A mental health patient allegedly punched two other patients in the head and stood on the head of another in an unprovoked series of attacks at Shellharbour Hospital.
The incident occurred at the Mirrabook unit on Saturday.
The alleged perpetrator was transferred to the Eloura High Care Area, but staff say the move was done without the necessary risk assessment checks.
"Staff had concerns about transferring him. We believe a risk assessment wasn't performed as per policy and staff were ordered by the director to transfer him," said another staff member.
"To transfer him to high care, if deemed too dangerous at that point in time, can be postponed until it's safe to do so. Mirrabook has a seclusion room if needed. But staff were overruled and ordered to walk the consumer to High Care from Mirrabook."
Illawarra Shoalhaven Local Health District Director of Mental Health Julie Carter said that if a consumer needs high-level escort or security, including police engagement, clinical staff will undertake a risk assessment to make their decision.
"This incident did not require that level of intervention and the consumer was transferred without incident," Ms Carter said.
People expect to be safe and families expect them to be in a safe environment. The service is failing these people and exposing staff to ongoing trauma.
"For all consumers that are identified as high risk, a risk management plan is developed and reviewed daily by the multidisciplinary team. Restrictive practices, such as seclusion and restraint, are used as a last resort and consumers are removed from seclusion as soon as it is safe to do so.
"We welcome opportunities for discussion with staff who may have concerns about how decisions are made in the care of consumers to allow for open collaboration."
One staff member said the incident was extremely scary and "the whole place is so unsafe".
She refused to be identified, saying she was concerned she would lose her job for speaking out.
It is believed one of the victim's loved ones witnessed the attacks.
"People expect to be safe and families expect them to be in a safe environment. The service is failing these people and exposing staff to ongoing trauma," another worker said.
Ms Carter said the district had commenced a review of "an incident involving consumers" at Shellharbour Hospital at the weekend.
"Those consumers were offered police assistance," she said. "Mental Health management has also directly discussed the matter with the families and carers of those involved.
"The Mental Health High Care Area provides care to consumers who often have complex mental health conditions and behaviours that may pose safety risks.
Lake Illawarra acting police commander Gordon Dunlop said police were called to investigate an incident on Saturday. The investigation had concluded and no further police action would be taken.