Environment of Care News, October 2015, Volume 18, Issue 10

ECNews

The Joint Commission

October 2015 Volume 18 Issue 10

Environment of Care | Emergency Management | Life Safety

Dangerous Denizens

Preparing staff, law enforcement, and your hospital to manage forensic patients

Last March, an accused bank robber who had a criminal history was admitted for treatment at Inova Fairfax Hospital in

Falls Church, Virginia.1 He snatched a security officer’s gun, fired a harmless shot while tussling with the guard, fled the facility, and carjacked a woman a few miles away.1 After an intense manhunt, the escapee was captured. Fortunately, no one was hurt.1

his incident underscores the hazards involved when a hospital hosts a forensic patient—defined here as a potentially violent convicted prisoner or suspected

criminal in the custody of law enforcement or someone declared as unfit to stand trial or not criminally responsible for mental health reasons. With risks from theft to disease transmission to assault to murder, these dangerous patients—often capable of sudden aggressive behavior—can pose serious threats to hospital occupants and put your organization at risk.

This is particularly the case when a forensic patient attempts to elope, which occurs more often than one might expect. A 2011 study by the International Association of Healthcare Safety and Security (IAHSS) found 99 documented cases of attempted and/or completed prisoner patient escapes from medical facilities in the 12-month period ending April 2011—approximately

8.4 incidents monthly.2

Not all forensic patients misbehave. Yet a risk remains that any forensic patients could be unfairly abused, neglected or discriminated against by hospital staff, security guards, police/ correctional officers, or even patients and visitors—creating legal

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Health care organizations must prepare themselves to manage the health and safety of patients and staff when a patient is in law enforcement custody.

Inside

2 Test Your Standards IQ

5 Protecting Patients and Staff from Infection Risks

Cleaning and disinfecting environmental surfaces

8 Clarifications and Expectations:

Testing and Maintaining Gaseous and Portable

Fire Extinguishers

Examining Standard EC.02.03.05, EPs 14–16

Dangerous Denizens

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liabilities for your organization.

Consequently, it’s crucial that every- one involved understand his or her related responsibilities and the risks involved and that they communicate and collaborate effectively. Staff should receive training on properly managing forensic patients.

When trouble walks in . . . Custody and safeguarding of forensic patients is typically the responsibility of external law enforcement personnel, whether it’s local police, state troopers,

correctional officers from a nearby jail or prison, federally contracted guards, or

injuries sustained from events like a fight, car accident, or driving under the influence. Others are transported from a place of incarceration, arriving hand- cuffed in a police vehicle to be admitted as an inpatient for chronic illness, says Dodd M. Day, MAS, CSP, CHSP, CPP,

a Dallas-based Life Safety Code®* surveyor for The Joint Commission.

“Police officer judgment may dictate continued use of handcuffs to restrain the patient in police custody in the health care environment. Hospital staff should understand that patients in cus- tody of sworn law enforcement officers may remain restrained for the safety of the officer, patient in custody, and hospi- tal staff,” Day says.

third-party security service professionals

hired to transport and supervise crimi- nals from an outside facility. These armed escorts can bring forensic patients into your emergency department at any time, without advance notice. Their job is to constantly remain with and secure the patient, typically standing guard outside the patient’s room.

“With the exception of a relatively few hospitals that have their very own law enforcement on campus, hospi- tals are largely unequipped to manage and restrain forensic patients and are dependent on their local law enforce- ment agencies to do so,” says Jim Miller, executive director, Support Services, Medical Center of McKinney, McKinney, Texas.

A hospital’s staff and employed or contracted in-house security personnel should not be allowed to take custody of or guard a forensic patient or relieve external law enforcement in the super- vision of a forensic patient, although hospital security should be permitted to

assist these officers if the patient attempts to inflict harm or escape. “In-house secu- rity and nursing staff should also perform increased rounding on forensic patients to ensure that security practices are being followed,” says Miller.

Many forensic patients suffer from

“Almost any hospital employee could potentially come face-to-face with a

forensic patient, which is why there should be some basic training provided to all staff.”

—Jim Miller, executive director, Support Services, for Medical Center of McKinney, McKinney, Texas

Professional hazards

Day says several unique vulnerabilities arise for both law enforcement and hospital staff when a forensic patient arrives—particularly in clinical treatment areas, restrooms, entrances/parking lots, and emergency rooms (where 39%, 29%,

17%, and 14% of attempted escapes have occurred, respectively, per the aforementioned IAHSS study2).

“Police may be inadvertently exposed to unique hospital hazards like blood- borne pathogens, radiation, and hospital emergencies. Hospital staff could be

Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.

Medical Center of McKinney makes this brochure available to all staff as well as external law enforcement.

unintentionally exposed to patient vio- lence if not aware of the criminal patient. And police may inadvertently compro- mise patient safety if they are unfamiliar with the environment of care,” says Day.
While most officers are highly trained to execute their specific police mission, hospitals should never assume that police have been trained to operate in the health care environment. “Police may not understand patients’ rights while per- forming their mission inside the health care occupancy,” says Day.

