Attack at Napa State Hospital leads to change in alarm policy

One day after a patient attempted to choke a Napa State Hospital employee, officials announced Thursday that staff members at the psychiatric facility who were ordered to wear new safety alarms on lanyards around their necks will soon have the option of carrying the devices on a belt-loop clip.

The attack on a psychiatric technician demonstrated with eerie precision the risk that employees had warned of.

As the worker sat monitoring a patient Wednesday evening, another patient punched him in the face, “grabbed the lanyard from the back and attempted to choke the staff,” according to an incident report read to The Times.

The employee, who has declined to be interviewed, managed to pull on the WiFi-enabled device during the scuffle, activating it while getting his hand “inside of the lanyard to keep it from making a complete seal around his neck,” said psychologist Andy O’Neall, among those who responded.


The assailant was pulled away. The staff member was treated at a local emergency room and is expected to make a full recovery.

But the incident, which came on only the second day of the alarm system’s rollout, fueled outrage among employees who believe the lanyards pose a strangulation risk. Workers’ unions that formed a safety coalition in the wake of rising hospital violence had unsuccessfully sought to delay the pilot program, launched in the section of the facility that houses patients accused or convicted of crimes.

“This was an attempted choking,” O’Neall said. “It’s a flawed design. It doesn’t take much to see that.”

The new system came in direct response to the October 2010 death of psychiatric technician Donna Gross, who was strangled by a patient on the fenced hospital grounds, where the old alarms did not work. CalOSHA has demanded that the facility — and the state’s other mental hospitals — improve their alarm systems. A federal consent judgment that has imposed strict oversight on Napa State Hospital since 2006 was extended in December, in part because the new alarms had not yet materialized.

The devices are designed to work throughout the facility and its vast grounds, transmitting information on the whereabouts of each employee and receiving data on the location of nearby co-workers in distress. While pleased with the technology, employees began raising concerns about the lanyards in May. Though they have a breakaway clip in the back, staff members explained to management that a savvy assailant could still grab the lanyard from the rear and use it as a choking tool.

Administrators have been working with staff to develop alternatives. Of 800 or so employees who have been wearing the devices since Tuesday, 103 were selected to test a metal carabiner that attaches to a belt loop.

Those not enrolled in the carabiner pilot program, however, have been ordered to wear their lanyards by management and hospital police who work at the facility entrance. On Thursday, many refused.

“I carried it in my hand, showed it to them and put it around my waist,” said psychiatrist Nader Wassef, who said he previously worked at two psychiatric facilities in Missouri where lanyards, ties, earrings and other items that could cause staff members harm were prohibited. “I told them, ‘Take my name down and report me.’ I can lose my job, but I’m not going to lose my life.”

Kathy Gaither, deputy director of the Department of State Hospitals, said in a morning statement on the assault that the lanyard had broken as intended, the “new alarm system worked as designed and staff responded consistent with the training received.” The lanyard, she said in a follow-up interview, “represents a minor risk, but the improvement in safety is so vast that it more than makes up for that risk.”

But pressure built. Assemblyman Michael Allen (D-Santa Rosa), a former psychiatric nurse who has pressed for improved safety at the hospitals, said he urged Gaither to heed employee concerns.

“They need to move away from these neck lanyards as quickly as possible … especially now that the staff have been proven right that they’re going to be viewed as a way to attack staff,” he said before driving to Napa State Hospital on Thursday to discuss his concerns in front of TV news cameras.

Meanwhile, Cal/OSHA spokeswoman Erika Monterroza said workplace safety regulators were “trying to ascertain the situation and determine if there are grounds to open an investigation.”

By midafternoon, Gaither made the decision: The carabiners, she said, will be available to all who wish to wear them “within the week.”

“It’ll be the employee’s choice,” she said.