Abstract: On May 22, 2004, an employee, a nurse was relatively new to the acute psychiatric unit and field of practice, with three to four months of experience at the unit. The employee had worked on the employer's geriatric psychiatric facility for approximately one year prior, and before that had worked in the field of drug and alcohol rehabilitation. The employee had been provided with one "refresher" formal training on violence prevention the week before the assault, and not the full-day "initial" formal training. The employee was assaulted by a patient. The assaulting patient was admitted the day before the assault and was suicidal and paranoid. The employee and a coworker, the charge nurse, worked the graveyard shift after the patient's first day of admission. The employee was assigned to wake the patient up to initiate an oral medication. At 1:15 a.m., the employee entered the patient's darkened room, approached the bed, and informed the patient about who the employee was and what the employee was going to do. As the employee was turning around to walk to the light switch, the patient punched the employee in the face. The coworker was the only other staff member on the unit that night. The coworker was at the nurse's station directly across from the patient's room and heard a yelp that the coworker interpreted as a possible assault. The coworker entered the patient's room and saw the patient and the employee lying on the ground bleeding. The coworker removed the employee to the nurse's station and phoned security. The employee suffered from a concussion, black eye, facial laceration, facial swelling, and prolonged neurological damage including damage of the vestibular system resulting in months of dizziness, headaches, and earaches. The employee was hospitalized. At the time, neither nurses were carrying a personal alarm which were earlier provided to some of the staff on the unit. The employee was not trained specifically on how to safely wake up a sleeping patient. The Unit policies did not indicate exactly which patients were to be labeled with "assault precautions" nor which work practices were to be implemented for those patients. A buddy system was only required for medical exams and seclusion and restraint rooms, when a buddy system was feasible for other hazardous situations. No requirement was in place to ask all able patients to walk out to the nurse's station to take medications. No requirement was in place to ensure that no employee was isolated on the unit while other employees took breaks. No clear procedure was established on exactly when outside help should be obtained in the event of an assault. One broken stationary panic alarm button was identified during the inspection and the system was not tested routinely.