registered Nurse (RN 7) caring for Patient 8 stated that he was confused and spoke minimal English. RN 6 said Patient 8 was not an elopement risk but because of his dementia, he had poor safety judgement and that, coupled with his blindness, made Patient 8 a high fall risk.

Record review of Parent 8's Nursing Plan of Care did not indicate a care plan for Patient 8's dementia, nor was Patient 8's blindness incorporated into his Safety/Fall Risk Care Plan. RN 7 acknowledged there was no Care Plan for Dementia.

The Nurse Manager (RN 9) was asked to provide copies of all of Patient 8's Nursing Care Plans. There was no care plan for 1:1 Close Observation of for Blindness provided.