State cites SF care facility over death of woman in hospital stairwell

State investigators have cited the facility where a missing elderly woman lived before she died in a stairwell at Zuckerberg San Francisco General Hospital for failing to provide “appropriate care and supervision.”

Staff at the hospital power plant discovered 75-year-old Ruby Andersen dead in a stairwell on May 30, 11 days after she checked herself out of the nearby Residential Care Facility for the Elderly on the campus of ZSFGH.

The California Department of Social Services on Aug. 23 found that the facility failed to recognize and report the deteriorating cognitive abilities of Andersen, who reportedly suffered from dementia. As a result, she was not reevaluated by her physician and “left the facility without appropriate care and supervision.”

The department’s Community Care Licensing Division ordered the facility to roll out measures to “prevent a repeated incident,” or face fines for wrongdoing. The division cited the facility with a “Level A” and a “Level B” citation.

The San Francisco Department of Public Health, which runs the facility, extended its condolences to Andersen’s family and loved ones in a statement from Roland Pickens, director of the department’s San Francisco Health Network.

“We appreciate the review by the state and are working with CCLD to develop a response and plan of correction to make improvements in observation, supervision and documentation to ensure safe and appropriate services for all residents of the Behavioral Health Center’s Residential Care Facility for the Elderly,” Pickens said in response to the findings.

Andersen checked herself out of the facility at 20th Street and Potrero Avenue at 9 a.m. on May 19. Facility workers, who had expected her back by 4 p.m., reported her missing the following afternoon.

The San Francisco Sheriff’s Department filed a missing persons report with police on May21 after checking with her family, the hospital, the jail and the Medical Examiner’s Office in an attempt to find her on May 20.

The following day Andersen’s family confirmed she was missing.

SEE RELATED: SF concedes gaps in protocol after woman dies in hospital stairway

Andersen’s death revealed shortcomings in security protocols at the hospital campus.

Since Andersen was a resident at the facility but not a patient at the hospital, sheriff’s deputies in charge of security did not search the power plant after she was reported missing on May 20 as they would have if she were a patient.

As a result of the death, hospital officials also instituted a security checkpoint for staff at the power plant, which was publicly accessible seven days a week.

“Upon discovering Ms. Andersen had died in a utility building, we immediately improved security on campus, especially at the building in which she was found,” Pickens said. “We continue to work with the San Francisco Sheriff Department to address safety and security issues on campus.”

Andersen was the second woman found dead in a stairwell at the hospital. Lynne Spalding, 57, was found dead in a stairway 17 days after she went missing from her hospital bed in September 2013.

The City later settled a lawsuit for nearly $3 million with her family.

Andersen’s family has since hired the attorney who sued The City in that case.

mbarba@sfexaminer.com

Michael Barba
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