RISKAlert Report Updated: GUAM MEMORIAL HOSPITAL AT RISK OF LOSING CMS REIMBURSEMENTS

RISKAlert Report Updated:  July 15, 2018                                                                                

Guam Memorial Hospital is at risk of losing CMS Medicaid reimbursements, unless dozens of deficiencies
are fixed include medical issues and facility issues by July 25th according to scathing 78-page report
.

The island’s only public hospital could lose Medicare funding for the Skilled Nursing Unit (SNU)  by July 25th
and its main facility if it fails to achieve “substantial compliance” with the federal participation requirements
for nursing homes participating in the Medicare and/or Medicaid programs by July 25. It will deny to reimburse
admissions, and If substantial compliance is not achieved by Oct. 25, CMS will terminate the provider agreement.

In a scathing 78-page report, regulators reported the results of an unannounced survey which was done
for recertification, complaint revisit and complaint investigation and uncovered issues including not checking
credentials for medical personnel, not reporting medical errors, and medical issues that put patients in an
immediate jeopardy situation.

The report said GMH failed to ensure that its performance improvement activities tracked adverse patient events, analyzed the cause of the adverse event, and implemented preventive action, the survey report states. Major
adverse events that hurt patients were not reported even 12 months after the event had occurred.

The CMS survey took issue with egress doors that had locks that do not meet federal requirements. “Failure to provide egress doors as required increases the risk of death or injury due to fire,” the survey stated.  The facility also lacked proper emergency lighting. An emergency power supply location was not provided with battery-powered emergency lighting, and the primary generator did not have battery-powered light. A Battery-powered light in a secondary generator room was not functional when tested during the survey.


LESSONS LEARNED

1.  Losing CMS Certification may reduce the Guam Memorial Hospital’s revenue by 50-70%.
Make sure to keep your CMS Certification current  to avoid a financial crisis!

2.  Many deficiencies were blatant and cite recurring problems that MUST BE CORRECTED
IMMEDIATELY to avoid more problems.

THANKS FOR READING THE RISKAlert Report©
For more information and a free subscription:  write to:  caroline@riskandsecurityllc.com
We provide the best CMS Facility All-Hazards Risk Assessments, as well as Active Shooter Training,
Workplace Violence Assessments, and Mass Casualty Drills & Training Programs.

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MAN AT SOCIAL SECURITY OFFICE STABS HIS MOTHER AND GRANDMOTHER IN WORKPLACE VIOLENCE INCIDENT BEFORE BEING SHOT TO DEATH BY FEDERAL SECURITY OFFICER

RISKAlert Report Updated:  July 9, 2018                                                                                       McComb,  Mississippi

MAN AT SOCIAL SECURITY OFFICE STABS HIS MOTHER AND GRANDMOTHER IN WORKPLACE
VIOLENCE  INCIDENT BEFORE  BEING SHOT TO DEATH BY FEDERAL SECURITY OFFICER

A 21-year-old Mississippi man, Branen Carter, went into the McComb, MS, Social Security Administration office with his mother and grandmother, and then he stabbed his mother and grandmother in the lobby before he was shot to death by a federal FPS (Federal Protective Service) security officer. 

The incident happened at 11 am, and the facility was put on lockdown after the incident.  Large numbers of law enforcement officers responded to the one-story brick building on the edge of McComb, which is about 100 miles south of Jackson.

Carter’s mother, Lee Anna Turnage, and grandmother, Ann Carter, were in stable condition at Southwest Mississippi Regional Medical Center, after what was reported as a family fight that turned violent.

Mississippi court records show Branen Carter was indicted in Marion County in December 2016, when he was 20, on two felony charges — one count of statutory rape and one count of sexual battery of a child between the ages of 14 and 16.  He pleaded guilty in May 2017 after the two felony charges were reduced to misdemeanors (WHY?), and he was given two six-month suspended sentences, which means he did not have to serve jail time. The attorney who represented him was out of the office Monday and could not immediately be reached for comment.

