State Cites Stanford Hospital in Attack That Injured Two Psych Nurses

This story was updated May 14, 2021

A series of security lapses at Stanford Hospital allowed a patient in a locked psychiatric unit to attack a 70-year-old nurse earlier this year, state workplace regulators said.

The assault occurred on March 12 in a part of the Palo Alto facility that lacked security, despite an order calling for the patient to be accompanied by guards, according to an investigation by the California Division of Occupational Safety and Health.

Catherine Kennedy, a registered nurse who had worked at the hospital for 17 years and had 30 years of psychiatry experience, suffered serious injuries from the attack. She told police that the patient threw her to the ground and beat her, punching her up to 20 times on her head and body, according to court documents. Her right knee was "shattered" and her lower leg fractured. Another nurse, who tried to separate the victim and the agitated patient, was also injured.

Cal/OSHA issued an $18,000 citation to the hospital earlier this month for failing to effectively implement its workplace violence prevention plan.

"This type of serious injury should never be part of the job," said Rachel Odes, a staff nurse at John George Psychiatric Hospital in San Leandro.

On the night of the attack, there were four nurses on duty at the hospital's psychiatric unit to handle 14 patients. The attack took place during a shift change, when visitors were allowed in the facility.

"It was chaotic and disorganized with visitor(s) congregating around the nurses station," the Cal/OSHA summary states.

The 36-year-old patient involved in the attack had checked himself into the hospital two days earlier. Although it's unclear what specific mental illness he was suffering from at the time, there was an order in place that he be accompanied by security.

"Due to staff shortage the security supervisor needed to pull the security officer assigned to the patient," the summary stated.

One of the visitors on the night of the attack was the patient's girlfriend. When she had visited him previously at the hospital, he became agitated, hospital staff told state inspectors.

One nurse, Sampaguita Pino, told a Palo Alto police investigator that the patient had been "loud, agitated, and intrusive all day," according to the incident's police report.

That night, the patient began pacing back and forth and took off his shirt. His behavior prompted one nurse to retreat into the nurses station, where patients are not allowed. The patient then walked into the station and confronted another nurse. A third nurse then pulled a panic alarm and called security.

Kennedy, who was hours into her overnight shift at the time, told police that the patient was "not directable, irritable, had been wandering in rooms, was disorganized."

Kennedy began administering medication to the patient to calm him down and gave him his shirt back and told him to put it back on. Instead he "threw me to the ground, tackled me and then beat me," she told police.

He allegedly lunged at Kennedy with a "scissor kick" and began striking her, according to the investigation. Pino tried to restrain the patient but was struck as well, at which point security officers and other staff entered the unit and restrained the patient. Kennedy was taken to the emergency room.

A security guard later told a police investigator that "security made no attempt to call the police, but that the family was advised they could call the police on their own." The attending psychiatric physician told the investigator that police were not called "because he did not consider this a crime due to the patient's me(n)tal condition at the time of the assault."

Cal/OHSA says the hospital made several mistakes the night of the attack, which included failing to ensure that staff were documenting and communicating information to each other between shifts "regarding conditions that may increase the potential for workplace violence incidents."

State workplace regulators also said there was not adequate security staffing in the psychiatric unit.

"The security staff were not available due to other assignments preventing them from immediately responding to an alarm," Cal/OHSA's report said.

In May the Santa Clara County District Attorney's Office charged the patient with felony battery, causing serious bodily injury and misdemeanor battery at a hospital. The patient pleaded not guilty in August.

A judge is expected to set a date for a preliminary hearing in the case next Monday.

The patient's lawyer, Trisha Luciano, declined to comment.

In the meantime, the hospital is fighting the state penalty.

"The safety of our patients and staff is the highest priority at Stanford Health Care. We are proceeding to file a formal appeal while working with Cal/OSHA to schedule an information conference during which we will review the circumstances to resolve this issue," said Stanford Health Care spokeswoman Julie Greicius in an email.

The attack came several weeks before some 4,000 unionized nurses employed at the facility and at Lucile Packard Children's Hospital voted to authorize a strike. That walkout was later averted by a deal that included wage increases, bonuses and improved workplace violence prevention plans.

A top official at the nurses union, the Committee for Recognition of Nursing Achievement (CRONA), said the Cal/OSHA report reveals a number of workplace safety deficiencies.

"These include findings that Stanford did not maintain sufficient numbers of security staff in the psychiatric unit and that security staff were not available due to other assignments, and thus were not able to respond immediately to an alarm," said CRONA Vice President Kathy Stormberg in an email.

"The state also found that Stanford's employee communication procedures regarding questions of workplace violence were lacking, a concern previously raised by CRONA," Stormberg said.

Odes, the expert in hospital work safety, said Cal/OSHA's findings point to the importance of safe staffing.

"Nursing staff did not have adequate support at the time of the incident," she said.

Odes also pointed to the victim's age.

"As the nursing workforce ages, it is going to be increasingly important for health organizations to proactively prevent injuries on the job," she said. "Even a very experienced provider can be victimized in the wrong situation."

Editor's note: We have updated this story to remove the name of the then-patient who was charged with attacking a nurse at Stanford Hospital after checking himself in for treatment. We decided to make this change after receiving a request from the patient to do so. KQED considers it part of our journalistic responsibility to protect people and their identities when they’re in a vulnerable state, and particularly when our coverage may induce further harm. In this case, the patient in question was seeking treatment, and we published his name after it was made available in a public record. We are re-evaluating our policy around vulnerable sources and have decided that removing the patient’s name is the ethical decision. We will be updating our newsroom’s policy accordingly.