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 (http://bit.ly/Ln1qkB) 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.