San Francisco General Hospital and Trauma Center
Statement on Improved Safety and Security by Sue Currin, RN, MSN, CEO
Changes Validated by Federal Inspection
January 24, 2014
San Francisco General Hospital and Trauma Center reports that the federal Centers for Medicare and Medicaid Services (CMS) has verified our compliance with our Plan of Correction (POC) to fix the problems that contributed to the tragic death of patient Lynne Spalding Ford, and that we have made significant progress toward a safer and more secure hospital. Her family is in the forefront of our minds as we continue to work to improve safety and security for all our patients.
CMS conducted a thorough investigation from October 30 to November 8 2013, following the hospital’s self-reporting of Ms. Spalding’s death. The survey covered general security, patient safety/security and privacy. The federal investigators returned this week to re-survey the hospital. The surveyors completed staff interviews, observed practice in the patient care areas, and reviewed documents before concluding that SFGH is in compliance with all requirements.
Many of the changes outlined in the POC already have been implemented and we can assure Ms. Spalding’s family, and all our patients, visitors and staff, that we are a safer organization today.
Working in collaboration with the San Francisco Sheriff’s Department, which provides security on the San Francisco General Hospital (SFGH) campus, we have made significant improvements in the key problem areas identified during the investigations: general security, patient safety/security and privacy.
General Security Improvements:
- Safer stairwells:
Security checks of all emergency stairwells are completed daily by Sheriff’s staff.
Emergency stairwell door alarms were converted to continuous audible alarms requiring deactivation with a key.
Security checks by Sheriff Deputies are triggered when a stairwell alarm rings.
Charge nurses check to ensure all patients are accounted for when a stairwell alarm rings near a patient care unit.
- Monthly meetings between the Sheriff and Department of Public Health Director.
- Weekly meetings between San Francisco Sheriff Department (SFSD) leadership and SFGH CEO are held to review ongoing security measures and the status of the POC.
- Sheriff’s Captain Kenneth Ferrigno assigned to SFGH as the on-site Institutional Police Unit (IPU) Unit Commander.
- Two SFSD Lieutenants assigned as SFGH Site Commanders providing 7-day per week supervision.
- SFSD Training Officer assigned to SFGH.
- All 46 SFSD staff at SFGH completed SFGH orientation and training on new security and safety procedures.
- SFSD developed a six-week training course for Department of Public Health sites that is being implemented.
- SFSD policies and procedures for IPU operations at SFGH were reviewed and revised.
Patient Safety/Security Improvements:
- The hospital’s policy on AWOL and AWOL At-Risk Patients was strengthened when the Sheriff agreed to include in searches patients who exhibit behavior that concerns the clinical staff as to their state of mind. The policy includes a script for staff to follow to ensure accuracy when reporting an at-risk patient leaving the hospital before their treatment is completed. The Sheriff also developed consistent and comprehensive search procedures for missing at-risk patients on our hospital campus.
- The hospital developed, implemented and trained all staff on an organizational response called Code Green when a hospital-wide search is needed to locate an at-risk patient. Sheriff and hospital staffs work collaboratively when campus wide searches are needed.
- The hospital has created a new Patient Tracking System policy and procedure for patients who are at-risk of leaving their units. The hospital has purchased a tracking system that we plan to begin using next month for patients who meet the criteria.
- The policy on the Close Observation of the Hospitalized Patient was revised to clarify required nurse and physician communication, triggers for patient evaluation, and documentation of physician orders and actions instituted to keep patients safe. We learned that for these patients, whose status can vary multiple times during their hospitalization, we had weaknesses in the areas of consistent documentation and communication of these changes and revisions to their care plan. Staff are being retrained and audited to ensure that these vulnerable patients get the care they need.
Privacy policies were effective and enforced:
- SFGH takes patient privacy extremely seriously and as such we conduct routine audits of medical records of high profile patients. During such an audit on October 21, we discovered four instances when hospital staff accessed Ms. Spalding’s medical record without authorization. This is unacceptable.
- We fully enforced our privacy policies to discipline the staff involved. All were placed on administrative leave immediately while an investigation took place. Since then, one has resigned, two have been terminated and one has returned to work.
- We reported these privacy breaches to the CA Department of Health and to Ms. Spalding’s family.
- There was an additional privacy violation by a member of the Sheriff’s Department staff at SFGH, who spoke on a recorded phone line about Ms. Spalding on the day she was found. Out of respect for Ms. Spalding’s family, we must clarify that the information given was not true. Even so, it still violated her privacy. We apologize for any additional hardship this may cause. That employee no longer works at SFGH or at any Department of Public Health site.
Ongoing independent review of SFGH security systems by UCSF continues. It includes:
- Evaluation of SFGH security system controls (e.g. cameras, alarms, panic buttons, exits).
- Review of policies and procedures related to patient, staff and visitor safety and security.
- Evaluation of SFGH campus security resources (staffing model, hours of service, post and patrol areas, job duties, training and job classifications assigned).
What happened to Ms. 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. 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. We want everyone in San Francisco to be assured that we take this very seriously and have taken significant steps to improve. Patient safety is our top priority.
With the support of Mayor Ed Lee, Director of Health Barbara Garcia and Sheriff Ross Mirkarimi, SFGH is a stronger organization. As the city’s only trauma center and care provider for more than 100,000 patients and their families each year, we want all our patients to have full confidence that in addition to excellent care, we will also provide a safe and secure environment.
San Francisco General Hospital and Trauma Center (SFGH)
San Francisco GeneralHospital and TraumaCenter is the sole provider of trauma and psychiatric emergency services for the City and County of San Francisco. A comprehensive medical center, SFGH serves some 100,000 patients per year and provides 20 percent of the city’s inpatient care. In 2011, SFGH became the first hospital in the country to be certified for a Traumatic Brain Injury program. As San Francisco’s public hospital, SFGH’s mission is to provide quality health care and trauma services with compassion and respect to patients that include the city’s most vulnerable. General Hospital is also one of the nation’s top academic medical centers, partnering with the University of California, San Francisco School of Medicine on clinical training and research.
Contact: Rachael Kagan (415) 206-3170, (415) 420-5107c or email@example.com