Category Archives: RiskAlert Incident Report

Former Nurse Commits Suicide in Hospital Bathroom at Valley View Hospital

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RISKALERT INCIDENT REPORT # 574 – Suicide in the Hospital Bathroom

August 6, 2014

Former Nurse Commits Suicide, Fires A Single Shot to the Head, Locked in a Public Restroom at Valley View Hospital, Glenwood Springs, Colorado.

A hospital staff member reported Eric Knurr dead in a bathroom stall a round 11:30 a.m. Monday, morning, August 4, after maintenance had to be called to unlock the door to the men’s restroom off the emergency department. The former male nurse had been formally admonished by state regulators for brushing a patient’s teeth until they bled, and also slapping the patient, who was in restraints at the time of the incident in 2005. He had applied for a job at Valley View Hospital in 2012, but was not hired.  In similar incidents:

  • In January, 2014, a man locked himself in the hospital bathroom at Cherokee Medical Center in Iowa, and committed suicide.
  • In August, 2013,   62-year-old man committed suicide in a public bathroom at the Veterans Affairs hospital campus at Fort Harrison, Montana, after locking the bathroom door and killing himself with a single shot.
  • In August, 2012, a similar incident happened at an Oklahoma hospital when a Oklahoma State University employee committed suicide in a public restroom off the emergency room.


LESSONS LEARNED

(1.)  Hospital staff should IMMEDIATELY report any locked bathroom door in a public restroom.  In several of the incidents, housekeeping “didn’t want to bother security” when they found the bathroom door locked, so they waited another two hours before reporting the problem, and by then it was too late.

(2.)  Not having any form of metal detection allows people to bring guns into hospitals, lock themselves in bathroom, and commit suicide.  Metal detectors or wand detectors can prevent a tragedy.

CHECK OUT:     In December, 2010, The Joint Commission Issued a Sentinel Event Alert on Suicide Risk Outside Psych Units in Hospitals, including medical units, surgical units, and emergency departments.  (http://www.jointcommission.org/assets/1/18/SEA_46.pdf).

“It is noteworthy that many patients who kill themselves in general hospital inpatient units do not have a psychiatric history or a history of suicide attempt – they are “unknown at risk” for suicide.   Compared to the psychiatric hospital and unit, the general hospital setting also presents more access to items that can be used to attempt suicide – items that are either already in or may be brought into the facility – and more opportunities for the patient to be alone to attempt or re-attempt suicide.

“This Alert presents strategies that can be used and suggested actions that can be taken by general hospitals to help better prepare their staffs and their facilities for suicidal patients and to care for both their physical and mental needs. Suicide has ranked in the top five most frequently reported events to The Joint Commission since 1995. The Sentinel Event Database includes 827 reports of inpatient suicides.  Of these events,  14.25 percent occurred in the non-behavioral health units of general hospitals (e.g., medical or surgical units, ICU, oncology, telemetry),  8.02 percent occurred in the emergency department of general hospitals and 2.45 percent occurred in other non-psychiatric settings.”              


           Stay Alert and Encourage Hospital Employee Awareness!

RISKAlert® is a publication of Risk & Security LLC at www.riskandsecurity.com
 

Aventura Hospital Patient Strangled in his Room on July 1st,, 2014

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RiskAlert INCIDENT REPORT 565 –

Patient Strangled in Aventura Hospital, Florida

32-year old Behavioral Health Patient found Strangled to Death
in his Hospital Room

32-year old Alex Paloumbis diagnosed with bipolar disorder and schizophrenia at a
young age, had been in the hospital for two weeks. He was on the fourth-floor psychiatric
ward when he was attacked by the patient in the next bed. 

The other patient in the room, identified by police as Alexander T. Jackson, 31,  was
charged with first-degree murder and remained in Miami-Dade County Jail on Monday
with no bond. Jackson, who is homeless, was admitted to the hospital around 10 a.m
Thursday,  the day of the murder, which occurred about 3 p.m. the same day. He was
put in the same room with Rios, according to the arrest report. 

 LESSONS  LEARNED:  

Behavioral health patients require extra controls including
live, continual camera monitoring, use of appropriate
medication and possible use of restraints.

