10Investigates: State finds deficiencies at Knoxville center where nurse suffered fatal injuries
Jan Allison died because of complications from a hip fracture after a patient pushed her while she worked at a behavioral hospital.
After Jan Allison died in October 2023, the Tennessee Occupational Safety and Health Administration said the East Tennessee Behavioral Health didn't furnish a place of employment safe from hazards, a citation said.
Allison, 61, died from complications of a hip fracture.
On Sept. 23, 2023, two patients at East Tennessee Behavioral Health were in the middle of an altercation. One of the patients walked up to Allison and pushed her to the ground, surveillance video of the incident shows.
10News obtained that video through an open records request of the Knoxville Police Department's investigation file into Allison's death.
Allison was taken to Fort Sanders Regional Medical Center, where she died on Oct. 25, 2023, from complications including respiratory failure, infection, pneumonia and other ailments, according to the autopsy report.
Assistant Medical Examiner Dr. Amy Hawes at Knox County Regional Forensic Center said Allison died from complications of a left hip fracture and classified her death as a homicide.
The Criminal Investigation The District Attorney General declined to bring charges.
On Dec. 7, 2023, KPD announced its homicide unit opened an investigation into Allison's death. The autopsy report said because someone pushed Allison, her manner of death would be "best classified as a homicide."
Assistant District Attorney Larry Dillon sent a letter to KPD Detective AJ Loeffler informing him the District Attorney's Office would not prosecute the man shown in the video pushing Allison.
"The death is without criminal intent, and the death did not occur in a proximate time connected to the actions of the defendant," Dillon wrote. "As you know, the defendant was in a therapeutic psychiatric facility, with a long-term diagnosis of a chronic mental condition."
"It doesn't seem like there's any repercussions for anyone involved with what happened," said Kathie Morris, Jan's sister.
Morris said Allison's family is concerned without criminal charges, the man who pushed Allison may not face any consequences and his record won't show he pushed a nurse.
10News has since learned that on Oct. 31, 2023, around six days after Allison's death, a hospital in Middle Tennessee filed for a court to appoint a conservator for the man who pushed Allison.
"[That man] lacks the capacity to consent to his discharge, transfer, or admission, and any financial arrangements or medical care necessary," the petition said.
WBIR is not identifying the man because he was committed to a mental institution at the time of Allison's injury and death.
Hospital Safety TOSHA cited East TN Behavioral Health for not maintaining a safe work environment.
Weeks after Allison's death, TOSHA conducted an inspection of East Tennessee Behavioral Health. The inspection found violations, including a serious violation, in which TOSHA inspectors said East Tennessee Behavioral Health didn't provide a place of employment free from hazards.
The hospital, which opened in July 2022 as a collaboration between Covenant Health and Acadia Health, was fined $6,000 for violations during that Nov. 1, 2023, inspection.
"Workers at this psychiatric hospital were frequently exposed to high instances of workplace violence when interacting with patients," said TOSHA's investigative summary. "There were approximately thirty workplace violence incidents that resulted in injuries between 2022 and 2023."
In an emailed statement to 10News, Acadia Healthcare said, "As you report on this, please keep in mind the statement cited in the document you shared quoting The Joint Commission, 'inpatient psychiatric and emergency departments have the most recorded incidents of workplace violence in the medical field' – due, in part, to the acute behavioral health needs of patients receiving care."
TOSHA's summary said security wasn't typically present at the hospital on weekends. It said hospital staff who were isolated didn't have panic buttons or communication devices to alert staff if they were attacked.
"It was stated by one employee that reporting such concerns to management would lead to reprisal," the investigative summary said.
It recommended East Tennessee Behavioral Health hire full-time security to respond to incidents that require the use of restraining.
"Since receiving the report from the Tennessee Department of Labor’s inspection in November 2023, we have been progressively working on an abatement plan," Acadia Healthcare said in the emailed statement.
10News asked Acadia if it had taken TOSHA's recommendation to hire full-time security. A representative said, "We have nothing further to add."
Family Reaction Jan's family wants to see accountability.
Around six months after Allison's death and the ensuing investigation, her family members felt her death was preventable.
"We think that, maybe, had there been security there, or enough staff, or protocols more thoroughly in place, she could still be here today," said Elena Caicedo, Allison's daughter.
Caicedo said that by law, workers' compensation is the exclusive remedy for job-related injuries. It means they can't sue the hospital. Instead, Caicedo said, the family received a workers' compensation payout of $500,000.
"There is no legal avenue for us. We're not able to pursue a civil case," Caicedo said.
Family members also said they would like to see criminal charges brought against the man who pushed Allison.
"If he ever assaults anyone in the future, there's nothing linking him to this," Morris said.
Acadia Healthcare full statement
"As you report on this, please keep in mind the statement cited in the document you shared quoting The Joint Commission, “inpatient psychiatric and emergency departments have the most recorded incidents of workplace violence in the medical field” – due, in part, to the acute behavioral health needs of patients receiving care.
Particularly with this fact in mind, we are committed to the highest safety standards and actively engage with our employees, including front-line clinical staff, to support them and their safety. Since receiving the report from the Tennessee Department of Labor’s inspection in November 2023, we have been progressively working on an abatement plan that includes, among other things, continuing to enhance staff education sessions on verbal de-escalation and workplace violence prevention, and continuing to reinforce consistent, detailed reporting on all work-related injuries and illnesses. We will continue to take all appropriate steps consistent with our commitment to our employees, our patients, and the delivery of high-quality care in a safe environment."