The Director of Communications for the Federal Protective Service, Robert Sperling, said that the FPS agency has a long history of using armed security guards at federal agencies it oversees. “It’s a cornerstone. We have officers in social security offices and most federal agencies across the country, such as the IRS,” Sperling said.

LESSONS LEARNED:

      1.  Workplace Violence can happen anywhere, and family disputes often spill over into
public workplaces.  This attack happened in the lobby of the federal agency.

  1. The FPS did an excellent job of countering the threat and probably saved the
    lives of both women.


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#Stabbing     #WorkplaceViolence

NURSING HOME MAY LOSE CMS MEDICARE FUNDING AFTER RESIDENT IGNITED OXYGEN TANK WHILE SMOKING, CAUGHT FIRE AND BURNED FOR 10 MINUTES

 

RISKAlert Report Updated:  July 5, 2018                                                                                           Helena, Montana

NURSING HOME MAY LOSE CMS MEDICARE FUNDING AFTER RESIDENT  IGNITED OXYGEN TANK WHILE
SMOKING, CAUGHT  FIRE AND BURNED FOR TEN MINUTES

Montana’s Health Department recently found that a Helena nursing home was neglecting patients, after an unsupervised resident smoking a cigarette on oxygen caught on fire and suffered second-degree burns in May.  The resident died several weeks later.  The facility had a new non-smoking policy in place.

As part of a CMS Survey, the Montana Department of Public Health &Human Services conducted a survey of Big Sky Healthcare Community after receiving a complaint about the facility. The survey found that the Helena facility neglected the resident when she was outside unsupervised on May 1.

The resident was on fire for approximately 10 minutes before staff reached her and called emergency medical services, according to a witness.  The survey also found the facility failed to report the incident, various staff members were unclear on the facility’s smoking policies and some residents were inappropriately left to administer their own medications.

The CMS Survey classified the incident as an “immediate jeopardy” situation, meaning the facility had to take immediate corrective actions to protect residents or risk losing its Medicare and Medicaid certification.  Big
Sky Healthcare successfully removed the immediate risk while the state workers were on site. The facility later had to submit a detailed corrective action plan to address all of the issues identified by the state.

The resident, who is not named in the report, was caught smoking multiple times by staff in the months prior to catching on fire. The resident came to the facility in December 2017 with a lung disease that restricts breathing and required supplemental oxygen.  The resident was burned on May 1, admitted to hospice on May 8 and died on May 24, according to the report.

A staff member said the facility’s policy required nurses to keep cigarettes and lighters stored away from patients, but nurses don’t enforce that. The staff member said management was aware nurses were not enforcing the policy. Another staff member said residents were allowed to keep cigarettes and lighters in their rooms.

LESSONS LEARNED:

  1. Nursing home residents should never be allowed to smoke. Policies should be adjusted to
    reflect this, and staff should be trained on how to report infractions.
  2. If residents are unfortunately allowed to smoke, They should be under constant supervision and
    oxygen tanks should be far away from the resident.


THANKS FOR READING THE RISKAlert Report©

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ACTIVE SHOOTER IN ANNAPOLIS, MARYLAND KILLS FIVE, INJURES THREE, AT THE ANNAPOLIS CAPITAL GAZETTE NEWSPAPER OFFICE

I WAS SHOCKED AND DISMAYED AS I WATCHED THE BREAKING NEWS:  ACTIVE SHOOTER IN ANNAPOLIS, MD YESTERDAY.   I teach Active Shooter Training, perform Active Shooter Drills and do Active Shooter Risk Assessments every week, but this one was different because I used to have an office right next to the Capital Gazette on Bestgate Road.

This horrific shooting had all the hallmarks of the other Active Shooters we have seen.  The shooter was mad over something that had been written about him 7 years ago, so he thought about it every day, and fantasized about getting even, and then one day, he picked up his gun and headed to the Capital Gazette newspaper office.

He used his shotgun to shoot out the front glass doors, walked inside and started shooting.  The extent of the carnage was kept out of the news for several hours, but then the Governor announced that five staffers had been killed and 3 other injured.  

