SAN FRANCISCO GENERAL HOSPITAL

Report ID: EK8W11.01, California Department of Public Health

Reported Entity: SAN FRANCISCO GENERAL HOSPITAL

Issue:

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.

Outcome:

Deficiency cited by the California Department of Public Health: DATA COLLECTION & ANALYSIS

Related Reports:

The report containing this deficiency also includes information about 5 other violations. Note that these may be related to the same event: EK8W11.02, EK8W11.03, EK8W11.04, EK8W11.05, EK8W11.06