Report finds hospital at fault in stairwell death
A state investigation into the death of a patient who was missing for 17 days before her body was found in a stairwell at San Francisco General Hospital has found the hospital and the nurses largely at fault for the death.
Hospital officials confirmed that 57-year-old Lynne Spalding disappeared on a busy fifth-floor corridor that passes a bank of elevators, a hallway to another unit, and numerous doors. Spalding had been admitted for complications related to an infection.
A report by the state health department, which investigated the incident on behalf of the Centers for Medicare and Medicaid Services (CMS), found that hospital staff members were under orders to watch Spalding continuously, but they did not do so. The San Francisco Chronicle obtained the state's report, which has not been released publicly. (The full newspaper report is available online at http://tinyurl.com/stairwellreport. For more on the background of the case, see Healthcare Risk Management, December 2013, p. 142.)
The report found that while it was clear Spalding needed 24-hour monitoring and a doctor had given written orders that she never be left unattended, nurses failed to record or fully heed that order, the newspaper reports.
Because Spalding had a frequent habit of getting out of bed, nurses disabled her bed alarm. She also was subject to periods of delirium, including an incident on Sept. 20, 2013, when she wandered to the nursing station and talked to them about working at an airport.
The next day, a doctor wrote an order that said "NEVER leave patient unattended."
A nurse on the unit told investigators that she "did not get a chance" to record the order for round-the-clock monitoring on Spalding's chart during a change of shifts. The patient disappeared two days later.
Without that order, nurses were instructed to keep Spalding under "close observation," checking on her about every 15 minutes, the newspaper reports. When she disappeared from her room, the monitor assigned to her had been called away.
The report also cited the local sheriff's department for its failure to locate Spalding after she was reported missing.