Ni 2012134520019 Vancouver Coastal Health Authority March 17. 2012 MSRFE BC- WORKING T0 MHKE DIFFERENCE INCIDENT INVESTIGATION REPORT Notice of incident number 2012134520019 Dale of incident March 17, 2012 Location of incident Detwiller Pavilion UBC Hospital 2211 Wesbrook Mall Vancouver, 3.0. Lead investigating of?cer Annie Strauss investigation lite number 2012?0038 incident outcome RY Report approved by manager, Fetal and Serious injury lovesligetions Sig not re Kenneth Bradley INVOLVED may 2 5272/3 Employer _Name and address Employer :0 Industry classi?cation Vancouver Coastal Health Authority 687435 766001 260 - 1770 Avenue West Acute Care Vancouver, BC V6J 4Y6 Worker Occupation I Injured Recreational Therapist Employer Name and address Employer iD industry Classificalion Paladin Security Group Ltd. 259264 764046 295 -- 4664 Lougheed Highway Security or Burnaby; BC V5C 5T5 Patrol Services Employer Name and address Employer ED Industry classi?cation Provincial Health Services Authority 689775 766001 Riverview Hospital Acute Care 2601 Lougheed Highway Coquitlam, BC V30 4J2 WorkSafeBC investigalions Workers? Compensation Board of 8.0, Page 1 of 63 This report is supplied to you by WorkSafeBC for your information only. 1! is no! 10 be made known to any other agency or person Whom the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastat Health Authority March 17, 2012 Persons mentioned in report Name Known in the report as Role in the incidentlinvestigation Worker Injured worker; part-time recreation therapist assigned to the POD who was assauited by Patient employed by the Vancouver Coastai Heaith Authority (VCHA) Patient A Patient who assaulted the Worker; one of five patients who were cohorted to form the was in the Aduit Tertiary Rehabilitation Program Patient New admission to the tW neuro- unit who required 1:1 care due to high ievel of needs; observed to have two interactions with Patient A prior to the assauit ?liS?bf'tic'sr': 12'2 3: POD Nurse ?1 Regulariy scheduied registered nurse working on the the oniy other worker in the POD at the time of the incident and the first to intervene in the assauit POD Nurse 2 Reguiarly scheduled registered nurse on the POD POD Nurse 3 Registered nurse working in a temporary position on the POD 1W Casual Nurse Casuai registered nurse working on iW who responded to the incident; the second person to intervene in the assault; called for a first aid response for the Worker 1W Nurse Reguiariy scheduied registered nurse working on 1W who observed Patient interact with Patient A in the taundry room prior to the assault; pressed her panic aiarm three times to initiate Code White response tE Nurse Registered nurse regularly scheduled on who was assigned to work for four hours on cailed the Code White through the Paladin Security Group's centrat office WorkSafeBC Investigations Workers? Compensation Board of 8.0. Page 2 of 63 This report is suppiied to you by WorkSafeBC for your information oniy. it is not to be made known to any other agency or person without the permission of WorkSafeBC. NI 2012134520019 Vancouver Coastat Health Authority March 17, 2012 Name Known in the report as Role in the incidentiinvestigation Student Nurse Student nurse who escorted the injured worker to the Urgent Care Centre at 080 Hospital Director of Mental Heaith and Addictions Director of Housing Manager Patient services manager for Director of mental health and addictions for VCHA since eariyi Director of housing for health and addictions since - Sesliidizgg; tertiary mental health services at UBC Heepitai and Vancouver General Hospital Supervisor Program coordinator for the Aduit Tertiary Program; direct supervisor 1W Manager Managed the WV unit at UBC Hospitai Project Manager Renovation project manager who oversaw the building renovations; employed by Fraser Heaith Authority Safety and Prevention Manager Manager of safety and prevention who oversaw health and safety at ati sites Site Safety Adviser Safety advisor for UBC Hospital Violence Prevention One of two violence prevention Specialist speciaiists for ail sites within VCHA Vioience Prevention VCHA provinciai violence Curricuiom Leader prevention curriculum leader who provided occupational heaith and safety training for managers and supervisors 1 Patient A's medicai manager of the program '5 2 on call the day of the incident BCNU Occupational Heaith and Safety Of?cer Oversaw occupational heaith and safety for the British Columbia Nurses? Union, inciuding vioience prevention advocacy WorkSafeBC investigations Workers? Compensation Board of 8.0. This report is suppiied to you by WorkSafeBC for your information oniy. Page made known to any other agency or person without the permission of WorirSafeBC. NI 2012134520019 Vancouver Coastat Health Authority March 17, 2012 Name Known in the report as Role in the incident/investigation Security Manager Paladin Security Group?s client service manager for the UBC Hospital site Security Of?cer 1 One of the first security officers to arrive; was the designated first aid attendant; employed by Paladin Security Group President of BC Mental Health and Addictions Wrote a letter to the Director of Housing to inform her that the patients had to move out of the BC Program area; emptoyed by Provinciat Heatth Services Authority Medicat Director of Medical Director of for VCHA WorkSateBC Investigations Workers? Compensation Board of 8.0. This report is suppiied to you by WorkSafeBC for your information oniy. Page made known to any other agency or person without the permission of WorkSefeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 Scope This incident investigation report sets out WorkSafeBC?s analysis and conclusions with respect to the cause and underlying factors leading to the workplace incident of March 17, 2012, at the Detwiller Pavilion, UBC Hospital, in Vancouver, British Columbia. The purpose of this report is to identify and communicate the ?ndings of this incident to support future preventive actions by industry and WorkSafeBC. This investigation report does not address issues of enforcement action taken under the Workers Compensaiion Act and the Occupational Health and Safety Regulation. Any regulatory compliance activities arising from this incident will be documented separately. Synopsis On March 2012, a recreational therapist was helping a patient with daily personal care activities. The patient threw his soiled clothes at the worker and then assaulted her. He choked the worker, repeatedly punched her in the face, and trapped her in the laundry room. Two nurses intervened and disengaged the patient from the worker. The worker sustained physical and injuries as a result of this assault. WorkSafeBC investigations Workers' Compensation Board of 3.0. Page 5 of 63 This repori is supplied to you by WorkSafeBC for your infomafion onr?y. It is not to be made known to any other agency or person without the permission of WorkSafeBC. NI 2012134520019 Vancouver Coastat Heailh Authority March ?17, 2012 Table of Contents 1 Factual 1.1 Work location .. 8 1.2 Firms .. 9 1.2.1 Provincial Health Services Authority Riverview Hospital .. 9 1.2.2 Vancouver Coastai Health AuthOrity .. 9 1.2.3 Paladin Security Group Ltd. .. 9 1.3 The Adult Tertiary Rehabilitation Program .. 10 1.3.1 Physical location .. 10 1.3.2 Patient A .. 13 1.4 Sequence of events .. 13 1.4.1 Events preceding the incident .. 13 1.4.2 Incident .. 14 1.4.3 Events after the assault .. 16 1.5 Temporary set-up of the POD on 1 West .. 17 1.5.1 Planning .. 17 1.5.2 Staffing the POD .. 18 1.6 Management and supervision .. 18 1.7 Training and experience .. 19 1.7.1 General staff training .. 19 1.7.2 Director of Mental Health and Addictions .. 19 1.7.3 Manager .. 19 1.7.4 Supervisor .. 20 1.7.5 Worker .. 20 1.7.6 POD Nurse 1 .. 20 1.7.7 Other persons responding in this incident .. 21 1.7.8 Rehabilitation workers .. 21 1.7.9 Peer support facilitators .. 22 1.8 Risk of injury from violence .. 22 1.8. 1 Assessment .. 22 1.8.2 Controls to minimize risk to workers .. 23 8.3 Communication of risk to workers .. 23 1.9 First aid .. 26 2 Anaiysis 26 2.1 Work planning for the Adult Tertiary Rehabilitation Program .. 26 2.1.1 Transfer of patients from Riverview Hospital .. 26 2.1.2 Renovations for housing ATRP patients .. 27 2.1.3 Move to Wiilow Chest .. 28 2.1.4 Move to the POD on .. 29 2.1.5 Staf?ng the POD .. 29 2.1.6 Changes associated with the move to the-POD .. 31 WorkSafeBC Investigations Workers? Compensation Board of 13.0. Page 6 of 63 This report is supplied to you by WorkSafeBC for your infonnation only. it is not to be made known to any other agency or person without the permission of WorkSafe-BC. Ni 2012134520019 Vancouver Coastai Heatth Authority March 17, 2012 2.1.7 Known history of violence .. 32 2.2 Precipitating factors leading to the assault .. 33 2.3 Assessment to determine the risk of injury from violence .. 35 2.3.1 Violence assessment not completed before opening Forest Edge 36 2.3.2 Violence assessment not completed before moving to the POD .. 37 2.3.3 Lack of oversight for initiating or tracking vioience risk assessments .. 38 2.3.4 No review of past violent incidents .. 39 2.3.5 Items for consideration in a violence risk assessment .. 40 2.3.6 Joint occupational health and safety committee .. 44 2.3.7 Request for assessment by the British Columbia Nurses? Union .. 44 2.4 Controls to minimize the risk of injury from violence .. 45 2.4. 1 Violence Prevention Program .. 45 2.4.2 Violence ALERT system .. 46 2.4.3 Code White .. 48 2.4.4 Initiating a Code White .. 49 2.4.5 Panic alarms .. 50 2.4.6 Seclusion rooms .. 52 2.5 Communicating the risk of violence .. 52 2.6 Lack of training .. 54 2.6.1 Orientation and training for workers .. 54 2.6.2 Training for managers and supervisors .. 54 2.7 Inadequate supervision .. 56 2.8 First aid attendant not available .. 57 2.9 Ineffective corporate oversight .. 59 3 3.1 Findings as to causes .. 60 3.1.1 Patient attacked the recreation therapist .. 60 3.2 Findings as to underlying factors .. 61 3.2.1 Lack of work location and work activity planning .. 61 3.2.2 Violence risk assessment not completed .. 61 3.2.3 Inadequate policies, procedures, or work environment arrangements .. 61 3.2.4 Inadequate communication related to the risk of violence .. 61 3.2.5 Inadequate training .. 61 3.2.6 Inadequate supervision .. 62 3.2.7 Ineffective corporate oversight .. 62 3.3 Other ?ndings .. 62 3.3.1 Inadequate ?rst aid services .. 62 Appendix 63 How the Investigation Was Conducted .. 63 WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 7 of 63 This report is supptt'eo? to you by WorkSafeBC for your information only. is not to be made known to any other agency or person without the permission of WorkSafeBC. NI 2012134520019 Vancouver Coastal Health Authority March 17, 2012 1 Factual Information 1.1 Work location The incident occurred within a adult tertiary rehabilitation program operated by Vancouver Coastal Health Authority (VCHA) in the Detwiller Pavilion at UBC Hospital. At the time of the incident, the area where the adult tertiary rehabilitation patients were located at UBC Hospital was known as the POD. The POD was on the ?rst floor of the Detwiller Pavilion in the 1 West Unit, the unit. In 2002, the Ministry of Health determined that mental health patients would be better served through community-based programs, rather than at Riverview Hospital, which had delivered provincially based care for complex mental health patients since l9i3. Over a 10-year period, starting in 2002, planning and the development of infrastructure to house patients proceeded throughout the province. The Ministry had developed a plan and provided it to BC Mental Health and Addiction Services, which operates under the umbrella of the Provincial Health Services Authority. Through this process, each health authority was tasked with planning for the provision of care for patients living within or associated with facilities within the boundaries of their geographical area. VCHA planned for and then initiated the transfer of patients into a program called the Adult Tertiary Rehabilitation Program (ATRP) in anuary/F ebraary 201 l. The ATRP prepares patients for community living readiness and was initially operated out of a location called Forest Edge in the Detwiller Pavilion. Forest Edge the Detwiller Pavilion. Patient A had been transferred from I participate in the rehab program and was originally cared form the Forest Edge location. The ATRP was using the Forest Edge site temporarily. The Provinical Health Services Authority (PHSA) expected that by January 2012 the ATRP patients would be moved to permanent locations at Vancouver General Hospital known as Willow Chest and Willow Pavilion. Both Willow locations required renovations to service mental health units. Occupancy of Willow Chest was planned for January 2012, and Willow Pavilion had a projected occupancy of March 2012. The Forest Edge site had been renovated to prepare it. for operating the BC Program, which was scheduled to move from Riverview Hospital in January/February 2012 and to be administered by VCHA. These renovations and the transition of the programs are discussed further in the Analysis (see section 2.1 on page 26). WorttSafeBC investigations Workers? Compensation Board of 8.6. Page 8 of 63 This report is supplied to you by WorkSafeBC for your infannation only. It is not to be made known to any other agency or person without the permission of WorkSafeBC. NI 2012134520019 Vancouver Coastal Health Authority March 17, 2012 1.2 Firms 1.2.1 Provincial Health Services Authority Rivervtew Hospital PHSA is the health authority providing provincially based specialized health care services to the people of British Columbia. PHSA works with the other health authorities across British Columbia to provide equitable health care for people who need specialized services, such as cancer treatment, cardiac care, and management of complex mental health problems. primary role is to ensure that B.C. residents have access to a coordinated network of high-quality specialized services. At the time of the incident, Riverview Hospital was governed by BC Mental Health and Addictions Services, which operated under the PHSA umbrella. 1.2.2 Vancouver Coastal Health Authority VCHA serves about 25 percent ofthe population in BC. within a large geographical area and employs about 13,000 regular employees, plus casual and contracted workers, including approximately 2,500 physicians. VCHA has 154 work locations registered with WorkSafeBC. Two of the work locations are discussed in this report. UBC Hospital is the VCHA work location where the incident occurred. it is a multiple-employer workplace with well over 100 workers on site. The other work location mentioned in this report is the Vancouver General Hospital work location. This work location encompasses a city block. Both Willow Chest and Willow Pavilion are located at the Vancouver General Hospital work location. The incident occurred in the Detwiller Pavilion of UBC Hospital, which houses both in-patient and out?patient mental health programs. Patient A was in the ATRP, which was an program moved to VCHA as part of the Riverview Hospital decentralization plan. Most of the workers mentioned in this report worked for or were contracted by VCHA. 1.2.3 Paladin Security Group Ltd. The Lower Mainland health authorities have combined resources to provide protection services at their health care facilities. A service group known as Integrated Protection Services oversees this responsibility, and as part of their activities, enters into contractual arrangements with security companies to provide on?site security services to the health care sites where security presence is required. VCHA contracted with Paladin Security Group Ltd. (Paladin) to provide the on-site security to those VCHA sites requiring it. UBC Hospital has three Paladin security officers on duty at all times, who provide service to all areas of the hospital, including the three separate pavilions known as Koerner, Detwiller, and Purdy.The Paladin of?ce at this site is located in the Detwiller Pavilion. WorkSafeBC Investigations Workers Compensation Board of 8.0. Page 9 of 63 This report is supplied to you by WorkSafeBC for your intonaation only. it is not to be made known to any other agency or person William the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 At UBC Hospital, Paladin?s duties include providing general site security and attending at situations when summoned by staff, such as responding to incidents of violence or responding to prevent anticipated incidents of violence. One of the security of?cers is designated as the occupational ?rst aid level 2 attendant on each shift. The ?rst aid attendant?s duty, as required by the Occupational Health and Safety Regulation, is to render ?rst aid to workers should they be injured. The Paladin security of?cer tasked with being the ?rst aid attendant is the person responsible for providing ?rst aid services to all three of the UBC Hospital pavilions. Paladin also conducts checks of the panic alarm system. When activated, this system alerts security and staff about an incidence of violence, and it launches a Code White response to assist a threatened worker. Paladin maintains records of responses for violence and aggression, and also keeps records of panic alarm testing. 1.3 The Adult Tertiary Rehabilitation Program The patients in the Adult Tertiary Rehabilitation Program (ATRP) are predominately patients relocated from Riveryiew Hospital to UBC Hospital, Detwiller Pavilion, as part of the decentralization process. The goal of the program is to prepare patients to live in a community- based setting. The patients are taught how to manage activities such as basic personal care, cooking, transportation, and money management, and to develop social skills. The program is a 24-hour program that includes outings into the community. Most patients in the program are expected to achieve community living readiness within 6 to 24 months, but some patients may require a longer stay. 1.3.1 Physical location At the time of the incident, the POD was a temporary work location in the 1W unit of the Detwiller Pavilion (see section 1.5, page 17, for more information on this temporary site). Five ATRP patients were moved to the POD from the Forest Edge unit on February 17, 2012, one month before the incident occurred. The Forest Edge unit was one floor above the 1W unit in the same building. These patients were moved into four rooms located the patients shared a room. Figure 1 shows the layout of the POD. lW staff and patients shared a laundry room, which was located close to the POD nurses? station. The laundry room is where the incident occurred. It contained a washer and dryer, sink, clean linen storage, ironing board and iron, and a large scale. The laundry room had single-entry access and had no emergency egress. The laundry room did not have a direct line of sight to the POD nurses' station or to the WV nurses? station located down the hall from the POD (see Figures 2 and 3). The door was left open to allow access. A small room, also with a single entry and no emergency egress, was designated as the POD nurses? station. The door to the nurses? station was generally left open to facilitate WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 10 of 63 This repon? is supplied to you by WorkSafeBC for your information only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coasta! Health Authority March 17, 2012 visual and auditory monitoring of the patients. The POD also included a large room that was used as a lounge and dining room for the ATRP patients. I To elevatws 1W tonnage 5 1w reception nurses? station 3' '5 9ft 2k]. 2 a - Torte .Medtcahon room (1W shared andPOD nurses? 