Workplace Violence

Q: How do I decrease workplace violence incidents in the hospital where I work?

A: In my experience working within a healthcare setting, the best way to decrease workplace violence incidents is to have a workplace violence plan that is specific to your facility. This document must also be re-evaluated on a regular basis and be updated accordingly.

Developing a workplace violence plan can be daunting, but it’s critical to the health and safety of your employees. The key components to include in your plan are:

  1. You should perform a risk assessment of the facility you work in. Ask yourself, “What are the significant safety hazards that exist?”
  2. Utilize data collection tools to collect specific information on each incident to determine which solutions are necessary.
  3. Consider implementing safety and/or security teams that can manage the information and report to the administration on a regular frequency (monthly).
  4. Develop a user-friendly safety reporting process that all employees are required to fill out.
  5. Implement and stick to a zero-tolerance policy that supports all employees and empowers them to press charges on any acts of violence.
  6. Provide customer service training for all employees, as well as de-escalation training for those in high-impact areas. It’s also best to consider situational awareness training for employees too.
  7. Develop a controlled access plan for your facility and minimize the number of entrances for visitors and employees. This will allow you to better control who enters and exits your facility.
  8. Provide regular, hands-on, scenario-based training for your employees to teach them how to best manage workplace violence.

If you have additional questions about how to implement a workplace violence plan, please feel free to email Carrie at

Aerosol Can Storage

Q: Our nursing home just completed a state survey and while we were not cited we were “warned” that all aerosols are to be put into fireproof cabinet. The metal cabinets and toolboxes we have them in currently are not adequate. We use metal toolboxes on housekeeping carts to store one can of each cleaning product we use. The surveyor said these would have be logged in and out daily from fireproof cabinet. Is this an actual NFPA requirement?

A: This is not a Life Safety Code requirement. I’m always suspicious when I hear a surveyor ‘warns’ a facility about an alleged issue rather than actually cite them. In this day and age of the CMS dominant mantra of “If you see it, cite it” mentally, I have to question why didn’t the surveyor actually cite it. One reason could be that it is not a violation of any code or regulation, but it is a surveyor preference. Perhaps the surveyor is using his/her authority to cajole the facility into doing something that is actually not required. Would the facility be safer if all aerosols are stored in a fire-rated cabinet? Perhaps, but if it is not a requirement then the ends have to justify the means.

You didn’t say what was in the aerosol cans; are the contents flammable? According to NFPA 30-2012 flammable liquids are permitted to be stored in their original containers up to 1-gallon in size, and you do not need special containment (i.e. fire-rated cabinet) until the aggregate total of the stored product (per smoke compartment) reaches 5 gallons. To me, aerosol cans placed on a housekeeper’s cart would not be considered in storage – they would be considered in use. However, there are other aspects to consider: Are the cans of aerosol products on the housekeeper’s cart safe from unauthorized individuals (i.e. children, dementia patients)? If not, then that may be a valid reason to place them inside a storage container.

I’m not telling you to NOT follow the surveyor’s advice, but I am saying the warning is not based on Life Safety Code or other NFPA requirements. Perhaps it is based on state or local regulations. If you haven’t already done so, ask him/her to cite the code or standard that requires the storage requirements. If there is an actual code or standard that requires it, then we learned something. But if there is not an actual code or standard that requires it, then the surveyor will back down and admit it is a recommendation or preference.

Heated Massaging Seat

Q: I work at an ICF facility. We have a person with arthritis and I was just asked if a heated pad massaging seat could be purchased for them. I know we can’t have heated blankets, personal heaters, etc. With this item having heat, I would assume it would probably not be approved either. Can I get your input??

A: There are no CMS codes or standards that would prohibit this type of device. Actually, there are no codes or standards that would prohibit electric heating blankets, but the perceived risk of danger usually disqualifies them from use.

