A day later, after the 57-year-old woman had wandered into a nursing station, a doctor reminded a nurse that the patient needed around-the-clock observation.
According to the San Francisco Chronicle, federal investigators say nurses failed to act on the doctor's orders. She vanished from her room on Sept. 21.
They also concluded that a sheriff's deputy was told to search the hospital stairwells for Spalding, but he understood it as something he could do if he had free time.
Spalding's body was found 17 days later during a routine check.