Supervisors press DPH and hospital leaders after revelations of resident abuse at Laguna Honda

Board President Norman Yee opened a public hearing Oct. 23 to review Laguna Honda Hospital’s reform plan after allegations that staff abused and recorded residents over a period stretching from 2016 into 2019.

"There is no excuse for what transpired," Yee told the Government Audit and Oversight Committee, and asked the Department of Public Health to explain the status of corrective actions and any active state or local investigations. He said families deserved to know what the hospital had done to ensure patient safety and to prevent future abuse.

Maggie Rykowski introduced Troy Williams, chief quality officer for Zuckerberg San Francisco General Hospital and Laguna Honda, who described the investigation and corrective work. Williams said the California Department of Public Health (CDPH) issued a plan of correction (a 2567 statement of deficiencies) and validated the hospital’s monitoring plan. He said Laguna Honda was found in regulatory compliance on Oct. 15, but CDPH would continue oversight and additional visits.

Williams described results of forensic analysis of staff cell phones that produced additional photos and videos reported to CDPH through mid‑August. He said the original count of 23 residents involved in early reports expanded to roughly 130 residents as additional images were reviewed. Of the original 23, Williams said 19 were substantiated as privacy breaches, seven as physical or psychological abuse, and five as involving use of chemical restraints; Williams added there was no evidence of sexual assault.

Williams confirmed an ongoing criminal investigation and said the San Francisco Police Department was coordinating interviews of residents. He said licensing and certification boards were also investigating; the hospital removed the employees involved and said those workers would no longer be employed by the city. Williams could not confirm whether separation terms affected pension access and offered to follow up with HR on that point.

On corrective actions, Williams outlined measures to strengthen the culture of safety and quality management: increased frontline engagement by leadership, regular safety culture surveys, recruitment of a permanent chief executive and a quality management director, a medication diversion prevention committee, increased medication pass audits, and a protocol that triggers urine toxicology screening if a resident shows signs of altered mental status or respiratory change.

During public comment, Dr. Derek Kerr, who identified himself as a former Laguna Honda physician and a whistleblower, said five patients were drugged with pilfered medications leading to life‑threatening overdoses and emergency transfers and asked why standard medical‑quality reviews failed to detect the problem earlier. Troy Williams acknowledged the hospital’s earlier internal and forensic reviews and confirmed cooperation with criminal and licensing investigations.

Cadell Child, a San Francisco ombudsman assigned to Laguna Honda units, urged a larger ombudsman presence and said residents were often reluctant to report concerns because of dependence on staff.

Presenters said the hospital paid a $780,000 fine that was assessed as part of the CDPH process and warned more fines could follow related to privacy breaches. Committee members pressed for ongoing oversight: presenters said Laguna Honda and Zuckerberg San Francisco General are part of the San Francisco Health Network, report to the network director and to DPH Director Grant Colfax, and that health commissioners and a joint committee will receive regular monitoring reports.

The committee accepted the presentation, heard public comment, and filed the hearing. Members said they would continue close monitoring until corrective measures are fully implemented and investigations are complete.