AGAIN, THE SHOOTING WAS OVER BEFORE THE POLICE ARRIVED.  They eventually had 105 law enforcement officers on the scene within two minutes, but it was too late to save anyone.

Because Annapolis is the capital of Maryland, and a relatively small town, this was another case of IT CAN’T HAPPEN HERE!  The newspaper office had no security in place.

Even though the shooter (who’s name I won’t use) had made many threats to the newspaper and its staff, the threats were not taken seriously, and there was minimal, if any, security at the Capital Gazette Office.  There was no security presence in the office, or the building, no panic alarm, and no case management program had been set up to track and attempt to manage the shooter’s threats.


LESSONS LEARNED:
 Effective Security is the only thing standing between YOUR STAFF and an Active Shooter.

1.  Effective Security is the only thing standing between YOUR STAFF and an Active Shooter.

2.  Even the most basic security threats, such as having a solid, bullet-proof door (not glass),
having a safe room for staff, can make the difference in saving a life.

3.  The newspaper had decided NOT to get a restraining order against him, thinking it would
make things worse, but instead, ignoring the threats is what inflamed the shooter.


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For more information and a free subscription:  write to:  caroline@riskandsecurityllc.com 
We provide the best Active Shooter and Facility Risk Assessments & Training Programs. Find out more
at   www.riskandsecurityllc.com .

 

 

 

 

 

 

77-Year Old Man in a Senior Care Retirement Home Fatally Shoots One Firefighter and Injures Another in Long Beach, California

RISKAlert Report # 1149         Updated:  June 27, 2017                                                    Long Beach, California

A 77-year-old retirement home resident identified as Thomas Kim, has been accused of intentionally setting a fire Monday morning to lure first responders to the facility.  After the firefighters entered the Home and
put out the fire, Kim fired on the men, killing one firefighter and wounding another.

It’s the first time we have seen anything like this said, Mike Duree, Long Beach Fire Chief..

Around 4 a.m. Monday morning, firefighters Capt. Dave Rosa and Ernesto Torres responded to reports of a fire, followed by an explosion and the smell of gasoline, at the Covenant Manor senior care facility, Duree said. As they approached the high-rise building, the firefighters noticed that the windows of one unit had been blown out and that the sprinklers were on.

After extinguishing the fire, Rosa and Torres remained inside the building to investigate the gas smell and explosion, the chief said. Ten minutes later, gunfire erupted and police received reports of an active shooter. Rosa, a 45-year-old veteran of the Long Beach Fire Department, was killed in the attack. Torres and another man, a civilian resident of Covenant Manor, were injured and taken to a local hospital.

Long Beach Police arrested 77-year-old Thomas Kim, who lived in the facility, in connection with the fire and the shooting.

They booked Kim  on suspicion of murder, as well as two counts of attempted murder and arson, and is being held on $2 million bail.  It is not known about where he got his weapon and how he started the high-rise fire.

Not much was immediately known about Kim, police said he was arrested years ago for auto theft and that detectives are looking into reports of erratic past behavior.  His family said that they were stunned to find out the suspect was alive, living in Long Beach, and was a suspect in the murder and arson investigation.


LESSONS LEARNED:

  1. Retirement facilities should institute a No-Weapons Policy for Residents. 
  2. Firefighters place themselves in danger every day, but didn’t expect to encounter
    a killer in the retirement home!
     


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    ©For more information and a free subscription:  write to:  caroline@riskandsecurityllc.com 
    We provide the best Active Shooter and CMS Facility Risk Assessments & Training Programs. Find out more at  www.riskandsecurityllc.com.

FEDERAL JUDGE RULES FOR OCR, FINES MD ANDERSON $ 4.3 MILLION DOLLAR FINE FOR MAJOR HIPAA VIOLATION INVOLVING UNENCRYPTED STOLEN DEVICES AND 33,000 PATIENT RECORDS

In the ruling, the Judge found that The University of Texas MD Anderson Cancer Center (MD Anderson) violated the HIPAA RULE for Privacy and Security Rules and granted summary judgment to the Office for Civil Rights (OCR) on all issues, requiring MD Anderson to pay $4,348,000 in civil money penalties to OCR. The $4.3 million dollar fine is the fourth largest amount ever awarded to OCR.

