SAN FRANCISCO—San Francisco’s Laguna Honda Hospital was fined $100,000 for safety violations that led to the death of a wheelchair bound patient who suffered from dementia, the California Public Health Department announced on Thursday, January 19.
According to the CPHD, the hospital received the most severe penalty the state can issue.
The unidentified patient died after falling out of his wheelchair,while on a group outing to a movie theater in November 2014. The patient ultimately died from head injures he sustained from his fall, the CPHD said.
According to CPHD’s investigation, a hospital staff member, a nurse and driver, failed to lock both wheels of the patient’s chair and briefly left the patient alone by a curb.
While the staff member was not looking, the wheelchair rolled off the curbed and the patient fell, landing face-first on the ground. The patient died two weeks after the fall on December 10, 2014. A medical examiner determined the caused of death to be blunt force injures to the head. The patient lived at Laguna Honda Hospital for 10 years.
According to the CPHD, the patient relied on a wheelchair to help with balance and weakness problems. Records indicated the patient should have been in the “line of sight” of hospital staff members at all times when he was in his wheelchair.
Hospital officials crafted a revised plan, approved by the state of California, to prevent similar accidents on future group outings.
The hospital made improvements on how group outings are conducted that include additional safety training for staff and quality assurance audits, indicated Mivic Hirose, Executive Administrator of Laguna Honda in a statement.
“We made immediate changes to how our outings are conducted, and there have been no accidents since. We are confident that our outings are now safe,” Hirose said.
