Behavioral Health Patients and Security: Understanding the ......7 In early 2016, OSHA 3826, “Workplace Violence in Healthcare –Understanding the Challenge” was released to supplement

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Behavioral Health Patients and Security:Understanding the Challenges

Bryan Warren, MBA, CHPA, CPO-I

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A recent study from the Healthcare Cost and Utilization Project and AHRQ indicates that the levels of behavioral health issues in the US are much higher than most people realize.

• In 2014, there were an estimated 43.6 million adults aged 18 years or older in the United States with a mental, behavioral, or emotional disorder during the past year, representing 18.1 percent of all U.S. adults.

• Approximately one in eight visits to emergency departments (EDs) in the United States involves mental and substance use disorders .

Trends Regarding Boarding of BH Patients in Emergency Departments

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• Between 2006 and 2013, the population rate for ED visits involving mental disorders increased faster than the rate for ED visits involving substance abuse disorders (SUDs)

• In this same time period, the population rate of ED visits involving depression, anxiety or stress reactions increased the most among males aged 45–64 years.

• Between 2006 and 2013, the proportion of M/SUD-related ED visits paid by private insurance decreased whereas the proportion paid by Medicaid increased.

Trends Regarding Boarding of BH Patients in Emergency Departments

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BH Patients ED Admissions 2006-2013

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Distribution by Payer Type

Excerpt from a Seattle Times Article

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In early 2016, OSHA 3826, “Workplace Violence in Healthcare – Understanding the Challenge” was released to supplement previous OSHA documents on the subject. Among its findings:

• From 2002 to 2013, incidents of serious workplace violence (those requiring days off for the injured worker to recuperate) were four times more common in healthcare than in private industry on average.

• In 2013, the broad “healthcare and social assistance” sector had 7.8 cases of serious workplace violence per 10,000 full-time employees (see graph below). Other large sectors such as construction, manufacturing, and retail all had fewer than two cases per 10,000 full-time employees.

OSHA and Workplace Violence

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OSHA 3826 Injury Rate DataViolent Injuries Resulting in Days Away from Work, by Industry, 2002-2013

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OSHA 3826 Injury Rate DataHealthcare Worker Injuries Resulting in Days Away from Work, by Source

Accreditation Agencies in the US

• The Joint Commission - An independent, not-for-profit organization founded in 1951, The Joint Commission accredits and certifies more than 20,500 healthcare organizations and programs in the United States.

• It is the only accreditor to incorporate evidence-based performance measurement into the accreditation process, and the only accreditor that provides a single accreditation manual chapter that integrates all its standards on patient safety into a patient safety system.

• Most common healthcare accreditation agency in the US


• HFAP - The Healthcare Facilities Accreditation Program was created in 1945 to conduct an objective review of services provided by osteopathic hospitals. It has maintained its deeming authority continuously since the inception of CMS in 1965.

• HFAP emphasizes that the accreditation decision is not based on the number of findings that the organization receives, but on their ability to resolve those findings. HFAP surveyors are professionals who utilize their experience working in healthcare facilities to offer guidance on resolving deficiencies that they observe


• DNV - An operating company of Det Norske Veritas (DNV), DNV Healthcare Inc. is an international, independent, self-supported, tax-paying foundation with corporate offices in Houston, Texas, and Cincinnati, Ohio. CMS granted it deeming status in 2008.

• Surveys are ISO 9001, based on the organization’s National Integrated Accreditation for Healthcare Organizations’ standards.


• AAHHS- Accreditation Association for Hospitals/Health Systems Inc. is an offshoot of the Accreditation Association for Ambulatory HealthCare (AAAHC), an accrediting organization for ambulatory care. AAAHC has been around since 1979, AAHHS was created in 2012.

• AAHHS focuses on small and rural hospitals and critical access hospitals. The survey process is rigorous, but it is there to assist hospitals without significant access to resources in reaching high levels of quality and safety for patients and hospital staff.


