A Brutal Attack Upended Her Life. It Also Exposed Gaps in California’s Hospital Safety Laws

The assault pulled like a riptide on Dr. Dani Golomb’s life, spinning her in unexpected directions, but not quite fully pulling her under.

Golomb was working on a California Pacific Medical Center inpatient psychology unit on Sept. 5, 2020, when a patient attacked and dragged her, grabbing her metal clipboard out of her hand and smashing it against her head, knocking her unconscious.

Golomb suffered a concussion and a traumatic brain injury, and the headaches and other symptoms still linger. She took multiple leaves of absence from her job, including one that lasted a year, setting her back on her journey to becoming a psychiatrist.

The attack happened shortly after she finished medical school and moved from Salt Lake City to San Francisco for a residency at California Pacific Medical Center, Sutter Health’s flagship hospital. Golomb wanted to practice psychiatry in the Bay Area, hoping to one day open her own private practice.

“That’s why I went to medical school. Most people go in because they are passionate about medicine,” she said. “I went in because I was passionate about working with individuals in therapy.”

Following the attack, Golomb — with her life and career upended — dedicated herself to improving safety protections for her colleagues. She shared her story with KQED, which triggered the California Division of Occupational Safety and Health, or Cal/OSHA, to launch an investigation, including an inspection of the psych unit where she was attacked.

The details of the investigation, which concluded last fall, have not been discussed publicly until now.

“I put so much work into providing [investigators] with as much information as I could, sending them documents, connecting them with people, talking to nurses about the importance of reporting,” Golomb said.

She feels state regulators and her employer fell short of providing the safety protections the hospital needs. Her story exposes holes in California’s workplace violence regulations for healthcare workers — namely, a lack of reporting on the part of employers and enforcement on the part of Cal/OSHA and its understaffed offices.

Cal/OSHA investigators identified numerous other colleagues who suffered attacks on California Pacific Medical Center’s inpatient psych unit. In one instance, a patient broke the nose and ribs of a nurse who “will never return again,” the Cal/OSHA inspection found.

In another case, a patient charged at an occupational therapist who was leading an exercise group and lifted them off the floor. “He carried me across the room by my neck,” the therapist reported, according to interview notes included in the Cal/OSHA report.

“He dragged me to a corner of the room and pulled a chair in front of us. He said if I don’t get to talk to the judge, ‘I am going to kill her,’” the therapist said, according to the notes. A security guard eventually defused the situation.

In 2022, two years after Golomb’s assault, Sutter Health relocated the inpatient psych unit where she was attacked to its Davies Campus. The hospital said it spent about $40 million outfitting the unit with cameras, panic buttons, duress alarms and secured doors to enhance safety. Staff can reach security by phone and a voice-operated device. The floor also has security officers during daytime hours, which Golomb said has made staff feel safer.

The Cal/OSHA report alleged numerous hospital failures at the new unit on security training, staffing, informing staff of “incident investigations and any corrective actions,” and a lack of “physical barriers between patients and clinicians” in some areas.

“A patient has jumped from the waist height counter onto a nurse from behind in the past, injuring his shoulders and neck,” the report said, noting blind corners, broken elevators and insufficient emergency exits.

All of the details in the inspection were validating, Golomb said.

But the first sign it might not produce the meaningful change Golomb sought came when investigators told her that her case fell outside the statute of limitations.

“I was like, ‘Wait a second, this is off the table?’ That was the impetus for this investigation,” she said.

As a result of the inspection, which cited KQED’s reporting, regulators issued two small citations to the hospital totaling $1,575: a fine of $525 for failing to maintain two failed separate exits and a $1,050 fine for failing to implement Sutter’s workplace violence prevention plan.

Cal/OSHA must issue a citation no later than six months after the “occurrence of a violation,” according to the labor code. But the “occurrence” continues until it is “corrected, or the division discovers the violation.”

Cal/OSHA did not appear to become aware of Golomb’s 2020 assault until she came forward with her story years later. Garrett Brown, a former field inspector who worked for more than two decades at Cal/OSHA, said regulators could still have examined Golomb’s attack.