Patients may pose a danger to others, as they did in this tragedy,
and should be under continuous supervision.

Rios was last seen alive at about 2:45 p.m. Thursday. At 3:36., a hospital
housekeeper found him face down on the floor.  “The defendant admitted
to killing the victim by strangling him with his hands and a bedsheet,”
according to the report.

While administrators declined to comment on the security procedures at the
hospital, IAHSS (the International Association for Healthcare Security & Safety)
President Marilyn Hollier said psychiatric floors generally have lock-down
procedures, metal detectors, seclusion rooms and cameras at the access
points.  It is not known whether any of these security controls existed at the
hospital.  Hollier also stressed that security officers need specialized
training to deal with behavioral health patients.

Aventura Hospital, located near I-95 north of Miami, Florida, has a large
behavioral health unit with 46 beds.  The victim’s mother said her son was
never violent. “He never, never, never raised his voice,” Paloumbis said.
The mother was summoned to the hospital Thursday. She was told come
quickly and then was ushered into a room where police officers and detectives
were waiting. Though she had limited English skills, she understood that
her son was dead and initially thought that he may have died from a heart attack
or other natural causes.

Stay Situationally Aware and Continuously Monitor Behavioral Health Patients!

 RISKAlert® is a publication of Risk & Security LLC at www.riskandsecurity.com

Two Nurses Stabbed on Easter Sunday in Different SoCal Hospitals

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Dateline:  April 21, 2014

Stabbing at Olive View – UCLA Medical Center

In the early morning hours of Easter Sunday morning, a nurse at Olive View-UCLA
 Medical Center in Sylmar, California  was critically hurt after being stabbed
multiple times.

Prior to the stabbing, deputies said the suspect had entered the hospital and
allegedly bypassed the weapons screening area.  As the deputies searched
for the perpetrator, they heard a woman scream, and located the nurse, who was stabbed in both the upper
and lower torso. The nurse was transported for medical treatment in critical condition.

Torrance Hospital – Later at 9:20 am on Easter Sunday,   Thomas Fredette walked
into Torrance Hospital, in the south Bay, and grabbed a nurse from behind and
stabbed her in the ear with a sharp object, according to Los Angeles County
Sheriff’s officials.  Fredette faces charges of assault with a deadly weapon,
sheriff’s officials said.  He is being held on $130,000 bail.

What We Learned:    

Strong Access Controls at Hospital Entrances and Exits are the first line of
defense against injuries to hospital staff.  Both events were random and
apparently unprovoked. 

Nursing staff in particular, should receive adequate training in situational
awareness, which may be in conflict with their total focus on caring
for patients.

 

Double Check these critical Potential Controls:  
Stronger Access Controls
Panic & Duress Alarms at Entry Points and on Nurses working late shifts
Better Weapons Screening

 

What Went Wrong at Fort Hood? Another Active Shooter?

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RISK Alert  Alert  #530 –  Fort Hood Active Shooter-April 2, 2014

 Dateline:  April 5, 2014

Shock and grief were the reactions when the news said, for a second time, a shooter
inside Ft. Hood near Killeen, Texas had killed 4 and injured 13 in another Active Shooting
Incident. Everyone remembered  the first major shooting attack in November 2013, when
a major killed 13 and injured 43 because he did not want to be deployed to Afghanistan.

A total of 73 injured and/or killed in the two incidents!

How could this have happened?  The Department of Defense had implemented many of
the recommendations of its internal, and independent review panels, and the changes had not
been enough to prevent another active Shooter incident.

The 34-year old shooter had apparently been denied a leave form, and asked to come
back the next day and he came back, with a .45-caliber Smith & Wesson semiautomatic
handgun, recently purchased at Guns Galore, and started shooting.  He eventually turned
the gun on himself, after firing 35 rounds in two buildings over a 2 block area.  He had a
history of mental issues, and had recently been transferred to Fort Hood.


What We Learned:    The After Action Review “Protecting the Force” had detailed 89
recommendations, but by Sept. .2013,  only 52 had been
implemented and none included an Active Shooter Risk Assessment.

A comprehensive Active Shooter Risk Assessment has to be the first recommendation
 after any Active Shooter event.  Recommendations from the previous shooting were concentrated
on new policies and procedures, mental health screening, education and training programs but
those controls did not directly influence PREVENTION of incidents.