MD Anderson is an academic institution and a comprehensive cancer treatment and research center located at the Texas Medical Center in Houston.  OCR investigated MD Anderson following three separate data breach reports in 2012 and 2013 involving the theft of an unencrypted laptop from the residence of an MD Anderson employee and the loss of two unencrypted universal serial bus (USB) thumb drives containing the unencrypted electronic protected health information (ePHI) of over 33,500 individuals.

OCR’s investigation found that MD Anderson had written encryption policies going as far back as 2006 and that MD Anderson’s own risk analyses had found that the lack of device-level encryption posed a high risk to the security of ePHI. Despite the encryption policies and high risk findings, MD Anderson did not begin to adopt an enterprise-wide solution to implement encryption of ePHI until 2011, and even then it failed to encrypt its inventory of electronic devices containing ePHI between March 24, 2011 and January 25, 2013.

OCR is serious about protecting health information privacy and will pursue litigation, if necessary, to hold entities responsible for HIPAA violations,” said OCR Director Roger Severino. “We are pleased that the judge upheld our imposition of penalties because it underscores the risks entities take if they fail to implement effective safeguards, such as
data encryption, when required to protect sensitive patient information
.”

LESSONS LEARNED

1.  MD Anderson had written encryption politics going back to 2006, and had identified lack of
encryption as a material weakness in their own risk analysis!

2.  If a HIPAA Risk Analysis identifies a weakness in a critical area like encryption, immediately
start encrypting all electronic devices.

THANKS FOR READING THE RISKAlert Report©
For more information and a free subscription:  write to:  caroline@riskandsecurityllc.com

We provide the best CMS Facility All-Hazards Risk Assessments, HIPAA Risk Analysis, as well as Active Shooter Training,
Workplace Violence Assessments, and Mass Casualty Drills & Training Programs.

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PARKLAND SHOOTING UPDATE: OF COURSE IT HAPPENED HERE SAID EX-SECRET SERVICE AGENT WHO REPORTED TO THAT MSD HIGH SCHOOL WAS VULNERABLE!

RISKAlert Report Updated:  June 11, 2018                                                           

According to a retired Secret Service agent, Parkland’s Marjorie Stoneman Douglass staff was well
aware of the lack of security as much as 60 days before the fatal shooting took place.  The former agent, Steve Wexler,
was invited to review the high school for security and he reported numerous weaknesses to the MSD staff including:
Gates were unlocked.  Students did not wear identification badges.  A fire alarm could send students streaming into the halls.  Active-shooter drills were inadequate,”  he said.

In addition, he noted, “This stuff is blatantly obvious. You’ve got to fix this,’” Wexler said.  He never
heard from the school again. His recommendations included:

1. School gates should be locked, and students should wear ID badges showing they belong on campus.
The shooter on Feb. 14 was able to get on campus because the gates were opened at the end of the school day.

  1. Active-shooter drills should be routine. After the shooting, some students said they had not been involved
    in drills this year.
  2. Any adult should be able to declare a Code Red to lock down the school. Clark, the school district spokeswoman, said that is the current protocol, but Wexler said he was told an assistant principal notifies the principal, who then makes the call. “That’s a problem,” he said he told the staff. “This stuff happens fast. This playing telephone is no good. By that time we could sit down and have breakfast.”
  3. Schools should not immediately evacuate students for a fire alarm without first confirming there’s a fire. During the shooting, the gunfire set off the smoke alarm, and students fled into the halls, where the shooter could take aim.

    LESSONS LEARNED

    1. If you have a security iny weaknesses identified by an expert – TAKE THEIR ADVICE AND
    fix the issues that were identified!

    2. Liability increases if staff were clearly warned BEFORE an incident that there were
    existing security weaknesses.


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©

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Hazards  Risk  Assessments, Drills &  Training Programs.

