Since being transferred to a new hospital, half of the patients from the shuttered critical care unit at St. Luke’s Hospital have died in the past year — a mortality rate that has garnered the attention of the San Francisco Board of Supervisors. 

A Thursday hearing was called by Supervisor Ahsha Safai, who had been contacted by family members of patients at the sub-acute skilled nursing facility, a critical care unit for the extremely ill. Many of the patients are on tracheostomies or machines intended to provide additional life support and require 24-hour care. 

Seventeen such patients were transferred last year from St. Luke’s to a new facility at California Pacific Medical Center Davies campus after Sutter Health bowed to public pressure after initially attempting to close the unit and transfer the patients to other counties.

Since then, eight of the patients have died. The patients’ families fault Sutter Health for providing subpar care.

During the two-and-a-half-hour hearing, Safai invited representatives from the city’s Department of Public Health and the patients’ family members to speak, as well as a representative from Sutter Health. 

This meeting was not without its share of high emotion. Gloria Rivera, whose sister has been a patient for years, said that the level of neglect at CPMC Davies is high and nurses will often only come in to check on patients once every couple of hours.

She explained that when the patients were at St. Luke’s, the unit had dedicated, full-time staff that cared for the patients around the clock. They even had an activities coordinator who was let go after the patients moved to Davies. But since arriving at the new facility, she complained, Sutter Health has only hired temporary employees to care for the remaining patients. 

Rivera additionally charged that Sutter Health had surreptitiously tried to make arrangements to transfer her sister, who is mentally disabled, to a group home — and that she only found out once the group home facility called her to confirm details.

“How do you explain eight deaths in a year soon after going to a new facility?” asked Rivera. Then she answered her own question: “CPMC is working diligently to get rid of these sick patients whether by transfer, sent home or by death.”

After public comment, Jim Macksood, the Vice President of External Affairs at Sutter Health took questions from the supervisors. 

Safai said that, during a recent visit to the facility, he saw a white board marked with red X’s next to the names of patients who had died. Safai said he had been taken aback by the experience, and grilled Macksood about it.

“It seemed like a countdown. I was stunned by it. Is that a practice you normally have in your facilities?” Safai said. 

Macksood denied knowing anything about this. 

The Rivera family. Photo by Abraham Rodriguez.

When he was asked about staffing issues at the sub-acute unit, Macksood said that every time the number of patients changes, the hospital is mandated to adjust the worker-to-patient ratio. With only eight patients remaining, the hospital has only two registered nurses and three personal care assistants. 

“We’ve consistently been in compliance with that. The staff that are in the unit are all trained and qualified to treat the most sensitive and fragile patient populations,” Macksood said.

Supervisor Hillary Ronen said that didn’t jibe with her personal experiences. She recalled that during a visit to the site last month, a patient’s alarm system began to beep loudly. In a panic, she and family members scoured the entire floor in search of someone to assist the patient — but the only employee present was a rehabilitation specialist who did not know how to turn off the alarm. 

Rivera, who was there with Ronen, said that patient died a few weeks later.

“There were not two patient care assistants and three nurses there. I can guarantee it. I walked the small halls. We couldn’t even find a staffer to ask what was going on,” Ronen declared.

Macksood tried to maintain composure even as Ronen insisted that his claims of five people giving care 24 hours a day was not what she saw. He was, at times, visibly uncomfortable during the hearing; he invited the supervisors to visit the unit again. 

Safai issued similar complaints, saying that during his visit, he had never seen any of the five hospital staff that were supposedly present.

Before adjourning, the supervisors said there needs to be a grander “conversation” about creating more subacute beds and asked Sutter Health to be part of the solution. The board will be reconvening in November to put together a bigger plan to add as many as 80 beds to the city’s stock of subacute facilities.

The care facility at St. Luke’s was the last sub-acute skilled nursing facility in the entire city. It closed down in August 2018 and the hospital transferred the remaining 17 patients to CPMC Davies that month. 

At the end of the hearing, Rivera and her family smiled and hugged each other along with other families. After taking a photo with Safai along with her family, Rivera looked elated. 

“If we get a permanent place then they have to keep adequate staff all the time,” she said.