A Review of the Most Important Active Shooter controls would have been more
likely to prevent a future shooter event, like:

  •           Tightened Access Controls for Facilities
    • Panic Alarms
    • Tracking of Potential Troubled Individuals
    • Metal Screening for Weapons
    • Policy on Personal Weapons on Base

      After the Navy Yard shooting in September 2013, another round of recommendations
      were made to improve security at all DOD installations, however, a  Pentagon official
      said on Thursday, April 4th, that the new recommendations had not yet been put into
      effect at Fort Hood.        Unfortunately, at Fort Hood, very little had changed from 2009
       regarding security procedures for soldiers at the entrance gates.

      Stay Alert and make sure that any Security Incidents are reported IMMEDIATELY!
                                                                      
                                     

After Action report on LAX Shooting Recommends Risk Assessments

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The Los Angeles World Airports (LAWA) released the long-anticipated After
Action Analysis on the LAX Active Shooter Incident in 2013.

The 83-page report was written by an independent consultant who analyzed
all aspects of the Shooting incident and includes a list of “Major Observations
and Recommendations.”   The recommendations are “to provide focus for
LAWA’s efforts toward continuous improvement in it’s security and emergency
preparedness programs.  

These areas were highlighted in the report as “7 priority observations that merit
special consideration.

Recommendation 1.1:  Evolve the LAX Security Program to reflect a more
integrated assessment of security risk and provide for the ongoing development
and management of mitigation measures.

Recommendation 1.2:  Based on the RISK ASSESSMENT and updated security
plan, consider the focus and structure of security functions to determine whether
realignment and integration are needed.

Recommendation 1.3:  With the benefit of recent vulnerability and risk assessments,
take a risk-based approach to evaluating current security programs and explore
intelligent use of technology.”

Once again, doing frequent Security Risk Assessments and managing the security
program and enhancements to follow the recommendations of the Risk Assess-
ment are the first recommendations in the After Action Analysis of an Active
Shooter Incident.

In my experience, in most organizations, Facility Security Risk Assessments are
not conducted correctly, are not reported to senior management, and not used as a
tool to ADJUST AND FOCUS the security program based on RISK.

Why aren’t security risk assessments done more often?  

1.  People don’t have the right expertise to do a full risk assessment.

2.  Security managers view Security Risk Assessments are too difficult
     to undertake.

3.  Law enforcement personnel still do not understand the concept of risk 
     assessments and instead, tend to rely on checklists of controls or
     security elements, rather than integrating all the information to
     create a true Risk-Based model for security.

The solution to this problem is to use affordable, easy to use software tools, like
the Risk-Pro Application for Facilties Security Assessment  and their Risk-Pro
Application for Active Shooter Incident to simplify the process of doing more
frequent risk assessments and using them as a management tool to focus
security so it will be able to recommend the security enhancements that are
needed, and not only how MUCH to spend, but actually dictate the order
of necessary controls.

Far from being a boring, intellectual exercise, well done security risk 
assessments can dramatically reduce the possibility of an active shooter
event, and also mitigate the many negative consequences that come
from such disruptive incidents.

 

 

 

Putin Analyzes his Risk on Invading Crimea

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The invasion of Ukraine’s Crimea region by Putin’s “un-labeled” troops
illustrated two major principles of a Risk Assessment.   

    #1 – Secure your Critical Assets First

It’s not about the citizens of Crimea, not about the Ukraine wheat fields, or
even it’s use as a pipeline pass-through area.  It’s all about the Black Sea
Ports.  These ports are absolutely critical to Russia (and also to PUTIN
– the EGO), because they are a critical place to ship gas and oil from,
and they also give Russia their only access to the Mediterranean,
in case Putin urgently needs a gelato!

The second principle of a risk assessment is

    #2 – Analyze all the Potential Threats

I read a great article over the weekend about how Putin had sized up the
EU and the European bankers, and calculated that the threat of any interruption
of the Russian-European banking relationship was zilch – zero.  Bankers are
not going to reduce their profits by refusing to do business with Putin.

