State officials have fined San Francisco’s Laguna Honda Hospital $100,000 for mistakes that led to the death of a wheelchair-bound patient with dementia in 2014.
The fine and class AA citation, the most severe penalty the state can issue to the county-owned skilled nursing facility, were issued for a Nov. 26, 2014, incident in which a patient fell out of a wheelchair while on a group outing, suffering a head injury that ultimately led to his death, according to the California Department of Public Health.
The hospital employee in charge of the patient’s care left the man, a patient with dementia and diabetes who had lived at Laguna Honda for 10 years, in his wheelchair next to a van while he went to turn on the heater.
The wheelchair’s brakes were not locked, and when the caregiver returned he found the man had fallen into the street face first, causing facial cuts, a hip fracture and internal bleeding in his brain.
The man died on Dec. 10, 2014, and a medical examiner’s report listed cause of death as blunt force injuries to the head.
Laguna Honda officials have made changes and improvements in how group outings are conducted for residents since the incident, including additional safety training for staff and quality assurance audits. A plan of correction has been verified by state officials, according to Mivic Hirose, the hospital’s executive administrator.
“We are committed to providing our residents an environment that is free from accident hazards. … We are confident that our outings are now safe.”