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Report: Nurses didn't heed orders to watch patient

LAST UPDATED: 11:43 a.m. HST, Feb 02, 2014

SAN FRANCISCO >> Nurses at a San Francisco hospital did not heed doctors' orders to maintain a constant watch on a patient who ended up leaving her room and was found dead in a locked stairwell 17 days later, a newspaper reported.

The San Francisco Chronicle cited the results of a Centers for Medicare and Medicaid Services investigation.

After Lynne Spalding was admitted to San Francisco General Hospital for a bladder infection and disorientation on Sept. 19 a doctor had instructed staff there in writing to "NEVER leave patient unattended," the newspaper reported.

The next day, after Spalding had wandered into a nursing station speaking incoherently, a doctor reminded a nurse that the woman needed around-the-clock observation. The staff's notes on Spalding, however, simply indicated that she was supposed to be monitored only with "close observation," and the nurse who had spoken with the doctor acknowledged she never updated the instructions, the Chronicle said.

Spalding, 57, went missing from her bed a day later. A building engineer conducting a quarterly inspection discovered her body in the stairwell located not far from her room on Oct. 8. 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 obtained by the Chronicle, which California public health inspectors prepared for the federal agency, contradicts statements hospital officials gave after Spalding's body was found. They said nurses were told to check on Spalding every 15 minutes and did, including right before Spalding left her room.

Instead, the state inspectors found, the patient went unsupervised for 85 minutes before her disappearance because the person assigned to watch her was called away and no one was assigned to replace her, the newspaper said.

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 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.

Spalding's family released a statement Sunday responding to the report, which has not yet been made public.

"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," it said. "Instead they ignored our calls, childishly pointed fingers at each other, and shuffled deck chairs on a waterlogged ship."

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cojef wrote:
Malfeasance by entire hospital where staff and attending doctor are not operating from the same page. The hospital certification should be suspended until remedial action are implemented.
on February 2,2014 | 11:07AM
paniolo wrote:
Nobody in the hospital noticed her missing from her bed? What about when they brought her meals or medications, or to check her vitals? Security don't make daily rounds of the stairwells? This hospital needs to clean up their act.
on February 2,2014 | 11:10AM
awahana wrote:
Nothing good happens in a 21st century medical system.
on February 2,2014 | 11:11AM
Kalaheo1 wrote:
Seriously? Good things happen all the time!
on February 2,2014 | 12:54PM
RetiredWorking wrote:
Nothing good? That's a very dumb statement.
on February 2,2014 | 07:30PM
atilter wrote:
on February 2,2014 | 11:33AM
GorillaSmith wrote:
Your caps lock key appears to be stuck.
on February 2,2014 | 11:44AM
atilter wrote:
just in case you can't see
on February 3,2014 | 02:40AM
WKAMA wrote:
Hard to believe, huh? Bad things happens all the time at hospitals. Avoid hospital if at all possible.
on February 2,2014 | 12:06PM
residenttaxpayer wrote:
Finger pointing and laying blame now begins...question is will anyone be held accountable and disciplinary action taken against those who were negligent....
on February 2,2014 | 04:54PM
maya wrote:
The issue is whether the physician meant 1: 1 nursing, or just watch the patient closely. 1:1 nursing means the hospital would have to get extra staff, most likely agency, to sit and watch a patient constantly. If the doc meant close monitoring, then that would be hourly or 15 min checks. So, it really depends on the actual physician order.Usually the order would state 1:1 if they wanted a constant observation. If a 1:1 was ordered, nursing administration would have to get involved, because generally insurance does not reimburse for that extra cost. Therefore, an order like this should have been made very clear from the doc, and the nursing adminstrators who should have had an idea from their nurses that this patient had issues.
on February 2,2014 | 05:37PM
HOSSANA wrote:
A legitimate lawsuit is in the making against S.F. General Hospital and the S.F. Sheriff's dept. Typical government incompetence by ignorant officials and that incl. the nurses esp. the one dr. communicated to have it written that she be monitored all the time. I can imagine the hurt and anger by the victim's family as I would be outraged at this incident.
on February 2,2014 | 11:27PM
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