9/15/2017...9/15/2017 5 Scenario 1: Police Scenario 2 A person wearing scrubs and a stethoscope whom you’ve never seen before is entering patient rooms, responding to “codes”

9/15/2017

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BAD BOYS, BAD BOYS…

WACHA GONNA DO?

Linda Laskowski-Jones, MS, APRN, ACNS-BC, CEN, FAWM, FAANJeffrey R. Evans, BS, NEMT, Deputy Chief, University of Delaware Police

Objectives

▪ Identify how to recognize high risk situations in the health care setting that require law enforcement involvement.

▪ Learn how to respond to these high risk events in a safe and effective manner.

▪ Describe event-specific management strategies that encompass both hospital and law enforcement perspectives.

The Criminal Element & Healthcare▪ Crime doesn’t stop at the hospital doors—

making the leadership case for awareness & action

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Headlines in the News Media…

Hospital violence is on the rise, health agency warns

Assault, rape and murder pose a growing threat to

medical caregivers…

Violence is symptom of health care dysfunction

By Kevin Pho|

…a surgeon at Johns Hopkins Hospital was shot by the distraught son of a

patient for whom he was caring. The man later killed his mother, then himself. A

week earlier, a patient in a Long Island, N.Y., hospital beat his nurse with a leg

from a broken chair, causing serious injuries. The following month, a psychiatric

technician at a Napa, Calif., state hospital was fatally attacked on the job.

msnbc.com

USA Today

Precipitating Factors

▪ Emotionally-charged situations / poor coping

Threatening behavior, assault, property damage

▪ Substance abuse

▪ Psychiatric / behavioral conditions

▪ Interpersonal violence

▪ Gang-related activity

▪ Opportunistic moments (e.g., theft, HIPAA violations, identity theft, impersonation, sexual misconduct)

Risks in the Hospital Environment

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Violence in Healthcare

The Stories You are About to Hear are True…

▪ The names & circumstances have been changed to protect the innocent

Scenario I

▪ A trauma patient is transported by paramedics into the ED trauma bay with an abdominal gunshot wound.

▪ Upon cutting away clothing, a hand gun and bag containing white powder fall to the floor.

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Scenario 1: Hospital

▪ Do not touch the weapon

▪ Contact hospital security to remove & secure the weapon

▪ Directly hand-off the bag with white powder to security

▪ Document the presence of the gun as well as the bag of white powder in the medical record.

▪ Document names of staff & security personnel in the hand-off process to provide a complete chain of custody for the gun & bag

Scenario 1: Police

▪ Contraband can pose dangers to healthcare providers

Guns, edged weapons, syringes, etc.

▪ Fusion Centers (DIAC)

Clearing houses for nationwide intelligence

Information sharing partners

Ability to “tie in” weapons

▪ Collected & disposed of properly (safely)

Scenario 1: Police

▪ Atypical weapons

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Scenario 1: Police

Scenario 2

▪ A person wearing scrubs and a stethoscope whom you’ve never seen before is entering patient rooms, responding to “codes” & participating in patient rounds with the medical staff. He even brought in donuts!


▪ Ask to see hospital-issued ID badge▪ Ask name of person’s supervisor▪ Inquire about person’s role▪ If found to be an intruder:

Contact security / law enforcement / risk management at once

Interview staff & patients about person’s actions and the nature of any patient contact

Ask witnesses to document observations in writing

Disclose event to all involved parties / regulatory agencies

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Scenario 2: Police

▪ “Blenders” – suspect surveillance practices

▪ Technological advances in identity fabrication / theft

Sophisticated printing & laminating equipment

Catalogs sell equipment to “look the part”

Police “Look Alikes”

Scenario 2: Police

▪ Everyone must maintain situational awareness

Everyone is responsible for perimeter integrity

Be responsible for propped doors & other perimeter vulnerabilities

Make it a point to know everyone working in your area

▪ Trespassers must be noticed prior to arrest

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Scenario 3

▪ A 34-year-old male patient, angry because he didn’t get a Percocet prescription, tells the nurse, “I’m going to get you later. I know your name.” He pulls a cigarette from his jacket & punches a hole in the wall with his fist as he leaves the area.