The hospital was legally required to file a violent incident report to state regulators within 72 hours, but Cal/OSHA has no record of the incident. Sutter Health acknowledged that it did not initially report Golomb’s assault or injury but said it did record the assault in an injury log filed with the state.

The statute of limitations should be six months after Cal/OSHA became aware of the assault rather than when it occurred, Brown said, adding that it’s “outrageous” and “pisses him off” that it didn’t look at Golomb’s case.

Sutter Health said it has the appropriate safeguards in place, follows state guidelines and is contesting both citations. Cal/OSHA declined to comment further because of that appeal.

A Sutter spokesperson told KQED in a statement that providing a safe place for employees to work and patients to receive care is the hospital’s top priority. “We continually reevaluate our procedures and facilities to ensure we are providing the safest possible environment,” the statement said.

The citations felt like a slap on the wrist for Sutter, Golomb said, and the hospital’s appeal was like a slap across her face.

“Seeing this was just like, ‘Oh, right, nobody cares about enforcement,’” she said. “And I don’t mean nobody cares about me. I mean, nobody cares about the safety of workers and poor patients.”

Part of the problem is what Brown calls an “outrageous understaffing” of Cal/OSHA inspectors, with only two individuals who are charged with overseeing all of San Francisco’s workplaces, according to a Cal/OSHA organization chart dated the first of this year.

“The district manager is under enormous pressure to open, close, open, close, open, close the inspections because there’s this stack that grows every day of complaints and accidents that report,” Brown said.

Daniel Lopez, Cal/OSHA’s communications deputy director, pushed back and said in a statement the number of available inspectors does not determine the pace of an investigation. “Timely enforcement is critical, as these cases often involve serious safety concerns that affect both employers and workers,” he said. “Cal/OSHA prioritizes inspection activities based on the greatest risk to employees, responding to imminent hazards, fatalities, serious injury and illnesses and serious complaints.”

Lopez added that Cal/OSHA recently hired an associate safety engineer, noting that San Francisco is a particularly competitive market and the agency is “actively” recruiting to fill three remaining vacancies in its office. “The division’s vacancy rate is among the lowest it has been in several years,” he said, pointing to a fact sheet that pegged it at 13%.

Since 2014, California health care facilities have been subject to the nation’s strongest workplace violence regulations.

California Sen. Alex Padilla, when he was a state lawmaker, crafted the rules with SB 1299 “to help ensure safer working environments for the nurses and doctors who provide critical care for our communities, but it’s clear that more needs to be done to build on our efforts,” he told KQED in a statement. “Physicians on the frontlines of our mental health crisis deserve a safe workplace.”

The California Nurses Association, which sponsored the legislation, has since criticized the state’s enforcement and hospitals for underreporting violent incidents.

Golomb pushed for accountability another way, thrusting herself into an organizing effort with her coworkers and leading residents to push for stronger protections.

Golomb and her resident colleagues joined the Committee of Interns and Residents, a local of the Service Employees International Union, and engaged in contentious bargaining with Sutter Health over demands for, among other things, 24-hour security in the inpatient psych unit.

San Francisco supervisors urged Sutter Health in a letter addressed to its leadership to step up safety measures. “Health care workers who keep us safe and healthy deserve safety in their workplace, too,” then-Board of Supervisors President Aaron Peskin said last June.

Last October, the residents and Sutter agreed to a contract, which included increased salaries and housing stipends, as well as an education fund to cover conferences and other professional development.

But the union failed to secure one key demand: round-the-clock security.

Golomb said it is hard not to feel disappointed. “A big piece of it is in the institutions,” she said. “But a part of me wants to say to myself, ‘Did I not fight hard enough?’”

She cannot remember what she first envisioned residency to be like. She certainly did not imagine she would have endured such a horrific assault.

“One that could have ended my career in medicine. Then to have a brain that has changed because of it,” she said. “I’ve come such a long way in my recovery, but I also feel that experience has made me even more clear about what my beliefs are in practicing medicine and the kind of doctor I want to be.”

She’s counting the days until she graduates at the end of June. She’ll take time off before starting a private practice in San Francisco, not too far from California Pacific Medical Center.

“It’s very exciting,” Golomb said. “But it’s very much like being a senior in high school and you’re just like, ‘Come on, let’s go.’”