• CIHQ - Established in 1999, the Center for Improvement in Healthcare Quality is a membership-based organization composed primarily of acute care and critical access hospitals. The Round Rock, Texas-based company moved from consulting to accrediting in 2011.

• Its standards and requirements are mirrored after the Medicare Conditions of Participation and interpretive guidance found in the CMS State Operations Manual. This means that its accredited hospitals do not have to worry about adhering to two different sets of rules—one by their accreditor and one by CMS.

The Domino Effect

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Regulatory Agencies - CMS

Centers for Medicare and Medicaid Services• Federal agency under the US Department of

Health and Human Services

• Administers the Medicare program

• Works with states to administer Medicaid and the State Children's’ Health Insurance program (SCHIP)

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• Hospitals must apply to participate in Medicare

• If a hospital does not participate, it cannot accept or be reimbursed for providing services to Medicare patients

• In order to participate in Medicare, a hospital must meet certain minimum standards, called the “Conditions of Participation” or “COPs”

• COPs are the regulations of CMS


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• Hospitals are subject to inspections (surveys) by CMS to make sure that they meet the COP standards– Annually– For Cause

• CMS contracts with states to perform the surveys

• CMS provides written guidelines interpreting the COP standards for the state surveyors to assist them in performing the inspections


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Patient’s Rights StandardsThe Patients Rights Standards are very broad and include a number of different issues, including the following:

• Right to participate in the plan of care

• Right to confidentiality of patient records

• Right to privacy and safety and;

• Right to be free from unnecessary restraint

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Patient’s Rights StandardsCovers two types of restraint:

• Restraint for acute medical and surgical care– CFR 482.13(e)

• Seclusion and Restraint for behavior management– CFR 482.13(f)

The patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. Such restraint includes physical restraints* or drugs being used as a restraint.* Physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patients’ body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body.

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Seclusion and Restraint for Behavior Management

• Seclusion is the involuntary confinement of a person in a room or area where the person is physically prevented from leaving.

• The use of restraint or seclusion must be:– Selected only when less restrictive measures have been found to

be ineffective to protect the patient or others from harm;– In accordance with the order of a physician or other LIP permitted

by the state and hospital to order seclusion or restrain;– In accordance with a written modification to the patients care plan;– Implemented in the least restrictive manner possible – In accordance with safe, appropriate restraining techniques– Ended at the earliest possible time

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Patient’s Rights StandardsSeclusion and Restraint for Behavior Management:

• Seclusion and restraint can only be used in emergency situations if needed to ensure the patient’s physical safety and less restrictive interventions have been determined to be ineffective.

• Used for emergency situations where the patient is violent or aggressive.

• The patient must be under some type of formal commitment order by the appropriate authority, otherwise they can leave AMA (Against Medial Advice) so long as they are an adult and no immediate life threatening circumstances exist.

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Kowalski v. St. Francis HospitalIn a landmark 2013 decision, the New York Court of Appeals held that a physician’s duty does not allow, let alone mandate, the involuntary detention of intoxicated patients wishing to leave a hospital.

• A patient with a very high blood alcohol level left the hospital’s emergency room where he had voluntarily sought treatment.

• After eloping from the hospital, the patient wandered onto a highway where he was struck by a car, causing him to become quadriplegic.

• The Court found no authority for a physician to detain an intoxicated patient at the hospital if that patient came in voluntarily….therefore the physician and the hospital had no authority, and therefore no duty, to detain the plaintiff.

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• Physician/LIP Order Requirements:– Orders for the use of seclusion or restraint must never be written

as a standing order or on an as needed (PRN) basis

– The treating physician must be consulted as soon as possible (if the restraint/seclusion is not ordered by the treating physician)

– A physician or other LIP must see and evaluate the need for restraint or seclusion within one hour after the initiation of a seclusion or restraint order.

– Each written order for a physical restraint or seclusion is limited to:

• 4 hours for adults• 2 hours for children and adolescents ages 9-17• 1 hour for patients under age 9

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• When the original order expires, a physician or LIP must see and assess the patient before issuing an new order.