3 -- station 23: 8; nu Exam 3 "room 28R. .. a? Storage in oattwayutw stretcher and Hattway patient lift POD POD Patient Patient A Figure 1: Diagram showing the layout and location ofthe POD (.1201 to scale). The ioca?on ofthe I Wrooms is (gyproximaie. WorkSafeBC investigations Workers' Compensation Board of 8.0. Page ?it of 63 This report is supplied to you by WorkS?ateBC for your tntonnatton onty. It is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastat Heaith Authority March 17, 2012 Figure 2: View?'om (he sing/e?enny doorway looking into 'the [morally room wher 3 the incident occurred. Figure 3: View ofthe laundry room to the righf ofthe door. There was no emergency egress from inside {his room. The photograph also shows the scale, ironing board, and the clean Iamzdiy earf kept in {he lazmdiy room. WorkSafeBC Investigations Workers' Compensation Board of B.C. Page 12 of 63 This report is suppiied to you by WorkSafeBC for your infomation only. it is not to be made known to any other agency or person without the of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 1.3.2 Patient A Patient. of self-harm. asdrio.1.eac? Patient A is about 6 inches taller than the Worker and weighs approximately 100 pounds more than she does. 1.4 Sequence of events 1.4.1 Events preceding the incident On March 16 2012 the evenin before the incident Patient docninent that Patient gl?e'p'iagatitih :the?. I checks throughout the night. On March 17, 2012, no rehab worker or peer support facilitator was working on the POD. POD Nurse 1 was alone on the unit until the Worker arrived to start her shift at 08:00. She put her belongings away in the nurses? station. Although it would be expected that she would get updated information on the patients, she did not read the Kardex or the nurse?s progress notes because the patients wanted her attention. The Worker went into the POD lounge and noticed a strong smell_ One of the other POD patients was making a ?big to-do? about it. The Worker spoke with Patient A and suggested that he have a shower. She noticed that he was resistant and agitated, and after recommending that he have a shower, she left him alone. Patient A went to POD Nurse i and said, need my money.? POD Nurse 1 told him that he had to have a shower and change into ciean ciothes. The Worker reported to POD Nurse 1 that Patient A was agitated and, because of his agitation, she would change his bed instead of directing Patient A to do 30. Patient A was resistant to having his bed changed, but the Worker did change the linen. WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 13 of 63 This report is suppiied to you by WorkSaieBC for yourinfonnaiion oniy. 1th not to be made known to any other agency or person without the permission of WorkSafeBC. N12012134520019 Vancouver Coastal Heatth Authority March 17, 2012 After the Worker changed the linen, POD Nurse 1 directed Patient A to have his shower. After a brief period, both POD Nurse and the Worker noticed that Patient A had showered but had not changed his clothes. He still smelled and was encouraged to change into clean clothes. Shortly before the incident, two of the nurses working on 1W observed interactions between Patient A and Patient B, a patient from lW. Patient B, a recently admitted patient, required care. Both interactions happened in the morning prior to the incident. The first incident occurred in the WV lounge and was observed by the IE Nursew?a nurse who routinely works on 1B, the mood disorder unit, but was reassigned to 1W for the morning to provide 1:1 care for Patient B. Patient A went to the fridge and collected some of his personal food. Patient grabbed the food from Patient A, and Patient A grabbed the food back. The 1152 Nurse was able to redirect Patient and the interaction ended without incident. The 1E Nurse said that this occurred at approximately 09:00. The IR Nurse was aware of Patient A?s history of violence through assaulted as m? Although she knew about Patient A, she did not know what he looked like and she I no know that the POD patient she and Patient were interacting with was Patient A. Shortly after this incident, the iW Nurse, who is a regularly scheduled nurse on 1W, and Patient went into the laundry room to get towels. The 1W Nurse observed Patient handling soiled clothing or bedding, which the 1W Nurse believed belonged to Patient A. She reported that Patient A observed Patient touching the soiled laundry moments before the incident. occurred. The 1W Nurse escorted Patient out of the laundry room and back to Patient B?s room to help her shower. She heard a contraction coming from the laundry room shortly after this incident. 1.4.2 Incident At approximately 09:05, the Worker went into the laundry room to put Patient A?s sheets into the washer. Patient A came back to the laundry room wearing clean clothes, and the Worker asked him to get his dirty clothes. The Worker was standing in the doorway of the laundry room, facing toward the hallway, when Patient A returned. Patient A threw the soiled clothes at the Worker. The Worker told Patient A that his behaviour was not appropriate and let him know that he would not be permitted to go on a community outing with that type of behaviour. Patient A apologized, and the Worker provided positive reinforcement. Patient A started to walk away and proceeded about 3 feet before he turned around and grabbed the Worker by the neck. He forced her into the laundry room, pushed her onto the washing machine, and pinned her down with his body. Since her arms were pinned, she was not able to reach her panic alarm. WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 14 of 63 This report is supplied to you by WorkSafeBC for your tnfonnation only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastat Health Authority March 2012 POD Nurse 1 was sitting in the nurses? station charting when the incident began. He heard the commotion and went to see what was happening. He observed Patient A pushing the Worker into the laundry room and grabbing her by the neck. He saw Patient A push the Worker up onto the washing machine and force her head under the tap of the laundry tub. Her feet were off the ground. Patient A continued to choke the Worker and repeatedly punched her. POD Nurse 1 immediately intervened, trying to release Patient A?s hands from the Worker. He yelled out to have somebody call a Code White. His panic alarm was in his pocket. The 1W Nurse also heard the commotion, which she described as a loud bang. She immediately pushed her panic alarm. She did this three times but did not hear a Code White called over the public address system as would be expected if the panic alarm had worked. The 1W Casual Nurse, who was sitting at the nurses? station, also heard the commotion. He got up quickly and walked down to the POD area. He checked the POD nurses? station, but saw that no one was there. He heard the incident happening in the laundry room. He observed POD Nurse 1 trying to move Patient A and saw a petite person underneath the patient. She was lying backwards on the sink with her head on the edge of the washer. Due to the positioning of POD Nurse 1, the 1W Casual Nurse could not see Patient A?s hands. The 1W Casual Nurse then worked with POD Nurse 1 to puil Patient A backward and got him into the hallway. Patient A was initially resistant but became increasingly compliant. During the struggle the WV Casual Nurse was also calling out for someone to call a Code White. The 1E Nurse phoned for security and spoke with a call taker at the Paladin of?ce in Burnaby. Security of?cers were dispatched sometime between 09:15 and 09:20. POD Nurse 1 said that it took about ?ve minutes for him and the 1W Casual Nurse to disengage PatieruA from the Worker. He described the Worker as POD Nurse 1 said that if he had been delayed another two minutes, the Worker would not have survived the incident. The Student Nurse was working under the direction of the 1W Casual Nurse. He also responded to the incident but did not engage in trying to free the Worker. He described the Worker?s position as being bent backward in a very aggressive way, iooking like a football lineman had pushed her forward. The Student Nurse said that POD Nurse 1 and the 1W Casual Nurse had dif?culty restraining Patient A and used as much force as possible to restrain the patient. POD Nurse 1 said that. when the Worker was freed, she sluiupedto the ground?e said it was hard to see her eyes but that she was; . The Worker attempted to get up and POD Nurse 1 told her to stay down. The Student. Nurse stayed with the Worker. WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 15 of 63 This report is supplied to you by WorkSafeBC for your infomatt'on only. It is not to be made known to any other agency or person without the pennission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 POD Nurse and the 1W Casual Nurse escorted Patient A down the hall toward the entrance of 1W. They were aware that the only seclusion room on the unit was temporarily allocated to Patient 8. Instead, they started to take Patient A to the second floor of the Detwiller Pavilion to use one of the BC Program seclusion rooms. 1.4.3 Events after the assault Two security officers were in the Paladin office in the Detwiller Pavilion when they got a call from Paladin?s centralized dispatch centre in Burnaby. Paladin?s records indicate that the call was received sometime between 09:15 and 09:20. The two security of?cers responded to 1W and met POD Nurse 1 and NV Casual Nurse as they were escorting Patient A front the WV unit. Security Officer 1 was the shift supervisor and the designated first aid attendant. Security Of?cer 1 took over restraint of Patient A at the request of the 1W Casual Nurse, allowing the nurse to stay on the unit with his patients. The two security officers and POD Nurse i escorted Patient A upstairs to the second ?oor seclusion room. The third security of?cer was in another building and did not arrive until the first two officers were on the second ?oor with Patient A. The 1W Casual Nurse directed the Student Nurse to get a chair for the Worker. The 1W Casual Nurse then called the Paladin of?ce requesting first aid for the Worker. Paladin reported that the ?rst aid call was made at 09:23. The 1W Casual Nurse was informed that the first aid attendant was not. available as he was busy on another call. During the phone call, the 1W Casual Nurse realized that the first aid attendant was one of the security of?cers attending to Patient A. No time was provided as to when the first aid attendant could respond. After several minutes, the Student Nurse, under the direction of the WV Casual Norse, took the Worker to the UBC Hospital Urgent Care Centre (UCC) in a wheelchair. The Worker arrived at the UCC at 09:38 and was triaged at at 09:48. At some point after that, Security Officer 1 arrived at the UCC in response to the earlier call for first aid and found that the Worker was already receiving medical attention. After going to the UCC to see the Worker, Security Officer I returned to lW to check on POD Nurse i. He completed ?rst aid records for both workers. The Manager said that she carries a pager 011 the weekend and was paged at approximately 09:15. However, she said that she did not get the page until about half an hour later due to a problem with the paging system. The Manager later spoke on the phone with POD Nurse and the Worker. She was aware that the Worker was going home after being treated at the UCC. At one point, the Manager contacted the 1W nurses and asked them to check on POD Nurse 1 throughout the day. The Manager did not go to the unit. POD Nurse 1 called the on-call 2) to the POD between 12:00 and 12:30. He arrived at 1W shortly after. POD Nurse 1 was now working alone with the patients. WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 16 of 63 This report is supplied to you by WorkSe feBC for yourinfonnation only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. N12012134520019 Vancouver Coastal Health Authority March 17, 2012 2 described his ?rst impression asi?i? POD Nurse 1 had blood on his sleeve, and 2 described 'h'in said POD Nurse 1 stated, if} . 2 observed that. POD Nurse 1 also had an injury and encouraged him to seek medical care that day. WorkSafeBC was not initially noti?ed of this incident. The Site Safety Adviser informed the local WorkSafeBC occupational hygiene officer of the incident on March 21, 2012, four days after the assault occurred. 1.5 Temporary set-up of the POD on 1 West 1.5.1 Planning As planned, by late January 20l2, Vancoaver General HOSpital?s Willow Chest site was ready for occupancy by the ATRP patients from Forest Edge at UBC Hospital. The newly renovated Willow Chest was designed to house 21 patients; however, the ATRP had 27 patients. VCHA planned to continue care for the six remaining ATRP patients at the former Forest Edge site until the Wiilow Pavilion was ready for occupancy. PHSA expected that all of the ATRP patients would be moved from Forest Edge before the BC Program took over the site in January 2012. VCHA knew before January 2012 that construction challenges had resulted in a delay and that the Willow Pavilion would not be ready for occupancy until May or June 2012. When VCHA moved the 21 patients to Willow Chest, VCHA staff selected the patients they believed to be the most likely to succeed in the ATRP. The six patients remaining at the former Forest Edge site were those in the program with the most challenging behaviours and the least prepared for living in a community~based setting. Those six remaining patients were now located on the BC Program unit. On January 1 t, 2012, President of BC Mental Health and Addictions wrote a letter to Director of Housing of the ATRP program, informing VCHA that, further to discussions in the previous week, the two patient populations were not compatible, and the remaining ATRP patients had to be moved to facilitate the full operation of the BC Program. In 2009 VCHA had committed to moving all the ATRP patients prior to admitting the BC Program patients. This plan was reiterated in February 201 1. As VCHA had not made other arrangements for the six remaining patients, urgent planning was required to relocate them. This planning was done at the same time as the 21 other ATRP patients were being relocated to the Willow Chest site. The planning and relocating of the remaining six patients to the temporary POD in WV was done within a four-to-six week period. Decisions about where and how to provide care for the WorkSafeBC Investigations Workers? Compensation Board of 8.0. Page 17 of 63 This report is supplied to you by WorkSafeBC for your infomation only. It is not to be made known to any other agency or person without the pennission of WorkSafeBC. NI 2012134520019 Vancouver Coastal Health Authority March 17, 2012 remaining patients were primarily made by Director of Mental Health and Addictions and the VCHA Medical Director of in conjunction with the Manager and the 1W Manager. The nurses, program supervisor, rehab workers, and other support workers were not consulted or included in the decision-making process. One of the ATRP patients was moved back to Riverview Hospital. it was decided that the other five patients should remain as a group and should have care provided by staff working in the ATRP. The ?ve remaining patients were relocated to the end of the 1W unit. A violence risk assessment was not completed as part of the planning for the move to 1W. 1.5.2 Staffing the POD Seniority generally determined which workers would remain at UBC Hospital to provide care for the ?ve remaining patients being relocated to the POD. All of the staff working in the POD were the mostjunior workers in the program. Staf?ng of the POD was planned to include one nurse and one rehab worker, 24 hours per day, seven days per week. In addition to the nurses and rehab workers, there were peer support workers, a part-time recreation therapist, a part?time occupational therapist, and a part-time social worker also assigned to the POD. Many of the POD positions were vacant for a variety of reasons. Staf?ng was a challenge due the vacancies resulting in frequent staff shortages. Workers were replaced with casual workers when available, Filling positions with staff working overtime was also common. 1.6 Management and supervision Director of Mental Health and Addictions in Vancouver is responsible for acute beds and out-patient programs in Vancouver, the Burnaby Centre, and the tertiary rehab programs. At the time of the incident, she was the operations director responsible for the overall running of the programs. Her portfolio included 325 beds and numerous out~ patient programs. At the time of the incident, the Manager was the patient services manager for tertiary mental started this . The Manager multaneously at the POD. The two sites are 10 kilometres apart. The the Supervisor went back and forth to the POD on a more regular basis than she The Supervisor was the program coordinator for the ATRP and was responsible for direct oversight of the workers. While the POD was operational, she supervised both Willow Chest and the POD. The Supervisor worked day shift, Monday to Friday. As the incident occurred on a Saturday, the Supervisor was not working at the time of the incident. WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 18 of 63 This report is supplied to you by WorkSefeBC for yourinfonnation only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. N12012134520019 Vancouver Coastai Health Authority March 17, 2012 1.7 Training and experience 1.7.1 General staff training The ATRP was a new program for VCHA, and staff were recruited and trained before patients were admitted. Staff hired for the opening of the unit went through a three-week training and orientation program. Examples of topics covered in that training included: Orientation to VCHA Non-violent crisis intewention training Foodsafe training Mental health housing Computer lab Overview of tertiary mental health and tertiary organization Recovery-centred clinical system The training for new workers was not mandatory, and not all of the new workers attended the full three-week session. This training program was not made available to workers who were hired after the ATRP opened. VCHA had a policy that required directors, managers, and supervisors to take a four-hour occupational health and safety course designed for managers and supervisors, and to complete online refresher training annually. 1.7.2 Director of Mental Health and Addictions of Menth Health and Addictions started in her ositiou at BefOre coming to VCHA, she At the time of the incident, she had been the director for Although the Director of Mental Health and Addictions was making decisions that could impact the health and safety of the workers, she had not taken four-hour occupational health and safety course for managers and supervisors. 1.7.3 Manager Before managing tertiary mental health programs at UBC Hospital and Vancouver General Hospital, the Manager, 5'5; She has been a manager in sinCe The Manager attended the fouruhour occupational health and safety course for managers and supervisors in She had not completed. . available since then. Inf-*3 22., the Manager participated in 5'59 WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 19 of 63 This report is suppiied to you by WorkSefeBC for your infometion only. it is not to be made known to any other agency or person without the permission of WorkSefeBC. Nt 201234520019 Vancouver Coastal Health Authority March 17, 2012 1. 7.4 Supervisor The Supervisor started in 21719.17 to working as program,poerdinator for the ATRP the Supe The Supervisor attended the same three-week training program as the first workers hired. In addition to this training, she also attended the four-hour occupation forrnanagers and supervisors. Before starting in her position, she ii: 1.7.5 Worker The Worker described her recreation therapist role at VCHA as one in which she supported the inte cess to leisure activities. She had worked I k. . 1 . was very different from the work she had been doing before The Worker did not start working in the ATRP during its start-up phase and was not offered the three-week training and orientation program that the ?rst group of workers received. As a result, she did not receive information on rehabilitation, the recovery-centred clinical system, and trauma-informed care that was offered to the first group of workers. She did receive some mentoring from another recreation therapist, but VCHA does not have training records to indicate what was covered in these mentoring sessions. The Worker described the mentoring as and she did not receive it until several weeks after she started working. Code White is a term used throughout the health authorities. It refers to a co-ordinated response to a situation where a patient is behaving in a potentially dangerous manner. The Worker had not received training in Code White responses, de-escalation techniques, or non-violent crisis intervention. 