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Newly Uncovered Cases of Patient Abuse at Laguna Honda

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The number of patients subject to various forms of abuse at San Francisco's Laguna Honda Hospital is now 130. (Scott Richard/Flickr)

The number of patients subject to various forms of abuse or had their privacy violated at San Francisco's Laguna Honda Hospital is now 130 — not 23, as previously reported by city officials.

The latest incidents were uncovered from a forensic analysis of the cellphones of six former employees, who allegedly carried out the abuse over a three-year period from 2016 to January 2019.

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The additional evidence means that a total of about 30 patients suffered “some physical, sexual and psychological abuse,” according to Troy Williams, chief quality officer at Zuckerberg San Francisco General Hospital, who is assisting with reform efforts at Laguna Honda.

Williams testified Wednesday before an oversight committee of the San Francisco Board of Supervisors.

He clarified that there is no evidence of sexual assault or touching, but rather photos taken of nudity. Some patients were also chemically restrained- sometimes drugged for staff convenience using narcotics brought in from outside the facility.

Approximately 25 additional patients were photographed or were visible in the background of photographs that were taken without their consent. Another 75 patients had their names disclosed in recordings, also a privacy violation.

Brent Andrew, spokesman for Zuckerberg San Francisco General Hospital supplied the latest tally in an email, to clarify earlier numbers.

The news of more incidents of abuse comes as city public health officials attempt to institute a number of reforms at Laguna Honda, one of the country’s largest skilled nursing and rehabilitation centers.

The reforms follow revelations made public by Mayor London Breed in June that six, now former, employees allegedly abused 23 patients, including kicking one, having sexual conversations with others, taking nude photos and inappropriately drugging patients.

An investigation by the California Department of Public Health (CDPH) found that deficiencies in the hospital’s medication management, workplace safety and hospital leadership were “primary contributing factors” in patient abuse.

Details of the abuse were obtained by the San Francisco Examiner through a public records request to the CDPH.

City officials have said they initially uncovered evidence of the abuse during an investigation of an unrelated staff complaint.

Williams said he is currently facilitating interviews between the San Francisco Police Department and Laguna Honda residents to assist in the department’s ongoing criminal investigation.

Williams also said his team has been in contact with all the relevant licensing and certification boards because “we don’t feel like those folks [the former employees] should ever work — ever again — in any health care setting.”


Supervisor Norman Yee suggested jail would be an appropriate fate.

As a result of the scandal, Williams revealed the city is already facing two lawsuits. The city has also paid a $780,000 fine and is expected to be hit with more, due to the additional recordings of abuse, according to Williams.

Following the initial revelations, Laguna Honda hospital CEO Mivic Hirose was fired. Margaret Rykowski, the Public Health Department’s chief integrity officer and director of compliance and privacy affairs, is now acting CEO.

However, Williams said the hospital is now in full compliance with state and federal regulations. The CDHP’s report this summer found the hospital out of compliance by failing to protect the privacy rights of patients, to ensure they are free of chemical restraints and to protect them from verbal, physical and mental abuse.

Yee said hospital officials will need to win back the trust of the city’s residents, “who cannot be asked to entrust the care of their 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.”

KQED's Matthew Green contributed to this report.

Editor's note: This story has been edited to correct conflicting information provided by the Department of Public Health about the number of patient abuse cases.

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