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After CMS' decertification, was Laguna Honda adequately prepared to transfer patients to other facilities?

Families Sue Laguna Honda for Transfer Deaths

• • • • • • • May 26, 2023 • • • • • • •

On 5/9/23, three families filed suit in SF Superior Court CGC-23-606373, alleging that Laguna Honda Hospital (LHH) was partly responsible for the deaths of patients transferred to outside facilities in 2022.

The lawsuit also charges the receiving facilities, SF Medical Respite Center, Burlingame Skilled Nursing (and its controversial owner, Shlomo Rechnitz), and Seton Medical Center Coastside, with alleged wrongful deaths. After the Centers for Medicare and Medicaid Services (CMS) decertified LHH in April 2022, it mandated patient transfers for substandard care.

Representing the plaintiff families, the law firm Stebner, Gertler, Guadagni & Kawamoto claims that LHH “acted recklessly,” aware that “there was an insufficient number of staff, that the staff…was not adequately trained, and that the staff…was not adequately supervised” resulting in a “lack of provision of care.” This knowing flouting of staffing regulations was part of… (a)…pattern and practice to cut costs at Laguna Honda.” The lawsuit supports this claim by noting LHH’s low overall rating in the CMS “Nursing Home Care Compare” website, mainly due to its 2019 patient abuse scandal.

Further, LHH “disregarded” the risk of transfer trauma that primarily affects elderly dementia patients who are abruptly transferred to unfamiliar environments. Such relocation stress can result in disorientation, withdrawal, depression, cognitive and physical declines. Allegedly, LHH “forced" the three decedents to transfer to other facilities without mitigating the risk of transfer trauma, resulting in "complications, including decline in condition and death.” These complications arose from “a systemic lack of communication, oversight and follow-up.” Underlying it all, the lawsuit complains, is a "culture of secrecy, wrongful conduct and abuse.

Laguna Honda Defendants

Among the defendants named in the lawsuit are LHH’s Interim CEO Roland Pickens and Acting Chief Nursing Officer Theresa Dentoni, along with Department of Public Health's Director Dr. Grant Colfax and Chief Integrity Officer Margaret Rykowski. Managers at LHH and the three receiving facilities allegedly “had advance knowledge of the unfitness of their employees…authorized the wrongful conduct alleged in this complaint, and/or were personally guilty of oppression, fraud, malice and/or recklessness.” The lawsuit rebukes LHH managers because those “… who are responsible for training staff in how to properly implement these policies and procedures are not adequately familiar with the policies and procedures in Laguna Honda…."

Ominously, some 100 unnamed “care custodians” at LHH and the three receiving facilities are also held “responsible in some manner for the occurrences alleged in this complaint.” The City Attorney's rebuttal has yet to be posted to the Superior Court website as of publication time. No trial date has been set.


Just when LHH won another reprieve from compelled discharges, it faces menacing lawsuits from these three families - as well as the Public Guardian and a Class Action suit. These are damaging to LHH and demoralizing for its dedicated employees.”

The Case of Edward Sanchez

Aged 63, Mr. Sanchez was admitted to LHH in April 2021. Chronically homeless and on opioid replacement therapy (e.g., methadone), his diagnoses included laryngeal cancer, hepatitis C with cirrhosis, HIV and “impulse control disorder.” LHH determined that his condition had improved and recommended discharge to the SF Medical Respite Center. Allegedly, he declined to sign the Discharge Notice.

His family believes his condition had not improved sufficiently and that he was "coerced, threatened and/or pressured” into the transfer on June 23, 2022. They claim he wasn’t provided transportation and had to walk "approximately four miles” to the Medical Respite Center. If so, that indicates a fairly robust stamina.

Once there, the staff allegedly "failed to ensure” that he was taking his medications, resulting in missed doses. On July 17, 2022, he was found dead on the toilet in the dormitory. The lawsuit claims Sanchez “died as a result of transfer trauma, neglect, and resulting decline in condition caused by…reckless and egregious acts and omissions.” It asserts that the defendants “had responsibility for…protecting him from health and safety hazards.” Neither the "safety hazards" nor the cause of death are identified.

