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Patient Safety Endangered by Cultural Wall of Silence
LHH Leadership Fingered in Patient Abuse Scandal

by Patrick Monette-Shaw

Here we are six months after first learning from Mayor London Breed on June 28, 2019 about the outrageous abuse of 23 patients at Laguna Honda Hospital (LHH) dating back to 2016.  We’re no closer to getting answers about key questions because the scandal remains shrouded in secrecy and remains an on-going State investigation.

On October 23, LHH’s leadership was finally fingered during a Board of Supervisors Government Audit and Oversight (GAO) hearing as having been a primary contributor to the patient abuse, and failure to report the abuse. 

Pull Quote 1Ironically, also on October 23, the Centers for Medicare and Medicaid Services (CMS) rolled out its new warning icon on its Nursing Home Compare website to alert consumers about long-term care facilities at which patient abuse had been uncovered.  LHH was promptly hit with the new icon by CMS somewhere between October 23 and November 30, 2019.  Thanks, “leaders”!

CMS initially assigned the abuse icon to 56 (4.7%) of California’s 1,193 CMS-certified nuring facilities.  That’s not good company for LHH — or LHH’s patients — to be in.

A culture of patient safety is particularly vulnerable to fatality if it collides with a culture of silence speeding out of control, careening throughout a hospital for over a decade-and-a-half.  The heart of the problem involves polar opposite cultures.

CMS Warning IllustrationToss in the nonsensical word-salad pabulum from Health Commissioner Dr. Ed Chow about a totally unrelated problem involving cultural humility, and you know there’s a real problem of culture and a likelihood the conspiracy of silence will prevail.  Some observers believe the problems at LHH definitely involved a conspiracy of silence across multiple departments, including its Nursing Department and its Medical Services Department.

On November 19, Supervisor Norman Yee was reported to have asked, “What the heck are we waiting for?” in an unrelated issue involving delays implementing safety measures to prevent injuries and deaths of pedestrians and bicyclists involved in traffic crashes.

When it comes to investigations into patient abuse and patient safety at Laguna Honda Hospital (LHH) announced over six months ago, I have my own questions for Yee:  “What the heck is taking so long to implement a culture of patient safety at LHH?  What were you waiting for?  The red-hand CMS warning icon?

Pull Quote 2Patient Abuse Scandal Erupts

San Franciscans first learned of the staff abuse of LHH patients in a San Francisco Examiner article on June 28 reporting a press conference Mayor London Breed held with Supervisor Norman Yee and the new Director of Public Health (DPH), Dr. Grant Colfax to announce the scandal.  During the press conference, Dr. Colfax claimed he was concerned about the culture of silence that allowed the patient abuse to have gone unreported and continued for so long.

The Examiner article reported LHH’s CEO, Mivic Hirose, had stepped down and that LHH’s Director of Quality Management (DQM) had also been “removed.”  DPH refused to name the DQM, claiming it was a personnel matter.  That’s preposterous.

First, Googling “Who is the director of quality management at LHH” returns information and Health Commission public records showing that Regina Gomez was LHH’s DQM.  Googling “Regina Gomez San Francisco” returns a link that takes you to her LinkedIn profile that lists she had been LHH’s DQM.  Her full LinkedIn profile appears to have recently been taken down and only a snippet of it remains on-line.  Meeting minutes of the Health Commission’s Joint Conference Committee with LHH’s leadership team show Gomez frequently presented Quality Management reports during LHH-JCC meetings.

Second, public employees typically do not have “employee privacy rights.”  Facilities must disclose basic information about city employee salaries and work locations, although their disciplinary records may not be subject to disclosure (now, only police officer disciplinary records must be disclosed, at least in part).

Initial reporting claimed just 23 patients had allegedly been abused over the past three years dating back to 2016.  Breed indicated the abuse was uncovered in February 2019 only because of a DPH investigation into an unrelated sexual harassment complaint filed by an LHH employee and stumbled across the potential evidence of patient abuse.  The City Attorney’s Office assisted in DPH’s investigation.  The initial article indicated that both the California Department of Public Health (CDPH) and the SFPD Special Victims Unit were also conducting investigations.

