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Patient Discharge

Laguna Honda's 12 Transfer Deaths

Culpability for the patient discharge mismanagement extends to the feds as well as LHH

•••••••••• January 26, 2023 ••••••••••

So far, twelve patients are dead shortly after their federally-imposed transfer from Laguna Honda Hospital. Eleven of the twelve patients were severely disabled and had profound cognitive impairment. This cannot be brushed under the rug. The California Department of Public Health (CDPH) investigated the tragic loss of these vulnerable seniors, and the resulting report reveals some concerning clues.

Dr. Tomás Aragón
Dr. Tomás Aragón

On 12/20/22, CDPH released its investigation of 12 deaths among 57 patients transferred out of Laguna Honda Hospital (LHH). These transfers were required as part of LHH's decertification by the federal Centers for Medicare and Medicaid Services (CMS). CDPH records show deficiencies in the care of all 12 deceased patients, resulting in Class B “Patient Care” fines - totaling $36,000.

Chiquita Brooks-LaSure, Administrator
Chiquita Brooks-LaSure,
Administrator, CMS

In a 1/17/23 presentation to the Health Commission, LHH officials stated; ”…in relation to the deaths of residents after transfer from Laguna Honda, CDPH issued 12 “Class B” citations, the lowest level of state citation. CDPH did not find that Laguna Honda caused serious harm or was the direct, proximate cause of any resident's death. We take these citations seriously and submitted plans of correction. And we do not agree with all the allegations and have started the appeal process…”

Patient Characteristics

As shown below, these transferred patients were old, averaging 81 years (range = 63 to 100). Yet the average age of LHH residents has dropped to 64 years since the 2004 Flow Project. Half of the transfers were women although LHH's female population has declined to 37%. Just 1 of the 12 had decision-making capacity. The others were cognitively impaired and mostly represented by Public Guardians or family members. In other words, these patients resembled the “Old Friends” featured in the 1999 campaign to rebuild LHH. They were among “our most vulnerable,” to borrow a favored DPH phrase.

patient chart

Patient ID #




Transfer Trauma Risk

Discharge Survival (days)

Cause of Death


84  F


Non-verbal, feeding tube





95  F







93  F


Wanders, incontinent



Transfer Trauma


71  M


Dementia, depression



Transfer Trauma


100  F


Non-verbal, bedbound





77  M


Dementia, Refuses food





79  M


Bedbound, non-verbal





79  M


Bed to chair, Incontinent



Transfer Trauma


68  F







79  M


“very sick man” emaciated





63  M


Self-caring, on methadone



Drug OD?


87  F


Dementia, schizophrenia



Transfer Trauma

Old Friends Shipped Out

Per an incisive 1/10/23 Press Release from the California Advocates for Nursing Home Reform; “Laguna Honda selected extremely disabled, sick, and dependent residents for eviction, who were known to be at high risk for transfer trauma. Many of the evicted residents had lived at Laguna Honda for years, and had become reliant on the facility environment and its routines. These should have been the last residents to be evicted but instead they went first.”

One must also question the medical ethics of transferring 5 patients who were receiving “Comfort Care” or “Palliative Care.” These derivatives of Hospice Care mean that life-threatening events are managed for comfort rather than rescue. Transferring such vulnerable patients to unfamiliar environments and caregivers is inconsistent with comfort or quality of life.

quote marks

Laguna Honda selected extremely disabled, sick, and dependent residents for eviction, who were known to be at high risk for transfer trauma. Many of the evicted residents had lived at Laguna Honda for years, and had become reliant on the facility environment and its routines. These should have been the last residents to be evicted but instead they went first.”

Causes of Transfer-Related Deaths

The CDPH reports focus on “transfer trauma,” the adverse psychological and medical effects of transferring frail, cognitively impaired patients from a familiar setting to a different location with unfamiliar staff. Research shows that up to 44% of patients who moved from one nursing home to another experience some degree of transfer trauma. Fatalities can occur. But the number of LHH transfer-associated deaths was alarming.

Over 33 days, 12 of 57 (21%) transferred patients died. In comparison, last year LHH averaged 7 deaths/month (range = 2 to 14 deaths/month). The interval between transfer and death averaged 28 days (range = 10 to 67 days).

Both LHH and the regulatory agencies were aware of this transfer risk. LHH's “Closure and Patient Transfer and Relocation Plan,” approved by CMS and CDPH in May 2022, aimed to “minimize resident transfer trauma” through “a patient-focused discharge process.” That means individualized assessments and support. Well, LHH caregivers determined that 8 of the 12 patients were at “high risk” for transfer trauma. Unfortunately, their Transfer Trauma Care Plans were generic and often absurdly inappropriate, ignored or even absent. Per CDPH, these deficiencies raised the risk of transfer trauma.

However, other factors contributed to these transfer-related deaths;

  1. Patient condition and prognosis
  2. Quality of discharge planning by LHH
  3. Quality of care at receiving facilities
  4. Regulatory pressure to evacuate patients from LHH

The CDPH reports focus on point #2 – LHH's discharge plans and procedures - especially transfer trauma risk assessments. As for point #1, there is scant data on causes of death. Given the patients' ages, medical problems and poor prognoses, their deaths weren't completely unexpected. The reports do not assess item #3, the care at the receiving facilities - some of which have major shortcomings. Predictably, there's no mention of the draconian pressures imposed on LHH by CDPH and CMS. That may explain why CDPH issued lesser Class B citations with $3,000 fines, rather than AA citations with $100,000 penalties.