To plan and protect
To balance the needs of the patient in custody and the safety of building occu-
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Copyright 2015 The Joint Commission
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Dangerous Denizens
(continued from page 3) Standards Connection
pants, hospital staff, internal security, and
outside law enforcement must continually interact and cooperate. “All parties need to be educated about all the risks ahead of time,” Day adds. Only with effective
To safeguard against forensic patient risks, adhere to the following Joint Commission standards and elements of performance (EPs) related to the Environment of Care (EC), Emergency Management (EM), Human Resources (HR), and Leadership (LD) standards:
communication and training can these dangers be managed to a suitable level.” To minimize forensic patient risks,
it’s important for a medical center to conduct risk assessments and hazard vulnerability analyses and evaluate and revise (if necessary) its Emergency Oper- ations Plan. In addition, hospitals should employ appropriate internal security measures and personnel, ensure that staff and internal security clearly understand their duties regarding forensic patients, and implement violence management/pre- vention and de-escalation training to any vulnerable employees and departments.
“Almost any hospital employee could potentially come face-to-face with a forensic patient, which is why there should be some basic training provided to all staff,” Miller says. “This training will help ensure the minimization of risk from a security incident, reduce the
anxiety of staff who may come in contact with the patient, and provide appropriate steps and behaviors to prevent escalating potential dangerous situations.”
Without knowing how to keep non- verbal cues nonthreatening, for example, an untrained employee could potentially unknowingly make a situation worse when dealing with a patient who is beginning to lose control.
Health care organizations should be aware that the US Centers for Medicare
& Medicaid Services (CMS) does not consider the use of weapons by organi- zation staff to be a safe and appropriate health care intervention. If the organiza- tion employs armed security guards, use of a weapon in this instance is considered to be a law enforcement action. CMS does not support the use of weapons by hospital staff in the course of restraining or secluding a patient.
EC.02.01.01, EP 1: The hospital
identifies safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospital’s facilities. (See also EC.04.01.01, EP 14)
Note: Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts.

EC.02.02.01, EP 7: The hospital
identifies individuals entering its facilities.
Note: The hospital determines which of those individuals require identification and how to identify them.

HR.01.04.01, EP 7: The hospital orients external law enforcement and security personnel on the following:
- How to interact with patients
- Procedures for responding to unusual clinical events and incidents
- The hospital’s channels of clinical, security, and administrative communication

Likewise, the use of handcuffs, manacles, shackles, or other chain-type restraint devices is considered a law enforcement action. CMS does not con- sider these devices to be safe, appropriate health care restraint interventions for

use by hospital staff to restrain patients. Organizations should also be aware that if law enforcement officers take a patient into custody, the hospital continues to be responsible for an appropriate assessment of the patient and for providing safe, appropriate care to the patient.

The CMS State Operations Manual

§482.13(f) A-0194 states: Without adequate staff training and competency, the direct care staff, patients, and others are placed at risk. Patients have a right

Distinctions between administrative

and clinical seclusion and restraint

LD.04.03.11, EP 6: The hospital measures and sets goals for mitigating and managing the boarding of patients who come through the emergency department. (Refer to NPSG.15.01.01, EPs 1 and 2; PC.01.01.01, EPs 4 and

24; PC.01.02.03, EP 3; and PC.02.01.19,

EPs 1 and 2)

Note: Boarding is the practice of holding patients in the emergency department or another temporary location after the decision to admit or transfer has been made. The hospital should set its goals with attention to patient acuity and

best practice; it is recommended that boarding time frames not exceed four hours in the interest of patient safety and quality of care.

LD.04.03.11, EP 9: When the hospital determines that it has a population

at risk for boarding due to behavioral health emergencies, hospital leaders communicate with behavioral health care providers and/or authorities serving the community to foster coordination

of care for this population. (Refer to LD.03.04.01, EPs 3 and 6)

to the safe application of restraint or seclusion by trained and competent staff. Staff training and education play a criti- cal role in the reduction of restraint and seclusion use in a hospital.

Hospitals that use Joint Commission accreditation for deemed status purposes with the Centers for Medicare and Medicaid need to be in compliance with Standard PC.03.05.17, EP 2, which states: The hospital trains staff on the use of restraint and seclusion, and assesses their competency, at the following inter- vals: At orientation, before participating in the use of restraint and seclusion,

on a periodic basis thereafter. Standard

PC.03.05.17, EP3, lists some of the

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Dangerous Denizens

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content that is essential to any training program on restraint and seclusion.

Strategies for safety success Experts recommend hospitals take several steps to minimize forensic patient perils, including the following:

STRATEGY Assign an appropriate staff person—such as the hospital’s security director—to be a liaison with outside law enforcement and to do the following:

Establish open lines of communica- tion between hospital security, staff, and area law enforcement officials who could bring a forensic patient into your facility
Become familiar with external law enforcement’s different rules and procedures for transporting, guarding, and managing these patients
Collaborate on a community response effort that is mutually beneficial for both law enforcement and the hospital

STRATEGY Partner with law enforcement—including area police—in training and planning.“Hospitals should always consider inviting police agencies to participate in emergency operations drill scenarios,” Day says.