1.7.6 POD Nurse 1 P_QD__Nurse is a registered nurse. He had been working__with VCHA since. Prior to working for VCHA, he was WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 20 of 63 This report is supptr'ed to you by WorkSafeBC for your infomatr'on only. It is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastet Health Authority March t7, 2012 POD Nurse 1 participated in the three-week orientation program VCHA provided for the employees initialiy hired for the program. He recalled that during the three week training there was mention of Code White responses but no training speci?c to VCHA. He had taken Code White trainin when he 1.7.7 Other persons responding in this incident The 1W Nurse is an experienced nurse. She is a regularly scheduled nurse working in 1W. Both the 1W Nurse and 1W Casual Narse worked under the 1W Manager, who reported that the WV staff had not received Code White training. The 1W nurse for on 1W. i nurse who worked casual on IE and on 1W. He had been a at the time of the incident. On the day of the incident, he was working The Student Nurse was on the 1W unit as part of histr the 1W Casual Nurse. He was 3 Preceptiag is a period of time where a nurse works With a registered nurse to CorrSOIidate skills. The IR Nurse is an experienced registered nurse who is regularly scheduled 011 IE. On the weekends, 1E covers breaks for nurses on 1W. On the day of the incident, clue to the needs of Patient B, the HE Nurse was started on 1W to assist with providing 1:1 care for this patient. When she arrived on 1W, she was provided with reports on the 1W patients but had not been provided with any information about the POD patients. 1.7.8 Rehabilitation workers The rehabilitation worker job description was established October 5, 2010, and revised four times after that date. he last revision was completed on December 16, 2011. VCHA has no de?ned training program for rehab workers. VCHA consider workers who acquire a social services diploma or certi?cate from a recognized health care worker educational program to be quali?ed for rehab worker positions. Such certi?cation includes a health care support worker certi?cate, a certificate in community mental health, a human service worker certificate, or an addictions certificate. in addition to these educational requirements, workers are required to have two years of experience working in a setting with individuals who have complex mental health and addictions issues, or to have other quali?cations determined to be appropriate and relevant to the levei of work. WorkSafeBC Investigations Workers? Compensation Board of 8.0. Page 2t of 63 This report is suppiied to you by WorkSafeBC for yourinfonnatton only. it is not to be made known to any other agency or person without the permission of WortrSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 1. 7.9 Peer support facilitators The peer support facilitator job description was established on October 5, 2010, and revised twice after that date. The last revision was completed on September 7, 2011. VCHA has no de?ned training program for peer support facilitators. VCHA requires that workers obtain either a diploma in a community social services program and two years of recent related experience, or a certi?cate in counselling skill and three years of recent related experience. In addition, VCHA requires that workers have personal experience with mental health issues and with accessing mental health services. 1.8 Risk of injury from violence 1.8.1 Assessment Between December 2011 and March 2012, the British Columbia Nurses? Union (BCNU) exchanged several emails with the Site Safety Adviser for UBC Hospital. The emails were also copied to Safety and Prevention Manager. In December l, the BCNU requested that a violence risk assessment be done speci?cally for the ATRP. The union expressed concern ,aboutth. fetr activitieshpl VCHA had not done a violence risk assessment to determine the nature and type of occurrences of violence that could be anticipated for the ATRP. VCHA had a Violence Prevention Program, which was dated 2004. It was confirmed by the Safety and Prevention Manager to be the most recent version of the program in effect at the time the incident. VCHA had hired two violence prevention specialists, who started at thetnne of the modest, these two violence prevention specialists had been VCHA for i . They were the only violence prevention specialists to provide assistance to all ofVCI-lA?s l54 registered worksites. The VCHA 2004 Violence Prevention Program speci?ed the need for violence risk assessments and designated the responsibility for the assessments to the manager on a ?risk based basis.? The VCHA program required managers to then communicate the results to the VCHA violence prevention advisor. At the time of the incident, VCHA did not have a system in place to monitor the completion of violence risk assessments. WorkSafeBC Investigations Workers? Compensation Board of 8.6. Page 22 of 63 This report is supplied to you by WorkSeteBC for your information only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 1.3.2 Controls to minimize risk to workers VCHA uses a Code White system to ensure immediate assistance should a worker be in a situation where initial de-escalation strategies are not successful. Code White is a standard process used throughout various health authorities and refers to a trained team response to a disturbance that is a beht vioural emergency involving a patient. A Code White team response is intended to regain control of the situation and ensure the safety of all parties. The Code White team uses verbal techniques, or, if necessary, physical techniques with the least restrictive measures possible for the shortest period of time. Physical techniques may include physical hand restraint, mechanical restraint, and the use of a seclusion room. VCHA has a policy called Emergency Response: Code White. This policy is included in the health and safety program. it was developed in 2004.T here is no documentation on the policy that indicates it has been reviewed since that time. The policy de?nes the roles of the responders during a Code White, including the care providers and the security of?cers. At Detwiller Pavilion, a Code White response involves available staff and all three of the on?site Paladin security of?cers. A Code White response at UBC Hospital can be initiated by activating the panic alarms, or by calling one of several phone numbers that direct the caller to either the Paladin central of?ce in Burnaby or to the UBC Hospital switchboard. As previously stated, Paladin conducts panic alarm testing on a basis and maintains records of these tests. VCHA facilities department workers do the programming and maintenance on the alarms. 1.8.3 Communication of risk to workers VCHA uses a form called the ALERT to communicate risks associated with specific patients. The ALERT communication system identi?es patients who have a potential for violence and aggression. The ALERT system was initiated at VCHA sites in 201 1. Workers complete an ALERT form when an initial screening indicates that a patient may pose a potential risk. Workers also complete the ALERT form when a patient. becomes violent or aggressive during a hospital stay. The ALERT form, which is a four-paged document, guides workers in the assessment of a patient, based 011 the patient?s current presentation and past history. Part 2 of the form outlines the steps workers should take to communicate the identi?ed risk of violence or aggression to other workers. These steps include completion of an electronic ALERT, where applicable, posting a visual ALERT form near the patient?s room, highlighting the patient?s wristband in purple, identifying the chart. with an ALERT sticker, placing the ALERT form in the front of the chart, and updating the Kardex. WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 23 of 63 This report is supplied to you by WorkSafeBC for your infometion only. it is not to be made known to any other agency or person without the pennission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 2012 Part 3 of the form is used to document individual occurrences of violence or aggression during the current hospital stay. Entries made in Part 3 also direct a worker to the location in the patient?s chart where the incident is formally documented. Part 3 also includes a space for a discharge summary of past and cun'ent violence. On the last page of the ALERT form is a chart that outlines the steps workers should take to manage a situation when a patient presents with escalating behaviour. One of the last steps to take during an incident is to call for assistance (see Figure 4). Page 4 of the ALERT form also de?nes violent and aggressive behaviours. Violent? is de?ned as threatened, attempted, or actual physical harm to someone. Aggression is defined as abusive or intimidating behaviour. Aggression toward a person includes yelling, swearing, or insulting. Aggression toward property includes hitting, kicking, throwing, burning, or breaking objects. Workers can ?nd other information about a patient?s history and the potential for violence in various places throughout the patient chart. Pertinent information can be found in health professional progress notes, the interdisciplinary care plan, nursing database, rehab plans, and doctors? progress notes. The Kardex, a day-to-day communication system, was not available for review as it is not considered to be a permanent part of patient records. WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 24 of 63 This report is supplied to you by WorkSafeBC for your information only. it is no:l to be made known to any other agency or person without the permission of WorkSafeBC. 2012134520019 Vancouver Coastai Heaith Authority March 17, 2012 ALERT VIOLENCE refers to threatened. attempted or actual punysicai harm to someone AGGRESSIOH refers to abusive or inzimkjaling behaviour. may be aggressSm lo a person (ye?ing at. swearing at. or insui?ng 50mm} 0: aggresskm to property (hitting. kicking. ihrowing. burning, or breaking objects) FHSK FACTORS refer to behaviours associated increased risk {or v?oiemo or aggression. They may be 01a var;er a! physicai or mania! beam: ESCALATING BEHAVIOUR MANAGEMENT Al all times ma?niain your safely and am in me best intemsi 0% care. wa?are and gammy 4o: slat! and the cheats) PRECIPITATING FACTORS An?hfng mar triggers or feeds to an fmrease in anxiety LEVEL RISING An changes the} you no?ce in c?enzs'behamw Substance! Intoxicaisonwahdrawa . agitation, anger, suspMM. confusion, disorientation, km:er paranoia} STAFF RESPONSE: Stay cam and be supportive. defuse?de-escalala, use verbai intervention and 52919 your expectations. ?1er promem sofve, otter attemalives if possit?e CUENT CONTINUES TO ESCALATE CLIENT RESPONDS TO STAFF INTERVENTION and demonstratesfsiates a reduction in anxiety fevei CLIENT BECOMES DEFENSIVE Verbal escalation to aggression: infatmtfon given, hsm'ring; lNom?ng. {swing or breakfng Mock) STAFF RESPONSE: Provkja direction. 531 ?mils. Don?t argue: reiniowe acceplatzia behavicm expecta?cns and identify consequenceis} to con?nued unaccepzabfe behaviour the! are reasoaable and enfmceabie. Gite: alternatives to help c?ien! decrease anxieiy as possible CUENT CONTINUES TO ESCALATE cuem? as To STAFF and a reduction in bohav?onr CLIENT ACTS OUT (5.9. Further andlw vidence (ac?ml, aliempfed or harm): my?mh?y our prisenl's a danger to 591?! and where, I: not responding to ream or [Men-er:th STAFF RESPONSE: Remove yourse}! [rem {he s?uai?on, cat: for helcfac?vale Code Whitmch pciicefsecm?dy. Activate persona} aiarm i? wearing CLIENT SHOWS Can-n. responds to direcn'en. can identify ma?piialrhg {ac-fats and (?scuss for comnxmica?on of concerns STAFF RESPONSE: Eragage diam in probiem solving. Non-puni?w, mailer oi lac! Figure 4: According to (his ALERT chart, workers are not directed to califor assistance (Code I'Vhize 0r.5'ccuri139 as the chem ?s (pariem behaviour escalates, bur {0 waif rmiil the alien! acts 0m. Source: CHA, Paziem A ?3 char! WorkSafeBC Investigations Workers' Compensation Board of 8.0. Page 25 of 63 This report is supplied to you by WonkSafeBC for your infomarion onfy. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Nt 2012134520019 Vancouver Coasts! Health Authority March 17, 2012 1.9 First aid UBC Hospital is required to have an occupational first aid level 2 attendant to provide care to workers in the event of injury or illness. At UBC Hospital, first aid is provided by VCHA through Paladin. VCHA, as a multiple-employer worksite, provides first aid to both VCHA workers and contracted workers through Paladin. VCHA has an occupational ?rst aid program as part of its overall health and safety program. The program was implemented in 2004 and was last revised in 2009. VCHA aiso has an occupational first aid policy, which was also implemented in 2004. The most recent revision to this policy was completed in 2009. The most recent ?rst aid assessment completed or reviewed for UBC Hospital was done in 2004. 2 Analysis The patients relocated to the POD at UBC Hospital were patients with signi?cant mental health illnesses, which required them to be hospitalized frequently or for long periods of time throughout their lives. The analysis will not focus on the illnesses of these patients but rather on responsibilities to ensure the safety of the workers providing care for them. The analysis will consider: Work planning for the Adult Tertiary Rehabilitation Program Precipitating factors leading to the assault Assessment to determine the risk of injury from violence Controls to minimize the risk of injury from violence Communication to workers of the risk of violence Training of staff Supervision First aid attendant availability Corporate oversight 2.1 Work planning for the Adult Tertiary Rehabilitation Program 2.1.1 Transfer of patients from Riven/few Hospital The relocation of the ATRP patients to UBC Hospital started in January 201 1. VCHA representatives attended five transfer meetings with representatives of Riverview Hospital between January 6, 201i, and February 17, 201 i. VCHA kept no minutes of these meetings. As part of the meetings, VCHA representatives sat in on patient-centred clinical planning and attended patient rounds with the intent of ensuring a consistent clinical approach for ATRP patients once they had moved. WorkSafeBC Investigations Workers' Compensation Board of 8.0. Page 26 of 63 This report is sapptied to you by WorkSafeBC for yourinfonnatr'on only. It is not to be made known to any other agency or person without the permission of WorkSefeBC. 2012134520019 Vancouver Coastal Health Authority March 17, 2012 Riverview Hospital provided documentation for each patient in a Master Transition Plan. These transition plans included patient-speci?c information such as the following: medical and diagnosis; special considerations and risk factors such as violence; and explanation of behaviour, including signs of decompensating or the presentation of violence characteristics. The majority of the patients in the ATRP were patients who were transferred from Riverview Hospital with documented histories of the potential for violence. Worker safety at all stages of planning and implementation of the ATRP should have been considered as the risk of injury from violence clearly existed. 2.1.2 Renovations for housing A TRP patients The Project Manager, who was responsible for the renovations of Detwiller Pavilion and of Willow Chest and Willow Pavilion, worked as part of a service group known as Facilities Management. Management is a group providing a consolidation of services for the Lower Mainland health authorities. This working group is operated by Fraser Health Authority. The Project Manager began work on the three projects in . Although he was overseeing renovations for VCHA, he is an employee of Fraser Health-Authority. VCHA and PHSA had an understanding from early in the planning stage that the second ?oor of Detwilier Pavilion had been renovated for the BC Program but would be used by the ATRP for one year white renovations were completed on the Wiilow sites located at Vancouver General Hospital. During the planning of the renovations, Safety and Prevention Department was included in a limited capacity. The Safety and Prevention Department was brought into the discussion at the end of the planning stage when the ?oor plans were already completed. These discussions included safety considerations such as egress, line of sight, and physical barriers. Partway through the renovations of Willow Chest and Willow Pavilion, the City of Vancouver required seismic upgrades. This resulted in a delay of severai months for occupancy. However, Willow Pavilion was never planned to be compieted at the same time as the Willow Chest site. From the time the renovations began to their completion, signi?cant changes took place in the clinical teams who would ultimately be responsible for providing care for the patients. Early planning was done with a clinical team that was not part of the adult tertiary rehabilitation programs when the sites were occupied. The clinical team was made aware of anticipated delays at Willow Pavilion, on a regular basis through weekly meetings with the Project Manager. The Director of Mental Health and Addictions, who provided oversight for the ATRP, attended these weekly meetings. As a result of ongoing communication from the facilities group, the Director of Mentai Health and WorkSafeBC Investigations Workers? Compensation Board of 8.6. Page 27 of 63 This report is suppiied to you by WorkSafeBC for your information oniy. It is not to be made known to any other agency or person without the permission of WomSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 2012 Addictions would have been aware of any anticipated delays. Therefore, she would have known that the move of ATRP patients to the renovated sites would be affected. She would also have known that there was room for only 21 patients at Willow Chest. 2.1.3 Move to Willow Chest Although VCHA knew that in January 2012 Willow Chest would have room for only 21 of the ATRP patients, it admitted another patient into the program in December 2011, bringing the total number of ATRP patients to 27. That leit six ATRP patients who could not be moved to Willow Chest. The Director of Housingfor mental health and addictions ha i Housing was also responsible for delivering the BC Program in January 2012. Although VCHA manages the BC Program, the beds within the unit are allocated to each of the health authorities throughout the province. The Director of Housing said that during the planning stages for the ATRP, they were acutely- aware that there were more ATRP patients than could be accommodated at the Willow Chest site. VCHA had anticipated that more patients would be discharged from the program before Willow Chest opened, From the planning stages,VCHA knew that there were more patients in the program than could be accommodated at Willow Chest. When Willow Chest opened as planned in January 2012, 21 ATRP patients were gradually moved to the new location. To determine which of the 27 ATRP patients would move to Willow Chest, the Supervisor said that the patients requiring more acute care were not transferred. Part of the reason for keeping the patients at Detwiller Pavilion was because of their potential risk. As Willow Chest did not have seclusion rooms, the patients with the most recent incidents of aggression were not transferred. These patients were also considered to be less ready for rehabilitation because they were the most. unstable of the tertiary patients. When the BC Program moved to the renovated Forest Edge site, VCHA had not made plans to move the six remaining patients to another location. VCHA assumed that it would be acceptable to leave those patients on the BC Program unit until the Willow Pavilion site renovations were completed. Thus, the ATRP, although operating independently from the BC Program, had six patients remaining in the unit. VCHA and PHSA discussed leaving the six ATRP patients in the Detwiller Pavilion after the BC Program moved in. Once the patients were admitted to the program, the unit had to be secured. VCHA did recognize the challenge of placing the ATRP patients in a secure unit after they had become accustomed to being in an unlocked unit, but, as previously WorRSafeBC Investigations Workers? Compensation Board of 8.0. Page 28 of 63 This report is supplied to you by WorkSefeBC for your information only. it is not to be made known to any other agency or person without the permission of WortrSafeBC. NI 2012134520019 Vancouver Coastal Health Authority March 17, 2012 mentioned, VCHA did not have an alternative plan for the remaining patients following the opening of the BC Program. At. the request Riverview Hospital sent a representative to do assessments on the six remaining patients. The assessments determined that they were correctly classi?ed as tertiary rehab patients. The patient who had been admitted in December 201 was transferred back to Riverview Hospital. PHSA expected that all of the ATRP patients would be moved off the anit before the opening of the BC Program. On January l, 2012, PHSA put these expectations in a letter to VCHA from the President of BC Mental Health and Addicitons. The letter stated that from the early planning stages for the ATRP in 2009, VCHA had committed to an interim use of the Detwiller location and had committed to moving the ATRP patients out of Detwiller before the opening of the BC Program. The letter stated that this initial plan was further reiterated in February 201 1. The letter also stated that the mix of rehab patients and refractory patients was not appropriate. 