Remarkably, Dr. Colfax stated during the press conference “We immediately started an internal investigation and found evidence to substantiate our initial suspicion.”  It was a stupid thing for Colfax to have said, because we later learned that a doctor at an external acute care hospital had e-mailed LHH’s Medical Director, Dr. Michael Mcshane, as far back as February 26, 2018 about an LHH patient who had stopped breathing and was transported to an acute care hospital on February 13, 2018 with life-threatening problems related to an overdose of opioids she had not been prescribed. 

Pull Quote 3Mcshane replied to the UCSF doctor that an internal investigation into the case was underway.  Nine months later, the same patient was again transferred on October 26, 2018 to an acute care hospital because of mental status changes as a result of other medications which had also not been prescribed.  A second LHH patient who had also stopped breathing and had respiratory arrest was transported to an acute care hospital on January 8, 2018.  A different acute hospital doctor had been told LHH’s staff was investigating the second case.  So, Colfax should have known that rather than starting an investigation in February 2019, LHH had purportedly been investigating for over a year.  Colfax should also have known that a third patient wrongly administered opioids he had not been prescribed died on September 2, 2018.

An on-line comment posted to the Examiner’s June 28 article was submitted by Dr. Maria Rivero, a former LHH doctor.  Rivero wrote:

Anyone who spoke out about patient concerns under Hirose lost their jobs; that was well known to the entire DPH.  Disgraced administrators should lose their Fat City Pensions.  That is the best deterrent to this type of problem.”

The issue of pensions resurfaced in late October, discussed further, below.

Additional Media Coverage

Following the Examiner’s initial June 28 article, a number of consecutive media reports surfaced:

Pull Quote 7“Class AA” Violations

Long-term care skilled nursing facilities risk losing their licenses if they receive a second, subsequent “Class AA” citation that has been sustained within a 24-month period following a citation review conference and following receipt of a first “Class AA” citation.

“Class AA” citations and fines result from abuse or neglect violations that CDPH “determined to have been a direct proximate cause of death of a patient or resident of a long term care facility.”

Some observers wonder whether the patient abuse went unreported to CDPH because LHH was then under a two-year period during which it could lose its license completely if it received a second “Class AA” citation from CDPH.

Pull Quote 8LHH had received a “Class AA” citation and a $100,000 fine on December 23, 2016.  As early as November 2, 2017 — within the first year — one of the five patients who had been drugged tested positive for Methadone he hadn’t been prescribed.  He was drugged eight additional times with different opioids through August 2018.  He died on September 2, 2018 while the two-year period for the 2016 “Class AA” citation was still in effect.  It’s probable LHH may end up receiving another “Class AA” citation for his death thanks, in part, to Hirose’s “leadership.”

It should be noted City Attorney Dennis Herrera filed a Superior Court lawsuit against CDPH on April 13, 2017 seeking to have the December 2016 “Class AA” citation dismissed and the $100,000 fine eliminated, arguing CDPH was “untimely” by having issued the citation five months after coimpleting its 2016 facility survey, rather than issuing the citation within 30 days.  That’s just more hogwash!  It took until January 22, 2019 before a Court filing announced a proposed settlement had been reached to reduce the citation to a “Class A” citation (one “A,” instead of two) but kept the $100,000 fine. The proposed settlement was contingent on approval by the Health Commission, Board of Supervisors, and the Mayor.

Pull Quote 36After the Health Commission approved the settlement, it then took the Board of Supervisors until November 5, 2019 to pass an Ordinance on second reading agreeing to pay the $100,000 fine, and ostensibly approve the settlement.  It’s not known on what date Mayor Breed may have approved the settlement.

