Napa State Hospital to roll out new alarm system


SAN FRANCISCO — It’s been nearly 22 months since Napa State Hospital psychiatric technician Donna Gross was strangled by a patient on the aging facility’s fenced grounds, where staff alarms do not function.

A push for a high-tech wireless system became a political priority, pressed by lawmakers and by Cal/OSHA, which has taken a heightened interest in safety at state mental hospitals.

The new alarm system is set to roll out Tuesday in the area of the 400-acre campus where patients accused or convicted of crimes are held. The “tags” not only transmit constant signals on the location of each employee, but also receive data so that workers can reach one another in emergencies.


“We don’t often get to give people good news,” said Kathy Gaither, chief deputy director of the Department of State Hospitals. “The fact that we’re going live with a big project that’s going to have such a huge positive impact for our staff and our patients, we’re very proud.”

But there’s one problem: Workers are being asked to wear the alarms on lanyards around their necks, creating what they contend is an ever-present risk of strangulation.

Employees had helped to vet the alarms, which are activated when the wearer pulls on them with at least 5 pounds of force. The alarms hang on a lanyard with a breakaway device in the rear that gives way at 10 pounds of force — too high for the lanyard to fall apart before the alarm can be sounded but high enough to break away if an attacker were to pull on it.

It wasn’t until training began a few months ago that staff members noticed a flaw: The breakaway device still leaves, for a savvy assailant, the length of the lanyard to possibly be used as a garrote.

“You don’t wear a tie if you’re working with patients on a psychiatric unit. Now everyone is going to have the equivalent of a tie,” said Dr. Richard Frishman, a psychiatrist and member of the union-based Safety Now Coalition who, like many staff members, has been brutally assaulted.

“The one saving grace is if they pull it from in front, it will break away,” he said. “If they pull it from behind, it’s not going to break away. It’s going to crush your larynx or strangle you or something terrible is going to happen. A lot of damage can be done in 2 to 3 minutes.”


Gross’ death came as assaults against patients and staff were rising systemwide. Patients in the secure treatment area where she died have been on lockdown ever since, allowed on grounds only with supervision.

Cal/OSHA regulators, which have cited all of the state hospitals for safety lapses, will allow those patients to move about more freely only when a new alarm system is in place. If Napa’s pilot program is successful, it would be used at Norwalk’s Metropolitan State Hospital and San Bernardino’s Patton State Hospital. Coalinga State Hospital and Atascadero State Hospital would follow next year.

But the roll-out is now overshadowed by employees’ concerns. Assemblyman Michael Allen (D-Santa Rosa) is also privately pressing for other options to be tested.

State hospital officials say they are open to alternatives to the lanyard and will test some belt-loop carabiners. But they are adamant that the system go live as scheduled. Employees want more time.

“People don’t want to be choked.... They do want the alarm system,” said Zach Hatton, a recreational therapist and union steward who said that of 200 members he surveyed, only two were comfortable with using the lanyards now.

The state contracted for the system with Virginia-based Ekahau, a global maker of WiFi-enabled “Real Time Location Systems.” Such tags have been used to track medical and nursing home patients as well as prisoners — even allowing authorities to receive warning signals if members of opposing gangs get within a certain distance of one another. The prisoner devices are secured to a wrist or ankle.


The tags sought by state mental hospital officials must receive as well as transmit information, making them too large to be worn on a wrist. Furthermore, a feature on Napa’s tags causes them to signal if they are dormant for a certain length of time, in case an employee is unconscious “or something worse,” Gaither said. If worn on a belt loop, where there is less body movement than on the torso, they could be more likely to trigger inadvertently, making the carabiner a poor alternative.

“The lanyard was the best choice,” she said.

An Ekahau spokeswoman said the company is “working with all of the parties concerned.” She declined to comment further.

Concerns were raised in force in late May.

“Safety?? What if a predator is coming from the back and pulls my lanyard?” read one of many “frequently asked questions” communicated to management after classroom trainings. The lanyard, read another, is an “advertisement” to patients “to grab it and choke staff. Is the hospital going to wait until the first person gets choked before they look for a sensible solution?”

Yet finding an alternative has not been simple.

At the time Gross was strangled, staff had been expressing safety concerns to higher-ups for years, with little or no response. After her death, new leadership promised transparency and communication.

When concerns arose about the alarms, hospital managers encouraged alternatives, giving a green light to one employee who formerly developed outdoor equipment in Colorado to experiment on during work hours.

Mike Jarschke, a psychiatric technician and all-around Mr. Fix-it, first tried a lanyard with three breakaway points — similar to one used in New York state’s mental hospitals. But those hold push-button alarms. When the force needed to trigger Napa’s device was applied, the lanyard fell apart before it could activate.


Next, Jarschke tried a clip-on option, but found it would leave small holes in staffers’ shirts. He sewed a plastic square with a loop for the tag onto a T-shirt, but it looked too much like a uniform. (Those were abandoned long ago as intimidating to patients.) The same went for a triangle of webbing he applied to a different shirt.

Jarschke then ordered and tested a number of breakaway devices, finding one that gives out at 16 pounds of pressure. Adding two to the sides of the lanyard might do the trick, he said, making it “less of a weapon of opportunity.”

Gaither is skeptical. Of the 800 or so employees who will be wearing activated alarms on Tuesday, 103 will test the carabiners. But, she said, “it’s very difficult to consider something that has been crafted by hand when it’s not available on the market.”

Patients who have previously attempted to choke staff while assaulting them have done so with their hands in an attempt to silence screams, she added, and a thin lanyard would not prove as effective in that regard.

“We need to move forward to improve the safety of our employees and our patients, and not having the alarm at all is a less safe situation than moving forward with the alarm,” she said.

Employees were directed to begin wearing the yet-to-be-activated alarms last week — and made their concerns clear.


“A number of staff have taken it upon themselves to remove the lanyard and clip the tag to their clothing,” said a hospital-wide email obtained by The Times. “This is not the appropriate and or approved method for wearing the tag. Please put the tag back on the lanyard and wear it as directed.”

Employees say the trouble has already begun: Last Tuesday, a female patient grabbed the lanyard worn by a male nurse and attempted to choke him with it, but he was able to push her away.