2.1.4 Move to the POD on 1W VCHA then planned the relocation of the ?ve remaining patients. This was happening while the other ATRP patients were being moved to Willow Chest. VCHA determined that it was best to keep the five remaining patients together and developed a plan to cohort the patients as a group at the end of NJ, in the unit. Doing so would maintain as much consistency for the patients as possible. A timeline provided by the Director of Mental Health and Addictions indicated that planning for the patients? relocation started January 1, 20l2. The actual decision to move the patients to 1W was made in the week of February 640, 20l2. The last four rooms of the WV unit were allocated to the ATRP patients and became known as the POD. An examination room was turned into a narses? station, and a four-bed patient room became a lounge/dining room area. A laundry room was to be shared with the 1W patients. The ATRP patients were moved to the POD on February 17, 2012. At that time, the nurses did not have access to the WV medication area, which required a pass code. They had to rely on the 1W staff to access medications. 1W and the POD operated under the direction of different managers and supervisors. 2.1.5 Staf?ng the POD Staffing the POD was an ongoing challenge. Because the program was now staf?ng both Willow Chest and the POD, workers were assigned to work at. either Willow Chest or the POD. The same number of workers were now providing care at two work locations. Of the positions assigned to staff the POD, about half of the postions were vacant positions. to workthe incident, a peer support This left POD Nurse 1 alone present. The staffing record shows that WorkSafeBC investigations Workers' Compensation Board of 8.6. Page 29 of 63 This report is supplied to you by WorkSafoBC for your infometion only. it is not to be made known to any other agency or person without the permission of WorirSafeBC. NI 2012334520019 Vancouver Coastal Health Authority March 17, 2012 with the patients for the first half hour of the shift until the Worker arrived. Had staffing gone as planned, the Worker would have been the third worker present on the day of the incident. iris-"section 22. i At the time or thrust-aha 011393119 Vacant nursing positions wasdue. to works incident, that nurse was The POD was open for approximately one month before the incident occurred. During that month, there were times when only one worker was scheduled in the POD. During the day shift, it was common for the Worker, rehab workers, or peer support facilitators to take patients off the unit for outings. This routinely left just the nurse in the POD. Due to the number of vacancies, many of the shifts were covered by casuai staff or people working overtime. There was no plan for POD workers to have breaks covered by 1W staff. Because of this, POD nurses were either on call during breaks or took no breaks during their 12-hour shifts. POD Nurse a: and had beenworking i program for abou __rto_1' to working for VCHA, she worked for '3 2 She described the situation in the roots the S. POD Nurse worked in for years. She was tern or'rrii itfor'k__i_ng__i__n the AT RP and was oriented to the program approximately" . When asked about staf?ng, POD Nursery; that the lack of censistency was creating anxiety for one of the patients. She stated that the nurses sometimes would work 16-hour shifts. Two peopie were supposed to work on evegy shift, but sometimes that didn?t happen, and a nurse had to carry the unit alone. POD Nurses; also said that she had worked one night shift and one day shift by herself. According to the staffing record, following the incident, which occurred at approximately 09:05, another worker did not. arrive to assist POD Nurse 1 until i5:30. Despite the impact on POD Nurse 1 from the incident and his own injuries, he was left. alone to work with the patients for several hours. had phoned the staff and asked them to check on him periodically. I I Nurse 1 was" WorkSafeBC Investigations Workers' Compensation Board of 8.6. Page 30 of 63 This report is supptied to you by WorkSefeBC for your information onty. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2032134520019 Vancouver Coastal Health Authority March 2012 Keeping the ATRP patients together as a group should have provided consistency and continuity for the patients during this temporary relocation. However, the staf?ng challenges on the POD did not allow for ongoing consistency of care providers. The staf?ng challenges may have contributed to the incident. 2.1.6 Changes associated with the move to the POD Although the patients moved to the POD did settle into the new area, there were several changes in their daily lives. 8. During an interview, spoke about the POD. Of concern to him was the lack of a dedicated interview room. Because of this, patients had to be seen either in the hallwayorgtlieisr Poems. It seemed inappropriate to to interview patients in their Although the small nurses?station was available for intervieWS, did "nor feel-comfortable using that room because there was only one door which would not allow for emergency egress. The room was also very narrow, and contained a lot of furniture and other items that could be used as weapons (see Figure 5). Figure 5: The view from the doorway of the single-eme nurses Marion, showing no emergency egress. Had a potion! gone into the nurses slaiion and presented aggressively, there would have been no method of escape. The nurses station contained several objecis that coald have been used as weapons. The door was generain le? open, leaving no physical barrier beirtreen die pariems (Hid the workers, (0 allowfor visual and auditory monitoring of (he paiienls. POD Nurse 1 was sitting in ?re moses ?siaiz'on when the incident occurred. WorkSafeBC Investigations Workers' Compensation Board of B.C. Page 31 of 63 This roped is suppiied to you by WoritSafeBC for your information oniy. it is not to be made known to any other agency or person without the pennission of WomSafeBC. NI 2012134520019 Vancouver Coastal Health Authority March 17, 2012 2 had two patients in the POD. He initially thought when the patients moved to 1W that they were comfortable there. Over time, they became increasingly bored because there was nothing to do. Once they moved to the POD, the patients no longer had access to the internet or cable TV or had ready use of a telephone. Two of the five patients were sharing a room, which had not happened before the move to the POD. Patients? meals were provided on individual trays, which was change from how patients had received food when they were on the second ?oor unit. Despite these changes in their environment, 1, Patient A?s treating thought that Patient A had settled into the POD and had been doing quite well in the month following the move. The Worker said that the loss of the internet, cable TV, and easy access to the phone was a loss of familiar, leisure programming for the patients. One patient had been accustomed to using the computer for researching and downloading music. One patient was always on the phone, and the television was another source of music that was important to the patients. Although it is not withinWorkSafeBC?s jurisdiction to determine the impact of the move on individual patients, the investigation did determine that there were significant changes in space, leisure activity resources, staffing, and the delivery of food. The move also had an impact on the space the could use for patient interviews. 2.1.7 Known history of violence Before Patient A was transferred into the ATRP at the Forest Edge site, informed VCHA that Patient A had a risk of violence. The in section were comprehensive documents outlining experience with individual patients and the ongoing strategies for working with their mental illness. WorkSafeBC does not have jurisdiction to consider the clinical aspects of patient care; therefore, the investigation focused on information communicated to the receiving facility that would assist it in identifying, planning for, and controlling the risk of injury from violence. The following list includes examples of the information provided in the Master Transition Plan for Patient WorkSafeBC Investigations Workers? Compensation Board of 13.6. Page 32 of 63 This report is supplied to you by WorkSafeBC for your infonnat?ion only. it is not to be made known to any other agency or person without the permission of WomSefeBC. N12012134520019 Vancouver Coastal Health Authority March 17, 2012 The following iist includes information found in the Master Transition Plan for Patient A under the headies_Cvr_rent Level. harmonies: Given the above, all VCHA staff working with Patient A should have known that he had a history of violence. Workers shoaid also have known that communication with Patient A about completing the activities of daily living could trigger assaultive behaviour. 2.2 Precipitating factors leading to the assault Suggesting why Patient A assaulted the Worker would be speculative. Patient A was not interviewed as part of the investigation. Therefore, the analysis of what happened to trigger the assault is based only on information provided through worker interviews, interviews, and documentation review. Physician notes following clinical rounds on March 7, 2012, were the most recent doctor notes in Patient A?s chart prior to March 17, 2012. The notes stated that there were no safety concerns. On the morning of the assault, Worker and PODNurse aware that Patient A was agitated. They also knew that he 39-099 25' He had been encouraged to shower and change into clean clothes. Unknown to the two POD staff, Patient A had been involved in two interactions with Patient prior to the assault. The first incident occurred in the lW patient lounge. Patient B, a 1W patient, had tried to take food from Patient A. The 113 Nurse managed the situation and redirected Patient 8. The IE knew that Patient A had a history (if previous assaults, but she did not know that he was the patient she had interacted with. Had she known, she would have been able to let the POD nurses know that an interaction with potential for triggering violence had occurred. WorkSateBC investigations Workers' Compensation Board of 3.0. Page 33 of 63 This report is Supplied to you by WorkSefeBC for your infomation only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. NI 2012134520019 Vancouver Coastal Health Authority March 2012 The 1W Nurse observed the second incident involving Patient on the morning of the assault. It is likely that this incident occurred after Patient A was originally instructed to shower. The 1W Nurse reported that she observed dirty laundry on top of the washer and that Patient had touched it. Patient A observed this happening as he was also in the laundry room. The 1W Nurse believes that the linen touched by Patient belonged to Patient A. She said that this interaction - took place only minutes before the assault. The POD was located at the end of the 1W unit (as shown in Figure 1 on page i 1). Until the POD took over this section, the entire unit was occupied by 1W. Therefore, no physical barriers separated the patient populations. Patients from both programs had ready access to all areas of the unit. The laundry room where the assault occurred was a shared-use laundry room for use by both the POD and 1W. However, because the POD and 1W operated as independent units, there was no cross-training or reporting related to individual patient?s needs or potential triggers for violence. The lack of ongoing communication between the staff of the two groups resulted in the POD staff not being informed of the two incidents involving Patient. on the morning of the assault. As a result, neither the Worker nor POD Nurse 1 had any information about these incidents that may have contributed to Patient A?s agitation. Patient had been noticed by POD Nurse 3 when admitted. On the morning of March 16, 2012, the day before the incident, POD Nurse 3 informed the Supervisor by email that Patient had been 111' In the .. (?hat Patient was Supervrsort at the POD'sta'ff 1a spoken .and-had told them to stay away from Patient B. 3 also madetheVSupervisor aware that Patient required 1:1 care. She thought that this Charting for Patient A the night before the assault indicated documented that Patient A wassettled and self-directed in the evening, and seemed relaxed. At 06:30, on the day of the assault, a rehab worker documented that Patient A appeared to be sleeping when checked hourly throughout the night. 1, Patient A?s stated that Patient A was doing quite well since moving to the POD next to 1W. Given the information provided by and recent entries in Patient A?s chart, it is likely that whatever triggered the assault on the morning of March 17, 2012, was situational. 2 was the on-call on the day of the incident. He conducted and doctrine lt 'th t' A hich indicated that Patient A jg; WorkSafeBC Investigations Workers? Compensation Board of 8.0. Page 34 of 63 This report is supplied to you by WorkSafeBC for your infomation oniy. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Heaith Authority March 17, 2012 Master Transition Plan clearly indicated that Patient A could become aggressive when confronted about completing activities of daily living. Both the Worker and POD Nurse i had interacted with Patient A about completing activities of daily living in the half hour prior to the assault. Both POD Nurse 1 and the Worker were aware that Patient A was agitated before they engaged with him about showering and changing his bed linen and clothes. The assault occurred only moments after an interaction between the Worker and Patient A. However, Patienteliad already. presented vi t1} assaultive behaviour in addition, P?tle?t A . .. . . get; Given his history, Patient-A had, istory of being unpredictable 111 terms of presenting with aggressiVe or demonstrated a h- violent behaviour. Both the Worker and POD Nurse 1 were aware that Patient A was agitated prior to the assault. On the day of the incident, there were several precipitating factors that were known to be triggers for Patient A. In addition, the changes to his daily living activities, changes to the living and care environment, and the staff?s lack of information about earlier interactions likely elevated the risk of Patient A becoming violent. 2.3 Assessment to determine the risk of injury from violence Violence-related incidents are the third leading cause of injury resulting in claims to health care workers in British Columbia. Approximately it percent of all injuries resulting in worker claims in the health care sectors are due to incidents of violence. The Occupational Health and Safety Regulation, section 4.28, requires that a risk assessment be performed in any workplace in which a risk of injury to workers from violence arising oat of their employment may be present. For the application of the Occupational Health and Safety Regulation, the Regulation defines violence as the attempted or actual exercise by a person, other than a worker, of any physical force so as to cause injury to a worker, and includes any threatening statement or behaviour that gives a worker reasonable cause to believe that he or she is at risk of injury. Section 4.28 speci?cally addresses the requirement to conduct a violence risk assessment whenever workers may be at risk of injury from violence. The violence risk assessment must include consideration of the circumstances and location where the work is taking piace. Since UBC Hospital, which is a VCHA work location, is a multiple-employer worksite, VCHA was required to conduct a violence risk assessment that considered the risk of injury to VCHA workers and to workers of other employers contracted by VCHA who might be exposed to incidents of violence. Examples of those contracted workers include security officers, physicians, housekeepers, and dietary workers. WorkSafeBC Investigations Workers' Compensation Board of B.C. Page 35 of 63 This report is suppiied to you by WerkSafeBC for your information oniy. it is not to be made known to any other agency or person without the pennissr'on of WorkSafeBC. N12012134520019 Vancouver Coastal Health Authority March 17, 2012 2.3.1 Violence assessment not completed before opening Forest Edge As part of this investigation, WorkSafeBC requested a copy of the violence risk assessments completed for the Forest Edge site and for the move to the POD. Violence risk assessments were not completed following the renovations of the second floor of the Detwiller Pavilion or when the ATRP program was first operational. In response to the request fora copy of the violence risk assessment for the Forest Edge site, the following was provided: [The Safety and Prevention Manager] reports that an exhaustive search of electronic records within Workplace Health has not uncovered a Violence Risk Assessment prior to the opening of Forest Edge for this site. He recalls that an assessment may have been completed at the Detwiiler Facility at some point after 2006, but unfortunately it was likely printed out in hard copy or saved electronically before centralized network drives were created and organized. As a result, the information is not attainable and therefore no information is available on who completed the assessment nor the resulting recommendations. in the absence of any documented evidence of its completion, we must regrettably assume that there wasn?t a comprehensive violence risk assessment completed. Even if a risk assessment had been completed ?at some point after 2006,? the assessment would not have been current enough to identify the potential risks to workers. The Forest Edge site had been renovated in 20l0, and the patient population had changed. The patients being treated at the Forest. Edge site were predominately patients with illnesses who had been cared for at Riverview Hospital for extended periods of time. Many of these patients were initially transferred to Rivetview by VCHA and were now, as part of decentralization, transferred back to VCHA. Most of these patients had documented histories of violence. A violence risk assessment requires consideration of previous experiences in the workplace and in similar workplaces as well as the location and circumstances where the work will take place. This includes an assessment of the physical location which is often referred to as an environmental risk assessment. An environmental portion of the violence risk assessment for the Forest Edge site was initiated approximately one month before the ATRP patients were transferred out of the unit. This was almost one year alter the start of the program. On January 6, 20l2, shortly after the environmental risk assessment was initiated, a list of 68 work orders was submitted to the maintenance department as the unit was transitioning from the ATRP into the location housing the BC Program which the unit had initially been renovated for. WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 36 of 63 This report is supplied to you by WorkSafeBC for yourinfonnalion only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March1?,2012 When the violence risk assessment was completed in July 2012 (?ve months after the ATRP had moved off the unit), 20 environmental concerns were documented. These included items such as the following: 0 Remove frosting from windows to improve line of sight. 0 Install protective coverings for ?re extinguishers to prevent unsafe usage or tampering. 0 Ensure that all phones on the unit have the most recent security stickers so that staff have the correct number in case of an emergency. Secure furniture above waist height in common areas. Where possible, remove potential weapons such as sharp or breakable objects. Install universal key systems in locks in the event of an incident requiring rapid intervention. Although the environmental portion of the violence risk assessment was speci?c to the Forest Edge site and not to the POD, it is signi?cant to the investigation becausefgii? an interview that she was not concerned about moving the patients to 1W Sir-ice that-unlit was essentially the same as the unit the patients were leaving. As shown above, the environmental portion of the violence risk assessment, once it was completed, identified many required changes to minimize the risk of violence to workers. 