As late as December 3, 2019 the City Attorney’s Office claims it still cannot disclose the dollar amount of city attorney time and expenses incurred in the lawsuit against CDPH during the two-and-a-half years since Herrera filed it in April 2017, because the matter isn’t fully closed:

Unfortunately, we cannot provide the requested information at this time because the matter is not yet closed.  Having Board of Supervisor authorization to settle a case does not necessarily conclude everything to the point that a matter can be closed.  You may check back toward the beginning of the new year to see if the closing process is finished by that point; however, we cannot make any predictions or guarantees.  Until the matter, is closed, the requested information is exempt as attorney work product.”

Pull Quote 9Because the lawsuit isn’t “officially” fully closed, it’s not clear on what date, if any, CDPH’s two-year period for “Class AA” violations may have stopped, or whether CDPH’s two-year clock had remained ticking at the time Patient 11 died in September 2018.  Thanks, Mivic!

Sadly, it’s not known how soon CDPH will conclude its investigation of LHH and whether it will issue, yet again, another “Class AA” ruling and accompanying State fine.  The California Advocates for Nursing Home Reform (CANHR) reported on October 24 that CDPH has an enormous backlog of open complaints and facility reports of abuse — over 17,000 cases — some of which were reported years ago.

In the movie Queen of Outer Space (1958), Zsa Zsa Gabor wryly opined, “soufflé is for people without teeth.”  When it comes to rapid and timely investigations of abuse in California nursing homes, CDPH appears to be eating soufflé, having no teeth!

Pull Quote 10Fines and Penalties Against LHH

On September 3, the federal Centers for Medicare and Medicaid Services (CMS) imposed a $1 million fine against LHH for the 156 days between February 6 and July 11, 2019 during which patient’s health and safety were in immediate jeopardy.  Since 2007, LHH has been fined at least $1.5 million, but has only had to pay $1 million because it received a handful of 35% discounts by waiving its rights and not contesting the determinations and fines.  The fines are expected to soar significantly higher.

Table 1:  Fines and Penalties LHH Has Paid to CMS and CDPH

Table 1

It may take several years before any of the blank lines in Table 1 become known.

Pull Quote 11What this suggests is that although there were fines imposed for patients wrongly administered opioid-level meds they had not been prescribed, no fines may have been imposed for other patients who were prescribed meds that they may never have received.  Again, not to put too fine a point on this, harm was caused to both patients drugged without orders, and more harm was caused to patients who may not have received their pain control meds.  Didn’t Hirose — or CDPH, SFDPH, the Health Commission, or the Board of Supervisors — notice this glaring problem?

In addition to the $1 million in fines actually paid out, lawsuits filed by at least two LHH employees since 2010 have resulted in nearly $1.5 million in additional costs to LHH and DPH.  Between the lawsuit filed by Cheryl Austin and the wrongful termination lawsuit filed by Dr. Derek Kerr, LHH had to pay out a little over $1 million in settlements to the two employees, plus another $468,585 in City Attorney time and expenses trying to stop their lawsuits, for a total of $1,487,037.  LHH’s former CEO, John Kanaley, was responsible for Austin’s racial discrimination and retaliation lawsuit, and Hirose was principally responsible for Kerr’s wrongful termination and whistleblowing lawsuit.

Between the $1.5 million in full fines assessed, and the $1.5 million in employee lawsuit costs, we’re up to at least $3 million in “leadership” problems at LHH.  That $3 million is probably far higher.  What took so long to sack Hirose?  Didn’t the Health Commission, or the Board of Supervisors, or the Director of Public Health notice the increasing costs under her problematic “leadership”?

The Patients Abused

Although Breed initially claimed 23 patients were involved in the abuse, DPH eventually admitted 130 patients had been affected in different ways in violation of state and federal law.  LHH admitted on October 25 that 30 patients had been abused by “chemical restraint” (drugging), sexual-related abuse, and physical or verbal abuse.  Another 25 patients had been photographed or were visible in photographs, which amounted to privacy violations.  Another 75 patients had their names, but not their photos, disclosed in recordings and text messages, also privacy violations.

Pull Quote 12On October 23, the Board of Supervisors were advised (below) that additional fines against the hospital are still expected because privacy fines take more time, and are typically steep.

I want to focus here on the five patients who were hospitalized with life-threatening conditions following administration of non-prescribed medications, and were not protected and kept free from “Chemical Restraints,” because that was particularly egregious.