▪ Contact security / law enforcement

▪ Document patient’s words & property damage event in medical record; be as specific as possible

▪ If surveillance cameras are in use, provide the time of the event & request that the recordings /footage be reviewed

▪ Flag patient’s potential for violence in medical record for future encounters

Scenario 3: Police

▪ Perpetrator must be held accountable

▪ Prosecution necessary for restitution

Police report without desire for prosecution questionable

▪ Helicopter security

Secure & monitored landing zone & on-site fuel facility

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Scenario 4

▪ Your unit clerk gets a call from an emotional man who claims he’s planted a bomb in the emergency department.


▪ Institute hospital bomb checklist immediately

▪ Keep caller on the phone & request details

▪ Quietly summon additional help to quickly notify security / law enforcement & hospital administrator

▪ Activate hospital code for bomb threat

▪ Consider placing ED on total divert / closed status

▪ Consider relocating or evacuating patients

▪ Arrange transport for all ED admitted patients to assigned unit or inpatient hallway

▪ Do not use cell phone s or electronic communication devices; can detonate certain types of bombs

Scenario 4: Police

▪ Bombs – IED’s:

Very easy to make

Internet sources for information “cook books”

Supplies can be legally purchased (large quantity purchases tracked)

▪ Evacuation / no evacuation

Decision made by property agent

Should have policy delineating response & who the “decision makers” are

May need additional resources (fire service)

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Scenario 4: Police

▪ Phoned in threat vs. discovery of suspicious package

Phoned threat – interrogate caller:

Time call received / When will it go off?

Where is it?

What does it look like?

What kind of bomb is it --how is it detonated?

Did you place it? Why?

Description of caller’s voice --Note caller ID if not blocked

Scenario 4: Police

▪ Suspicious package

Establish perimeter (public safety)

Do not use cell phones or other electronic communication devices

Be able to thoroughly describe the package

Scenario 5

▪ A shooting victim dies in the ICU. After next-of-kin is notified, grief-stricken & angry family & friends arrive en mass to the hospital, push through doors & begin a melee that destroys property & terrorizes everyone.

Intensive Care Unit

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▪ Activate panic button if available

▪ Call security / law enforcement

▪ Initiate hospital / unit lock-down

▪ Focus staff efforts on taking actions to protect patients from harm

▪ Close doors to patient rooms & secure areas / critical equipment to the best degree possible

▪ After situation is controlled, ask staff to immediately document observations / description of events

Scenario 5: Police

▪ “Scene continuation”

Family members

Victim associates

Perpetrator associates

▪ Gang awareness

Member appearance

Communication techniques

▪ Secure ED’s

Facilities to protect triage personnel

Ability to “isolate” the ED

▪ Lockdown procedures

Scenario 6

▪ A community pharmacy calls seeking order clarification. The patient who was just discharged from your unit with a hand-written prescription for 4 Percocet has just presented a prescription for 40 Percocet to the pharmacist.

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▪ Document nature of phone call in event reporting system / notify Risk Management / law enforcement

▪ Flag patient’s fraudulent activity in medical record for future encounters

▪ Preventative measures:

Computer-generated Rx on security paper

ePrescribing system

Scenario 6: Police

▪ Must follow up with law enforcement—Perpetrators often involved in regional fraud

▪ Many agencies have a sub-group of detectives in their drug units to handle nothing but prescription fraud and prescribed drug abuse.

Scenario 7

▪ An admitting clerk recognizes a patient whom she’s sure she admitted in the past. This time, however, he’s using a different name. The name he’s using matches the one on the insurance card he offered at check-in.

