Federally ordered changes have been made at San Francisco General Hospital following the death of a patient who was found in a stairwell at the hospital last October.
The hospital Friday released fixes and plans to address problems outlined by the U.S. Centers for Medicare and Medicaid Services that contributed to the death of 57-year-old Lynne Spalding.
Spalding, a San Francisco resident who was well known in the hospitality and travel industry, was admitted to SFGH on Sept. 19 with an infection. She went missing two days later. Eventually she was found dead in a fourth-floor stairwell on Oct. 8, after a massive Bay Area-wide search effort.
The sheriff's department, which provides security at SFGH, was asked to search the entire campus after Spalding had been missing for more than a week. But it was later determined that the search only included half the stairwells, even though staff had been instruction to search everywhere. Sheriff's officials also failed to follow up on a report made on Oct. 4 of a person lying in a stairwell in the hospital.
It has also been revealed that there were technical problems with security alarms and surveillance cameras.
Transcript records between sheriff and hospital staff show confusion about Spalding's disappearance when it was first reported. At first she was described as a black woman wearing a hospital gown. Spalding was a white woman and was wearing her own clothing when she was found eventually in the stairwell.
The hospital has since undergone several reviews of the facility's procedures and safety and security systems. The sheriff's department has made staffing changes including reassigning a dispatcher, two senior deputies, and a sergeant away from the facility. Additionally, a captain, two lieutenants, two sergeants and two
senior deputies were brought in at the hospital.
Federal investigators were at the hospital this week to re-survey the hospital for general security, patient safety and security and privacy.
Investigators had conducted an initial investigation from Oct. 30 and Nov. 8, following Spalding's death. According to hospital officails, the survey found the hospital in
compliance with safety requirements and recommendations.
The hospital is also working with the sheriff's department to make improvements identified during the federal investigation. Some of those changes include daily security checks of all stairwells, better alarm systems on doors, and other security checks. All sheriff's officials assigned to the hospital will undergo new training on security and safety and there is a new six-week training course that was developed through the city's Department of Public Health.
The hospital's policy on missing or at-risk patients has since been modified to include a script for staff to follow to ensure accuracy when reporting a patient leaving the hospital before treatment is complete.
Additionally, the federal investigation uncovered that hospital staff accessed Spalding's medical record four times without authorization. Hospital staff said Friday "this is unacceptable" and have called for enforcing their own privacy policies. According to the hospital, staff involved with the privacy breaches have resigned, been fired or placed on administrative leave. One staff member involved has returned to work.
The hospital said the privacy violation was reported to the state Department of Public Health and to Spalding's family. Another privacy violation involved a sheriff's official who no longer works at the hospital or any other health site.
There will be ongoing review of the hospital's security system by an independent review by the University of California at San Francisco Medical Center.
In the report released Friday hospital staff said, "What happened to (Spalding) was horrible and never should have happened. We have worked diligently to fact find, cooperated with multiple investigations and developed a plan to become a safer, more secure organization."