SAN FRANCISCO GENERAL HOSPITAL

Report ID: EK8W11.06, 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 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.

Outcome:

Deficiency cited by the California Department of Public Health: QUALITY IMPROVEMENT ACTIVITIES

Related Reports:

The report containing this deficiency also includes information about 5 other violations. Note that these may be related to the same event: EK8W11.01, EK8W11.02, EK8W11.03, EK8W11.04, EK8W11.05