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Scenario 7: Hospital ▪ Request a picture ID

▪ Contact insurance company to review information contained within their system

▪ Contact law enforcement if fraud is suspected

▪ Preventive measures:

Photograph at registration; picture on ID band & medical records

Biometric authentication devices (e.g., palm vein, iris scanning)

Patient Wristband with Photo

Adapted from Standard Register SMARTworks®

Website

Scenario 7: Police

▪ Hospital constables (as opposed to “security guards”) have certain police privileges

Can run a database check on the patient’s name in law enforcement computer system in suspicious situations

Involve law enforcement for fraudulent / criminal activity

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Scenario 8

▪ A nurse performs a venipuncture. The patient experiences pain & roughly grabs the nurse’s wrist. When she asks him to let her go, he laughs, spits in her face & continues to hold her tightly.


▪ Attempt to pull away / act in self-defense

▪ Loudly call for help; if possible, activate code / stat call button to summon response team

▪ Call security / law enforcement

▪ Wash out eyes / face & receive immediate medical evaluation for injury

▪ Test patient for hepatitis / HIV (nurse also must undergo baseline screening)

▪ Document situation in event reporting system & file an employee injury report

▪ File assault charges

Scenario 8: Police

▪ This kind of behavior cannot be tolerated

▪ Definitions:

Offensive touching: touch by another that causes alarm. This includes extensions of the body such as body fluids

Assault: touch by another that causes injury. It is a felony to assault a health care provider (some states)

Justifiable force: force to protect oneself or others

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Scenario 9

▪ A stranger carrying a large tote bag approaches a new mother in the maternity unit & asks to hold her baby.


▪ Pre-event: teach all new parents not to allow strangers or those without proper hospital ID to hold their babies; use infant security system

▪ Ask stranger for ID; who is person visiting?

▪ If stranger can not be found, contact security & activate infant abduction response

▪ Assure all babies are accounted for; post employees at all entrances / exits

▪ Search all large bags

Scenario 9: Police

▪ Predators prey

Review birth announcements in media

Lawn signs, “welcome home” signs, etc.

▪ Newborn Unit perimeter systems

Secured doors

Alarmed exits, even stairways

Patient alarm mechanisms

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Scenario 10

▪ The husband of a nurse who is in the process of getting a divorce repeatedly calls the nursing unit. He expresses his anger over their break-up to anyone who answers the phone. He claims he will “get her back.”


▪ Record details of call: specifically what was said, what the caller intends to do

▪ Notify security / law enforcement

▪ Notify nurse about the phone calls

▪ Consider posting picture of caller in nurses’ station, break room & with security; note warning to call security if he is on the property

▪ Assure nurse has escort to her vehicle

▪ Initiate lockdown if there is an imminent threat

Scenario 10: Police

▪ Domestic workplace violence increasing

Suspect knows where the victim works, but may no longer know where she / he lives

Workplace often provides easy access to victim

▪ Definitions

Stalking: a person knowingly engages in a course of conduct directed at a specific person and that the conduct would cause a person to fear physical injury to himself / herself or to another person… or suffer mental anguish as a result of the conduct

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Scenario 10: Police

▪ Definitions

“Course of conduct”: three or more separate incidents

Terroristic threatening: “…person threatens to commit a crime that will cause physical injury / death to another” “…commits an act meant to cause an individual to believe that they have been exposed to a substance that will cause the individual death or serious physical injury…”

Scenario 11

▪ You go into the locker room. As you open the door, you startle a nurse who appears to be putting items into his locker. You see a syringe in his hand & a tourniquet on his arm – he drops a vial of fentanyl onto the floor.