Repeating the link, the CDPH survey of LHH revealed that five patients who developed life-threatening conditions were transferred to acute care hospitals for over-sedation, respiratory depression, and/or altered mental status after receiving medications they had not been prescribed.

The survey reported that a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) intentionally administered non-prescribed medications for staff convenience.

The five residents were:

On October 23, Troy Williams — who was brought in from SFGH as LHH’s Acting Director of Quality Management — testified to the Board of Supervisors GAO Committee, saying:

“There is evidence to support the possibility of those staff members bringing medications [in] from the outside.  You know, there is some evidence to support that maybe they could have diverted it from Laguna Honda, but a lot of the things I’ve been privy to, it’s quite honestly probably medications that they brought [in] from the outside and were medicating patients with medications that were not prescribed.”

Pull Quote 15Hogwash!  The CDPH July 12 survey reported LHH’s Director of Pharmacy, Michelle Fouts, had told state inspectors that the meds appeared to have purloined by the fired nursing staff from patients who had been prescribed them, and was not likely the result of illegals drugs having been brought in from the outside.

During an interview on July 2] “The Director of Pharmacy (DOP) stated that LVN 1 was drugging Residents.  The DOP also stated that LVN 1 most likely was taking patients medications to give to other patients.  The DOP said that LVN 1 texted a picture to CNA 1 holding a bag of medications.  The DOP believed that LVN 1 would take one patients’ medication and put them in a bag to later give other patients that were not prescribed these medications.


In an interview on 7 /3/19 at 3:00 PM the DOP stated that the medications in the bag were clearly from Laguna Honda Hospital.”

Scope and Severity of Patient Abuse at LHH

Table 2 shows LHH received five major deficiencies — all involving sub-standard care in long-term care facilities — in the CDPH July 12, 2019 survey, including the worst “L” finding, and received five additional lesser deficiencies during CDPH’s September 3 resurvey.

Table 2:  CMS Substandard Care Deficiencies “Severity and Scope” Scale

Table 2                      

All five of the July 12 severity-and-scope findings involved sub-standard quality of care.

When CDPH returned for its follow-up re-survey conducted between September 3 and September 6, it slapped LHH with another five lesser citations that didn’t rise to the level of sub-standard care, but were still violations:

Pull Quote 16Of note, the 61-page CDPH July 12 survey report noted in three separate places that LHH had a) Not identified incidents of abuse, b) Failed to report incidents of abuse in a timely manner to CDPH, and c) Failed to train staff as “mandated reporters” to report incidents of abuse directly, and within two hours, to CDPH.

Unfortunately CDPH did not include in its July 12 report which LHH incidents — and how many — hadn’t been reported at all, or which incidents — and how many — were not reported in a timely manner, nor did CDPH report the dates on which specific incidents weren’t identified or the dates on which incidents were not reported in a timely manner, so we have no idea at this point just how far back the unreported events occurred.

Pull Quote 18LHH’s “Leadership” Belatedly Fingered in Abuse Scandal

Four months after Breed’s June 28 press conference announcing the scandal, the San Francisco Board of Supervisors slowly got around to holding a hearing.  During the Board’s Government Audit and Oversight (GAO) hearing on October 23, Supervisor Norman Yee asked whether LHH’s leadership had either ignored, or didn’t know about, the patient abuse scandal.  Acting LHH CEO Margaret Rykowski — brought in from DPH to replace Hirose — responded, saying:

[SFDPH’s] review … did identify deficits in executive- and management-level positions as a primary contributor … that allowed cases of abuse … to occur, perpetuate, go unreported, and be improperly investigated over extended periods of time.  We’ve made initial steps [changing LHH’s] executive leadership, and will continue to make more, as needed.” 

Rykowski didn’t elaborate on which leadership “deficits” were discovered.