The next potential threat is U.S. retaliation or sanctions.   Putin correctly
calculates that the US didn’t get out of Iraq and almost out of Afghanistan
to immediately send any boots on the ground to Crimea or eastern Ukraine.
We can threaten to curtail his trips to Vegas and Disneyland, but the U.S.
is not going to start a war over this.

Putin did his risk calculation and decided that his chance of getting in any
serious trouble was VERY SMALL and his potential gain was VERY HIGH:

1.  He gets to look like a tough guy again.

2.  He gets lot of media attention from the whole world (doesn’t care what
media writes about him, as long as they spell P*U*T*I*N  correctly and
gets him back on the world stage again.

3.  And, the clincher is that he can pull the troops out anytime he wants,
send them back home, and no real harm done.

But I did pay attention in my history class, and I am hoping out loud that
we are not on the precipice of another war!

RiskAlert Incident Report #473 – Hospital Admin Killed at Home

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RiskAlert  INCIDENT REPORT 473 – ACTIVE SHOOTER 12-27-2013

Oschner Hospital Administrator Shot to Death in his Home in Active Shooter Spree

Dateline:  December 27, 2013   pm

A Louisiana man attacked his former in-laws, his current wife, and the Administrator of a hospital
where he’d worked, killing three and wounding three others before killing himself, authorities said.

The shooter, Ben Freeman, 38, was found late Thursday night in his car along a highway,
dead from a self-inflicted gunshot wound to the head.

The shootings happened at four locations in two parishes about 45 miles southwest of New Orleans
on Thursday. The first report came about 6:40 p.m., when Lafourche Parish Councilman Louis Phillip
Gouaux, who was shot in the throat, called 911 from his home in Lockport, Houma, La.

The suspect, Ben Freeman, 38, was the ex-husband of Gouaux’s daughter Jeanne, Lafourche Parish
Sheriff’s Office spokesman Brennan Matherne said in a news release.

Gouaux’s wife, Susan “Pixie” Gouaux, was dead when deputies arrived.  Louis Phillip Gouaux and his
daughter, Andrea Gouaux, were injured and taken to Interim LSU Public Hospital in New Orleans.
Both were in critical but stable condition, Matherne said.

About 20 minutes later in Raceland, Ochsner St. Anne General Hospital Administrator Milton Bourgeois
was shot and killed at close range at his home.  His wife, Ann Bourgeois, was shot in the leg, and taken
to the New Orleans hospital, where she was listed in stable condition.  Raceland police said Bourgeois
was shot at close range and his wife was shot in the leg.

Houma,LA Shooter

 

Freeman had been employed at three area hospitals over the last few years, including Oschner St. Anne Hospital, where Lafourche Parish Sheriff Craig Webre said he had been a registered nurse before he was fired in 2011. All three hospitals were put on lockdown for a while Thursday.

Freeman’s wife, Denise Taylor Freeman, was found dead in the couple’s home in Houma in Terrebonne Parish. Matherne said her cause of death was not immediately known.

 

  RISKAlert is a publication of Risk & Security LLC at www.riskandsecurityllc.com.

Get Management’s Attention for Security – Shooter Kills the Hospital Administrator

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Every Security Officer I’ve ever met has mentioned how difficult it can be to get funding for additional security!  It is a never-ending mission, to get the budget for a security program that will truly protect an organization.

Hospitals are no exception.  They have suffered their own financial problems and because security is not seen as a ‘clinical’ or ‘patient care’ issue, it is easy to take money from security and put it somewhere else.

But there’s one sure way to get management’s attention for Security — having a security incident.  And if you don’t have one at your organization, high profile security incidents at other facilities will all grab management’s attention.

In my Risk-Pro Security Incident Report today, a shooter killed four, wounded three, and then killed himself.   What was unusual about this incident was that the shooter went to the Hospital Administrator’s house and shot the administrator dead, and then shot his wife who was taken to an area hospital.

AdministratorHome-Louisiana

 

 

 

Most executives and administrators think about security as sort of an abstract concept, that doesn’t directly affect them.  But it might, and by sending your management a copy of our Risk-Pro Incident Report, you’ll get their attention this time!

(Subscribe to the Risk-Pro Incident Report program by sending an email with the word SUBSCRIBE on it to info@riskandsecurityllc.com)