That being said, the available information suggests that at least 4 patients (#24, #17, #7, #21) likely died from transfer trauma. However, at least 4 patients (#38, #31, #2, #53) likely died from underlying or new illnesses. For example, patient #31 succumbed to COVID, patient #53 died in a Navigation Center toilet, perhaps from a drug overdose, and 2 others seemed medically unstable at discharge. For the remaining 4 patients, the role of relocation stress is unclear. The problem with diagnosing transfer trauma is that illnesses like infections, heart failure, stroke, etc. can produce similar symptoms.

Befuddled Discharge Planning

Roland Pickens and Mayor London Breed
LHH Interim Director Roland Pickens
and Mayor London Breed

Standard practice in Skilled Nursing Facilities is to develop an “individualized” Care Plan for each patient. Every involved discipline contributes to these Care Plans. Nursing is responsible for ensuring the Care Plans are complete and updated. As part of LHH's approved Closure Plan, staff also had to develop Discharge Plans with Transfer Trauma Plans for all residents. Social Workers are responsible for coordinating Discharge Plans.

There's a technical distinction between a Discharge Plan and a Transfer Plan. A discharge generally means moving to the community or another facility - when the patient is not expected to return. A transfer implies a temporary move where the patient is expected to return. All 12 patients were “transferred.” But LHH Social Workers used a Discharge Plan template instead of a Transfer Plan template. Per the CDPH report, they; “used a template meant for patients to be discharged to the community and not to another skilled nursing facility or to the same level of care.”

Many of these 12 patients had previously been designated as “Not Ready for Discharge,” meaning they weren't suitable for community placement. Technically, social workers should not have used a discharge template for these transfers. Why didn't they formulate a specific Transfer Plan template? “This is a new process for us,” one told CDPH inspectors. Because a Discharge Plan applies to patients who are stable for community living, it doesn't require a transfer trauma assessment. By using the discharge template for transfers, Transfer Trauma Plans were sometimes incomplete. As one State inspector recounted, the distinction between discharges and transfers; “was not clear to facility staff, complicating the pre-discharge patient assessments. This lack of staff training led to the failure in properly assessing (patients) prior to transfer to another SNF facility.”

Customarily, when patients are transferred to another facility, the physician, nurse and social worker contact their counterparts at the receiving facility to brief them on the patients' care needs. The process is called a “hand-off.” In 2 cases, LHH physicians neglected to conduct a handoff. Another 2 cases failed to document nursing handoffs. Such lapses can impede safe transitions and continuity of care.

CANHR press release

Patient transfers were also compromised by LHH dashing to abide by an unreasonable evacuation timeline. As noted previously, 2 patients seemed medically unstable. Another, patient #31, a 68-year-old, non-verbal female was sent to a nursing home undergoing a COVID outbreak. LHH learned of this outbreak a day before the transfer. She died from COVID 11 days later.

As CANHR's Press Release aptly noted: “Laguna Honda's doctors and nurses failed to provide the kind of follow-up care that may have minimized transfer trauma. Once the residents were out of sight, they were out of mind.”

Cookie-Cutter Transfer Trauma Plans

The CDPH found deficiencies in virtually all Transfer Trauma Care Plans for the 12 transferred patients. In fact, the transfer trauma risk assessment templates were identical for vastly different patients. That is, “a pre-populated Care Plan for all residents” as one LHH Nurse Manager admitted to CDPH inspectors. Another nurse confessed; “There's no template specific to transfer trauma.”
Moreover, since these pre-packaged Transfer Trauma Care Plans were irrelevant for severely demented patients, some LHH nurses ignored their own written plans – a regulatory deficiency. For example, several of the patients were non-verbal and barely responsive. Bizarrely, their Transfer Trauma Care Plans included gems like; “Encourage verbalization of feelings/concerns/expectations,” “Encourage patient to set small goals for self” and “Reinforce positive adaptation of new coping behaviors.” Such cookie-cutter plans violated LHH's own policies as well as State and federal regulations requiring “patient-centered” care.

Who's to Blame?

Everyone contributed to this debacle - except the patients. It all began when LHH received citations for 2 near-fatal drug overdoses and uncontrolled drug and contraband use in October 2021. LHH vowed to fix these problems within 6 months. When CDPH inspectors returned, the drug-related problems had worsened! Now, LHH has bungled individualized Care Plans – a deficiency that previously drew citations and contributed to LHH's decertification. This recidivism raises doubts about LHH leadership's understanding of long-term care and its regulations.

CMS and CDPH imposed unrealistic requirements on LHH. When LHH asked for 18 months to evacuate its patients, CMS insisted on a 4-month timeline. That proved unworkable and catastrophic for a 700-bed safety-net facility. There is regulatory culpability for LHH's transfer stampede.

As the Westside Observerpreviously noted, physicians are legally responsible for discharging patients from hospitals. Granted, they were pressured by regulators and LHH administrators to get patients out. Still, physicians are ethically obligated to place patient welfare above other considerations. LHH has a Medical Ethics Committee. It should review how its doctors justified these transfers.

Dr. Derek Kerr is a San Francisco investigative reporter for the Westside Observer and a member of SPJ-NorCal. Contact:

January 26, 2023

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