During the GAO hearing, Rykowski asserted that LHH’s leadership “was made aware of the [abuse] incidents” in February 2019.  That’s utter nonsense, when not wishful thinking.  Mcshane knew of the drugging of patients problem a year earlier, in February 2018, and he should have made LHH’s entire leadership — and the Health Commission’s LHH-JCC — aware of the problem then, in order to thoroughly investigate the root cause of what was going on.

For his part, Troy Williams indicated “leadership creates and really sets the tone for the culture.”  He added, “culture starts with leadership.” 

The abuse scandal comes down, in part, to not having checks and balances on LHH’s leaders, including Hirose, Gomez, Valencia, and the Health Commissioners on the LHH-JCC, too.  Supervisor Yee specifically noted that maybe the Health Commissioners didn’t ask the right questions.  Williams tired to assert he didn’t know how the Commissioners would know about the problems unless Laguna Honda’s leadership knew about it and came forward with the information to the Health Commissioners.  It’s clear LHH’s leadership may have kept the abuse problems away from the Health Commission.

Pull Quote 19During the same GAO hearing, Supervisor Aaron Peskin asked whether it is true the terms of separation of the six nursing assistants apparently fired by May 6 include “the fact they can no longer access pensions.”  As of November 22, that question hasn’t been answered.  Peskin also asked whether the City Attorney could additionally sue the perpetrators for civil monetary penalties to help recover the City’s state and federal abuse-related fines. 

Why the six nursing line staff involved in the actual abuse were apparently fired by May 6, but LHH's executive and management team weren’t fingered as having allowed the abuse to have occurred, go unreported, and be properly investigated until October 23, is worrisome. 

For that matter, since the six nursing staff were fired as early as May 6, why did it take Mayor Breed two months before staging her press conference on June 28?

Pull Quote 20More worrisome is why the six perpetrators who were fired may lose their pensions and face civil monetary penalty (and criminal) lawsuits, but no questions were raised during the October 23 GAO hearing about whether the three leaders may face the same penalties.  Shouldn’t the three leaders forced out also lose access to their fat City pensions and face similar civil monetary penalties for their failure to promptly report the abuse to the State?

The Three Nursing Management Amigos

Even before Breed’s June 28 press conference, LHH CEO Mivic Hirose was forced to step down, and LHH’s Director of Quality Management was removed.  The City tried to block release of the QM director’s name, claiming it was a “personnel matter,” but public records and a Google search easily revealed the name of the director — Regina Gomez, RN.

The two leaders were pushed out even before CDPH released it’s 61-page investigation July 12 survey report.  The report revealed Hirose and Gomez were interviewed by CDPH investigators three times between May 29 and June 19 in the presence of a Deputy City Attorney and LHH’s Director of Nursing (DON).  A Google search and public records revealed the DON was Madonna Valencia, RN.

Hirose, Gomez, and Valencia were also interviewed individually between May 29 and June 5.  But Valencia wasn’t pushed out until October 7.  It took four months before we learned that Valencia was also ousted.  The three Nursing management amigos are not to be confused with Donald Trump’s and Rudy Giuliani’s three amigos:  Kurt Volker, Gordon Sondland, and Rick Perry.

The executive- and management-level staff Rykowski was referring to who were eventually forced out — but  handed soft landings in cushy positions — were, essentially, toadies.  They are:

There you have it:  The patient abuse scandal involved the failure of nursing staff supervision under Valencia, and involved executive- and management-level failures by Hirose and Gomez.  Good riddance to all three of them!

Pull Quote 28History of LHH’s Leadership Problem Evolution

Without putting too fine of a point on this, LHH’s leadership problems have had a long “colorful” history.  It’s helpful to review that history.

Back in 2003 and 2004, then-Director of Public Health Mitch Katz instituted a disastrous “flow project” to discharge dangerous, robust behaviorally-challenged younger patients from SFGH into LHH, mixing them in with elderly vulnerable patients, many of whom had dementia’s, creating a volatile milieu for both patient populations.  Katz did so by forcing successive changes to LHH’s Admissions Policy because he remained angry that LHH’s medical staff and hospital administrators had refused to accept and admit dangerous psychiatric patients from SFGH.