2.3.2 Violence assessment not completed before moving to the POD A11 assessment to determine the risk of injury from violence, as required by the Regulation, was not completed for the POD. UBC Hospital?s April 2012 minutes from the joint occupational health and safety committee, under section 2.1, state in part: ?Risk assessment was not of?cially done prior to moving; the relocation was decided by senior authorities.? This was in reference to the March 17, 2012, incident. The ?ve patients being relocated to the newly created POD were patients identi?ed as having the potential for vioient behaviour. They were known to the ATRP staff and were the patients selected as the most appropriate patients to stay at UBC Hospital in the transition of the program to the Willow Chest site. ATRP staff described these ?ve patients as having used the seclusion rooms most recently, having the greatest likelihood of presenting with aggression or violence, and being the least ready for rehab. VCHA was aware that there was a real and predictable risk of injury from violence to the workers providing care in the POD. Not only were the ATRP workers at risk, the 1W workers were also at risk because there were no physical barriers between the two units. The relocation of the ATRP patients also exposed 1W staff to the risk of violence because they were not made aware of the known risks associated with the POD patients. The 1W staff did not know what circumstances or factors could trigger violent behaviour, and they did not know how the patients presented during episodes of aggression or violence. Although the names of the patients were put on a white board at the 1W nnrses? station, the 1W staff did not generally interact with the POD patients and did not, unless by chance, know them by name. WorkSafeBC Investigations Workers? Compensation Board of Page 37 of 63 This report is supplied to you by WorkSafeBC for your infomation om'y. it is not to be made known to any other agency or person without the permission of Won?tSafeBC. Ni 2012134520019 Vancouver Coastai Health Authority March 2012 Consultation with workers is an expected part of doing a violence risk assessment. In the decision?making process to move the patients to the POD on 1W, the program the Supervisor, and the workers were not consulted. boil; and, asks visits I 1 . . - 331d {halWhenheheard absinthe move he thought the patien wouid be integrated into the regular population of 1W patients. He also thought that the staff using the WV nurses? station would provide mutual support and a ethical.massefstaff he Crowded, and the patients had little space. nurses" station was The violence risk assessment should have been completed before setting up a temporary unit for the ATRP patients. 2.3.3 Lack of oversight for initiating or tracking violence risk assessments 2004 Violence Prevention Program identi?esi? as the person responsible for the completion of a violence risk assessment, but there was no formal oversight process to ensure that this task had been completed for the ATRP at either the Forest Edge site or the POD. based 01133333 ?2 was aware that there was a risk of violence in the ATRP. Some strategies-?inch as the ?rehab plans,? were implemented, These included some procedures to mitigate the _risk__o_f__iniury from violence but the rehab plans were primarily patient?focused, However, 3399? ?3 22- did not complete a violence risk assessment to determine what the environmental or patient-speci?c risks were. Without the violence risk assessment being completed, as required by Violence Prevention Program, strategies to mitigate the risk of injury from violence did not effectively minimize the risk to workers since specific risks to workers had not been identi?ed. Identifying that there was a risk of injury from violence should have causedigig? to initiate a violence risk assessment. Like most health care facilities, there is likely a risk of worker injury from violence at most of work locations. However, VCHA lacks a corporate ?agging system to determine which work locations or departments have completed or have not completed violence risk assessments. Section 7 of the Violence Prevention Program directs managers to communicate the results of violence risk assessments to the violence prevention adviser; however, there was no tracking system to document assessments that were done or to ?ag locations where a violence risk assessment was not done. WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 38 of 63 This report is supplied to you by WorkSafeBC for your information oniy. it is not to be made known to any other agency or person withom the permission of WorkSafeBC. Nt 2012134520019 Vancouver Coastat Heatth Authority March 17, 2012 2.3.4 No review of past violent incidents The nature, severity, and frequency of violent incidents are factors to consider when doing a violence risk assessment. In addition, a violence risk assessment must consider experiences in similar workplaces. To determine the number and severity of incidents that occurred in the ATRP, WorkSafeBC reviewed Paladin?s incident reports. The following information is based on the reports provided by Paladin, covering incidents that occurred between March 20ll and March 2012. These reports were generally well documented and provided a significant amount of information about the incidents that had previously occurred. The reports also documented any anomalies related to calls for security support in response to incidents of aggression or violence. During the above time period, there were 35 calls for a security response in the ATRP. Of those, 22 were ?agged as Code White responses, with 6 resulting in physical intervention. To put this number of Code White responses into perspective, WorkSafeBC reviewed Paladin?s security incident reports for 1W (a unit) and for lE (a mood disorder unit). In the same time period, 1W, which is a much smaller unit, made 42 calls for security. Only one of those calis was ?agged as a Code White, but it did not require physical intervention. WorkSafeBC noted that lW staff regularly used security preventively, which likely explains the high number of calls and the low number of incidents that escalated to a Code White status. In the same time period, 1E, also a smaller unit than the ATRP, made 30 calls to security. Six of those calls were ?agged as a Code White, and four of those required physical intervention. Taking into account the variation due to the differences in unit size, 1E, which had more Code White responses than 1W, had approximately 40?50 percent fewer incidents ?agged as Code White responses than the ATRP. Both 1E and JW had a signi?cantly lower number of incidents of Code White responses. The numbers suggest that in this time period the ATRP did not utilize security proactively as some of the other units did, but instead had a higher number of incidents that resulted in Code White responses. Situations that escalate to Code White place both unit staff and security of?cers at a greater risk of injury. VCHA should have reviewed previous incidents as part of a violence risk assessment to ensure that the ATRP was using the security resources available and that the risk of injury of violence was being minimized. The information available in the Paladin incident reports provides valuable information that VCHA managers could have used to look for commonalities in incidents that had already occurred. Using this information, VCHA could have identi?ed and weakness in dealing with incidents of violence. VCHA could also have identified program-speci?c norms for calling or not ceiling security preventiveiy. Any time-of-day consistencies related to incidents of violent behaviour could have been identifed, as well as patient or staff consistencies related to incidents of violence and aggression. Incident reports are readily available to managers within VCHA and WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 39 of 63 This report is suppiied to you by WonkSaieBC for your information oniy. it is not to be made known to any other agency or person without the permission of WorkSaieBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 . would have provided valuable information to the ATRP to assist in completing the required violence risk assessments and, in part, for ongoing monitoring of the effectiveness of strategies implemented to control the risk of violence. 2.3.5 Items for consideration in a violence risk assessment WorkSafeBC Policy R4.28-l provides guidance for determining compliance with Occupational Health and Safety Regulation, section 4.28.1 Reviewing the policy can help employers determine if they are meeting minimum regulatory requirements. The policy states that the objective of the violence risk assessment is to determine the nature and type of occurrences of violence anticipated in the place of employment and the likelihood of them occurring. The policy provides direction as to what should be considered when doing a violence risk assessment but also acknowledges that each workplace has specific circumstances. In the numbered lists below, the topics in bold are from WorkSafeBC Policy 428-1. The bulleted lists are intended only as examples of information VCHA could have considered or identi?ed if they had conducted a violence risk assessment using the WorkSafeBC policy. This section is not intended to be an all-inclusive violence risk assessment but rather is provided to demonstrate how utilizing WorkSafeBC resources could have assisted the employer in completing the required assessment. 1. Number, frequency, location, nature, timing, and severity of violent incidents The POD patients had histories that indicated they had a likelihood of or had previously presented with violence or aggression. A review of past incidents that occurred at both UBC Hospital and at Riverview Hospital should have been conducted to identify commonalities such as the frequency of violent incidents involving speci?c patients or staff members, triggers to violence, time of day that incidents occur, and individual patient interactions and behaviours. Strategies that had previously been effective to mitigate the risk of violence should also have been reviewed. 2. Layout and condition of the place of work, including decor, furniture placement, physical barriers, and access and egress 6 Since they were located at the end of the hallway with staff using a separate norses? station, the workers in the POD were largely isolated from the WV workers. a The 1W workers lacked a line of sight to the POD, which would have enabled them to observe what was happening there. Because they did not have line of sight from the WV nurses? station, the WV workers would likely only respond in an emergency on the POD if there was an auditory alert to the event. 0 Although the ATRP and 1W operated as separate units, there was no physical barrier to prevent interactions between the patients in the two units. Despite the likelihood of 1 Policy R4.28-l available on WorkSafeBC website: i WorkSafeBC investigations Workers Compensation Board of 3.0. Page 40 of 63 This report is supplied to you by WorkSafeBC for your infonnation only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. N12012134520019 Vancouver Coastai Health Authority March 17, 2012 interactions between patients from the two units, neither ATRP workers nor 1W workers received any training or information related to the potential of violence associated with the patients from the other unit. 0 Two of the POD patients were required to share a room after being accustomed to private rooms. The impact of sharing a room needed to be considered for the individual patients and also for how any disputes between those two patients could impact the POD. 0 When the POD ?rst opened, the nurses did not have access to the medication room, which required a pass code. They had to rely on the 1W staff to access medications including PRN medications, which would have been required in an incident of violence or aggression. 0 The POD nurses? station lacked egress. The door was usually left open as there was no way to conduct visual or auditory monitoring of patients with the door closed. 0 The POD nurses? station and the laundry room on 1W provided no physical barriers to limit patient access and had no emergency egress options (see Figures 2 and 3 on page 12). - Hallways were cluttered with items that could be used as potential weapons or to impede access or egress (see Figure 6 below). The POD nurses? station was also cluttered with objects that could be potential weapons (see Figure 5 on page 3 as was the laundry room. Figure 6: View of Ilze hallway a! {lie end of} W. The equipment, which belonged to {lie 1 Warm, was stored directly across ?'om Patient/1 is room. The equipment not only cluttered the hallway, it could have been used to famede access or egress, and loose items could have been used as weapons. WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 41 of 63 This report is supplied to you by WomSafeBC for your information only. it is not to be made known to any other agency or person without the permission of WorkSaleBC. Nt 20121345200t9 Vancouver Coastal Health Authority March 17, 2012 3. Extent and nature of contact with persons other than fellow workers Patient interactions and contact with family members, patients from other units, and the generalpublic should havesbeen considered. Patient; had previously assaulted a patient from another unit. Before the move to the POD, the impact on interactions with a different patient population should have been considered. Interaction with the patients and how it might affect the rehab patients should have been considered and strategies should have been planned for situations such as the admission of Patient B. 4. Age, gender, experience, skilts, and training of workers The workers assigned to the POD were the least senior workers in the program. However, they were caring for the ATRP patients with the greatest potential for violent behaviour, in a living situation that was new to the patients and a work environment that was new to the workers. The Worker had been working part time in the program for approximatelyf: ectio 22.. and had no previous experience working with patients. a The Worker had not been provided training in Code White procedures, de-escalation techniques, or non-violent crisis intervention, and she had not taken the violence prevention core training. The Worker had not been offered the original three-week orientation and training that had been provided for the ATRP. The work experience and training of the casual workers used to fill the vacancies had to be considered. The Director of Mental Health and Addictions had not taken occupational health and safety orientation course for managers and supervisors. The Manager had not completed the annual online occupational health and safety orientation update formanagers and supervisors The Supervisor, who had not received training to become knowledgeable it out i. 1e regu ations spec: to to the work being supervised. Neither the POD workers nor the lW workers had Code White training to understand their roles during a Code White, as speci?ed in Code White policy. 5. Existing violence prevention initiatives or programs Theinost recent rehab plan for Patient A provided by VCHA was dated The plan was last reviewed on January 4, 2012. The plan stated that Patient A was ahvays to have two staff members present when interactions occurred, including during night checks and when using the tub room. However, this was often not possible once the POD was operational because of staf?ng vacancies and staff being off the unit with patients on outings. Sometimes there was only one worker on the unit. Other times, some of the patients were taken off the unit with one of the staff members, which could leave the nurse alone in the POD. The rehab plan did state that Patient A could have fresh air breaks three times a day with only one staff member present. WorkSafeBC Investigations Workers' Compensation Board of 8.0. Page 42 of 63 This report is supplied to you by WorkSafeBC for your infannalion only. It is not to be made known to any other agency or person without the permission of WomSafeBC. NI 2012134520019 Vancouver Coastal Health Authority March 17, 2012 - VCHA has a Violence Prevention Program that was last reviewed in 2004. This document is part of overall health and safety program. The program was not followed as it pertains to risk assessment and the communication to workers of the risk of injury from violence. :1 Identi?cation of any known triggers that could result in POD patients presenting with aggression or violence should have been communicated to the WV staff. Because they were not told about patient history and triggers for violence, the UN staff were not prepared to limit or control situations that could trigger violent incidents. The lW staff were also not made aware of the importance of observed incidents to the POD staff. 0 VCHA has a template for completing environmental violence risk assessments and has assessment tools within its violence prevention program. The violence prevention specialists can both assist with risk assessments or make the template available but this option was not utilized. 0 Although VCHA had only two violence prevention specialists for all VCHA sites when the move to the POD was taking place, they were available but not contacted to assist with the completion of the violence risk assessments for the ATRP when it was first created or when it moved to the POD. 0 UBC Hospital had a panic alarm system. There were several documented incidents where the response to the activation of the panic alarm did not go as planned or as anticipated by the worker activating the alarms. Paladin keeps records of battery testing that indicate not all alarms are tested with the expected frequency. 0 Work orders for maintenance of panic alarms indicate previous concerns with the panic alarms. - Between August 2011 and February 2012, concerns about panic alarms, Code White responses, and violence risk assessments were topics of discussion at all of the UBC joint occupational health and safety committee meetings and are recorded in the minutes of those meetings. a The November joint committee minutes document that the Site Safety Adviser was to communicate to his department that the joint committee raised concerns about the need for training courses such as violence prevention for front-line workers. 