The Centers for Medicare & Medicaid Services (CMS) requires skilled nursing facilities to plan for emergencies and disasters to protect the vulnerable population they serve. The regulations cited in Appendix Z indicate that facilities must develop emergency plans by assessing all of the potential threats and perils that can impact their operations both internally and externally through a risk assessment per the requirements of E-006. Once the hazards are identified, skilled nursing facilities are compelled to utilize an “All Hazards” approach to manage the types of adverse incidents that can impact their operations.
A common threat that is identified by every healthcare facility focuses on the potential for violence in the workplace. In some cases, violence can be targeted against employees and in other cases against residents. Sadly, there have been many incidents where shots have been fired inside of skilled nursing facilities and occupants were killed or injured.
One tragic incident that serves as a reminder that skilled nursing facilities are not immune from this type of violence occured in Carthage, NC, in March of 2009, where where eight people, including residents and one staff member, were killed on a seemingly peaceful Sunday morning.
Unlike other occupations where for the most part, individual employees can simply focus on their own personal safety in the workplace, the long-term care environment is clearly different. The workforce in these healthcare facilities oftentimes become connected with their residents on a personal level and during an emergency, will simply not leave them to fend for themselves. Specific protocols have been developed by security experts that focus on the nuances of the long-term care environment. These simple protocols provide practical solutions and the “options” that can be considered including a life-saving strategy known as “The Four Outs” to effectively respond to these types of fast-moving and unpredictable incidents.
Long-term care facilities including skilled nursing facilities and rehabilitation centers are unique in the way they must approach preparedness for an armed intruder or active shooter. In most industries with an adult workforce, workers are trained in survival techniques based on “me focusing on me;” in other words, each adult takes care of themselves. In the LTC environment, much like elementary schools, you not only have yourself to worry about, but you have to worry about others who can’t take care of themselves and rely on you.
The “Four Outs” is a program that addresses this factor as it applies to skilled nursing facilities and similar inpatient healthcare operations. Often compared to the RUN-HIDE-FIGHT protocol promoted by the U.S. Department of Homeland Security, the team at Sorensen, Wilder & Associates developed the Four Outs as a program based on practical choices for those situations when you have to think about more than just yourself. When applying the Four Outs, it must be done with both the resident and the caregiver or other staff members in mind.
Broken down, the key elements of the Four Outs are as follows:
GET OUT – Move residents and staff out of and away from the building to a designated
reunification point. Remember, licensure regulations require SNFs to develop an emergency plan to identify a designated reunification point(s) and provide for an immediate accountability of all employees and residents during an emergency evacuation.
HIDE OUT – When getting out isn’t possible as is often the case in a LTC facility, Plan B is to hide out. Staff should seclude themselves in a room preferably with a locked door where you can remain out of the line of sight of the shooter. Lights should be turned off and steps should be taken to cover interior windows to provide additional concealment.
KEEP OUT – As is common in a LTC facility, not all rooms have locks on the doors and in many cases; locks are prohibited by regulatory standards. When doors cannot be locked, you will have to create your own barriers to keep out the offender. This may include barricading the room’s door with a bed (remember to lock the wheels) or other large furniture items in a room. The more material used to barricade the door, the better. In other areas, you can use anything and everything available to create a “wall of obstruction” in front of hallway smoke doors or other points of entry.
These barricades are not intended to prevent the doors from being opened (many swing in opposite directions) but rather, the “wall of obstruction” that you create is intended to slow down the offender who is looking for targets-of-opportunity Encountering this wall of obstruction may cause the assailant to move on rather than set down their weapon and waste time trying to move all of the obstructions.
TAKE OUT – As a last resort, and only as a last resort, you may have to fight back. This is a
fight against the offender and is truly a fight for your life. There are no rules, there is no “fair fight” and your focus is on your survival by stopping the offender by incapacitating them. Use any “weapon of opportunity” available (scissors, stethoscope, fire extinguisher, chair, trouser belt, etc.) and be prepared to do whatever you must do to stop the offender and save yourself; up to and including the use of lethal force.