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Western State Hospital (Tacoma, WA), Could Lose $65 Million in Federal Funds as CMS Finds Serious Risk for Exposed Fire System Devices that could be used by Patients to Commit Suicide by Hanging

 

 

 

 

RISKALERT  #1040 – Report Updated:  May 30, 2018

In a memo sent to top staff earlier in the week, “CMS identified a serious risk of harm to patients due to ligature risks
from the fire system in patient care areas of Building 21
,” said the memo, which was obtained by public radio. Building 21 is where civil, or non-criminal, patients are treated on five different wards. Typically a ward has 30 patients. Western State Hospital is a Psychiatric Residential Treatment Center (PRTC) with over 800 beds.

A CMS finding of serious risk of harm is also known as an “immediate jeopardy.”  The memo also said that if the issue is not resolved, funding could be lost in 23 days.

Since 2015, Western State Hospital has been under scrutiny for serious repeat violations that inspectors said put patients and staff at risk. The litany of troubles included violent assaults on patients and staff, the 2016 escape of two high-risk patients and scores of unauthorized patient “walkaways.”

The safety violations were discovered by a team of 22 federal surveyors who were re-inspecting the hospital last week as part of a turnaround plan that is approaching the two-year mark. The sprawling hospital, which serves civil and forensic patients, must meet standards on 26 federal “Conditions of Participation” in order to continue receiving federal funding.

A “root cause” report in 2016 identified ineffective management, staff reductions and turnover leading to patients who felt “neglected” and a “culture of helplessness” among staff. A review by the Department of Corrections also found numerous security gaps including 25,000 master keys unaccounted for.

LESSONS LEARNED

1.   CMS requires all residential treatment facilities to maintain a safe physical environment, and any
identified risk situations should be addressed immediately to prevent loss of CMS reimbursement funds..

  1.  Management must take the lead even in facilities related issues, instead of leaving the improved
    implementations up to lower level staff members.

    THANKS FOR READING THE RISKAlert Report
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    Hazards  Risk   Assessments, Drills &  Training Programs.

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SEVENTEEN-YEAR-OLD ACTIVE SHOOTER AT SANTA FE,  TEXAS HIGH SCHOOL KILLS 10, INJURES 13, AFTER STUDYING MASS SHOOTING TECHNIQUES

SEVENTEEN-YEAR-OLD ACTIVE SHOOTER AT SANTA FE, TEXAS HIGH SCHOOL KILLS 10, INJURES 13, AFTER STUDYING MASS SHOOTING TECHNIQUES

       

 SEVENTEEN-YEAR-OLD ACTIVE SHOOTER AT SANTA FE,  TEXAS HIGH SCHOOL KILLS 10,
INJURES 13, 
 AFTER STUDYING  MASS 
SHOOTING TECHNIQUES FROM NEWS REPORTS

RISKAlert Report #1035 Updated:  May 20, 2018                                                      Santa Fe, Texas

At 7:25 am on a Friday morning in Santa Fe, Texas, a 17-year-old student walked into his classroom, wearing a trench coat and armed with his dad’s Remington 970 shotgun and .38 caliber pistol that he used to shoot 23 people inside his school.  Ten were killed and 13 were injured in the planned shooting.  Armed officers responded within four minutes and a gun battle
ensued with the subject.

Although a romantic failure may have triggered the attack, the shooter had long been a fan of active shooters and studied previous shootings, like pulling of the fire alarms in the recent Parkland shooting. He wore a trenchcoast, mirroring the horrific Columbine High School shooting in April, 1999, in which two teenage boys with weapons hidden under trench coats killed 12 students and one teacher

According to a witness, the shooter yelled “WOO HOO”, as he shot up the classroom.  Multiple media accounts say the gunman taunted some of his victims, asking some hiding in a closet if they wanted to answer their ringing cell phones. “You want to get that?” the attacker said, according to The Wall Street Journal.

