INCIDENT REPORT FORM

Section A: Information Step 1

Company Name: Prisma Health Date: 06/01/2022

Investigator or Team Name(s) and Titles:

NAME TITLE
1. Lead Investigator: Nancy McCollough HCR 264 Student

2. Jessie Jones, M.D. Physiatrist

3. John Riggs Safety Officer

4. Robert Baker Jr. Sumter County Coroner

Section B: Incident Description/Injury Information Step 1 and Step 2

1) Name and age of injured employee: Kevin Robinson

Employee’s first language: English

Employee’s job title: Mental Health Technician

Type of employment:
☒ Full-time ☐ Part-time ☐ Temporary ☐ Seasonal ☐ Other:

Length of time with organization: 11 years

Length in current position at time of the incident: 11 years

2) Description and severity of injury: Robinson was kneed in the groin by a patient who was
being restrained. Robinson then went into cardiac arrest
and later died.

3) Date and time of incident: May 27, 2022, 06:10 am

4) Location of incident: Prisma Health- 129 N. Washington St. Sumter, SC 29150

5) Detailed description of incident from injured employee’s perspective. Include relevant events
leading up to, during and after the incident.

1
Adapted from OSHA Incident [Accident] Investigations – A Guide for Employers. Retrieved from https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015.pdf
 I was working my shift as a mental health technician on May 27,2022. A patient, Imani Cox,
was admitted to the facility for a court related mental health screening (Joseph, 2022). Cox
was agitated and stated she was hearing voices (OSHA, 2022). The patient was unable to
leave the hospital due to safety reasons. We moved the patient to the emergency department
overflow for observation when the patient attempted to leave (OSHA, 2022). Cox attempted to
leave the building and resisted staying in the overflow area. I assisted the security in
restraining the patient (OSHA, 2022). While I was assisted in restraining the patient, she was
able to knee my groin area (OSHA, 2022). I backed away and vomited (OSHA, 2022).

Robinson then collapsed and was taken to ICU due to a heart attack (OSHA, 2022). Robinson
then passed away four days later on May 31, 2022 (Joseph, 2022).

6) Description of incident from eyewitnesses, including relevant events leading up to, during and
after the incident. Include names of persons interviewed, job titles and date/time of interviews.
Joshua Histle, security guard. Date/Time of interview: 05/27/2022, 07:30 am: I was working
my assigned shift on May 27th. I was called over to assist with an agitated patient who
attempted to leave the hospital but was not allowed to due to safety reasons. When I arrived
on scene there were two mental health technicians attempting to restrain the patient. I
assisted the technicians as the patient was becoming more violent. The patient began hitting
the technicians. She hit Kevin Robinson in the groin. Robinson then backed away and became
sick. Shortly after he collapsed and was taken to the ICU.

Gene Smith- Mental Health Technician. Date/Time of interview: 05/27/2022 8:00am: I began
my shift at 5:30am on 05/27/2022. I was called over to assist with a court ordered mental
health exam. I was working with Kevin Robinson. It was determined that it was not safe for
the patient to leave the hospital. We determined that she needed to be moved to the overflow
area before being admitted. Once we moved the patient, she began to become more agitated
and attempted to leave the facility. I called security to come over and assist with restraining
the patient. In her attempts to get away she struck Kevin Robinson. He moved away from the
patient, vomited, and soon after collapsed. Working with the ER staff he was moved to ICU
where they determined he had suffered a heart attack. He passed away several days later.

Section C: Identify Root Causes – What Caused or Allowed Incident to Happen? Step 3

The root causes are the underlying reasons the incident occurred, and are the factors that need to
be addressed to prevent future incidents. If safety procedures were not being followed, why
were they not being followed? If a machine was faulty or a safety device failed, why did it
fail? It is common to find factors that contributed to the incident in several of these areas:
equipment/machinery, tools, procedures, training or lack of training, and work environment. If
these factors are identified, you must determine why these factors were not addressed before the
incident.
After investigation it was found that Prisma Health has a workplace violence training offered
annually (Joseph, 2022). All staff members were up to date on this training. There were also
active policies related to workplace safety in place prior to this event (Joseph, 2022).

