Inspection Detail

Inspection: 312696297 - San Francisco General Hospital & Trauma Center

Inspection Information - Office: San Francisco District Office

Investigation Summary

At approximately 7:30 p.m. on July 14, 2013, Employee #1, registered nurse, was working in Unit Number 7A. Unit Number 7A was a locked, adult and acute psychiatric facility. The employer operated a large public hospital that included several varieties of psychiatric and nonpsychiatric units. All of the workers at the facility were employees of the hospital and not contract employees. As Employee #1 was working, she was assaulted by a patient that had a significant history of assault and that had regularly been confined to a seclusion room for that reason. The patient was confined that day in a seclusion room that shared a toilet room with a standard room used by non-secluded patients. The practice and policy of the hospital was that the door between the toilet room and seclusion room would normally remain locked. That door was manually unlocked to provide seclusion room patients access to the bathroom, and then manually locked after the secluded patient was done. Employee #1 had attempted to manually close and lock the aforementioned door, which was wide open and projected into the seclusion room. The attempt was made while a coworker tried to distract the patient through the window of the closed and locked door at the primary entrance to the seclusion room. When the patient noticed Employee #1 in the bathroom, the patient ran to the bathroom and captured her in a bear hug. They fell over and Employee #1 suffered two leg fractures. She was transported to a medical center, where she underwent surgical procedures and was hospitalized for two nights.

Keywords: FRACTURE, STRUCK BY, FIGHTING, LEG