6. Staff deployment and scheduling a The POD operated with multiple position vacancies. Vacancies were not always filled, Casual workers or existing staff working overtime were used to fill vacancies. - On the day of the incident, no rehab worker was present. The activities of daily living that the Worker was interacting with Patient A about, would normally have been completed by a rehab worker. Because of the vacancies, roles became unde?ned. POD nurses frequently could not leave the unit for breaks because they were the only nurse in the POD. No coverage was arranged to allow for breaks for nurses. - Occasionally, workers worked alone in the POD. WorkSafeBC Investigations Workers' Compensation Board of 3.0. Page 43 of 63 This report is supplied to you by WorkSafeBC for your information only. It is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 - As a worker who started later than the regular shift change, the Worker had limited opportunity to receive verbai reports from the previous shift about the patients. In addition to Policy R428, WorkSafeBC has published Preventing Violence in Health Coma2 in this publication, Step 2 speaks about the requirements for a violence risk assessment. In addition to the WorkSafeBC resources, Violence Prevention Program includes risk assessment tools in Appendix A and in Appendix B. 2.3.6 Joint occupational health and safety committee A violence risk assessment should involve the joint occupational health and safety committee. Con?rmed by the number of Code White incidents that occurred between March 2011 and March 2012, introducing the ATRP was a significant change in operations at UBC Hospital. Since the ATRP patients had ready access to leave the unit, ATRP workers were not the only ones at an increased risk of injury from violence. As part of the investigation, WorkSafeBC reviewed minutes from the joint occupational health and safety committee for December 2010 and for January, February, and March of 201 i. The introduction of the ATRP to UBC Hospital or the need for an associated violence risk assessment was not mentioned in these minutes. vas a member present at the December 2010 and maternal 1' meetings. Althougl was not present at the January 2011 meeting, the Site Safety Advisor spoke about the vioience ALERT system used at UBC Hospital for ?agging violent or aggressive patients. He also offered his services to provide on violence prevention. in addition to the requirement for minutes of the meetings to be posted, as required by the Workers Compensqion Aer, section 138, it would be expected that the minutes would have been made available to since she was a member of the committee. Had she read the January 2011 millutes,sl'1e' ould have been aware of the Site Safet Adviser?s offer of assistance to provide on violence prevention. should have known the requirements for compieting a violence risk assessment and for the expectations for the completion and utilization of ALERT system. Request for assessment by the British Columbia Nurses? Union Between December 2011 and March 2012, there were several email exchanges between the BCNU Occupational Health and Safety Of?cer and the Site Safety Adviser about a violence risk assessment. The emails were also copied to the Safety and Prevention Manager. in the emails, the union expressed "concern about the safety of its workers in relation to Pat_ien__t_ A, The union also queried and WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 44 of 63 This report is suppiied to you by WorkSaieBC for your infomaiion only. it is not to be made known to any other agency or person without the permission of WorkSaieBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 in December 2011, the BCNU Occupational Health and Safety Officer sent an email requesting that a violence risk assessment be done speci?cally for the Forest Edge site. The request was made three months before the incident occurred. In December 20 1 I sent an email response to the union stating that a risk assessment was underway for the Fore-St Edge site. However, only the environmental portion of the violence risk assessment was underway in December 2011. The environmental portion of the violence risk assessment was initiated in December 201 and completed in July 2012. All of the AT RP patients had all been moved out of the Forest Edge site by February 17, 2012. sang; \should have been aware that the ATRP patients would be relocated after the BC Program took over the Forest Edge site in January 2012, and that the violence risk assessment would no associated with Patient A. This information was not communicated in I email to the union. When he responded to the email ii The question about whether or not a violence risk assessment had been completed was also discussed during the December 201 1 joint occupational health and safety committee meeting. The BCNU regional occupational health and safety representative had atte_n__ guest at the 2011 December and January meetings. The meeting minutes con?rm that present at the December meeting. I 2.4 Controls to minimize the risk of injury from violence Providing medical and care for patients will usually include ongoing assessment and monitoring, use of medications, therapeutic programming, and other strategies determined appropriate for individual patients. It is not within the jurisdiction of WorkSafeBC to evaluate the provision of medical care. Therefore, this investigation focuses on controls implemented to minimize the risk of injury to workers. VCHA had occupational health and safety advisers assigned to each of their work locations, including UBC Hospital. Each adviser serviced several sites. In addition to the safety advisers, VCHA had two violence prevention specialists servicing all of the VCHA sites. All of the advisers reported to the Safety and Prevention Manager, whose office was located at the Vancouvet~ General Hospital. 2.4.1 Violence Prevention Program The Safety and Prevention Manager confirmed that the 2004 Violence Prevention Program was in effect at the time of the incident. The joint occupational health and safety committee has a role in reviewing violence prevention programs. WorkSafeBC Policy R4.29-2, section discusses requirements for reviewing the WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 45 of 63 This report is supplied to you by WonkSafeBC for your information only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 2012 violence prevention program.3 The policy states that provision should be made for an annual review to evaluate the program?s performance in eliminating the risk of injury from violence. The review is to be documented and the program should be revised as necessary.VCHA is aware of requirements for the program review. Appendix I of Violence Prevention Program is a checklist designed speci?cally for a review of the program. Signi?cant changes occurred at VCHA between 2004 and 2012, which should be reflected in the Violence Prevention Program. Violence Prevention Curriculum Leader explained that, at one point, violence prevention teams had participated in violence risk assessments, and that VCHA had a violence prevention advisor for each location. That changed when safety services were amalgamated with those of other health authorities. The amalgamation lasted approximately one year, between 2009 and before the safety advisers were realigned with their health authorities. However, that was the time when the becoming operational, so there was a gap in the provision of violence prevention support. in VCHA hired two violence prevention specialists that started at approximately the same time as the Riverview patients were being transferred. At the time of the incident, they were the only two violence prevention specialists for all 154 worksites registered with WorkSafeBC. Considering the signi?cant changes in how violence risk assessments were conducted since 2004, the Violence Prevention Program did not accurately reflect the process for initiating or conducting a violence risk assessment. Annual reviews should have been completed to evaluate the effectives of the program in eliminating the risk of injury from violence. The reviews should have been documented and the Violence Prevention Program should have been revised as necessary. 2.4.2 Violence ALERT system As discussed in section 1.8.3 on page 23, VCHA uses the ALERT system to communicate the risk of violence to workers. This system had been in operation since approximately May 20l l, but audits to determine its effectiveness had not been completed at the time of the incident. The ALERT form is to be placed in the front of the patient?s chart so that staff are aware of the potential for violence. in addition, staff are also directed to place an 8 i 1 ALERT form on the patient?s door or in'another easily observed location. This ALERT form is a visual cue to the staff members who do not have access to the patient?s chart that they may need more information to ensure their personal safety. As well, a purple mark is to be made on the patient?s wristband. Neither marking the wristbands nor posting the ALERT form near the patient?s door were used in the POD. 3 Policy 11429?2 is available on WorkSafeBC?s website: WorkSafeBC Investigations Workers? Compensation Board of B.C. Page 46 of 63 This repon? is supplied to you by WorkSafeBC for your information only. it is not to be made known to any other agency or person withom the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 The ALERT form in the front. of Patient A?s chart was not completed as intended and had missing information. It recorded only two previous incidents of violence, and these were not entered chronologically. There was almost no other information documented on the ALERT. The charts of the four other POD patients were reviewed with the Safety and Prevention Manager and discussed in an interview during the investigation. Of the four charts, which were all marked with a purple sticker to identify the risk of violence, ALERT. forms were found for only two of the patients. During the interview, in response to the review of the charts, the Safety and Prevention Manager said, ?We?ve seen that only the screening information of those tools has been completed, and even that is just very minimally completed. In some cases, just two or three words that indicate a history, but the remainder of the document is not complete. So this is on two of the four charts that we have here, so I suspect that there is a gap in terms of utilizing the tools.? It was also dif?cult to find the information related to violence in the patient?s chart. There was information in the progress notes, but it was difficult to navigate through the narrative chartng to find relevant information about violence. The rehab plans for Patient A were reviewed as part of the investigation. The plans did not provide adequate information for workers to identify triggers for violence. The investigation found incensistency in the de?nition of violence. Violence Prevention Program rises the definition of violence from the Occupational Health and Safety Regulation, section 4.27, which defines violence as ?the attempted or actual exercise by a person, other than a worker, of any physical force so as to cause injury to a worker, and includes any threatening statement or behaviour which gives a worker reasonable cause to believe that he or she is at risk of injury.? This is the de?nition used in determining compliance to the sections of the Occupational Health and Safety Regulation that pertain to violence in the workplace. However, the ALERT does not use the same de?nition. Instead, on the ALERT form, violence refers to ?threatened, attempted or actual physical harm to someone.? The ALERT also uses the term aggression when referring to ?abusive or intimidating behaviour. It may be aggression to a person (yelling at, swearing at, or insulting someone) or aggression to property (hitting, kicking, throwing, burning, or breaking objects)? Neither of the ALERT de?nitions includes a worker?s subjective consideration of the risk of violence that is re?ected in the Regulation?s wording: ?gives a worker reasonable cause to believe that he or she is at risk of injury.? A third de?nition of violence is introduced in Workplace Violence Prevention Policy, which was last reviewed in 2009. policy defines violence as ?incidents where persons are abused, threatened or assaulted in circumstances related to their work, involving a direct or indirect challenge to their safety, well being or health.? Again, it does not include a worker?s subjective consideration of the risk of violence. WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 4? of 63 This report is supplied to you by WarkSafeBC for your information only. It is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 These three de?nitions of violence may, in part, explain why the ALERT forms reviewed during the investigation do not accurately present information about incidents of violence. Workers may not have been clear on which incidents were required to be documented on the ALERT. The ALERT system is relatively new for VCHA, and compliance with and effectiveness of the system have not yet been audited. However, the lack of information on the ALERT forms reviewed with the Safety and Prevention Manager is also likely due, in part, to a lack of training and a lack of monitoring. in the POD, the ALERT forms were not being used as VCHA intended, and therefore were not effective in adequately the risk of violence. 2.4.3 Code White VCHA uses a Code White system to provide immediate assistance when patients presenting with aggressive or violent behaviour do not respond to initial denescalation strategies. To support this process, VCHA has a Code White Emergency Response Policy that was developed in 2004. The copy of the policy provided during the investigation indicates that the policy had not been reviewed since that time. The Code White policy de?nes roles for members of the Code White team during a Code White intervention. The policy also includes specific actions to be taken by members of the Code White team, including security of?cers. In Part 3 of the Code White policy it states: ?Patient fclient care staff who are at risk for aggression/violence receive core training and education in non-violent crisis intervention and de-escalation techniques as directed by VCH education plan.? The Worker had not received non?violence crisis intervention training nor training in de-escalation techniques. The policy also mentions that when the Code White team includes both patient care staff and security officers, the roles, responsibilities, and procedures must reflect site variances but remain within the scope of the VCHA policy. The policy does not mention Code White training or practice drills for either patient care staff or security of?cers. Paladin provides its workers with training in physical intervention strategies, which are speci?c to health care sites, to be used during a Code White. In the initial three-week training program for the ATRP workers, a Code Blue training session and a three-hour session on all codes used within VCHA were conducted. However, the agenda for the three-week course did not show time speci?cally allocated to Code White training. The Worker had not received Code White training and neither had POD Nurse 2. POD Nurse 1 could not recall specific Code White training but did remember that Code White was mentioned in the three-week training program. in an interview, the WV Manager said that Code White training and non-violent crisis intervention training are being organized, and that all staff will receive this training. At the time of the incident, iW staff had not received Code White training. WorkSafeBC Investigations Workers' Compensation Board of 3.0. Page 48 of 63 This report is supplied to you by WomSafeBC for your infomtation only. it is not to be made known to any other agency or person without the permission of WorirSafeBC. NI 2012134520019 Vancouver Coastal Heailh Authority March 17, 2012 Essentially, the only workers involved in this incident trained in a Code White response were the Paladin security officers, who were the last to arrive on the scene. The security officers arrived after POD Nurse 1 and the 1W Casual Nurse had physically intervened to disengage Patient A from the Worker. They were met by the security of?cers as they were escorting Patient A off the unit to go to a seclusion room on the second floor. A policy that identi?es specific actions and defines speci?c roles, but is not supported with training for the workers, does not ensure that expected responses will occur and does not minimize the risk of injury to workers. 2.4.4 Initiating a Code White Workers have several options for initiating a Code White response. One way is to telephone the main Paladin security of?ce in Burnaby. This main call centre takes calls from all of the health care facilities within VCHA that are serviced by Paladin. This call centre has both an urgent and a non~urgent number workers can call. When workers call the Paladin call centre, the security officers within the hospital are contacted by radio. With this method of initiating a Code White, other workers within the UBC Hospital campus are alerted to the Code White so the response is limited to security officers and any workers in the direct work area. Workers can also call directly to the UBC Hospital reception desk, which aiso has an urgent and a non-urgent number. When workers call the reception desk, a public announcement is made, and other workers are noti?ed of the incident so that they can then respond to the Code White. Another option for calling a Code White is to use a panic alarm. Panic alarms are either fixed, mounted aiarms or personal alarms worn by workers. When a panic alarm is activated at UBC Hospital, notification is received through the computer in the reception area. The receptionist then announces the Code White through the public address system. In the March 17 incident, the WV Nurse pushed her panic alarm three times but did not hear the Code White announced over the public address system, as would be expected it" the panic alarm was functioning and the receptionist reSponded appropriately. While this was happening, the WV Casual Nurse went down to the POD. While the 1W Casual Nurse and POD Nurse 1 were pulling Patient A off the Worker, they were calling out to have someone call a Code White. The IE Nurse called the Paladin call centre to initiate the Code White. The call centre dispatched the security officers, and two of the three officers arrived on the 1W unit just as the 1W Casual Nurse and POD Nurse 1 were escorting Patient A off the unit. A third attempt was made to initiate a Code White by calling the reception desk through the non- argent local. However, the identity of who made this call and why the call was made through the non-urgent number are unknown. The record of the call shows only the time and the local of the call. WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 49 of 63 This report is suppiied to you by Won-(SafeBC for your information only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March ?17, 2012 The problems in initiating the Code White response resulted in the assault continuing for a longer period of time than should have been expected. This time lag left the WV Casual Nurse and POD Nurse 1, who had received no VCHA Code White training, to physically intervene to stop the assault on their own. POD Nurse 1 said that it took about five minutes from the time he arrived to disengage Patient A from the Worker. Once the security of?cers were notified, they responded quickly. The first two officers arrived within minutes. The third security officer was in another building and did not arrive until the first two of?cers were on the second ?oor with Patient A. 2.4.5 Panic alarms Detwiller Pavilion is ?tted with fixed alarms in some locations. Workers also have battery? operated personal alarms, which they carry on their person. Considering that these alarms are intended to activate a Code White, they must be reliable to ensure the safety of the workers during an incident of violence. Paladin is responsible for conducting battery testing of both the fixed and personal panic alarms. At the time of the incident, the panic alarm system at the Detwiller Pavilion was about 12 years old. When activated, Detwiller?s alarms alert the receptionist stationed at the admitting desk in the Koerner Pavilion. Each alarm is programmed for a specific unit. When the panic alarm is pressed, the unit location is ?ashed on the receptionist?s computer screen. Should a worker leave the unit with a personal panic alarm and need to activate it, the receptionist will see only the location the unit is programmed for and will send the Code White response to that unit. The panic alarms at Detwiller Pavilion do not have a GPS-type tracking system, so they are ineffective if a worker leaves the unit they are programmed for. On the day of the incident, only three of the six workers were wearing their personal panic alarms. The Worker could not activate her alarm during the assault because her arms were pinned. POD Nurse 1 had his alarm in his pocket, but his priority was trying to stop Patient A from choking the Worker. The only 1W nurse wearing a personal panic alarm was 1W Nurse, and her alarm did not work the three times she tried to activate it. There is no administrative system to ensure that each worker is wearing an alarm. There is no sign-in and sign-out system for alarms that would track worker compliance with wearing the personal panic alarms. Also, should an alarm go missing or malfunction, it cannot easily be identi?ed or tracked. The lack of a sign-in and sign-out system also affects the ability to do battery testing because the whereabouts of personal alarms is not always known. The 1W Nurse said that when her panic alarm failed, she reported it to Security Officer 1 after he returned to the unit at the end of the Code White. There is no reference in Security Officer 1?s notes to indicate that a failed panic alarm had been reported. WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 50 of 63 This report is supptied to you by WorkSafeBC for your infonnatton only. It is not to be made known to any other agency or person without the pennission of WorkSafeBC. NI 20t2134520019 Vancouver Coastal Health Authority March 2012 However, on March 27, 2012, the Violence Prevention Specialist sent an email to the Security Manager informing him that. staff had reported that the panic alarm had malfunctioned. The Violence Prevention Specialist also requested information on the frequency of panic alarm testing, and wanted to know if all panic alarms are tested with the expected frequency. The Security Manager responded by email on March 28, 2012, reporting that all panic alarms are tested to ensure they are functioning, and if there are any problems, the alarms are removed and given to maintenance department for repair. As part of WorkSafeBC?s investigation, records for battery alarm testing were reviewed for the WV, 1E, and Forest Edge work areas. The testing records maintained by Paladin do not support the assertion that testing is done on all of the panic alarms. Throughout the records, there are multiple panic alarms that are recorded as ?not found.? in the March 2012 records, which documented the most recent testing prior to the incident, four out of six alarms programmed for 1E were reported as not found. On 1W, three out of six of the personal alarms were not found, and for the former Forest Edge site, 11 out of 25 of the alarms were not found. There were no notes on the battery-testing records to explain that. the ATRP had moved to 1W and that the BC Program had taken over the Forest Edge site. The same record indicated that the ?xed alarms in the Forest Edge site were ?skipped due to unit transition to BC However, the BC Program was in operation on the former Forest Edge site in March 2012 when the testing was done. The August 2011 joint occupational health and safety committee meeting minutes discussed the increased number of Code White responses for the first three months of the year. The Manager reported that it might have been due to unintentional activation of panic aiarms. There was group consensus at thatjoint committee meeting that an audit needed to be done of the panic alarms. WorkSafeBC?s review of Paladin?s incident reports (March 201 to March 20l2) revealed that there were documented incidents where: 0 Panic alarms did not function as workers expected 0 Workers attempted to use their panic alarms in areas outside the unit the alarm was programmed for - The reception desk did not respond appropriately when a panic alarm was activated 0 Security responded to an anticipated Code White to find that the staff on that unit had not called The WorkSafeBC investigation also determined that another source of information that should be reviewed regularly is the number of work orders being generated for repairs to panic alarms. Many of the work orders for malfunctioning alarms are generated by workers other than the security of?cers. Had VCHA regularly reviewed Paladin?s incident reports, it would have been aware of other incidents where panic alarms were not reliable or were used incon?ectly. VCHA could have WorkSafeBC Investigations Workers? Compensation Board of 8.0. Page 51 of 63 This report is supplied to you by WorkSafeBC for your information only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. NI 20t2134520019 Vancouver Coastal Health Authority March 17, 2012 remedied these situations to ensure that when needed, the alarms would function. Routinely reviewing the work orders and Paladin?s incident reports would have provided further information on the reliability of the panic alarms at the Detwiller Pavilion. Review of the testing records would have identi?ed that panic alarms are not always being tested on a basis and that the number of panic alarms allotted to a unit may not indicate the number of alarms available to workers. It is absolutely vital for workers to have reliable access to assistance during a serious physical assault, yet there was very little monitoring by VCHA of the effectiveness of the panic alarms or of the testing of the alarms conducted by Paladin. 