• A restraint and seclusion may not be used simultaneously unless the patient is:

– Continually monitored face-to-face by an assigned staff member or

– Continually monitored by staff using both audio and video equipment. Such monitoring must be done in close proximity to the patient.

• The condition of the patient in restraint or seclusion must be continually assessed, monitored and reevaluated.

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• The hospital must report to CMS any death that occurs while a patient is restrained or in seclusion, or where it is reasonable to assume that the patients’ death is a result of restraint or seclusion.

• All staff who have direct patient contact must have ongoing education and training in the proper and safe use of seclusion and restraint application and techniques and alternative methods for handling behavior, symptoms and situations that traditionally have been treated through the use of restraints or seclusion.

• This includes security personnel / off duty law enforcement that are providing security services for the facility (even those working as independent contractors).

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Interpretive Guidelines for Patient’s Rights Standards

• In May 2004, CMS updated the Guidelines to address the use of weapons and handcuffs in restraining patients

• Language in the Guidelines on use of weapons is the same for both acute medical and behavioral standards

• “CMS does not consider the use of weapons in the application of restraint as safe, appropriate healthcare interventions.”

• “CMS does not approve the use of weapons by any hospital staff as a means of subduing a patient to place the patient into restraint/seclusion.”

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What is a…….• Patient - An individual awaiting or under medical care

and treatment.

• Criminal - A person who has committed a crime.

• Involuntary Commitment- An Emergency Involuntary Admission is a process by which a person can be admitted to a psychiatric hospital (or psychiatric unit within a general hospital) against his or her will.

• Weapon- can include but is not limited to:– Pepper Spray – Stun Guns– Mace – Batons– Cattle Prods – Pistols or Firearms– Tasers – Other such devices

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• Use of a weapon is allowed only if a crime is committed, and is considered by CMS as a law enforcement use and not a health care intervention.

• If a weapon is used by security (or law enforcement) personnel on a person in a hospital (patient, visitor or staff) to protect people or hospital property from harm, CMS expects the situation to be handled as criminal activity and the perpetrator to be turned over to local law enforcement.

• While the decision to arrest lies with the appropriate law enforcement agency, the healthcare organization has a duty to report the incident to local law enforcement or else violate the CMS standards for Patient Rights.

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Example: North Carolina General StatuteNCGS 15A-404 • (a) No Arrest; Detention Permitted. - No private person may arrest

another person except as provided in G.S. 15A-405. A private person may detain another person as provided in this section.

• (b) When Detention Permitted. - A private person may detain another person when he has probable cause to believe that the person detained has committed in his presence:

– (1) A felony,– (2) A breach of the peace,– (3) A crime involving physical injury to another person, or– (4) A crime involving theft or destruction of property.

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What is Mens Rea• The intention or knowledge of wrongdoing that

constitutes part of a crime, as opposed to the action or conduct of the accused.

• As an element of criminal responsibility, a guilty mind; a guilty or wrongful purpose; a criminal intent. Guilty knowledge and willfulness.

• A fundamental principle of Criminal Law is that a crime consists of both a mental and a physical element. Mens rea, a person's awareness of the fact that his or her conduct is criminal, is the mental element, and actus reus, the act itself, is the physical element.

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What is Armstrong v. Pinehurst?• Armstrongwasamentallyillman

beingseizedforhisownprotection,wasseatedontheground,washuggingaposttoensurehisimmobility,wassurroundedbythreepoliceofficersandtwoHospitalsecurityguards,andhadfailedtosubmittoalawfulseizureforonly30seconds.

• Where,duringthecourseofseizinganout-numberedmentallyillindividual,policeofficerschoosetodeployaTaserinthefaceofstationaryandnon-violentresistancetobeinghandcuffed

• Findingbythe4th CircuitCourtofAppealswasthat“Taseruseisunreasonableforceinresponsetoresistancethatdoesnotraiseariskofimmediatedanger”

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What is Armstrong v. Pinehurst?• Armstrong v. Village of Pinehurst - TASER use as a

pain compliance tool against a resisting subject is prohibited by the Fourth Amendment unless the officer can articulate “immediate danger” to the officer apart from the fact of resistance alone.

