On Nov. 28, the Centers for Medicare and Medicaid Services (CMS) issued a new QSO memo to hospitals (QSO-23-04-Hospitals) on workplace violence and prevention. While there is no enforcement change for nursing homes within the new memo, one violence prevention expert noted, “[nursing homes] would do well to heed new CMS messaging. The ongoing stress of working short-staffed, and even the holidays themselves, can make healthcare facilities an even more vulnerable environment, safety experts said this week.”

What Does the Memo State?

CMS states in its opening section: “Workers in hospitals, nursing homes, and other healthcare settings face risks of workplace violence. Many factors contribute to this risk, including working directly with people who have a history of aggressive behavior, behavioral issues, or may be under the influence of drugs.”

Regulators such as CMS, the Joint Commission, and the Occupational Safety and Health Administration share a vision that healthcare workers have a right to provide care in a safe setting. In 2015, the Minnesota Legislature passed a law that hospitals must design and implement preparedness and incident response plans for violence on their premises and provide employee training.

CMS also states it “will continue to enforce the regulatory expectations that patient and staff have an environment that prioritizes their safety to ensure effective delivery of healthcare.”

To close its memo, CMS provided several examples of systemic failures in facilities (hospitals) that put patients and staff at risk. Those examples included situations where:

• A nurse in a unit without adequate staffing was sexually assaulted by a behavioral health patient who was stopped only through intervention by other patients;
• A patient died after hospital staff, and law enforcement performed a takedown that resulted in a hospital staff holding the patient down on the floor with his knee against the patient’s back, during which the patient stopped breathing and died; and
• A patient was acting out and was shot in his hospital room by off-duty police officers following the failure of hospital staff to perform an appropriate assessment and de-escalation of the patient.

Workplace Violence Prevention Requirements

While the QSO memorandum focuses on the hospital requirements, nursing facilities have emergency preparedness requirements at 42 CFR §483.73 “Emergency Preparedness” that closely mirror those for hospitals. Some critical elements of those requirements are that emergency preparedness plans must:

• Be based on, and include a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach;
• Include strategies for addressing emergency events identified by the risk assessment as well as address the resident population, including, but not limited to, persons at risk;
• Also, provide the appropriate level of education and training to staff regarding identifying patients at risk of harm to self or others, identifying environmental patient safety risk factors, and mitigation strategies.

Workplace Violence Prevention Mitigation Strategies

Below are several action steps adapted from the Minnesota Department of Health Prevention of Violence in Health Care toolkit to consider when evaluating your internal systems to prevent violence and create a safe environment for residents and staff.  

• A timely reporting process is in place to collect and track information on all incidents of violence and any concerns related to potential risks of violence.
• Data collection includes information gathered from post-event huddles and root cause analyses to understand the key factors that contributed to any incidents of violence.
• All staff understand their role in prevention and in speaking up if they have concerns (and a straightforward process is in place for raising concerns and is communicated to all staff). 
• Leadership communicates to staff that violence is not an accepted part of their job, and they should speak up if they do not feel safe.
• Include violence prevention on your QAA Committee meeting agenda to review concerns, risk factors, and any incidences or near misses and develop actions plans to address identified issues.
• Expectations and supporting education related to violence prevention are incorporated into new employee orientation for clinical and non-clinical staff, with additional training provided at least annually. 
• Training may include identifying situations with potential for violence, de-escalation strategies, environmental risk assessments, personal safety strategies, and reporting violent incidents and concerns.
• A process is in place to ensure all staff are familiar with how and when to call for assistance in the event of an act or threat of violence. Consider instituting a Rapid Evaluation Team (RET) process and include scenarios of threats of violence or escalating behaviors in monthly RET drills.
• A process is in place to focus interventions for residents at higher risk for violence on the resident’s individual risk factors vs. general interventions with clear steps for staff to take in the event of an escalation.

You can read the full CMS memo to learn more.