California Fines Healthcare Facility for Safety Violations Leading to Death of Doctor

Dr. Erlinda Ursua was beaten and strangled to death by a patient Nov. 19, 2003 in an examining room at John George Psychiatric Pavilion in San Leandro, Calif., and the state says the public psychiatric hospital should have done more to prevent such an incident from occurring.

California's Division of Occupational Safety and Health (Cal-OSHA) issued $54,000 in fines against John George Psychiatric Pavilion. According to a report issued by the agency, the hospital's written Injury and Illness Prevention Program, required by law, has a safety management plan requires the unit manager or designee to "inspect patient areas at least weekly to identify unsafe equipment or environment. Takes action to remove/repair unsafe areas."

According to Cal-OSHA's report, "The employer did not effectively inspect the workplace in that the examination room of Unit C was in an isolated location where employees working in the space could not be readily heard or seen by other employees. The exam room was behind locked doors and physically separated from the work areas where other employees were located."

Cal-OSHA's report claims hospital employees also failed to follow hospital policies that doctors were not to be left alone with potentially violent patients and that staff members were not allowed to wear scarves or jewelry. Allegedly, Ursua was strangled by patient Rene Pavon with her own scarf.

The citations and fines include: Ineffective hazard inspections resulting in the use of an isolated exam room, $18,000; Ineffective attendant policies resulting in staff meeting alone with potentially violent patients, $18,000; Ineffective enforcement of policies including observation/assault precautions, dress code, and response to unauthorized patient possession of exam documents, $9,000; and ineffective alarm system, $9,000.

Hospital spokesman Jeff Raleigh said officials have not decided if they will appeal the Cal-OSHA penalties.

According to Raleigh, the room where Pavon killed Ursua is no longer used for examinations and he disputed Cal-OSHA's claim that doctors were not accompanied by other staff members when seeing potentially violent patients.

Pavon is awaiting trial for murder, and Ursua's family have filed a wrongful-death lawsuit against the hospital, claiming the hospital lacked adequate security.

This is not the first time the hospital has been cited and fined by Cal-OSHA for complaints about inadequate security measures following workplace assaults. Investigations in 1998 and 2003 found the hospital failed to report two assaults on staff members and did not have an injury-prevention program.

Cal-OSHA spokesman Dean Fryer said the hospital administration "should have taken greater steps to ensure safety of the employees, and we didn't see that happening."

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