Nurses at a San Francisco hospital “inadvertently discontinued” a doctor’s orders to have a staff member maintain a constant watch on a patient who ended up leaving her room and was found dead in a locked emergency stairwell 17 days later, California public health inspectors found.
A report the inspectors prepared for the federal Centers for Medicare and Medicaid Services states that Lynne Spalding was considered an “elopement” risk from the time she was admitted to San Francisco General Hospital for a bladder infection, sepsis, unexplained weight loss and disorientation.
Staff members working the graveyard shift on Sept. 20 initially were instructed to check on Spalding every 15 minutes and cautioned in writing, “NEVER to leave patient unattended,” according to the findings first reported by the San Francisco Chronicle and obtained by The Associated Press on Sunday.
Later that morning, after Spalding had wandered into a nursing station and been unable to identify the date and spoke nonsensically, a doctor wrote an order for a “coach/sitter” to provide around-the-clock bedside supervision. But the nurse to whom he had given the order told investigators she “did not get a chance” to enter the information onto the form used to convey patient care instructions between the day and night shifts.
Sitting with patients who are at risk of falling or wandering away is one duty of patient care technicians, who are not nurses but lesser-skilled hospital workers. One already had been assigned to the room to keep Spalding and her roommate safe from falls. But the sitter was told to suspend her vigil when the roommate was transferred in the afternoon, and she then resumed checks four times an hour.
The charge nurse on duty at the time “stated that if he was aware of the physician’s order, he would let the coach/sitter stay in the room,” the report says.
Spalding, 57, went missing from her bed on Sept. 21. A building engineer conducting a quarterly inspection discovered her body on Oct. 8 in the stairwell that was locked on the inside and located 99 yards from her room. The San Francisco coroner attributed her death to dehydration and an electrolyte imbalance likely related to chronic alcohol use, but could not pinpoint when she died.
San Francisco Sheriff Ross Mirkarimi, whose department provides security for the public hospital, has conceded that deputies failed to conduct a thorough search for Spalding.
The report prepared for the federal agency contradicts statements hospital officials gave after Spalding’s body was found. They said Spalding was supposed to be checked on every 15 minutes and had been, including right before she left her room.
Instead, the state inspectors found, she went unsupervised for at least 40 minutes before her disappearance because the staff member assigned to look in on her was called away for an errand and a meeting and no one was assigned as a replacement.
A hospital spokeswoman did not respond to an email seeking comment on Sunday, but San Francisco General officials reiterated in a statement to the Chronicle that they have worked hard to improve patient safety protocols since Spalding’s death and “we are a safer organization today.”
The federal report provided more details about the approach sheriff’s deputies took to the search for Spalding. It states that on Sept. 30, nine days after Spalding was reported missing, four different deputies were all told to search the hospital’s 10 stairwells. One searched the grounds but no stairwells, and another two checked only a pair of stairwells a piece.
A commander said the fourth deputy reported completing the check, but the deputy informed the state investigators he hadn’t because he thought he was supposed to search for Spalding only if he had free time.
“This report confirms what we have saying since September 21, 2013 when Lynne Spalding disappeared: SF General and the SF Sheriff’s Department never took seriously the safety and welfare of Lynne Spalding,” the woman’s family said in a statement Sunday. “Instead they ignored our calls, childishly pointed fingers at each other, and shuffled deck chairs on a waterlogged ship.”