He spared others saying he wanted his story told. Police also found five homemade pipe bombs that did not detonate.

The shooter had pursued a romantic interest, Shana Fisher, for the past four month, according to her mother, but she refused to date him.  Shana was shot and killed in the incident.  Her mother said that the previous week, her daughter, Shana, has said in media accounts that her 16-year-old daughter had rejected four months of aggressive advances from Pagourtzis.
Fisher finally stood up to him in front of the entire class, and proclaimed she would never go out with him, embarrassing him in class, her mother told the Los Angeles Times.

Many of the aspects of the attack mirrored one of the worst school shootings in American history: the massacre at Columbine High School in April, 1999, in which two teenage boys with weapons hidden under trenchcoats killed 12 students and one teacher.

LESSONS LEARNED

       1.  Even with a relatively quick 4-minute response time, there were still 10 killed and 13 injured, demonstrating that
            even a well-armed police officer cannot quickly stop the killing, once  shooting starts!!

  1. Texas State officials blamed the attack on video games, on abortions, and on too many entrances and exits
    to the high school buildings, even though the school lacked any access control, no metal detection and
    no screening of any kind.
  2. Underage students should not have ready access to firearms. The shooter’s parents apparently missed the fact that
    he assembled pipe bombs in his bedroom, had access to guns, and avidly recounted mass shootings.

  3. Why are parents fined if their child is late in returning a library book, but not if their child shoots
    and kills people with daddy’s guns?

    The massacre claimed Shana Fisher’s life, and also claimed the lives of students Sabika Sheikh, a Pakistani exchange student; Chris Stone; Jared Black, Angelique Ramirez; Christian Riley Garcia; Aaron Kyle McLeod; and Kimberly Vaughan. Teachers Glenda Ann Perkins and Cynthia Tisdale were also killed.

The people hospitalized included retired Houston police Officer John Barnes, who served as a resource officer at the school and confronted the gunman.

Pagourtzis did not attempt suicide, like the Columbine shooters, but Texas’ governor, Greg Abbott, a Republican, told reporters that the youth wanted to kill himself, citing the suspect’s journals, but lacked the courage to do so.

Dimitrios Pagourtzis,  is being held without bail and is accused of capital murder of multiple people and aggravated assault on a public servant.  he suspect won’t face the death penalty if he is convicted. Under Texas law, offenders who are under age 18 and charged with a capital offense face a maximum punishment of life in prison with the possibility of parole after 40 years.

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 & CMS Facility Risk Assessments, Drills &  Training Programs.  
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19-year old Teen Victim Sues Michigan Hospital After Being Punched in the Face in the Hospital’s Emergency Room

RISKAlert Report Updated:  April 10, 2018

A nineteen-year old woman is suing Beaumont Hospital in Dearborn, Michigan after she was injured by another patient in the hospital’s emergency room. The entire attack was caught on hospital security video.

The video showed the woman, who was wearing a hijab head scarf, had just started talking to the staff at the ER desk, when, with 5 seconds, an older man came up behind her and started to repeatedly punch her in the head. The man who attacked her, 57-year-old John Deliz, had been dropped off at the hospital by police, after leaving a group home.

Police records show he was warned about harassing others in the hospital lobby before the attack occurred, according to The Detroit News.  Deliz admitted in court that that he had been diagnosed with bipolar disorder and schizophrenia  and had not been taking his medications.

The hospital security staff immediately responded and restrained Deliz, who was subsequently arrested.

The lawsuit claims that “the hospital was aware of his condition as he was brought because he needed mental treatment. Instead of treating him, they discharged him into the ER waiting room,” her lawyer, Mr. Moughni told CBS. “Instead of giving him mental treatment, they put him back in the patient pool, thereby giving way to his attack.”
LESSONS LEARNED:

1.   Using the Emergency Room as a temporary holding area for behavioral health individuals
exposes the hospital to potential lawsuits and liability for any damage they might do.

2.   Behavioral health patients need to be isolated in a holding room and/or continuously supervised, and
not allowed to freely  circulate within the Emergency Room.

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