▪ Ask nurse for explanation

▪ Follow occupational health procedure for employee evaluation / drug testing & event documentation; accompany nurse to evaluation

▪ Consider procedure to search employee locker & belongings

▪ Place on administrative leave pending review

▪ Investigation by Office of Narcotics & Dangerous Drugs; report to professional licensing authority

▪ Facility may choose to prosecute for theft

▪ Professional & legal consequences

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Scenario 12

▪ A patient on your unit is a home care nurse involved in a car crash. Upon arrival, she admitted to taking her patient’s narcotics, but is denying it now. She is due for discharge & plans to immediately resume her work with a hospice agency.


▪ Document patient statements in medical record

▪ Contact the hospital risk management department / legal counsel regarding the duty to report to state licensing board & patient’s employer; document the outcome of the conversation & the path forward.

▪ Review personal obligations as a licensee / contact Board of Nursing as indicated

▪ Anticipate investigation by Office of Narcotics & Dangerous Drugs

Scenario 13

▪ Active shooter

A man enters the facility through the main lobby and starts randomlyshooting people

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▪ Policy development & training regarding active shooter are essential

Should address notification of staff as well as lockdown & concealment techniques

“Run, Hide, Fight” education

Should train through drills

▪ Example: School drills:

Doors locked, lights out, people quiet, concealed along inside wall

Scenario 13: Police

▪ Law enforcement agency response to active shooter:

No longer wait for SWAT (Columbine lessons)

Initial officers enter facility with goal to locate & eliminate shooter

Will not help with evacuation or care of injured

▪ “Pause in action” concept:

Survivalist attitude essential

Take control of the situation (Virginia Tech reports)

Promote a Safe Work Environment

▪ Staff awareness / training in violence prevention

▪ Conflict resolution / de-escalation techniques

▪ Zero tolerance policy

▪ Signage

▪ Mandatory reporting

▪ Critical incident debriefing after event

▪ Key card door access

▪ Monitored access points / security

▪ Bullet-proof glass

▪ Panic buttons

▪ Lock-down capability

▪ Video surveillance

▪ Magnetometer wands / metal detectors

▪ Canine program

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Signage Example

We are committed to providing a safe, healthy, respectful environment through the prevention

of violent, abusive & aggressive behavior.

We have a ZERO TOLERANCE policy for all forms of abuse.

We reserve the right to take appropriate measures, which may include requesting you to leave or

legal action if the policy is violated.

Thank you for your cooperation.

Security Measures

Bullet Proof Glass Hospital Canine Security

Metal Detectors

Pass–through detector Hand Wand

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Selected References▪ Arnetz, J. E., Hamblin, L., Essenmacher, L., Upfal, M. J., Ager, J., & Luborsky, M.

(2015). Understanding patient‐to‐worker violence in hospitals: a qualitative analysis of documented incident reports. Journal of advanced nursing, 71(2), 338-348.

▪ Delaware Criminal and Traffic Manual, LexisNexis 2011, T11 s464, s601, s612(4), s621(a1,3), s1311(a), s1312(a).

▪ OSHA (2015). Workplace violence in healthcare. https://www.osha.gov/Publications/OSHA3826.pdf

▪ Papa, AM, Venella, J. (2013). Workplace violence in healthcare: Strategies for advocacy. Online journal of issues in nursing, 18(1), 101.

▪ Sauer, PA. Workplace Violence: Not Part of the Job. West J Nurs Res. 2017 Aug 1:193945917729622. doi: 10.1177/0193945917729622. [Epub ahead of print]

▪ The Joint Commission (June 03, 2010; addendum Feb 2017 ). Sentinel event alert: preventing violence in the health care setting. http://www.jointcommission.org/SentinelEventAlert/sea_45.htm

▪ The Joint Commission (2017). Workplace violence prevention resources for healthcare. https://www.jointcommission.org/workplace_violence.aspx.

http://www.jointcommission.org/SentinelEventAlert/sea_45.htm

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9/15/2017...9/15/2017 5 Scenario 1: Police Scenario 2 A person wearing scrubs and a stethoscope whom you’ve never seen before is entering patient rooms, responding to “codes”