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

OSH ACT of 1970 Section (5)(a)(1): Section 5(a)(1) of the Occupational Safety and Health Act of 1970: The employer did not furnish employment and a place of employment which was free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed to the hazard of being physically assaulted by clients exhibiting aggressive behavior, causing serious injuries, while working at the Lakeview NeuroRehabilitation Center, Inc. facility. a. On or about December 6, 2012, at 244 Highwatch Road, Effingham, NH, direct care employees working with clients who pose a risk to themselves or others, were exposed to workplace violence hazards when they interacted with these clients, especially when engaging with escalating clients. The employees have suffered puncture wound from a stabbing, concussion and/or contusion from hits to the skull, kick to the nose causing a broken nose, kicks to the abdomen/stomach, kicks to the groin, dislocated shoulders, and injuries to the knee, wrist, eyes, neck, arms, legs, and back, when working with clients in the school or residential areas, and when escorting them on campus, as the clients become combative (including, but not limited to, stabbing, pulling, pushing, punching, biting, and kicking). This has resulted in workplace violence that is likely to cause death and/or serious physical harm. The employer had not developed and/or implemented adequate measures to protect its employees from this hazard. Among other methods, feasible and acceptable means to abate the hazard of workplace violence at Lakeview NeuroRehabilitation Center include: (1) Ensure Lakeview NeuroRehabilitation Center reviews its policies, such as, Workplace Violence Prevention Policy, Manage Violent Situation Policy, Physical Intervention Policy, and Safety Policy to ensure that the following elements are integrated into a comprehensive workplace violence prevention program that addresses: a. A Workplace Violence Policy Statement, including responsibilities of all staff for workplace violence addressing accountability elements of management performance, hazard assessment, prevention, data review of incidents and injuries which is shared with staff AND clients; b. A Hazard/Threat/Security assessment including records review of incidents, ensure continued work with the loss prevention carrier, inspection of the worksite, and employee survey; c. Implementation of workplace controls and prevention strategies, including procedures that maximize safety and minimize the likelihood of assaultive behavior; d. Ensure continued training and education of all staff with a focus on the specifics of Lakeview NeuroRehabilitation Center's program. Provide refresher training on de-escalation (such as the Mandt system currently in use) on a quarterly basis for new hires and include real world scenarios during training events; e. Review incidents and ensure that staff are trained on the personal safety skills to break out of holds applied by cllents or to prevent biting injuries, as currently occur; f. Develop effective client containment strategies; g. Implement incident reporting and investigation into root cause for each assault incident; h. Implement a system for reporting safety concerns internally, and provide employees with assurance that concerns can be reported without fear of retaliation; i. Review the Workplace Violence Prevention policies at least annually and include solicitation of employee input in this review. j. Address direct care worker protections during client transport off campus and during outings. (2) Implement a system for alerting employees to a client's history of violent behavior: a. Determine the behavioral history of new/transferred clients; b. Ensure client information is exchanged during shift changes; establish a procedure such as chart tags, log books, or verbal census reports for identifying clients with a history of violent behavior; c. Implement procedures to ensure communication of any incident of workplace violence to any staff that might come in contact with the client, so that staff who may not have access to the client?s daily chart would be aware of previous acts of aggression or violence; d. Develop a hazard identification process to identify clients with a tendency toward ?predatory? violence and to train staff on ?predatory? vs. ?affective violence?. Staff safety training should include being able to effectively respond to clients who exhibit either predatory or affective violence. e. Train all staff to understand this system of communication. (3) At least annually review and update the facility's Workplace Violence Policies, including the existing Mandt Crisis Intervention Policy and the Personal Safety Emergency Policy, to ensure that procedures are in place for managing worst-case scenarios in which staff are unable to control or contain an incident, and to ensure that these policies allow staff to impose physical control measures in accordance with treatment plans determined by mental health physicians when necessary to ensure their own safety. (4) Update First Report of Injury Quality Assurance Review forms to include documented supervisor input and follow-up with the affected employee, and to note review/comments from the Quality Assurance Team. Perform root cause analysis for each reported incident of assaultive behaviors, such as but not limited to, hair pulls, bites, scratches, punches, kicking, etc. Root cause analysis should include, among other items, a hazard identification process, such as identification of clients with a tendency toward ?predatory? violence? or ?affective violence?. Ensure that personnel performing incident investigations are suitability trained in how to perform root cause analysis. (5) Conduct new hire and refresher training to ensure affected employees are aware of what the company's workplace violence policy is, where it can be found, and what the expectations are of the company for dealing with workplace violence hazards. Training should be conducted in a manner in which employees can easily understand the terminology and should incorporate hands-on exercises and practice drills to improve staff skill and confidence levels. Training should also include the company policies and requirements for recording and documenting on the daily chart when a client is exhibiting aggressive or violent behaviors. (6) Ensure that adequate numbers of properly trained designated responders are available for each shift who are readily and immediately available to render assistance in the event of an incident of aggressive and violent behavior, and ensure that the designated responders are not assigned to a one-to-one client so that they can quickly respond if summoned without leaving their client without the required supervision. The designated responders for any given shift should be personnel who have specialized training to deal with aggressive and violent behaviors. Develop policy and training to address the gaps in the current client containment strategy, particularly those gaps associated with staff and client injury. (7) Provide staff with a reliable way to rapidly summon assistance when needed, such as an electronic alarm and/or walkie-talkies or a pendant-type wireless personal emergency assistance alarm. Ensure equipment coverage for each direct care worker on each shift. (8) Clarify the written policy for contacting law enforcement in the event of an actual or threatened violent attack. Communicate this policy to employees. (9) Implement assault prevention/control measures for direct care workers to employ when de-escalation techniques (Mandt procedures) are inadequate. Clarify purpose of post-incident debriefing with employee, e.g,. to determine lessons learned vs. reprimanding. (10) Ensure Rehab Specialist representation at all workers compensation and/or risk management periodic meetings. (11) Assign the duties of an overall workplace violence prevention program to a specific position (individual) as soon as possible; ensure the position includes overall coordination of the campus?s Workplace Violence Prevention program and the responsibility for conducting thorough incident investigations with assistance from the workplace violence prevention management team. (12) Ensure that the coordinator and the workplace violence prevention management team have the requisite skills to identify the underlying causes of violence and develop effective intervention strategies. (13) Ensure adequate staff for coverage on all shifts so that direct care staff can deliver the required level of supervision for clients without putting themselves at risk by taking on additional clients, and so that direct care staff who are assigned to one-to-one clients are not also required to be designated responders, which could hinder assistance to another staff summoning help. (14) Explore the policy of using shatter-proof glass or tempered glass whenever renovations or repairs are needed for the facility?s glass windows, doors, lights, etc. Replacement materials should be shatter-proof or be made of other material that could not be used as a weapon when broken/shattered. (15) Follow through with the implementation of the Employee Assistance Program (EAP) for employees as described in the Medical Management section of the Workplace Violence Prevention Plan, which states that employees who are victims of violence will be provided with medical and emotional treatment. Additionally, referrals (to outside specialists) shall be made for appropriate evaluation, treatment, and assistance both at the time of the incident and for any follow-up treatment necessary. (16) Ensure that clients, client's relatives, and employees are informed that violence or threats are not permitted and will be investigated.