In a prior analysis based on State inspections, the Westside Observer reported that Mr. Sanchez, aka Patient #53, faced a low risk of transfer trauma. Records indicate he was alert and largely self-caring at LHH. The circumstances surrounding his death raise the possibility of a drug overdose. We obtained Mr. Sanchez’s Death Certificate. Interestingly, no autopsy was performed. Perhaps it wasn’t necessary to determine why he died. Ten months post-mortem, his cause of death is “Pending,” awaiting toxicology results from the Medical Examiner.

The Case of Ngo Vi Lieu

Aged 84, Mr. Lieu was admitted to LHH in February 2021. His diagnoses included stroke with left-sided paralysis, loss of speech, difficulty swallowing — requiring a feeding tube, and multi-stroke dementia. In a May 2022 Discharge Assessment, an LHH Social Worker reportedly wrote that Lieu was "Not Discharge Ready" due to "Palliative Care" and "Chronic Progressive Disease.”

Yet, his daughter says  LHH staff repeatedly urged her to transfer him elsewhere. On June 8, 2022, she received a Discharge Notice indicating that Mr. Lieu would be sent to Burlingame Skilled in two days. The daughter alleges that she requested a one-week postponement to confer with family and visit Burlingame Skilled. The family believes LHH ignored this request, and they were “coerced and/or pressured” to accept the transfer.

Days after arriving at Burlingame Skilled, Mr. Lieu was transferred to a hospital because his feeding tube was obstructed. While there, a nurse allegedly told his daughter that Burlingame Skilled was “not adequately taking care of him.” During his five-week stay, Mr. Lieu was transferred to the ICU “approximately every week” due to repeated blockages of his feeding tube and required “several hospitalizations.”  Transfer stress may have ensued. He died 36 days post-transfer from LHH.

The lawsuit alleges that; “Burlingame Skilled was not told about decedent’s Lieu’s care needs, did not understand (his) care needs, and/or was not adequately staffed…." It blames "reckless and egregious failures," including his "forced transfer” from LHH “despite his vulnerable and worsening condition.” Supposedly, Laguna Honda's missteps and Burlingame Skilled’s neglect caused the patient's transfer trauma. Both institutions are accused of a “pattern of substandard care, insufficient supervision and understaffing.” The lawsuit faults LHH for pushing Mr. Lieu into an allegedly ill-equipped facility to manage his care. No evidence of transfer trauma is given, as compared to examples of care lapses at Burlingame Skilled.

The Westside Observer’s prior analysis of State investigations showed that Mr. Lieu (Patient #3) was deemed at high risk for transfer trauma. As a comfort care patient, it’s hard to justify his transfer. But, given his poor condition, prognosis, and alleged neglect, his death wasn’t clearly related to relocation stress, per se.

The Case of Quiy Pham

Aged 80, Mr. Pham was admitted to LHH from home in July 2021. His diagnoses included Alzheimer’s dementia, dizziness with repeated falls, bladder and bowel incontinence. According to his daughter, she was told during a June 8 meeting with LHH staff, that Mr. Pham was a candidate for transfer — and that she could appeal that decision. However, she alleges being “threatened that if she were to appeal, (Mr. Pham) would be forced to go to another facility farther away from family.” Once LHH found a spot for Mr. Pham at Seton’s skilled nursing facility, his daughter claims that LHH staff said she “would be billed $40,000-$50,000 per month” – if she refused the transfer.

LHH transferred Mr. Pham to Seton on July 8, 2022. The family claims that "Seton was not told about and/or did not understand” Mr. Pham’s care needs. For example, his daughter “would see a water pitcher on a table in her father’s room, but (he) needed assistance for drinking and could not drink the water from the pitcher on his own.” While it's possible that Seton staff used the pitcher so they could administer fluids to him, family members say that when they visited and offered water, Mr. Pham “would drink the water with a great sense of relief, as if he had not had water for days.”

