Press Release - Laguna Honda Patient Care

Health Department Announces

Patient Care Incidents at Laguna Honda Hospital

Evidence disclosed of patient mistreatment by staff over a several-year period

Immediate changes in place



Brent Andrew
San Francisco Department of Public Health


SAN FRANCISCO (June 28, 2019)

The San Francisco Department of Public Health (DPH) announced today that it has uncovered evidence of patient mistreatment by staff of Laguna Honda Hospital (LHH), and has taken immediate steps to assure patient safety, hold staff accountable and make changes to improve patient care.


In February 2019, as part of an investigation into an employee HR complaint, evidence of patient privacy violations was obtained. In response, DPH, in addition to conducting its own quality review, asked the City Attorney’s office to conduct an HR investigation.  Interviews of LHH staff and leadership were conducted, revealing evidence of policy violations and patient abuse. In addition, the California Department of Public Health was notified and is conducting its own independent investigation.

DPH uncovered evidence that twenty-three residents were subjected to privacy violations and abuse in the form of photo and video recordings made and exchanged via text message by staff without patient consent between 2016 and early 2019.  Other misconduct, primarily in 2017 and 2018, was also discovered.  The misconduct discovered includes: verbal and physical abuse of residents; sexualized conversations with residents; neglect; privacy violations; failure to report violations; medication errors; and a pattern of inappropriate administration of non-prescribed substances to some residents in an attempt to sedate them. Six staff members were found to have engaged in some part of these types of misconduct and are no longer employed by the Health Department.

“What has recently come to light is so profoundly hurtful, offensive, and heartbreaking for so many of us who care deeply about this hospital,” said San Francisco Mayor London Breed. “I appreciate that the Department of Public Health, under the leadership of Dr. Grant Colfax, took swift action to investigate these allegations and hold staff responsible for their horrific actions, including the leadership charged with overseeing the Hospital.”

Laguna Honda CEO Mivic Hirose and the LHH Director of Quality Management have been removed from their positions. Margaret A. Rykowski, DPH Chief Integrity Officer and Director of the Office of Compliance and Privacy Affairs, is now Acting CEO. The Laguna Honda Quality Department will be overseen by Troy Williams, Zuckerberg San Francisco General Hospital Director of Quality, while improvements are made.

Steps Taken Immediately

“The San Francisco Department of Public Health and Laguna Honda Hospital have no tolerance for the mistreatment of residents,” said Dr. Grant Colfax, San Francisco Director of Health. “In response to our findings, we have immediately taken steps to ensure patient wellness and safety.”

These steps include:

  •  Removed the Chief Executive Officer and Chief Quality Officer of Laguna Honda Hospital
  •  Notified all impacted patients and their decision makers or conservators
  •  Conducted thorough wellness checks for all impacted patients
  •  Informed all relevant regulatory and law enforcement agencies
  •  Retrained staff in prevention and reporting of patient abuse
  •  Improved drug dispensing and testing practices

Moving Forward

Margaret A. Rykowski, Acting CEO of LHH, will lead the hospital’s patient care and safety improvement efforts on a daily basis. Additionally, the Health Department will undertake a turnaround plan for Laguna Honda, informed by external experts in long term care, working in partnership with Health Department leaders.

Rykowski has worked for the San Francisco Department of Public Health since 1994 and currently serves as the Department’s Chief Integrity Officer and Director of the Office of Compliance and Privacy Affairs. In addition to her work with DPH, Rykowski served in the United States Navy Reserve from 1986 – 2013, holding leadership positions within Navy Medicine throughout 26 years of Naval Service.  She retired in 2013 with the rank of Rear Admiral.

Anyone with concerns about patient care or staff conduct is encouraged to call the confidential DPH Compliance Hotline at 855-729-6040.

Public Announcement Details

Friday, June 28, 2019, at 12:15pm

City Hall, room 200

Mayor London Breed, Dr. Grant Colfax, Director of Health, Roland Pickens, SFHN Director, Maggie Rykowski, Acting CEO, LHH

About the San Francisco Department of Public Health

The mission of the San Francisco Department of Public Health (DPH) is to protect and promote the health and well-being of all in San Francisco. DPH is an integrated health department with two primary roles and two major divisions to fulfill its mission: Protecting the health of the population, which is the primary responsibility of the Population Health Division; and promoting the health of our patients, which is the primary responsibility of the San Francisco Health Network.

About Laguna Honda Hospital

Laguna Honda is a skilled nursing and rehabilitation center owned and operated by the San Francisco Department of Public Health. Located on a 62-acre campus in the heart of the city, Laguna Honda is one of the largest skilled nursing facilities in the United States, and represents the one of the most extensive commitments by any city or county to therapeutic care for seniors and adults with disabilities. It was founded in 1866 to care for one of the first generations of San Franciscans, the Gold Rush pioneers. A century and a half later, it remains a civic icon representing San Francisco’s tradition of service to the underserved.