2.4.6 Seclusion rooms One of the reasons specific patients were selected to stay at the Detwiller Pavilion was that they were the patients most likely to require the use of seclusion rooms. However, when they were transferred to the POD on 1W, there was only one seclusion room. At the time of the incident, the WV seclusion room was temporarily allocated to Patient B. As a result, Patient A was placed in seclusion on the second ?oor after the incident. Having only one seclusion room was not an underlying factor in this incident. However, given that one of the reasons for selecting the patients who were not transferred to Willow Chest was their recent need for seclusion, it should have been a concern when Patient was admitted and required ongoing use of the only seclusion room in the unit. - 2.5 Communicating the risk of violence The ATRP used a Kardex system to relay information, and it is assumed that information related to the potential for violence would be included in the Kardex. However, the Kardex is not a permanent document that is maintained in a patient?s file, and information is changed regularly. Because the incident was not reported to WorkSafeBC in a timely manner, investigators did not have the opportunity to see what information was in the Kardex at the time of the incident. Since the Kardex is not a permanent record, it is not a reliable tool for analyzing the frequency or circumstances of previous incidents of violence for a specific patient. At the time of the incident, Patient A had been in the ATRP for a; Patient A?s rehab plan did not have suf?cient information to adequately alert workers about What might trigger him to present in a violent manner. By contrast,__ "H?s Master Transition Plan did contain comprehensive information about Patient-A" that Would have alerted workers to proceed with caution or with pro-planned strategies to prevent incidents of violence. Information must be available and must be current to accurately re?ect the worker?s risk of violence from a specific patient. The Occupational Health and Safety Regulation, section 4.30, requires employers to inform workers of the nature and extent of the risk of violence. Section 430(2) provides further WorkSafeBC Investigations Workers? Compensation Board of 8.0. Page 52 of 63 This report is suppiied to you by WorkSafeBC for your fnfonnation only. It is not to be made known to any other agency or person William the permission of WorkSafeBC. NI 2012134520019 Vancouver Coastal Health Authority March 2012 direction to employers: They also have a duty to provide information related to the risk of violence from persons who have a history of violent behaviour and whom workers are likely to encounter in the course of their work. In a health care setting, employers must provide workers with information specific to individual patients. Had the ALERT form been completed more thoroughly, it would have given a clearer indication of the incidents of violence involving Patient A that had occurred since his arrival at UBC Hospital. Because the ALERT did not identify all of the incidents of violence and provide the dates of the occurrences, it was difficult to access that information in Patient A?s chart. However, even if the ALERT form had been properly ?lled out, it still would not have provided workers with sufficient information to understand what Patient A?s triggers for violence were, what strategies would have worked to mitigate the risk, what the safety concerns were once he started escalating, or what actions should have been taken once he was agitated. In this incident, both POD Nurse 1 and the Worker were aware, some time before the assault, that Patient A was agitated. Because the Worker routinely started work after the verbal report was given during shift change, she did not have the opportunity to hear or participate in the regular change-over discussion. In addition, as a part-time worker, she would not be familiar with day?today incidents that did not result in violence but were situations that had been successfully de-escalated. Narrative charting does not provide workers with ready access to the information they may need to prepare themselves with preventive strategies. During an interview, one of the registered nurses stated that because workers without speci?c training, such as the rehab workers, were charting on patient status, the information in the chart might not reliably describe the patient?s wellness. Determining who is qualified to document in a patient?s chart would be a clinical decision. However, if the documentation in the chart does not accurately identify potential risks from violence, it would have an impact on communicating the risk of violence to workers. In addition to informing the POD staff, VCHA was responsible for informing the workers on 1W as to the nature and extent of the risk of violence they were exposed to. Had the WV workers been informed of Patient A?s significant history of violent incidents, they likely would have with the POD staff about the interactions between Patient A and Patient on the morning of the assault. if both the POD and the 1W workers had been provided information about the two patient populations, they would have been better prepared to work collaboratively to maintain the highest level of safety while the patient populations shared the unit. Had the 1W staff been made aware of the risks, they may also have been more likely to wear their personal panic alarms. Had that happened, there may have been multiple immediate attempts to initiate a Code White, and security likely would have intervened sooner. WorkSafeBC Investigations Workers' Compensation Board of 8.0. Page 53 of 63 This report is supplied to you by WorkSafeBC for your information only. is not to be made known to any other agency or person without the permission of WorkSefeBC. N12012134520019 Vancouver Coastal Health Authority March 17, 2012 2.6 Lack of training 2.6.1 Orientation and training for workers The greatest risk of injury to the workers in the ATRP was from violence. Many of the nurses had experience working with patients. Many of the other workers did not. Most of the rehab workers hired had experience working with mental health patients who were housed in community settings but had not required ongoing hospitalization. Since there is no speci?c certificate training or provincial standard for rehab workers or peer support facilitators, the workers had a variety of educational and practical skill backgrounds. Some of the rehab workers or peer support facilitators were present for the initial three-week orientation. However, any workers hired after the initial orientation did not receive the bene?t of this training. These workers do, however, chart in the progress notes. In the three-week training and orientation offered to workers who started at the beginning of the ATRP, there was a one-day course on non-violent crisis intervention training. There were also short sessions on a variety of topics but little emphasis on the safety of workers. The Worker was hired after the initial intake and was not offered the initial training and orientation program. The Worker, who . did not receive any specific training in caring-for patients complex mental illnesses when she came to work in the ATRP. VCHA did not provide documentation con?rming that new and young worker training and orientation was completed for the Worker, as required by Occupational Health and Safety Regulation, section 3.23. VCHA did provide records of a ?buddy orientation? for some workers but not for the Worker. The buddy orientation checklist does not include most of the topics itemized in the Regulation that must be included in training for new workers. The buddy orientation checklist is predominately patient-care based and is not a health and safety orientation. who was doing work that posed different risks to her safety than her previous work did not get the training offered to other workers such as non-violence crisis intervention, which would have given her skills or strategies to assist in violence recognition and de-escalation. 2.6.2 Training for managers and supervisors VCHA has a workplace policy called Safety Orientation for New Staff, Managers, and Supervisors Educators. The policy states: ?All Executive, Directors, Managers, Supervisors or Educators will complete the Safety Training for managers and supervisors within 2 months of beginning their new positions. Online annual refresher training for managers, supervisors and educators is also mandatory.? The policy was implemented in 2009 and last reviewed in January 2012. WorkSafeBC Investigations Workers' Compensation Board of 8.6. Page 54 of 63 This report is suppifed to you by WorkSafeBC for yourinfonnation only. it is not to be made known to any other agency or person without the permission of WorkSefeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 The Work-SafeBC investigation determined thattheDirectorofMental Heaith and Addictions, who had started with VCHA -, had not taken the four-hour health and safety orientation training course required by policy. The Manager had taken the COW-ism but. had not modules. since then- She. had The Director of Mental Health and Addictions and the Manager had not attended the training course or completed the online refresher training as required by the policy requiring them to do so. There was no system in place to ?ag this lack of training or to ensure that the required training was completed. The Supervisor directly supervised the workers in the ATRP and reported to the Manager. Prior to starting her position as the program coordinator, the Supervisor took a leadership course through VCHA. She also attended four-hour occupational health and safety course for managers and supervisors. four-hour course provides an overview of health and safety information required by managers and supervisors. The Violence Prevention Curriculum Leader delivered this training for all of sites. Training sessions were not restricted to any one work classi?cation or department. Participants in a course might include managers or supervisors from a variety of areas such as maintenance, administration, or patient care units. Managers in each of these areas of work have the same responsibilities under the Workers Compensation Act, but regulatory requirements speci?c to the individual work areas will be different. The information presented in the course covered managers? and supervisors? responsibilities under the Workers Compensation Act. The course did discuss requirements related to safety inspections, incident reporting and investigations, due diligence, and the joint Occupational heaith and safety committee. The course did not however, provide information specific to the Occupational Health and Safety Regulation. There was no assessment following the course to ensure that participants have understood their health and safety responsibilities as presented in the training session. in the slide presentation used for the training, one slide addressed the risk of violence but referred speci?cally to ALERT system and two slides covered domestic violence. One slide addressed occupational first aid requirements, including speci?c reference to ensuring that first aid assessments were up to date. The Violence Prevention Curriculum Leader said that VCHA runs the courses twice a month and often the courses do not have the maximum number of participants in them. Attendance at the training is tracked, but there is no system in place to identify new managers or supervisors, or to WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 55 of 63 This report is supplied to you by WorkSafeBC for your tnfonnation only. It is not to be made known to any other agency or person without the permission of WorkSafeBC. Nl 2012134520039 Vancouver Coastal Health Authority March 2012 ensure that they register for the training. Managers and supervisors who do not complete the required annual online training are also not tracked. However, completion of the online refresher module is documented. Whether managers or supervisors do the online training is somewhat self?regulated. The Violence Prevention Curriculum Leader stated that it ?may be an assumption? that people in management positions understand what their legal responsibilities are in the workplace. The Supervisor described the occupational health and safety course for supervisors and managers as being an introduction. This is likely a fair description of the course, as it did not address specific regulatory requirements. Although VCHA requires directors, managers, and supervisors to attend this course, currently VCHA has no system or corporate oversight to ensure that they are made aware of and become knowledgeable about applicable regulations. Section ll? of the ll?orkers Compensation Act requires that supervisors are knowledgeable about the regulations specific to the work being supervised, and would include the Violence in the Workplace sections. The WorkSafeBC investigation determined that the Supervisor had not received training sufficient to ensure the health and safety of the workers. The investigation also determined that VCHA has no monitoring system to ensure that training such as the occupational health and safety course for supervisors and managers has been completed. 2.7 Inadequatesupervision The Manager and Supervisor were required to setup two patient units simultaneously, which were located at different hospital sites. The planned move of 21 ATRP patients to the newly renovated Willow Chest site, located at Vancouver General Hospital, required ensuring that furniture, equipment, and supplies were ready for service. it also required supervision to assist patients and staff in the transition to the new site. At about the same time, the Manager and Supervisor were tasked with planning for and moving the POD patients onto the WV unit. The set-up of the POD required the same considerations as the move to Willow Chest. However, in the timeline provided by the Director of Mental Health and Addictions, the decision to move the patients to the POD was made between February 6 and 10, 2012 and the move to the POD occurred on February 17, 2012. While these units were being set up, the Manager was also actively involved in interviewing job applicants in preparation for the opening of Willow Pavilion, another 79-bed facility located at Vancouver General Hospital. Once the ATRP was split between the two sites, the Supervisor was expected to supervise the workers at both locations. The two sites were approximately 10 kilometres apart. In interviews, both the Manager and the Supervisor spoke about the challenges of trying to manage the two sites. The Manager reported that it was primarily the Supervisor who travelled back and forth between the sites. WorkSafeBC Investigations Workers? Compensation Board of 8.0. Page 56 of 63 This report is supplied to you by WorkSafeBC for your information only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 Considering all of the expectations simultaneously placed on the Manager and the Supervisor, it is unlikely that effective supervision to ensure the health and safety of the workers could have been achieved even if the Supervisor had been experienced and knowledgeable about the regulations applicable to the work being supervised. As previously mentioned, the Supervisor 1."er train; 5 an introduction. She stated that The investigation determined that the POD was not effectively supervised to ensure the health and safety of the workers. 