Soon, the family noted a “dramatic decline,” including an “inability to swallow and dehydration.” Reportedly, Seton staff did not inform them of this change in condition. Mr. Pham died on July 25, 2022, 17 days post-transfer. Here again, the lawsuit claims “transfer trauma” contributed to his death while mainly referring to “neglect” at Seton. The implication is that LHH “failed to take precautions” to protect Mr. Pham, then “transferred him to an unsafe and hazardous environment.” Allegedly, a “pattern of substandard care, insufficient supervision and understaffing” factored in Mr. Pham’s demise.

In our prior analysis of State records, Mr. Pham (Patient #39) was deemed at high risk of transfer trauma, but evidence of transfer trauma was lacking. Those records did not assess his care at Seton. CMS’s Nursing Home Care Compare website gives Seton’s nursing home an “above average” score for staffing and a mediocre score overall. Still, his cause of death may be related to advanced illness and complications thereof.   

Causes of Action

The above allegations form the basis for four Causes of Action;

  1. Dependent Adult/Elder Abuse/Neglect

Citing various statutes, the lawsuit claims that LHH and the receiving facilities engaged in “abuse” “neglect” and “abandonment” of the three  decedents, thereby causing “physical pain and/or mental suffering.” Specifically, LHH’s transfer of these patients allegedly constituted, “desertion or willful forsaking of an elder or dependent adult.”  Plus, LHH “falsely promoted, advertised and held” the receiving facilities as having the expertise to care for the patients, causing them to “incur the expense of emergency medical services, all to their special damage…."

  1. Violation of Patient’s Rights

The lawsuit claims that the decedents were transferred without consideration of their right to dignity, to adequate and qualified caregivers, and to be transferred for their welfare.

  1. Negligence

Allegedly due to “negligence and carelessness” by LHH and the receiving facilities, the patients “were severely injured and died.”

  1. Wrongful Death

Due to the “acts and omissions” of LHH and the receiving facilities, the families were deprived of “love, comfort, companionship,” and incurred burial costs. The lawsuit seeks damages for “pre-death pain and suffering,” funeral expenses, legal costs, and fees.


Attributing these deaths to “transfer trauma” or relocation stress is shaky. Ill-advised transfers or adverse outcomes do not necessarily involve transfer trauma. The demise of debilitated patients with poor prognoses is often due to inter-current infections or expected complications. In a prior Westside Observer analysis of State reports on 12 transfer-associated deaths, just four cases were persuasively tied to relocation stress. Four were likely due to their illnesses, and four were questionable. None of the three decedents named herein clearly fell in the transfer trauma group.

However, the State investigations provided limited clinical data and did not delve into the quality of care at the receiving facilities.

Similarly, the claims of understaffing at LHH are tenuous. While LHH lacks staff to manage active drug users and volatile behavioral disorders, it has always exceeded nursing staffing requirements.

Nonetheless, LHH faces liability for these post-transfer deaths. State surveyors faulted LHH for sloppy, cookie-cutter Transfer Plans and Care Plans, resulting in minor citations and $36,000 in fines. These penalties partly served to shield CMS from liabilities arising from its draconian demands to evacuate hundreds of patients from LHH swiftly. While LHH disputed these citations, it decided against appealing them formally in order to focus on regaining its certification. Accordingly, the citations stand as uncontested indictments of LHH’s transfer practices. Worse, LHH’s own consultants documented widespread mismanagement.

Just when LHH won another reprieve from compelled discharges, it faces menacing lawsuits from these three families - as well as the Public Guardian and a Class Action suit. These are damaging to LHH and demoralizing for its dedicated employees. But litigation may be the best way to determine why 12 of 57 patients died soon after transfer - and how a patient abuse scandal festered undetected and undisclosed for three years. Sadly, the folks who deformed Laguna Honda – by purging competent executives and breaching regulations to sustain the DPH Flow Project - are now flailing to fix the resulting mess.

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

May 26, 2023

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