Planning for a Recaptured Prisoner

Hospitals need to be ready to treat prison escapees who are taken into custody and require immediate medical attention—as was the case with David Sweat, the

on-the-run fugitive inmate who was recaptured in upstate New York in late June and treated at Albany Medical Center in Albany, New York.1

According to Michael Cahoon, emergency management director at the University of Vermont Health Network—Champlain Valley Physicians Hospital, Plattsburgh, New York, planning, communication, and a good working relationship with law enforcement are crucial to managing these situations effectively. Cahoon suggests the following tips:

Keep your primary focus on the patient. “Having inmates in our emergency department is a fairly common occurrence, and it does not preclude us from caring for others who turn to us. An escaped inmate, of course, poses additional risks. The department would be secured by our security team and additional security measures instituted,” Cahoon notes.
Have policies in place. “As the only hospital within 50 miles of Clinton Correctional Facility in Dannemora, we have forensic policies in place that guide the care of inmates in an inpatient as well as outpatient setting,” Cahoon says.
Have a plan. “Organizationally, we have a disaster plan in place and conduct frequent tabletop and mock exercises. This allows us to put appropriate resources in play when needed,” says Cahoon.
Communicate effectively. “Part of our disaster plan includes regular updates via e-mail to the entire staff. Our marketing and communication department handles the communications between our organization, the media, and patient families. They would also facilitate communication with the Department of Corrections and/or law enforcement. The goal is to allow the clinical team to focus their energies on the care of the patient while keeping all appropriate parties up to date,” he says.
Foster relationships with local law enforcement. “The relationships we have with our local law enforcement teams, city police, New York State troopers, the border patrol, and the State University of New York police are important,” says Cahoon. “In a time of crisis, it’s good to know you can pick up the phone, and they will offer assistance.”

Reference

1. Toppo G, Winter M. Second N.Y. prison escapee caught near Canadian border. USA Today, Jun 30, 2015. Accessed Jun 30, 2015. http://www.usatoday.com/story/news/nation/2015/06/28/escaped-prisoners

/29421401/.

STRATEGY Create standardized procedures and policies for staff, in- house security, and external police/cor- rections officers to follow and establish best practices for the following:

Transporting and restraining these forensic patients
Taking infection control precautions, including hand-washing and use of personal protective equipment
Knowing how to call and respond
to the right hospital emergency color code pertaining to a forensic patient– related incident
Protecting forensic patients, who should have the right to treatment,
the right to be informed and partic- ipate in all decisions involving their care, and the right to personal privacy and confidentiality
Reporting and responding to an adverse clinical event being experi- enced by a forensic patient, such as choking, vomiting, bleeding, seizure, chest pain, or shortness of breath
Relieving or fortifying security/law enforcement personnel who need help with guarding patients:
- Never leaving forensic patients unattended
- Never sharing personal information with or about a forensic patient

STRATEGY Put your rules and policies in writing and provide copies, as well as printed information regarding the Health Insurance Portability and Accountability Act (HIPAA), safety/ security/fire procedures, and compliance with Joint Commission standards to all staff, security, and law enforcement.

“Medical Center of McKinney created a tri-fold pamphlet made available to all visiting law enforcement and security per- sonnel, which assures evidence of standards compliance,” says Miller (see page 3).

STRATEGY Allocate particular holding rooms or treatment spaces

where only forensic patients can be taken and remove all hazards/potential weapons from those areas.

STRATEGY Ensure that sufficient outside law enforcement personnel are assigned to transport/manage the forensic patient (insist on at least two

officers if the patient is considered higher risk), including, in the case of a female forensic patient, at least one female law enforcement officer.

STRATEGY Promptly and accurately report any incidence of escape or harm caused by/to forensic patients to proper law enforcement authorities, regulating

bodies, and The Joint Commission. “Nursing staff should be given the tools and education to ensure that breaches to hospital security policies are immediately reported and addressed,” says Miller.

Lastly, remember that risks will always occur when the worlds of law enforcement and health care suddenly and unexpectedly collide. “Ongoing and effective dialogue between the hospital and [law enforcement officers] will help assure greater outcomes and a safer envi- ronment of care for patients and staff,” Day says. EC

References

Bruton F.B. Wossen Assaye, who fled Inova Fairfax Hospital in Virginia, captured by
authorities. NBC News, Mar 31, 2015.
Accessed Jun 11, 2015. http://www.nbcnews
.com/news/us-new s/police-inv estigate
-incident-inova-hospital-fairfax-virginia
-n333051 .
Kucera C. Healthcare security professionals and healthcare facilities grapple with prisoner escapes. International Association for Health- care Security & Safety. Oct 3, 2011. Accessed Jun 11, 2015. http://www.iahss.org/news
/224735/HEALTHCARE-SECURITY
-PROFESSIONALS-AND-HEALTHCARE
-FACILITIES-GRAPPLE-WITH
-PRISONER-ESCAPES.htm.
Mikow-Porto VA, Smith TA. International Healthcare Security and Safety Foundation: The 2011 Prisoner Escape Study—Jun 2011. Accessed June 12, 2015. http://www

.campussafetymagazine.com/files/resources

/2011prisonerescapestudy-1.pdf .

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