• ‘Physical resistance’ is not synonymous with ‘risk of immediate danger.’” On the same note: “Even noncompliance with police directives and non-violent physical resistance do not necessarily create ‘a continuing threat to the officers’ safety.’”

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• Handcuffs cannot be used by hospital staff to restrain patients for healthcare.

• “Handcuffs, manacles, shackles and other chain-type restraint devices are considered law enforcement restraint devices and would not be considered safe, appropriate healthcare restraint interventions for use by hospital staff to restrain patients.”

• The use of handcuffs or other restrictive devices applied by law enforcement officials (who are not employed or contracted by the hospital) is for custody, detention and public safety reasons, and is not involved in the provision of healthcare.

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• If law enforcement officers bring a prisoner wearing handcuffs to the hospital for care, the officers are responsible for monitoring and maintaining custody of their prisoner.

• The law enforcement officers will determine when the prisoners restraint device can be removed.

• Such use of handcuffs, or other means of forensic restraint, are not governed by the Patient’s Rights Standards.

• This does not diminish the hospitals responsibility for appropriate assessment and care for the patient.

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The Bottom Line• Hospital clinical staff may not use ‘weapons’ or handcuffs to

restrain patients for healthcare intervention

• Hospital security staff may carry ‘weapons’ and handcuffs per hospital policy, State and / or Federal law.

• Hospital security staff may only use ‘weapons’ and handcuffs in criminal situations, where the perpetrator will be turned over to local law enforcement.

• Patients’ Rights Standards do not apply to law enforcement personnel who bring a prisoner to the hospital for treatment.

• The Patients’ Rights Standards DO apply to ‘off duty’ law enforcement officers contracting with the hospital to provide security services

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Training Considerations for Patient Sitters

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Create a Safe Environment for the Patient7. Unsecured Pictures/Glass Frames

8. Unapproved Medications

9. Metal Eating Utensils

10. Metal or hard plastic ink pens

11. Unanchored lamps

12. Unsecured Lighting Fixture

13. Non-recessed fire sprinkler

14. Unsecured window

15. Mini Blind Cords

16 Unanchored Furniture

17. Electrical Cords

18. Unsecured Electrical Plates

19. Metal or Hard Plastic Trash Cans

20. Large/Overstuffed Blankets

21. Excessive Clothing

22. Belts

1. Safety Glass/Plastic Mirror

2. Towel Bar

3. Exposed Plumbing

4. Accessible Ventilation Ducts/Grills

5. Shoe/Boot Laces

6. Telephone Cords

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Patient Sitter Sample Guidelines• Stay alert at all times. Be aware of your surroundings

and ensure that the room is safe for you and the patient.

• Obtain report from outgoing Patient Observer/Sitter.

• Give report to incoming Patient Observer/Sitter.

• Patients should not leave the room unless absolutely necessary and should never be left alone.

• This includes being left alone in the bathroom. The door must remain ajar and the light must remain on at night.

• Patients must be within viewing distance from the Patient Observer. Never allow a patient to walk behind you.

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Patient Sitter Sample Guidelines• No smoking or smoking paraphernalia is allowed.

• Report any patient changes to the RN immediately.

• The sitter must be relieved for breaks, restroom, etc.

• No eating, no drinking, no cell phone/texting in patient’s room.

• No knitting, reading, watching TV or DVDs, wearing of headphones, or any other distracting activity.

• No psychiatric or religious advice – Remain Neutral.

• The sitter should give out no personal information about themselves and should report any inappropriate remarks or behavior immediately.

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Patient Sitter Sample Guidelines

• Position yourself so you always have an exit.

