The main entrance to Laguna Honda Hospital and Rehabilitation Center on Thursday, Sept. 5, 2019. (Kevin N. Hume/S.F. Examiner)

SF pays $780K fine in Laguna Honda abuse scandal affecting 130 patients

More penalties expected as city seeks to restore faith in skilled-nursing facility

UPDATE Oct. 25, 2019: The Department of Public Health has now confirmed 130 patients were affected by the Laguna Honda Hospital abuse scandal. An updated story is here.

UPDATE Oct. 24, 2019: San Francisco Health Department officials on Thursday retracted an earlier statement made at a Board of Supervisors hearing Wednesday that an investigation had found up to 130 patients may have been invovled in a patient abuse scandal at Laguna Honda Hospital that was first made public in June.

Hospital spokesman Brent Andrew on Thursday said that Troy Williams, chief quality officer at Zuckerberg San Francisco General Hospital, had misspoken in his testimony and had meant to say that up to 130 incidents had been uncovered, not patients.

The original story remains below. An updated story has been published separately.


The City has paid a $780,000 fine in connection with a patient abuse scandal at Laguna Honda Hospital and the number of patients impacted has grown to 130 after a monthslong investigation, health department officials said Wednesday.

The six staff members directly involved in the abuse, which included life-threatening drugging, photos and sexualized conversations, have lost their jobs, but it remains unclear if the San Francisco Police Department will arrest them. A criminal investigation is ongoing.

The latest details in the patient abuse scandal at the Department of Public Health’s 780-bed skilled nursing facility came during Wednesday’s Board of Supervisors Government Audit and Oversight Committee meeting, the first hearing the board has held on the issue since Mayor London Breed revealed the abuse during a City Hall press conference in late June.

Evidence of abuse surfaced as a result of a hospital worker’s human resources complaint in February, prompting the City Attorney’s Office to investigate.

Since then, forensic analysis conducted on cell phones that former hospital workers used to take photos and videos of patients and text each other about the alleged abuse has uncovered more evidence.

The new evidence shows the rights of 130 patients were violated, far more than the 23 announced in June, according to Troy Williams, the chief quality officer for Zuckerberg San Francisco General Hospital, who was sent over to Laguna Honda to assist in the investigation.

Williams said that the additional evidence from the phones includes “some physical, sexual and psychological abuse, but the majority of the additional images” he said are privacy breaches of the patients. Examples of the privacy breaches, he said, included “residents being seen in the background” of photos.

Williams noted that the sexual abuse is photos of nudity, not sexual assault. He said that the additional evidence did not implicate any additional employees.

As a result of the abuse allegations, the California Department of Public Health, launched an investigation into Laguna Honda Hospital and found a number of deficiencies the hospital has since corrected. This has resulted in fines.

“We did receive a $780,000 fine, which we paid,” Williams said. He said the fine was paid about two weeks ago, but he anticipates additional penalties from the phone evidence, which they turned over to CDPH on a rolling-basis until mid-August. He said that privacy beaches “carry a pretty heavy fine.”

Patients or their decisionmakers who were impacted were notified by The City. Williams said that so far two legal claims, precursors to lawsuit, have been filed against The City. The City Attorney’s Office has yet to provide requested copies of the claims.

Williams confirmed a criminal investigation by the San Francisco Police Department is still underway. “In fact, we met with the San Francisco Police Department yesterday and are developing a plan to help facilitate interviews with residents,” Williams said.

“They should be in jail,” said Board President Norman Yee, who called for the hearing.

Margaret Rykowski became the acting chief executive officer of Laguna Honda Hospital in June, replacing longtime Laguna Honda CEO Mivic Hirose. Hirose remains employed with the department, but no longer at Laguna Honda, the San Francisco Examiner previously reported.

“A lot of work has been done between February and now,” Rykowski said. “And I can tell you that we are very proud that on Oct. 15 Laguna Honda was found to be in regulatory compliance with the state.”

To achieve compliance, the hospital implemented a number of “corrective actions,” such as better oversight of medications and requiring urine toxicology test if a patient exhibits unusual change in behavior like altered mental state or sleepiness to check for unprescribed medication.

Williams said that there is evidence that these medications were “brought from the outside” as well as from Laguna Honda.

One of the problems at the hospital, Williams said, was a culture of silence, where staff members were afraid to report issues for fear of retaliation. Those in quality management positions lacked expertise to investigate issues as they came up, Williams said.

Rykowski said that hospital is “headed in the right direction.”

“I think staff are feeling better,” she said. “They are feeling more comfortable bring issues to our attention.”

The Department of Public Health is currently looking for a CEO to run the hospital and a quality management director.

“There is no excuse for what transpired. Families like my own depend on Laguna Honda for care that they should be able to trust is going to be the highest quality,” Yee said. “We cannot ask our residents to entrust the care of our loved ones to any entity that cannot prove that they have an effective system that guarantees the safety and well-being of every single patient.”

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