2
Adapted from OSHA Incident [Accident] Investigations – A Guide for Employers. Retrieved from https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015.pdf
 It was determined that the restraint/de-escalation portion of this policy was not followed. The
policy states that restraints can be used on any patient is a danger to themselves or staff
(ACEP, 2020). These restraints can be mechanical in nature or a sedative (ACEP, 2020). There
was no documentation of de-escalation or restraints being used prior to the event. Through
interviews it was determined that no sedatives or mechanical restraints were in place prior to
Imani Cox’s move to the overflow room. It has been determined that a more in-depth exam
prior to Imani Cox being moved to be admitted would have revealed her agitation and a need
for closer observation and care. This might have prevented her move to the over flow room,
or shown a need for more serious treatment.

Section D: Recommended Corrective Actions to Prevent Future Incidents Step 4

It is recommended that Prisma Health review their restraint and de-escalation policy for
mental health patients and create training for all medical staff. Including where the
responsibility lies for judging the need for restraints. There should be a review to see if this
policy needs to be updated and how they can best implement the changes.

The training should include de-escalation techniques and how to handle patients that get
increasingly agitated. It should also cover how to restrain patients in the least restrictive
manner possible and who makes the call for those techniques. This training should be made
available to all employees that work directly with patients. It should also be repeated annually.
Security should also be trained in how to properly treat and restrain aggressive patients.

It is also advised that in situations where a mental health patient needs to be admitted to the
hospital, the number of rooms moves that the patient goes through, keeping them in a more
secure room.

Section E: Corrective Actions Taken/Root Causes Addressed Step 4

In order to address the cause of Patient Inami Cox attacking Mental Health Technician Kevin
Robinson, it has been determined that better knowledge and use of restraint policy could have
prevented this incident. Additional repeated training on restraints will address this. By creating
additional training opportunities, it will allow the facility to specifically address how to properly
treat, de-escalate, and restrain an aggressive patient, reducing chances of injury to
themselves or others (ACEP, 2020).

In addition to the medical staff being trained in restraints and de-escalation, the security staff
should be trained in how they can assist with restraining a patient and keep the patient,
workers, and surrounding individuals safe (ACEP, 2020). By providing training to both the
medical staff and security staff it ensures they will be on the same page when it comes to
incidents with aggressive patients.

3
Adapted from OSHA Incident [Accident] Investigations – A Guide for Employers. Retrieved from https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015.pdf
 Also the taskforce on workplace violence within the organization should review the policies and
procedures regarding aggressive patients and update the policy as needed. This will help
address prevention and workplace safety.

If the facility is able to create a room for those individuals in mental health crisis that is free of
objects that can be used to cause harm to themselves or others, they would be able to reduce
the amount of room changes and general movement of the patient while they assess and
determine if they need to be admitted. This reduces the amount of stimulus the patient is
introduced to and reduces the chances of them attempting to leave.

4
Adapted from OSHA Incident [Accident] Investigations – A Guide for Employers. Retrieved from https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015.pdf
 References

Joseph, C. (2022, June 6). Prisma Health employee dies after mental patient strikes groin.
https://www.wistv.com. Retrieved February 12, 2023, from
https://www.wistv.com/2022/06/06/prisma-employee-dies-after-patient-attack/

United States Department of Labor. Inspection Detail | Occupational Safety and Health
Administration osha.gov. (2022, November 28). Retrieved February 12, 2023, from
https://www.osha.gov/ords/imis/establishment.inspection_detail?id=1599486.015

Use of patient restraints. ACEP //. (2020, February). Retrieved February 12, 2023, from
https://www.acep.org/patient-care/policy-statements/use-of-patient-restraints/

5
Adapted from OSHA Incident [Accident] Investigations – A Guide for Employers. Retrieved from https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015.pdf