An active shooter can show up at any workplace, but some industries and workplaces like healt care and social assistance have higher risks for violence.
A former employee shows up at the workplace and shoots five workers, killing four, before driving to another former employer’s place of business to kill three others.
A patient in a behavioral health facility jumps over a nurse’s station and stabs an employee with a pair of scissors.
A patient, attempting to leave a substance abuse facility, throws a chair at a mental health associate and three nurses; another patient kicks a nurse in the stomach; and a patient repeatedly smashes a mental health associate’s head into an air conditioning unit, resulting in a concussion.
Workplace violence may be seemingly random or all too predictable. Are you ready?
Workplace violence has long been recognized as an occupational safety hazard. The Occupational Safety and Health Administration (OSHA) considers workplace violence a “widespread problem” but says workers in health care and social services face unique safety risks. Bureau of Labor Statistics (BLS) data has shown that workers at psychiatric and substance abuse hospitals experience the highest rate of violent injuries resulting in days away from work—a rate six times that for workers at nursing and residential care facilities.
Federal, state regulation and enforcement
There is no current federal workplace violence prevention standard. OSHA cites employers under the General Duty Clause of the Occupational Safety and Health Act, usually after an injury, a hospitalization, or a fatality.
In 2015, OSHA issued a set of voluntary guidelines for healthcare and social services.
The agency now has a rulemaking to establish a workplace violence prevention standard for healthcare and social assistance. The rulemaking is one of six economically significant regulatory actions at OSHA, along with those for industry-specific standards for communications towers and tree care, new emergency response and infectious disease standards, and modernizing the process safety management (PSM) standard to prevent major chemical accidents.
OSHA put out a request for information (RFI) in December 2016, seeking input from healthcare employers, workers, and subject matter experts on the impacts of violence, prevention strategies, and other information about a possible industry-specific standard.
A federal workplace violence prevention standard might include requirements for the following:
- A written program produced with management commitment and employee participation;
- Worksite analysis and hazard identification;
- Hazard controls, including engineering controls, administrative controls, and personal protective equipment (PPE);
- Health and safety training; and
- Recordkeeping and program evaluation.
In a report examining OSHA’s current workplace violence prevention efforts, the Government Accountability Office identified nine states with workplace violence prevention requirements: California, Connecticut, Illinois, Maine, Maryland, New Jersey, New York, Oregon, and Washington.
The California Division of Occupational Safety and Health (Cal/OSHA) requires employers in the state to develop written workplace violence prevention measures under the state’s injury and illness prevention program standard.
State, federal enforcement
Cal/OSHA recently cited two Half Moon Bay, California, farms where seven workers were shot and killed and another wounded on January 23.
A former employee of California Terra Garden and Concord Farms has been accused of shooting and killing four workers and wounding a fifth at California Terra Garden before driving to Concord Farms and fatally shooting three workers there.
Cal/OSHA cited California Terra Garden for 22 violations and Concord Farms for 19 violations, 3 of them serious.
The agency cited both employers for failing to establish a workplace safety plan that evaluated the threat of workplace violence and trained workers in a language they can understand.
California Terra Garden failed to establish procedures to address the hazards posed by an active shooter, according to Cal/OSHA, resulting in fatal and serious injuries. The employer should have established procedures for evacuation or sheltering in place during an active shooter incident. The agency also cited California Terra Garden for failing to maintain surveillance cameras or establish procedures for reviewing surveillance cameras.
In previous incidents at Concord Farms, a resident was assaulted by employees, and employees were threatened and bullied by others. The employer should have developed a program of progressive discipline within its injury and illness prevention program, according to Cal/OSHA.
Federal OSHA has cited a number of healthcare employers this year for workplace violence violations.
The agency cited the Texas Children’s Hospital of Houston, Texas, with a serious violation after an aggressive patient pulled a security officer to the ground by the hair and kicked the officer repeatedly in the chest and abdomen. The officer lost consciousness, was taken to the emergency room, and was later hospitalized. OSHA also noted there were 15 recordable incidents of workplace violence in 2022 when a patient showing signs of aggression assaulted an employee.
Nurses, assistants, security officers, and other staff at Texas Children’s have been exposed to physical threats and assaults, such as being bitten, punched, kicked, scratched, and spit on by behavioral health patients exhibiting signs of aggression in the hospital’s pediatric acute care unit.
The agency also cited The Big Lots Behavioral Health Pavilion at Nationwide Children’s Hospital of Columbus, Ohio, for failing to protect employees, including nurses and mental health professionals, from patients whose bites, kicks, punches, and other assaults caused serious injuries. Injuries suffered by nurses and mental health staff included concussions, contusions, lacerations, and sprains, according to OSHA.
