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NORTHERN COCHISE COMMUNITY HOSPITAL
PERSON OUT-OF-CONTROL POLICY


DEPARTMENT: Safety
SUBJECT: Person Out-Of-Control/Staff Needs Assistance

Reviewed By:
Review Date:
Committee
07/20/17
Med Staff
08/28/17
Governing Board
09/26/17

REFERENCES:

SCOPE: All NCCH Staff.

POLICY: Person Out-Of-Control/Staff Needs Assistance

PROCEDURE:
    Person Out-Of-Control/Staff Assistance Needed - will be defined as needing assistance with an agitated, threateningor an unreasonable person or hostage situation.  In the event of a Staff Needs Assistance incident the following procedures shall be followed:

    Involved staff shall obtain assistance when unable to diffuse the situation by making an overhead page of "Staff Needs Assistance", and location (X)", three (3) times.

    Procedure:
      1. Available members of management (response team) shall respond to the zone and area of the code.  (Zones and areas are identified on hospital map.)
      2. The response team shall determine the severity of the situation and take appropriate action.
      3. The response team shall notify Administration at this time if applicable.
      4. If the response team determines the severity to be low, they may enter the area to relieve staff/personnel, attempt to calm the situation, and/or move to a more appropriate place (i.e.: outside, or in an area away from other customers and patients.)
      5. If there is an opportunity to evacuate customers, patients, and staff, this shall be done by the response team or designated staff.
      6. If the response team determines the severity to be high or out-of-control, (INVOLVING BUT NOT LIMITED TO HOSTAGES OR WEAPONS), the team designee shall dial 911 and ask for assistance from the proper authorities.  At this time all information shall be given to the authorities (description of person, situation facts, etc.)
      7. Upon arrival of the authorities, all hospital personnel shall abort the situation and let authorities take control.

    The Response Team will be as follows:
    • Available managers (normal working days)
    • Charge Nurse and available managers (evenings and weekends)

    Always remember:
      1. Patients must never be abused (physically or verbally), threatened, or mistreated.  They are considered not responsible for their behavior.
      2. If the agitated person has a weapon, nursing personnel are NOT to approach him/her.  If he/she threatens others and states that he/she wants to leave, encourage him/her to do so.  Staff is NOT to attempt to confiscate a weapon.  Any staff member who is able should call 911.
      3. In the event that life/limb of patient/visitor/staff are in danger, call 911 for emergency.

    Evaluation:
      Following each activation of any Code Green Plan an evaluation may be conducted.  The evaluation may be facilitated by NCCH Administration, or DNO or designee, and would normally include staff directly involved with the Code Green.  Such evaluations would be conducted at the discretion of NCCH.

      In such evaluations, all information provided is considered confidential and for the purposes of quality assurance review activities.  A healthcare entity or employee that provides information, takes action, or makes a decision or recommendation in the course of a quality assurance process will not be subject to liability for civil damages or any legal action in consequence of such action (ARS 36-2402).

    SAFE-PLAN-005-1