Text For Citation: 01 Item/Group: 001 Hazard:

29 CFR 1960.8(a): The Agency head did not furnish employment and a place of employment to each employee that were free from recognized hazards that caused or were likely to cause death or serious physical harm in that employees were exposed to hazard of being assaulted by patients. The Pathway Home: On or about March 9, 2018, employees at the Pathway Home in Yountville, CA were exposed to assaults while working with patients making physical threats to employees. An adequate workplace violence program had not been implemented. On March 9, 2018, an employee was fatally shot by a patient who had a history of homicidal and suicidal ideation. Recommended Corrective Actions: 1. Ensure all employees on-site and off-site are periodically trained in and understand protocols for reporting patients who make physical threats to employees to the Disruptive Behavior Committee. Employ other methods including on and off-site workplace signage and periodic emails to all staff reinforcing the protocols. Include host employers and community based outreach centers in the distribution of the information. 2. Ensure that the DBC responds promptly to actual and potential reports of workplace violence wherever VA employees are working, and that the DBC monitors and tracks the response to the reports. 3. Ensure that the DBC identify and the types of reports of workplace violence which require an immediate response. 4. Reinforce existing protocols which require the Suicide Prevention Team to report threats to staff to the DBC. This could be done through frequent training, email reminders and workplace signage. 5. Ensure all VA employees have a mechanism to immediately communicate actual or threats of workplace violence to all employees who may come into contact with the patient. 6. Review existing workplace violence prevention policies where available for all VA employees working at contractor sites. Assess existing engineering and administrative controls and ensure controls are put in place through contract language where applicable. Where possible when working with outside providers, consider including contract language that addresses employee safety and physical security. 7. Require the VA to review and approve outside providers workplace violence prevention programs, prior to any VA employees working on their site. Such a review should include an assessment of the engineering and administrative controls put in place to reduce or eliminate injuries from workplace violence. 8. Enhance current training by assessing the content and frequency of training. Ensure updated trainings include active shooter and body mechanics training.