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 patient involved in the attack, 36-year-old Raymond McKoy, 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 McKoy'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 McKoy had been "loud, agitated, and intrusive all day," according to the incident's police report.
That night McKoy, who is originally from Georgia and had at one point been a student in Stanford's neurosciences program, 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. McKoy 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 McKoy was "not directable, irritable, had been wandering in rooms, was disorganized."
Kennedy began administering medication to McKoy 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 McKoy but was struck as well, at which point security officers and other staff entered the unit and restrained McKoy. 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.