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Feds sign off on San Francisco hospital's reforms after patient found dead in stairwell


By Associated Press
Posted: January 25, 2014 - 10:15 am ET
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Federal regulators have approved a San Francisco hospital's plans to beef up its security procedures after the a patient was found dead in a locked stairwell more than two weeks after she went missing from her room, hospital officials said Friday.

San Francisco General Hospital said inspectors from the CMS signed off this week on a series of corrective actions the hospital took after Lynne Spalding's disappearance and death.

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The reforms include equipping stairwell doors with alarms that can only be shut off with a key, having nurses account for all their patients when the alarms sound, and arranging for sheriff's deputies who provide security at the hospital to search the stairwells daily.

San Francisco's sheriff has acknowledged that after Spalding, 57, was reported missing on Sept. 21, deputies never searched the stairwell closest to her room despite repeated requests to do so. A building engineer eventually found her body there 17 days later.

The coroner has ruled the death an accident, saying it probably was caused by a chemical imbalance related to chronic alcohol abuse. A lawyer for Spalding's family has disputed that she had an alcohol problem and insisted she died of starvation or dehydration.

Along with instituting daily stairwell checks, Sheriff Ross Mirkarimi has agreed to assign deputies to look for patients who, like Spalding, had shown signs of being disoriented or confused before they disappeared. Previously, the sheriff's department only searched for patients who were on involuntary legal holds or who had another person with legal authority to make medical decisions for them, hospital spokeswoman Rachael Kagan said.

The hospital revealed for the first time Friday that four curious employees looked at Spalding's medical records without authorization after her body was found. Chief Executive Officer Susan Currin said the patient privacy breaches were revealed during an audit routinely performed for high-profile patients. All four staff members were put on administrative leave for violating patient privacy rules, and two were fired.

"What happened to Ms. Spalding was horrible and never should have happened," Currin said. "This is not simply about passing inspection. It is about the memory of Lynne Spalding Ford, our patient, and the tragedy that occurred on our campus."

The CMS monitors hospitals that treat patients receiving government-subsidized healthcare to make sure they are complying with health and safety standards. The agency launched an investigation after San Francisco General reported Spalding's death and in accepting the hospital's reforms has closed its case, Kagan said.


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