Nurses at Laguna Honda Hospital kicked a patient, had sexually explicit conversations with others, took nude photos and drugged patients in a potentially life-threatening manner, according to new details documented by investigators of a patient abuse scandal that rocked City Hall earlier this year.
In one case, a patient was administered Narcan to reverse an apparent drug overdose due to unprescribed opioids.
The new details of the abuse by nurses no longer employed in the facility are in reports from the California Department of Public Health’s investigation of the abuse conducted in June and July and obtained by the San Francisco Examiner through a public records request. The abuse is said to have occurred between between 2016 and January 2019.
The details provide a more graphic look at the incidents that were previously only broadly discussed by Mayor London Breed and Department of Public Health Director Dr. Grant Colfax, in June, when they first revealed the scandal during a brief press conference at City Hall. The abuse, said to have occurred over a period of three years, remains under investigation by the Police Department for possible criminal charges, a spokesperson confirmed on Wednesday.
The state documents show the existence of video and photographic evidence of the abuse on the former nurses’ cell phones and toxicology tests showing unprescribed medications.
In total, the state report said 19 patients were photographed without their consent. Three were photographed naked.
One photo showed a patient’s “buttocks with an open wound, with pinkish and foaming white discharge coming from the wound,” according to the report.
Another showed the patient “on his side with his buttocks exposed” while “a caregiver’s hand can be seen administering a Fleet’s enema to the resident.”
City officials provided the state investigators with files of the photos, videos and text messages obtained from the nurses’ personal cellular phones.
City officials said they uncovered evidence of the abuse during an investigation of a human resources complaint between employees and notified the state. The obtained state documents contains a statement from an unidentified nurse manager who said, “The only reason these incidents came out is because a staff member complained to me of sexual harassment from another staff member … and these [the videos] were found.”
Evidence includes two undated short video segments from the cell phones of a vocational nurse and two nursing assistants of a resident “lying in bed covered with a blanket, eyeglasses on and fully awake.”
One nursing assistant, identified in the report as CNA 2, “is heard agitating Resident 14 to get a response and making derogatory statements.”
The nurse points to the patient’s last name initial letter and asks what it means. The patient responded by giving his full name. The nurse stated “I thought it meant …” and used a slur in Spanish for a gay man. The report redacts the slur.
“The videos also showed CNA 2 asking Resident 14, four times, if he wanted a towel to wipe ‘the cum off … ‘ These statements by CNA 2 provoked an immediate strong emotionally angry response from Resident 14 exhibited by Resident 14 screaming profanities in both English and Spanish and moving his hands.”
Another video, dated January 8, 2016 at 9:32 a.m., shows physical abuse of an adult patient whose mental capacity is the equivalent of a seven year old.
“The video showed Resident 13 lying on his side in bed and suddenly being kicked on the buttocks by a staff member (the only thing seen of the staff member was the leg and foot wearing a black boot), causing the resident to jerk,” the report said.
One set of six videos of patient identified as Resident 4 are dated from August 2018.
Four of the six videos show the nurse questioning the patient “on sexual practices.” Another video shows the nurse prompting the patient to say “sexually explicit remarks.” The remaining video shows “staff borrowing money from Resident 4.”
The reports also provides new details on the drugging of patients.
The report said that a vocational nurse and a nursing assistant “intentionally administered non-prescribed medications” to five patients “for staff convenience.”
“This failure resulted in residents being hospitalized for over-sedation, respiratory depression, and/or altered mental status,” the report said.
Drugs used included methadone, morphine, tramadol and oxycodone.
Text exchanges between a vocational nurse and nursing assistant show them discussing drugs using code words like chocolates or Mercury, a drugstore in the Philippines.
In one exchange, a photo is texted of a patient sleeping in a wheelchair.
The exchange shows the vocational nurse inquiring about what the patient is doing, to which the nursing assistant answered “Asleep! Lol.”
In response, the vocational nurse pointed out that the patient was sleeping “Thanks to Mercury!”
Health officials seek to restore public ‘faith’ in Laguna Honda Hospital
Last week, San Francisco Health Network Director Roland Pickens presented a 60-day reform plan for the hospital to the Health Commission.
The 780-bed skilled nursing facility and rehabilitation center is owned and operated by the Department of Public Health and has an operating budget of about $300 million.
The plan responds to operational deficiencies found by CDPH’s investigation of the hospital around medication management, workplace safety and hospital leadership that were “primary contributing factors” in the patient abuse.
The CDPH report said 21 patients were impacted.
The 60-day plan details how the hospital has or plans to improve the conditions.
The CDPH’s report found the hospital to be out of compliance with state and federal regulations by failing to protect the privacy rights of patients, ensure that patients were “free from chemical restraints” and protect patients from verbal, physical and mental abuse.
The report also found that the hospital failed to report the abuse in a timely manner to CDPH, the residents and their caretakers, and had not adequately trained staff to report misconduct.
In its reform plan, the hospital said it has already conducted wellness checks for the patients who suffered abuse and has fired the employees who were directly involved.
The hospital also said it conducted workplace culture surveys, interviews and trainings with staff, including the appropriate use of cell phones and reporting misuse of medication as abuse.
The hospital has employed a door monitor to oversee visitors and staff and conducted a random audit on medication administration in the nursing department.
Pickens said that the hospital will continue to work with local and federal experts to improve operations, and that staff from Zuckerberg San Francisco General Hospital were deployed to Laguna Honda Hospital to assist in quality and safety management there.
Amid the scandal, the hospital’s longtime CEO stepped down. The search for a new CEO of the hospital is ongoing. Pickens stated that the hospital will deliver regular reports on compliance to oversight bodies, including the Board of Supervisors.
Pickens promised to restore public “faith in our ability at Laguna Honda Hospital to deliver high quality safe and abuse-free care to the next generation of San Franciscans.”
“We must and we will all pledge to rededicate ourselves and hold each other accountable for [creating] a new ethos — one that values safety, quality and transparency…above all dignity and respect,” he said.
Commissioner Edward Chow urged the hospital to develop strict timelines for implementing some of the corrective actions that remain outstanding.
He added that the reporting criteria should also include consistent reports to the Health Commission and a greater emphasis on cultural familiarity in the employee application process.
“There’s been a lot of discussion [about] looking at culture. It’s not just a culture of reporting but one of cultural humility which may be at the core of the problem which we saw,” said Chow. “This is a good start, but we need some timelines and regular reporting back so that we are sure that we are on target. And that if there are needs we all become aware of [them] and work together with The City to ensure we are responding to those.”