When in a position of relative safety and as quickly as possible, the authorities should be called through the 9-1-1 system. A concept taught by the team at SWA and other security professionals is that there is no such thing as “too many calls to 9-1-1” during these types of violent and fast-moving emergencies. Additionally, many jurisdictions now have 9-1-1 texting capabilities so emergency text messages can be sent to the 9-1-1 center instead of voice communications when hiding out. It is important to know if this service is available in the jurisdiction where your facility is located. Once confirmed, all members of your team should be trained on proper 9-1-1 procedures including text messaging, if available.
The program developed by SWA also focuses on making the most difficult decision that may need to be considered in times of peril. Of course, that decision is whether to focus on yourself or your residents? Identified as the Safety Transition Adjustment Formula (STAF) Protocol, caregivers are trained in what to look for in the initial moments of an event that will guide them to making the right decision on personal and resident safety.
When a shot is heard, the normal (and expected) reaction is anxiety. That is understandable. But when that moment occurs, your first question needs to be, “Where am I in relationship to where the shot came from?” If you are close to the shooter, then personal safety comes first. If the shooter is a distance away from you, perhaps on a different floor or in a different part of the building, you can then focus on resident safety first, using the Four Outs to evacuate residents or secure them in place. And remember, when the best option is placing yourself first, you aren’t being a coward or being selfish. If something happens to you, who will take care of them?
The recovery aspect of a shooting incident is often the part of the preparedness continuum that is overlooked considering that no organization or individual thinks this will really happen to them. If you are willing to accept the fact that an incident involving an armed intruder or active shooter can really occur at your LTC facility, then you must also realize that when the initial incident ends, you must initiate the recovery process in order to eventually return to a “state of normalcy,” For those who have experienced “The Unthinkable,” they know that this is not as easy as it sounds. The recovery process must be addressed long before the first shot is ever fired and requires the development of relationships with outside providers who will likely be needed to provide support after the incident. This includes the restoration resources that may be needed to address physical damage to the facility as well as the emotional support that will be needed from mental health professionals to address the psychological trauma associated with this type of adverse incident.
Training, both in the didactic mode and the practical skills mode are essential elements of an effective armed intruder/active shooter awareness program in a LTC facility. While both authors of this article are strong supporters and allies of law enforcement, relying on your local police department or sheriff’s office for training may not give you the results you need. Law enforcement training focuses on law enforcement’s response to the threat. Your facility’s training must focus on how to minimize casualties and maximize survivability from the moment the first shot is fired until the time police arrive on the scene. To do this, your facility’s training program should be provided by a qualified team who is intimately familiar with the LTC environment and the unique challenges that your staff and residents face.
The thought of an armed intruder or active shooter in a skilled nursing facility is truly unthinkable. Providers must prepare their staff for the unexpected by empowering them with the knowledge needed to exercise one of “The Four Outs” or take other appropriate action to protect themselves and those in their care should this type of emergency occur.
Stan Szpytek is the president of the national consulting firm, Fire and Life Safety, Inc. based in Mesa, Arizona. He is a consultant for the American Assisted Living Association (AALNA) and is the Life Safety/Disaster Planning Consultant for the Arizona Health Care Association, California Association of Health Facilities (CAHF) and Utah Health Care Association. Szpytek is a former deputy fire chief and fire marshal with more than 40 years of experience in life safety compliance and emergency preparedness. For more information, visit www.FLSafety.org or e-mail Szpytek at [email protected].
Steve Wilder is President and CEO of Sorensen, Wilder & Associates (SWA), a nationally recognized healthcare safety/security consulting group based in Bradley, IL. Since 2014, SWA has been the recognized leader in Active Shooter Preparedness in the Senior Care industry. A retired fire chief in the suburbs of Chicago, Wilder was the 2019 recipient of the Leadership in Emergency Preparedness for his leadership role following the murder of two residents in an Assisted Living community in Pennsylvania. For more information, visit www.swa4safety.com or contact Wilder at [email protected].
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
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