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State Investigation Finds Several Laguna Honda Residents Nearly Drugged to Death


When San Francisco City and County officials held a press conference on June 28, 2019 to address an abuse scandal at Laguna Honda, they described acts of its employees as horrific. They reported that a group of six employees abused 23 residents over a period of years, subjecting them to verbal and physical abuse, sexual harassment, drugging, humiliation and neglect. But they gave few details while assuring the public that residents were now safe.

The extreme nature of the abuse is now coming to light. On September 6, 2019, the San Francisco Examiner published a story describing findings of a California Department of Public Health investigation (CDPH) on the abuse scandal with a link to the state’s investigation report dated July 12, 2019.

Its most startling finding is that a licensed nurse and certified nursing assistant (CNA) intentionally gave powerful non-prescribed drugs to chemically restrain at least five residents throughout 2018 and early 2019, and perhaps longer. Laguna Honda’s Director of Pharmacy told investigators that the nurse had a bag of drugs that he likely withheld from other residents at Laguna Honda and he used these drugs to sedate residents under his and the CNA’s care. Evidence included a picture of the bag of drugs the nurse had texted to the CNA and multiple text exchanges about residents they were drugging. Among the drugs in the bag were Morphine, Clonazepam and Oxycodone and a syringe of Methadone Liquid Suspension.

One of the drugged residents died on September 12, 2018. Weekly urine toxicology screens showed that he had dangerous drugs in his system – including Methadone, Morphine and Oxycodone – at least 8 different times in 2018 and twice in the month before his death. None of these drugs had been prescribed for him.

Four other residents were hospitalized one or more times due to life threatening conditions including respiratory failure and altered mental status between February 13, 2018 and January 8, 2019. Each hospitalized resident tested positive for opioids or psychoactive drugs that were not prescribed for them. The drugs included Morphine, Methadone, Oxycodone, Quetapine, Tramadol, Gabapentin, Mirtazapine and unspecified benzodiazepines.

The CDPH report describes hospital doctors raising alarms with Laguna Honda about the overdoses of non-prescribed opioids and psychoactive medications as early as February 2018. In January 2019, UCSF Medical Center took extraordinary measures to protect one of the drugged residents. His hospital doctor told an investigator that the resident “could have died” from the opioid intoxication, that she had heard of several similar incidences at Laguna Honda, and that she kept the resident at the hospital for one week because she did not want to send him to his death.

Even after the June 28 press conference, residents were not safe. According to the 61-page investigation report, on July 11, 2019 CDPH made four separate immediate jeopardy findings, declaring that Laguna Honda’s failure to protect 21 residents from physical, mental, verbal, and sexual abuse, and chemical and physical restraints, put residents at risk of serious harm. Nineteen residents were photographed without their consent, three of them while they were naked. Four residents were sexually abused, another was demeaned and provoked to make sexually explicit statements. One of them was kicked by a staff member. And one resident was mentally and physically abused when a towel was tied over her mouth as a restraint.

Laguna Honda submitted a 35-page plan of correction to CDPH. CDPH lifted the immediate jeopardy declaration on July 12, 2019 but it has yet to post its findings. The Examiner reports it obtained the CDPH findings through a public record act request.

Despite the CDPH findings, the abuse scandal at Laguna Honda remains shrouded in secrecy and many key questions remain. Who are the perpetrators and what is being done to bring them to justice? What is the police department doing? Is its investigation compromised by a conflict of interest? Why hasn’t the State Attorney General’s Elder Abuse Unit filed charges against the perpetrators? How could such horrific abuse go on so long without detection and response? When was the drugging first detected, reported and investigated? And why hasn’t the California Department of Public Health denounced the abuse and publicly released its findings?