OSHA cited Universal Health Services, Inc. (UHS), for workplace violence violations at a Jacksonville, Florida, behavioral health and substance abuse disorder facility. Workers at UHS’s Wekiva Springs Hospital were assaulted and confined by patients and suffered broken bones, concussions, and wounds from being scratched, bitten, punched, and kicked, according to the agency.
Workers at the UHS facility endured regular and often intense incidents of workplace violence, according to OSHA, with reports of 182 alleged incidents in 2022—nearly 70 percent during a 6-month period required police response.
This past spring, an administrative law judge (ALJ) with the Occupational Safety and Health Review Commission upheld OSHA’s citation of UHS of Delaware Inc. (UHS-DE) and UHS of Fuller Inc. for exposing their employees to workplace violence without adequate protections at the Fuller Hospital in Attleboro, Massachusetts. Over 500 incidents of aggression occurred at the hospital over a 7-month period, according to OSHA.
The judge determined that OSHA’s proposed abatement measures were feasible and would reduce the hazard of workplace violence.
OSHA’s proposed abatement measures included the following:
- Ensuring units are adequately staffed to handle behavioral health emergencies,
- Providing employees with personal panic alarms,
- Adequately training new employees,
- Conducting post-incident debriefings and investigations, and
- Staffing trained security personnel on all three shifts.
The judge also sanctioned both companies for destroying surveillance videos showing workplace violence; sanctioned UHS-DE for failing to comply with its discovery obligations; and ordered the companies to pay the Department of Labor (DOL) $20,175 in attorneys’ fees.
Last year, a DOL ALJ found that UHS had destroyed surveillance videos showing instances of workplace violence at a UHS Bradenton, Florida, psychiatric facility.
The review commission has a four-pronged test it uses when reviewing citations for General Duty Clause violations:
- “A condition or activity in the workplace presented a hazard.”
- “The employer or its industry recognized this hazard.”
- “The hazard was likely to cause death or serious physical harm.”
- “A feasible and effective means existed to eliminate or materially reduce the hazard.”
The panel often is skeptical of General Duty Clause citations, calling them a “gotcha” and “catch-all” for hazards without formal standards.
However, in 2019, the commission upheld OSHA’s citation of Integra Health Management, Inc., for failing to protect an employee who was repeatedly stabbed during a home visit to one of Integra’s clients who had a history of violent, criminal behavior. The employee later died.
The review commission ruled that employers are responsible for protecting employees from recognized hazards, even if those hazards include violent actions committed by third parties that occur outside the employer’s premises.
Workplace violence prevention
Workplace violence prevention programs may vary by industry depending on the levels of risk faced by employees.
High-risk settings for health care and social assistance include:
- Hospitals and large institutional medical facilities;
- Residential treatment facilities, such as alcohol and drug addiction treatment facilities, nursing homes, psychiatric facilities, and other long-term care facilities;
- Nonresidential treatment or services facilities like small neighborhood clinics and mental health centers;
- Community care facilities like community-based residential facilities and group homes; and
- Fieldwork, including home healthcare or social services home visits.
Comprehensive programs typically include:
- Worksite analysis, hazard identification, and risk assessment, consulting employee assistance, human resources, occupational safety and health, operations, and security staff; reviewing injury and illness logs and workers’ compensation claims; and performing individual job hazard analyses;
- Engineering controls like closed-circuit video cameras and metal detectors, door locks, enclosures with bulletproof glass, and “panic” buttons at workstations or personal alarm devices worn by employees;
- Training supervisors and employees to recognize warning signs of potential violence; and
- Administrative controls like login and logout procedures, reporting history or incidence of violence during shift changes, double-teaming and using “buddy systems” to ensure workers aren’t alone, and staffing trained security officers and personnel trained in de-escalation.
You also might develop procedures for handling an active shooter at the workplace. In 2019, the American Society of Safety Professionals (ASSP) released a technical report, “How to Develop and Implement an Active Shooter/Armed Assailant Plan” (ASSP TR-Z590.5), laying out steps for developing workplace violence prevention and response programs.
Steps you can take include:
- Assessing risks,
- Developing a comprehensive prevention plan,
- Training and communicating with employees,
- Responding to an incident,
- Developing post-incident procedures, and
- Conducting drills and ongoing program audits.
According to ASSP, armed assailants can include a robber or another criminal; a client, patient, or customer; a current or former employee; or an employee’s relative, spouse, or domestic partner. Terror attacks or anonymous shooters are rare.
Steps recommended by ASSP include:
- Determining points of facility or worksite vulnerability;
- Hardening sites with badge entry systems and security cameras;
- Training staff through tabletop drills, tactical drills, and practice sessions;
- Coordinating with local emergency response agencies, inviting firefighters, police officers, and other first responders to tour the facility to familiarize themselves with the site before an incident; and
- Preparing to handle post-incident issues, creating a business continuity plan in case the facility must remain closed while law enforcement agencies process the crime scene.