• Don’t let the patient between you and the door

• Move if patient becomes aggressive or hostile

• Know the location of any panic alarms

• Don’t sit or stand too close to the patient

• Do not touch the patient. They may feel that you are trying to harm them.

• Never call the patient by any other name than his or her own name, even if they ask you to.

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Job Aid • Speak clearly, calmly and softly, but make

sure the patient is still able to hear you.

• Reassure the patient. Never shout, argue, or be disrespectful toward the patient..

• Body attitude: Calm, confident, caring, reassuring body posture.

• Body position: Avoid stepping/reaching into the patient's comfort zone area Each person needs certain personal space to feel comfortable. Usual rule to consider is to keep at least an arm's length and a half distance from the patient. Keep your body slightly at an angle to avoid looking threatening or intimidating.

• Your hands: Keep your hands visible to the patient at all times. Never hit, slap, punch or kick the patient.

• If a patient approaches your personal space or comfort zone, step back.

• Approach patient from the font, never from behind so that the patient can hear and see you at all times

• Remember: Pay close attention to the patient's behavior. Physical problems or behavior problems can happen at any time. Don't let your guard down. Stay ALERT and AWAKE. Report these changes to the nurse immediately.

• Avoid turning your back toward the patient whenever possible.

• Keep a clear path to the patient door in the room for you to get help easily. Sit on the side of the room nearest the door.

• Dress with safety in mind. No dangling, hoop-like earrings; no unbreakable items around your neck; wear closed toe shoes; if you wear a ponytail, use a scrunchi (not a rubber band); no sharp-teeth hair clips.

• If you need to leave the patient for any reason, inform the nurse before you leave and make sure there is someone available to take your place.

• Ask the nurse for any special considerations or approaches to use in communicating with the patient. Ask the nurse how to signal for help

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Security Scenario TrainingAside from any mandated de-escalation training or other required education, healthcare security leaders should consider creating their own scenario based training programs so that security personnel can experience realistic scenarios involving behavioral health patients in a controlled and safe environment.

Such program not only enforce your programs polices and procedures, but also provide a higher level of confidence for security personnel and when combined with video recordings of such training can allow for instant review of the “game footage” to identify opportunities for improvement.

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Creating Your Own Scenario TrainingCreating such a program is not as daunting as one might imagine. To start, you will need the following:

• A space large enough to accommodate dynamic training, to allow for plenty of room for movement as well as safety of all participants.

• Teammates that are willing to “act” the part of a behavioral health patient (if they have worked healthcare security for any length of time they likely know exactly what to do in order to emulate such behaviors).

• Several recording devices. Ideally, a body worn camera that can show the point of view from the officer as well as the patient is ideal, but you do not have to invest in specialized equipment.

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Creating Your Own Scenario Training

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Additional ResourcesThere are a number of existing resources that can assist with your security program as it relates to behavioral health patients. The International Association for healthcare Security and Safety (IAHSS) offers a number of guides and white papers on a variety of topics that can help with this patient population.

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Additional ResourcesThe American Society for Industrial Security-International (ASIS) Healthcare Security Council also recently released a white paper entitled “Strategies to Enhance Security’s Role in Reducing Violence on Behavioral Health Units” that offers a variety of ideas to help solve this issue.

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In ConclusionBehavioral health patients present a challenging situation for security personnel, not only due to their vulnerability and potential for unpredictable behavior, but also due to the many legal and regulatory issues that must be taken into consideration when working with this type of patient.

While many resources exist to assist with such situations, one of the most effective approach's is that of multidisciplinary training between security and clinical personnel in a scenario based environment. Consultation should also be made with Risk Management, the Office of General Counsel / Legal Department and local law enforcement to get the most up to date information on the involuntary commitment process and any potential use of force considerations when restraining or secluding such patients.

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Discussion

Documents

Behavioral Health Patients and Security: Understanding the ......7 In early 2016, OSHA 3826, “Workplace Violence in Healthcare –Understanding the Challenge” was released to supplement