A state investigation has found that key errors were made by San Francisco General Hospital and the San Francisco Sheriff's Department after a disoriented woman went missing last fall.
Lynne Spalding, 57, disappeared from her hospital room in September of last year. Her body was found weeks later in a locked hospital staircase.
According to an investigation report by state health inspectors from the Centers for Medicare and Medicaid Services, hospital staff made errors in Spalding's care including ignoring a doctor's order that Spalding should be monitored at all times.
Spalding was suffering from an infection and was disoriented when she was admitted. Two days before she disappeared nurses were ordered to "NEVER leave patient unattended," the report said.
However rather than constant care, the report alleges nurses instead only checked on Spalding every 15 minutes after a nurse failed to update her care instructions.
Additionally, a week after Spalding went missing a hospital orderly reported that he saw an unconscious person on the fire stairway and altered a nurse, who suspected it might be a homeless person, the report said.
The nurse called the dispatcher for the sheriff department, but the dispatcher did not log the call and assign any deputies to investigate, according to the report.
Officials at San Francisco General Hospital said they would make changes based on the report.
"Many of the changes outlined in the (report's corrective plan) already have been implemented, and we can assure Ms. Spalding's family, and all our patients, visitors and staff, that we are a safer organization today," hospital officials told the San Francisco Chronicle in a statement.
An independent request for further statement from ABC News was not immediately answered.
Additionally the report found that the San Francisco Sheriff's deputies assigned to look for Spalding allegedly did not do a thorough job.
The reports states that only three public stairwells were searched and an additional seven stairwells with fire-alarmed doors were not searched.
The report found there was no coordinated plan to search for a patient and that one deputy did not search in the fire stairway because he had no training in how to open the door without setting off the alarm. Another deputy believed it was a "generic" order meaning that he should only search if he had "free time."
In addition, the wrong information was provided to deputies, a charge nurse initially described Spalding as an African-American woman even though she was Caucasian.
Request for comment from the San Francisco's Sheriff's Department were not immediately answered.
David Perry, spoking on behalf of the Spalding family on "Good Morning America" last fall, called the hospital's actions "completely inexcusable."
"It's a horrible, horrible nightmare," he added.