S.F. hospital fined over patient’s death

San Francisco’s Laguna Honda Hospital has been fined $100,000 for safety violations that led to the death of a patient, the California Public Health Department said Thursday.

The fine is the most severe penalty regulators can level under state law.

The incident occurred in November 2014, when the patient, unnamed in the state report, fell out of his wheelchair while on an outing to a movie theater.

According to the investigation, a hospital staff member — a nurse assistant and driver who has been with Laguna Honda since 2009 — failed to lock both wheels of the patient’s wheelchair and then briefly left the patient alone on a curb.

While the staff member was not looking, the wheelchair rolled off the curb and the patient fell, landing face-first on the ground. The patient suffered a severe head injury and a broken hip. He died two weeks after the fall.

The patient had been living at Laguna Honda since July 2004. He had dementia, among other chronic conditions, and relied on a wheelchair due to balance and weakness problems.

Patient records indicated he should have been in the “line of sight” of hospital staff members at all times when he was in his wheelchair, the state report said.

In response to the citation, Laguna Honda officials created a plan, approved by the state, to prevent similar incidents. The staff member was reassigned from driving duties, though his current assignment was not included in the state report.

“We made immediate changes to how our outings are conducted, and there have been no accidents since,” Mivic Hirose, executive administrator of Laguna Honda, said in a statement Thursday. “We are confident that our outings are now safe.”