Flexing his biceps, Katz forced LHH’s Medical Director, Dr. Terry Hill, to resign, and eliminated Mary Louise Fleming’s position as LHH’s Director of Nursing.  Katz also ousted LHH’s then Executive Administrator, Larry Funk — an at-will “exempt” employee.  LHH’s then-Chief Operating Officer, Robert Christmas, offered himself for the CEO position.  Katz declined, telling Christmas “you are too nice for the job.”

Katz appointed John Kanaley as Funk’s replacement in November 2004.  Mr. Funk was the last LHH CEO to actually hold a Nursing Home Administrator license. 

When news surfaced Funk had been forced out, 415 LHH staff — including nurses, certified nursing assistants, social workers, activity therapists, dietitians, physical therapists and occupational therapists, hospital volunteers, psychologists, and clerical and secretarial employees, among others — signed a petition to the then-president of the Health Commission, Edward Chow, MD urging that Funk be restored immediately to his position as CEO. 

Pull Quote 29Another 32 members of LHH’s Medical Services Department of doctors and psychiatrists signed a separate petition to Dr. Katz and the full San Francisco Health Commission, including Dr. Chow, expressing their wholehearted support of Funk, and urging Katz to re-instate Funk as CEO.  Within weeks of Kanaley’s appointment, a contingent of LHH’s high-level senior administrators met with Dr. Katz regarding concerns about Kanaley’s appointment and his lack of credentials, experience, and qualifications.  Katz reportedly told the contingent it didn’t matter because he wanted somebody who would “kick the [LHH] doctor’s asses.”

Kanaley’s prior job experience was in “facilities management,” not hospital administration.  He had served for 14 years in facilities management in SFGH’s Plant Services Department.  He had earned a master’s degree in public health in 2001 — just three years before being appointed LHH’s executive administrator — authoring a thesis involving evaluation of hazardous waste operations.

Many people believed Kanaley was sent to perform hazardous employee removal of LHH’s staff.  Kanaley had no experience whatsoever running a skilled nursing facility, and certainly had no experience or training in running a 1,200-bed nursing home having approximately 1,500 employees.

Kanaley also forced out Cheryl Austin, LHH’s Medical Records Director, who sued alleging racial discrimination and retaliation.

Shortly after becoming CEO, Kanaley managed to oust Christmas in an unlitigated deal at unknown expense to the City, setting in motion Kanaley’s future purges of LHH staff.  LHH staff quickly learned that Kanaley was in way over his head, unqualified, and was both paranoid and a bully.

Also within weeks of his appointment to LHH, Kanaley summoned Sister Miriam Walsh, Maria Rivero, MD (who previously served as LHH’s Medical Director but had stepped down to return to practicing medicine as LHH’s Admitting Ward doctor), and I into his office, one by one, seeking to silence our collective First Amendment right concerns about the safety and care of LHH’s patients.  The three of us essentially told Kanaley “no deal,” but that didn’t stop him from pursuing us.

[Full Disclosure:  When Dr. Rivero was LHH’s Medical Director, she made the hiring decision in May 1999 to hire me to work in the Rehabilitation Services Department following a final job interview.]

Following the protracted battle between LHH staff and Katz, and facing mounting political pressure, then-Mayor Gavin Newsom eventually ordered Katz to reinstate LHH’s admission policy to its pre-2004 level.  That helped, but we continued advocating for patient safety.

The stress of his job as CEO may have contributed to Kanaley’s fatal heart attack on March 19, 2009.  It’s not known if his paranoia and bullying were contributing causes of death.

LHH’s leadership problems extended to leadership of San Francisco’s Health Commission.

Fear of Retaliation Drove Silence

During the Board of Supervisors October 23 GAO hearing, Troy Williams bemoaned LHH’s lack of a culture of safety.  He testified:

“I think this is a very important piece to this.  One of the things we learned as a part of our investigation is that there was a culture of silence.  These things were able to go on undetected for years.  And, you know, what we’ve learned is that people were afraid to report.  Retaliations — specifically, we heard a lot about these specific individuals involved, that there was some fear of them and retaliation from them. …  I think that is something that is really important, because leadership creates and really sets the tone for the culture.”

