Inspection Detail

Inspection: 1452180.015 - California Department Of State Hospitals

Inspection Information - Office: American Canyon District Office

Investigation Summary

At 6:49 p.m. on December 10, 2019, an employee was working as a licensed practical nurse (LPN) or licensed vocational nurse (LVN) at a state psychiatric or substance abuse hospital. This state facility housed a population of over one thousand individuals, of whom approximately 90 percent were forensic. The individuals were referred through local governments or the court system, so the propensity of these individuals to become unstable, aggressive, or violent was increased. Accordingly, these individuals were housed in areas categorized as high-level security access. The employee provided care to the individuals housed there. She watched over patient on a one-to-one basis. The incident occurred at the end of seclusion hallway C2 on the second floor of building unit Q6 at the hospital. Seclusion hallway C2 was classified as a high-level security access area. The 62-year-old employee was in hallway C2 looking after a restraint patient. The patient had wrist and waist restraints. The patient began to have a panic attack, and before the employee was able to call for help, the patient physically attacked her. During the attack, the employee fell and hit her head on the ground. While the employee was on the ground, the patient continued to kick her from head to toe. The employee lost consciousness during the attack. She suffered bruises to and swelling on her head and left shoulder, left ribs, and left upper and lower leg. She was hospitalized for three consecutive days. During her hospitalization, it was also determined that she had internal bleeding in her skull. Her employer notified the American Canyon Cal/OSHA district office via phone at 8:48 p.m. that same day. The district office initiated an investigation at approximately 10:00 a.m. on December 13, 2019.

Keywords: Abrasion, Brain Bleed, Contusion, Fall, Fall On Same Level, Head, Hospital, I2P2, Leg, Lost consciousness, Nurse, Rib, Shoulder, Skull, Subdural Hematoma, Workplace Violence