2.8 First aid attendant not available The Worker did not receive initial ?rst aid care because the first aid attendant, Security Officer 1, had been assigned duties that prevented him from responding to the request for first aid. Although the lack of first aid services was not a causal factor leading to this assault, preventing injury aggravation is a primary focus of ensuring adequate first aid services are provided when a worker sustains an injury. The lW Casual Nurse placed a call for a first aid response to attend to the Worker, after security took over control of Patient A. According to Paladin, the 1W Casual Nurse?s first aid call was made at 09:23. The Paladin call taker told the WV Casual Nurse that the first aid attendant was busy on another call. When asked how long it might take for a first aid response, the call taker could not give a time estimate. At the time, Security Officer 1 was in the seclusion room with Patient A, along with the other two Paladin security officers. The lW staff arranged to take the Worker to the Urgent Care Centre (UCC) located in the Koerner Pavilion of UBC Hospital. The Student Nurse assisted the Worker to a wheelchair and took her for assessment by a physician. According to the hospital?s records, the Worker arrived at the UCC at 09:38 and was assessed by the triage nurse at 09:48. At some point after that, Security Officer arrived at the UCC to check on theWorker. Security Officer 1 confirmed in an interview that the Worker was being treated in UCC when he first saw her. During this investigation, Paladin provided several different documents reiated to the timelines of events. After reviewing these timelines, the security officers? notebooks, Paladin?s incident reports, WorkSafeBC and RCMP interviews, and the hospital admission times, WorkSafeBC determined that Security Officer 1 first saw the injured worker about 25 minutes after the first aid call was made. That would have been 33 minutes after the Code White phone call was made to Paladin and could have been as long as 38 minutes from the time the assault first started. The Worker did not receive the first aid care expected under the Occupational Health and Safety Regulation because the first aid attendant had been assigned work that prevented him from responding to the ?rst aid call. Occupational Health and Safety Regulation 318(2) specifically states that an employer cannot assign activities and a ?rst aid attendant cannot accept assignments that will interfere with the attendant?s ability to respond to a request for first aid. WorkSafeBC investigations Workers? Compensation Board of 8.0. Page 57 of 63 This report is supplied to you by WorkSafeBC for your infomation only. it is not to be made known to any other agency or person without the permission of WorkSafeBC. Nl 2012134520019 Vancouver Coastal Health Authority March 17, 2012 The associated guideline speci?es that the ?rst aid attendant should be ready to depart to where the worker is situated within 3 to 5 minutes. According to Paladin?s incident reports, between March 2011 and March 2012 there had been 29 Code White responses in just the Detwiller Pavilion, which is one of the three pavilions at UBC Hospital. As all Code White responses at UBC Hospital are required to have three security of?cers, and there are only three security of?cers on site, each time there is a Code White, the ?rst aid attendant cannot respond to a ?rst aid call. ?rst aid program identifies Worksafe and Wellness as the department responsible for the administration and co-ordination of the Occupational First Aid Program for all sites. Worksafe and Wellness works in collaboration with in-house services and contracted agencies providing ?rst aid. Secton 1 1.2 of the ?rst aid program states that the ?rst aid attendant must not undertake employment activities that will interfere with the attendant?s ability to receive and respond to a request for first aid. Section 11.6 of first aid program states that all sites requiring ?rst aid attendants should have a backup plan to ensure coverage for both planned and unplanned events. VCHA did not follow its own ?rst aid program. The Occupational Health and Safety Regulation requires employers to do a ?rst aid assessment for each of their work locations to determine the need for ?rst aid services at each site. That assessment must be reviewed at least within 12 months from the previous assessment, and any time there is a change in circumstances that could affect the ?rst aid assessment. This essentially requires, at a minimum, an annual review. The most recent ?rst aid assessment VCHA had for UBC Hospital was completed in 2004. Section 15.5 of ?rst aid program states that WorkSafe and Wellness and the joint health and safety committee will evaluate ?rst aid site assessments on an ongoing, annual basis. VCHA did not follow its own Occupational First Aid Program. In the health care industry, as in all industries, employers must provide ?rst aid services as required by Section 3. i6 of the Occupational Health and Safety Regulation. WorkSafeBC, recognizing the expertise available in hospitals, provides an opportunity for health sector employers to obtain certi?cation for speci?c health care professionals. Section 2.2.1 of WCB Standard OFA 1: Certi?cation of First Aid Attendants applies speci?cally to health care.4 It states, in pait, that an employer of a health care facility can apply in writing for an OFA L2 certificate for a physician or a registered nurse with at least six months? emergency room experience. An employer can also apply in writing for an OFA L2 certi?cate for a physician or registered nurse who has successfully completed a recognized course of training in 4 WCB Standard OFA is available on WorkSafeBC's website: WorkSafeBC Investigations Workers? Compensation Board of 8.0. Page 58 of 63 This report is supplied to you by WorkSafeBC for your information only. It is not to be made known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouver Coastal Health Authority March 17, 2012 obtainQFALZ certificates: for staff on the units. However, in this case, rreitlterif?f?g would have quali?ed for the GPA L2 certi?cate as outlined standard. I - emergency procedures. VCHA had not taken advantage of this section of the WCB to The Worker did not receive the ?rst aid care WorkSafeBC expects for injured workers. Given the way she was assaulted, consideration shouid have been given for potential spinal injuries before she was moved at the scene of the incident and before being transported by wheelchair to the UCC. In this incident, the UCC was able to provide treatment to the Worker; however, the UCC is only open from 08:00 to 22:00 daily. The next closest hospital is Vancouver General Hospital, 20 kilometres away. If there was an alternate arrangement in place for times when the ?rst aid attendant could not respond, the Paladin call taker did not offer it to the 1W Casual Nurse when he requested ?rst aid. 2.9 ineffective corporate oversight WorkSafeBC found that there were many contributing factors that resulted in the serious physical assault to the Worker: 0 The planning of the work location for the POD did not ensure the health and safety of the workers. 0 The Director of Mental Health and Addictions, Manager, and Supervisor were not adequately trained and educated to understand their responsibilities in ensuring the health and safety of the workers under their direction. 0 VCHA did not follow their poiicy for mandatory training for the Director of Mental Health and Addictions and the Manager. VCHA did not provide effective supervision to ensure the safety of the workers. 0 VCHA did not provide the Worker with sufficient instruction and training to ensure her health and safety. 0 VCHA did not ensure that a violence risk assessment was completed. 0 VCHA did not establish work environment arrangements to minimize the risk of injury from violence, including access and egress for workers who could become trapped. 0 Risk of violence and strategies to mitigate the risk were not adequately communicated to the workers. 0 VCHA did not effectively monitor its own ALERT system to ensure that risk from violence was effectively cormnunicated. 0 VCHA did not follow its own program for violence prevention and did not update the violence prevention program on a regular basis. I VCHA did not effectively monitor the contractors tasked with testing of the panic alarms. WorkSafeBC Investigations Workers? Compensation Board of 8.0. Page 59 of 63 This report is supplied to you by WorkSa feBC for your infomation onmade known to any other agency or person without the permission of WorkSafeBC. Ni 2012134520019 Vancouvor Coastal Health Authority March 17, 2012 In addition, WorkSafeBC found the following safety concerns: - VCHA did not ensure that the Worker received ?rst aid care when she sustained an injury. - VCHA did not review the ?rst aid assessment at least annually. 0 VCHA did not follow its own Occupational First Aid Program. VCHA provided an organizational chart for the Employee Engagement Workplace Health Department, dated March 20l2. The executive director of this department oversees both workability (disability management) and safety and prevention. On the safety and prevention side, the Safety and Prevention Manager oversees seven segmented divisions. The investigation determined that there were only six occupational health and safety advisers to provide assistance for all of the 154 registered work locations. One of those positions was vacant at the time of this incident. Only two violence prevention specialists were available to provide support for the safety advisors or managers in meeting the violence prevention requirements for all of the VCHA sites. Considering the large geographical area covered by VCHA, and the fact that there are 13,000 regular and casual employees, as well as thousands more contracted workers, it is unlikely that this department with its current staf?ng resources can, by itself, provide suf?cient assistance, training, and oversight to ensure the health and safety of all the workers. The employer has the responsibility to ensure the safety of all workers present at a worksite. Every employer must ensure that each worker is provided with the instruction, training, and supervision necessary to ensure their safety. Individual managers and supervisors also have the responsibility to ensure the safety of the workers under their supervision. To do this, they must be provided with adequate training and resources. 3 Conclusions 3.1 Findings as to causes 3.1.1 Patient attacked the recreation therapist The Worker was attacked by a patient in the Adult Tertiary Rehabilitation Program, which was temporarily located on 1W at the Detwiller Pavilion of UBC Hospital. The Worker, while encouraging the patient to complete activities of daily living, was physically assaulted following a discussion about the patient?s aggressive behaviour. The Worker sustained physical and injuries as a result of the attack. WorkSafeBC investigations Workers? Compensation Board of 8.6. Page 60 of 63 This report is supplied to you by WorkSefeBC for your information only. it is not to be made known to any other agency or person without the pennisslon of WorkSafeBC. Nl 20t2134520019 Vancouver Coastal Health Authority March 2012 3.2 Findings as to underlying factors 3.2.1 Lack of work location and work activity planning The employer did not adequately plan the work locations or activities for the Adult Tertiary Rehabilitation Program. As a result, the employer created a temporary work location on short notice. The temporary work location did not allow for access to the programming that the patients were accustomed to. Sta?'mg of the unit was not consistent. The temporary work location was not planned in a manner that ensured the health and safety of the workers. 3.2.2 Violence risk assessment not completed The employer was aware that a risk of injury from violence was present for workers in the Adult Tertiary Rehabilitation Program. The employer did not complete a violence risk assessment for this program when it was ?rst located on the newly renovated second floor ofDetwiller Pavilion, and did not complete a violence risk assessment when the program moved to the temporary work location on 1W. 3.2.3 Inadequate policies, procedures, or work environment arrangements The employer did not establish or implement suf?cient policies, procedures, or work environment arrangements to minimize the risk of injury from violence to workers in the Adult Tertiary Rehabilitation Program. The employer did not follow its own policies and procedures related to violence and did not follow its own violence prevention program. The employer did not review the violence prevention program to determine its effectiveness for minimizing the risk of injury from violence. 3.2.4 Inadequate communication related to the risk of violence The employer did not adequately inform the Worker of the risk of violence from patients who had a known history of violent behaviour. The employer did not instruct the Worker on how to recognize the potential for violence or how to respond to violent incidents. The employer did not instruct workers on procedures related to reporting and documenting incidents of violence including the employer?s ALERT system. 3.2.5 Inadequate training The Supervisor and the workers did not receive training specific to the risk of injury from violence related to patients with a known history of violence due to their illnesses. The Supervisor did not receive suf?cient training to be knowledgeable about the sections of the Workers Compensation Act or the Occupational Health and Safety Regulation that pertain to the work being supervised. The employer did not adequately instruct supervisors or workers on established policies or procedures to minimize the risk of violence. WorkSafeBC Investigations Workers' Compensation Board of 8.0. Page 61 of 63 This report is supplied to you by WorkSafeBC for your information only. it is not to be made known to any other agency or person without the pennisston oi WorkSaieBC. N2 2012134520019 Vancouver Coastal Health Authority March ?17, 2012 3.2.6 Inadequate supervision The employer did not ensure that the Manager or the Supervisor had suf?cient knowledge and training to ensure the health and safety of the workers working in the Adult Tertiary Rehabilitation Program. The Supervisor could not effectively ensure the health and safety of the workers who were working at two sites located about 10 kilometres apart. 3.2.7 Ineffective corporate oversight The employer does not have a system to ensure that its own health and safety program, which includes violence prevention and ?rst aid programs, was being reviewed and followed. The employer does not have a system to ensure all workers in supervisory positions are trained and knowledgeable about regulatory requirements. The employer is not monitoring its workers or work locations to ensure that regulatory requirements are being met for the prevention of violence and for the provision of first aid services. 3.3 Other findings 3.3.1 Inadequate first aid services The Worker did not receive ?rst aid services when requested because VCHA did not ensure that the first aid attendant was assigned only duties that would not prevent him from responding to a call for first aid. The first aid attendant was not available to respond to the call for ?rst aid as he was performing his duties as a security officer and was dealing with Patient A in the seclusion room after the incident. The employer did not do an annual review of the ?rst aid assessment at UBC Hospital to determine ?rst aid requirements. WorkSafeBC Investigations Workers' Compensation Board of 8.0. Page 62 of 63 This report is suppiied to you by WorkSafeBC for your infomation only. it is not to be made known to any other agency or person withom the pennission of WorkSafeBC. N12012134520019 Vancouver Coastal Health Authority March 2012 Appendix How the Investigation Was Conducted WorkSafeBC?s Investigations Department conducts health and safety investigations using a methodology that involves collecting information from various sources to understand the facts and circumstances of the incident and analyzing that information to identify causal and underlying factors that led to the incident. The ?eld investigation generally involves the following: Securing and examining the incident site, including any equipment involved Taking notes and photographs Interviewing persons with relevant information such as employer representatives, supervisors, workers, and witnesses Collecting pertinent documents such as equipment operating manuals, written procedures, and training records Conducting tests of materials or equipment, if necessary The analysis of the data usually includes: I 0 Determining a sequence of events Examining signi?cant events for unsafe acts and conditions Exploring the underlying factors that made the unsafe act or condition possible identifying health and safety deficiencies WorkSafeBC investigations Workers' Compensation Board of 8.0. Page 63 of 63 This report is supplied to you by WorkSafeBC for your inionnaiion oniy. it is not to be made known to any other agency or person without the permission of WorirSafeBC. INSPECTION REPORT Worker and Emptoyer Services Divtsion 5951 Washimter Itgrmay. name so Memo Address: PO Box 5350. Van-acme! 80. we 5L5 Teephone so: zeta-31:0 T03 Free 143385213233 Fax 604 2mm? The Workers Compensation Act requtree that the employer must post a copy of report in a coneplcoous place at or near the workplace Inspected for at least seven days, orfunttl compliance has been achieved, whichever Is the tonger period. A copy of report must atso be given to the gain: committee or worker health and safety lepresentative, as app?cable. Inspection Report VANCOUVER COASTAL HEALTH AUTHORITY UBC HOSP ITAL NOI AppilcebIe 2211 WESBROOK Mail VANCOUVER BC BC Data. 61 Initiating Jut 18. 2014 Jul18, 2014 Jut18,2014 THERE IS ONE (1) ORDER OUTSTANDING ACTION REQUIRED New '5 Status:0utstandihg Cited: (qust'andln'g Order Outstanding ?Action Required to Achieve Compliance Complied Compliance Achieved - No Further Action Required Closed Order Could Not be Followed Up No Further Action Requlreti Rescinded Order has been oanoetted - No Further Action Required IR 201410862051A Printed: Jul 18. 2014 11:45 Page 1 of 4 INSPECTION REPORT Worker and Employer Services Division 201410862061A 6951 tighten}. Richmond. 30 Mating Address: PO Box 5360. Venom-re: BC. V63 5L5 Telephone 604 2703100 Tot! Free 16386213233 Fax 60-1 276824? NOTES NOTE: Notwithstanding what is stated on page one of this inspection report, the date of the Initiating inspection (IR 2013108620047) for administrative penalty RFS 201300629 is March 17, 2012. ORDER FOR ADMINISTRATIVE PENALTY RFS 201300029 Section 196, Workers Compensation Act (the ?Act?) On March 17, 2012, an inspection of a workpiece at Detwiller Pavilion, Adult Tertiary Rehabilitation, UBC Hospitai, 2211 Wesbrook Mail, Vancouver, BC determined there was a vioiation of sections 115(i)(a). 115(2)(e) of the Act and sections 4.280% 4.29tb), 430(2), of the Occupationai Health and Safety Regulation (the ?Regutation?). inspection Report 2013108620047 was issued to the employer, Vancouver Coastal Health Authority (the 'Empicyer') which described the vioiations. Upon consideration of at! avaiiabte evidence. and in accordance with section ms of the Act and applicabie Prevention Policy, WorkSafeBC is imposing an administrative penalty because the Employer: 1. has failed to take sufficient precautions for the prevention of work rotated injuries or illnesses: 2. has not complied with sections 115(2)(e) of the Act or 428(1), 429(b). 430(2), of the Reguiation; 3. has not maintained a safe workpiece or safe working conditions; and 4. did not exercise due diligence to prevent these circumstances. The amount of the penalty is $75,000.00 and was determined in accordance with Prevention Policy Dt2w196-6 based on the iotlowing: the Empioyer?s payroll; and 2. the nature of the violation (determined as Category The Empioyer, a worker, a union. or other person identified under section 96.3 of the Act who is directiy affected by this decision may request a review of the decision by the Review Division of WorkSateBC. if you wish to request a review you must notify the Review Division in writing within 90 days of the date on this report. A Request for Review does not act as a stay or suspend the operation of this Order. Further information about the Review Division and a Request for Review Form can be found online at: or by the Review Division at 604-214-5411 or 1-888-922-8804. A copy of the Review Division?s decision, with reasons, will he provided to sit parties who participate in the review. NOTE: The Ernployers? Advisers Office of the Ministry of Labour is avaiiabte to provide advice or assistance to employers. Their teiephone number is toll free at 1-800-925-2233. The Workers? Advisers Office of the Ministry of Labour is availabie to provide advice or assistance to workers. "their telephone number is toii free at 1-800?663?4261. 1R 201410862061A Printed: .10! 18. 2014 11:45 I Page 2 0i 4 INSPECTION REPORT Worker and Employer Servicos Division . 201410862061A 6951 Rom-3y. Wed, BC - Mean-mg F0 80:: 5350. Vanoomer BC, V68 51.5 Tefeptmeem 276-3100 To! Ftee 1343:8621-sz Fax 604 216-324? ORDERS An employer who fails to comply with Part 3 of the Workers Compensation Act, the Occupationat Health Safety Regulation, or WorkSafeBC orders ma be subject to monetary or other sanctions as prescribed by the Workers Compensation ActOrder No.1 Status?utstanding . Cited: WCA1 96(1) A copy of this inspection report must be posted in the work paid, whichever is tater. piece, in a conspicuous location for 30 days or until the penalty is Pursuant to Section 196(1) of the Workers Compensation Act, Vancouver Coastat Health Authority is ordered to pay 3 75.000 to the Workers' Compensation Board Accident Fund. 1R 201410862061A Ptinted: Jul 28. 2014 11:45 Page 3 0154 6951 ?meditate: Highs-av. Rid-mend, BC Mating Address: PO Box 5360. 80. V63 Teiephme 604 36-3100 To? Free 13835214233 Fax 6-04 276-324? INSPECTION REPORT Worker and Employer Services Division 20141 osszosm? .. . . 687435 CID WORKPLACE HEALTH ?66i301 003 215 2775 HEATHER ST VANCOUVER BC V523J5 inert-ea Protest. ?Q?earttzaiteagswcal 3 Annie Strauss 1.00 0.00 *The time recorded above re?ects the cumuiative inspection time and travel time associated to the inspection activity cycle. Additional time may be added for subsequent activity. 1?800-663-4261. Ridht to a Review of Orders Any employer, worker, owner, supplier, union, or a member of a deceased worker's family directly affected may, within 90 calendar days of the deiivery date of this report, in writing, request the Review Division of WorkSafeBC to conduct a review of an order, or the non-issuance of an order, in this report by contacting the Review Division. Employers requiring assistance may contact the Employers' Advisers at 1-800-925-2233. Workers may contact the Workers' Advisers at IR 201410862051A Printed: Jui 18. 2014 11:45 Page 4 of 4