Pull Quote 31No kidding, Troy.  While not diminishing the likelihood that some employees were afraid of peer-to-peer retaliation from low-level Licensed Vocational Nurses (LVN’s) and Certified Nursing Assistants (CNA’s), the greater fear of retaliation that drove the culture of silence was from senior hospital administrators.

In December 2004, one Laguna Honda Hospital doctor shared with me:

The only time [LHH’s] administration addresses [patient] safety issues is when it gets sued or cited [by state or federal agencies investigating patient abuse].  Whuzzup?

Pull Quote 32The same doctor remembered being told in the early 2000’s that if she reported patient-on-patient physical or verbal abuse due to inappropriate admissions and inadequate staff supervision on her ward of dementia patients, that there was no whistleblower protections for LHH doctors.  That appears to have led to the 2014 inspection citations for failing to report the patient-on-patient abuse to CDPH, which Gomez may not have known was legally required.

Given Hirose’s well-known history of retaliation against Gayling Gee and Dr. Kerr, and perhaps others, the fear of retaliation from Nursing leadership is far higher.  How can Mr. Williams, Ms. Rykowski, and Supervisor Yee not have known this?

Pull Quote 33Unanswered Questions

Many key questions remain.  CANHR asked on September 11:  What’s being done to bring the perpetrators to justice?  What’s the Police Department — specifically its Special Victims Unit — doing?  Why hasn’t the State Attorney General’s Elder Abuse Unit filed charges against the perpetrators?  And why hasn’t CDPH denounced the abuse and publicly released its findings?

Pull Quote 34After all, the drugging of patients with unprescribed opioids was first detected and reported to LHH’s Medical Director, Dr. Michael Mcshane, as early as February 26, 2018 by doctors at other hospitals where five patients had been transported with life-threatening conditions, including respiratory arrest.  Mcshane replied the same day that an internal investigation was underway at LHH.  Did Mcshane ever conclude that internal investigation?  Why hasn’t he been forced out, too?

In his terrific November 2019 Westside Observer article, former LHH physician Dr. Derek Kerr — wrongfully terminated in June 2010 in retaliation for whistleblowing — asked what had happened with investigations by LHH’s physician-run Medical Quality Improvement Committee and its Performance Improvement and Patient Safety Committee, since both committees appear to have fallen victim to, and have offered, silence.  That mirrors LHH’s pandemic culture of silence.  Kerr noted “Ignoring root causes [of problems at LHH] is a structural component of LHH’s Culture of Silence.”

Personally, I wonder why the San Francisco District Attorney’s Office hasn’t announced criminal charges in this scandal.  After all, aren’t District Attorneys supposed to focus on the victims of crimes and the impacts of the crimes on them in a timely manner?

Pull Quote 35Hirose, Gomez, Valencia, Chow, Sanchez, and Mcshane all had to have known the December 2016 “Class AA” citation’s two-year period hadn’t ended.  Is that why the patient abuse wasn’t reported promptly to the State?

On, November 19 CDPH responded to a records request saying “CDPH cannot comment on an ongoing investigation.”  Why has CDPH’s investigation dragged on from at least May 29 to November 19 without conclusion?  The answer may be as CANHR reported on October 24:  CDPH’s backlog of over 17,000 cases of open complaints and facility reports of abuse.

That backlog may have contributed to Dennis Herrera having been able to wrangle the reduction of the 2016 “Class AA” citation down to a “Class A” violation.  How many citations in other abuse cases were also reduced because of CDPH’s backlog of investigations?

What DPH and LHH may be ignoring at their own peril is that there will always be employees who have eyes and ears, and despite the culture of silence the truth will eventually come out.  Hopefully, when future employees see something, they’ll say something now that Hirose’s and Gomez’s reigns of terror are finally over.

Watch this space.

Monette-Shaw is a columnist for San Francisco’s Westside Observer newspaper, and a member of the California First Amendment Coalition (FAC) and the ACLU.  He operates  Contact him at