The 75-year-old woman who left a care center on the grounds of San Francisco General Hospital alone and was found dead nearby days later was in such frail medical and mental condition that she was supposed to be escorted on appointments, an NBC Bay Area review of newly disclosed medical records shows.
Ruby Lee Andersen left the Residential Care Center for the Elderly, located on the grounds of the hospital, at about 9 a.m. on May 19, according to the care center log the city recently gave to the family's attorney. On May 30, her body was found in a stairwell of a hospital engineering building just a few hundred feet away from the center.
“I think it’s outrageous,” said the family attorney, Haig Harris, about what he uncovered in more than 1,700 pages of medical and care facility records in the Andersen case.
“They did not provide her the care that’s required by law,” Harris said in an interview with NBC Bay Area. “They let her leave and they did nothing to really try to find her.”
Via a source, NBC Bay Area separately obtained the sheriff’s missing persons report that was filed more than 24 hours after Andersen did not return.
It shows that deputies alerted the jail, medical examiner and hospital to watch out for Andersen on the day it was filed. But no one actively searched for her.
Sheriff’s officials said early on that there was no search of the hospital grounds because Andersen was not actually a patient of the hospital. As a resident of the unlocked care center, they said, she could come and go as she pleased.
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But the missing persons report quotes a member of the center's staff referring to Andersen as a “patient” who was given unspecified medications the day she disappeared.
Her medical records show that Andersen had suffered a stroke last year, was taking insulin for Type-2 diabetes and was deemed at risk for falling. She had severe hearing loss as well, according to the records Harris provided for our review.
“She is in obvious decline and confused,” her private primary care doctor concluded in an assessment in January.
He suspected dementia at the time. He wanted her moved to a skilled nursing facility, citing her deteriorating medical condition as well as her worsening confusion, signs of paranoia and auditory hallucinations.
Despite the doctor’s finding, Andersen remained at the city run care center, where in April, a staff assessment called for her to be escorted to appointments.
“Clinician to provide case management as needed and escort to appointments when peers are unable to do so,” the assessment indicated.
But the actual sign-out sheet confirms that she left at 9 a.m. on May 19, without an escort, apparently to look for a battery, possibly for her hearing aid.
The log entry shows Andersen planned to be back in two hours.
Despite her age and condition, it took more than 24 hours for the staff at the center to file a missing persons report . Yet that report did not mention any health concerns or any restrictions on her being able to leave.
“It’s very shocking to me,” Harris said after being shown the report by NBC Bay Area. “They all knew she was an at risk patient – it’s in her records.”
The city’s Department of Public Health said in a statement that the family had requested that the department not discuss the case. But they say they improved security in the stairwell where she was found and are assessing efforts hospital-wide.
“We extend our sincere condolences to Ms. Andersen’s family and loved ones. Her family has requested that we not talk about Ms. Andersen publicly, and we will abide by their request.
"Our top priority is the safety of all people on our campus, who receive services, work or visit there. In May, we immediately improved security at the power plant. Since then we have reviewed our annual comprehensive assessment of our 23-acre campus, and conducted an updated assessment of all campus buildings and grounds, to ensure the safety of all staff, patients and visitors. We continue to work with the San Francisco Sheriff Department to address safety and security issues on campus.”
The sheriff’s department said they were unable to learn the full details of Andersen’s condition because of medical privacy laws. But they say they should have nonetheless searched for Andersen based on her age alone.
However, they say that such a search would not have normally covered the non-public area where Andersen was ultimately found.
The sheriff's department explained the deputy who wrote the report "misidentified Ms. Andersen as a patient."
Given that Andersen was missing from the "unlocked residential facility that allows its patient to come and go as they please," as detailed in the report, "our staff understood that she was not an in-patient," according to the sheriff's statement.
The department immediately called various agencies and alerted her family and, after her family called back, issued a "be on the lookout" flier that was circulated around the hospital campus.
But the department acknowledged that more should have been done.
"Ms. Andersen’s condition and medications were HIPAA-protected and were not shared with SFSD at the time of her disappearance. Due to her age, SFSD should have identified Ms. Anderson as high-risk. We are reviewing our protocols and training to ensure this does not happen again. At the same time, labeling Ms. Andersen as high-risk would not have facilitated a search of" the building she was ultimately found.
The engineering building where Andersen was found, the department said, "is not open to the public including residents and/or patients and is not part of either search protocol as per our agreement with the Department of Public Health."
"SFSD is working with the Department of Public Health to review and update our search protocols and staffing agreement," the statement continued. "We have assigned a full-time investigator from our Criminal Investigative Unit to manage missing persons cases at Department of Public Health facilities."
Harris said the state agency that oversees care centers, the Community Care Licensing Division, has sought access to medical records in the case. The agency is investigating whether the city run center met care standards for someone with dementia.
“That level of care obviously wasn’t given,” Harris said. “You can’t let a person with dementia leave on her own, when she’s not going to remember where to come back to.”
Meanwhile, Harris said Andersen’s grief stricken family is still grappling with what happened and has questions about what happened after she left the center.
“They’re devastated,” he said, “ They are devastated more with the fact with what happened after they learned mother had disappeared in not being able to get any answers from anybody about what are you doing to find her.”