There will be risks in using this heated, massaging seat that you need to address, such as:

  • Trip hazard with the electrical cord
  • Something heavy rolling on the electrical cord creating a pinch-point, thereby causing a short-circuit over time
  • The seat becoming too hot for the patient

If you address these risks in a risk assessment and mitigate them to the satisfaction of the surveyor, you should be fine.

Save The Date…. Another Keyes Life Safety Boot Camp!

Web 2April 3 & 4, 2017 is the date of the next Keyes Life Safety Boot Camp, to be held in Charleston, SC.

  • This two-day boot camp on the 2012 Life Safety Code is designed for healthcare organizations that want to:
  • Understand practical applications of the Life Safety Code
  • Learn from actual Life Safety surveyors on what to prepare for during surveys
  • Recognize how the new 2012 Life Safety Code will impact your organization
  • Appreciate key requirements of the 2012 Life Safety Code as they apply to health care facilities and related occupancies

Who should attend:

  • Facility managers
  • Safety officers
  • Chief operating officers
  • Accreditation coordinators
  • Architects / Engineers
  • Consultants
  • AHJs

Watch for further announcements on information to register.

This boot camp is co-presented by Brad Keyes (Keyes Life Safety Compliance, LLC) and Alise Howlett (Codenity, LLC), and is sponsored by:




Electronic Cigarettes

My good friend Tom Cuthrell, Safety Officer at CarolinaEast Health System in New Bern, NC wanted to know if Joint Commission has said anything about the use of electronic cigarettes in hospitals. As far as I can tell, Joint Commission has not addressed the issue of e-cigarettes. That means you get to decide how you want to move on this issue. But before you do, take a serious look at all sides of this subject.

Former smokers who use e-cigarettes say the devices have saved them from a lifetime of smoking-related health problems. Yet public health and tobacco control officials have been loath to embrace them. For one thing, the devices are completely unregulated by the federal government, with no industry standards for safety in manufacturing or marketing. That has prompted some states and municipalities to enact regulations on their own. Please check with your local and state authorities to determine what (if any) regulations they may have.

There is no heat or flame used in e-cigarettes, so from a fire safety point-of-view, they do not present a risk. But other issues may arise if you consider allowing them in your organization. I found some basic information on the website that address e-cigarettes:

What is an E-cigarette?

  • E-cigarettes are battery-powered devices that deliver nicotine through a flavored vapor.
  • They are made so users can feel like they are inhaling tobacco smoke, without the burning tobacco that occurs with a cigarette.

Are E-cigarettes safe?

  • We do not know if E-Cigarettes are safe. The E-cigarette is not currently approved by the FDA as a safe and effective method to help smokers quit.
  • E-cigarettes release secondhand vapor (not smoke) that can be seen and smelled. Further research is needed to determine any health related consequences.

What do we know about the E-Cigarette?

  • The amount of nicotine in an E-cigarette is unknown. Although the E-cigarette cartridges are advertised with specific amounts of nicotine, the U.S. Food and Drug Administration (FDA) testing has shown that their actual amounts can be incorrect.
  • An FDA study found that the E-cigarette products contained toxic chemicals- including the ingredient found in anti-freeze.
  • More research is needed to find out what other ingredients are in the E-cigarettes and what kind of health or other effects they have on people who use them.

What does this information mean?

  • E-cigarettes should not be used to replace smoking because there is no scientific proof that they can help smokers quit.
  • FDA approved medications such as nicotine patches, gum and lozenges are proven to help smokers quit and should be used.
  • Medications approved by the FDA in combination with individual or group counseling are shown to be the most successful ways to help smokers quit.
  • It is important to talk with a health care provider when considering alternatives.

While there are no direct regulations controlling the use (or non-use) of e-cigarettes, I would recommend that they are not allowed in the healthcare organization, for the following reasons:

  • They are not known whether or not they are safe for users or if the second-hand vapor is safe for others
  • The use of an e-cigarettes will inadvertently promote the use of real cigarettes since they look so much like an actual cigarette
  • This is not an area where you want to be a leader… Let someone else blaze the trail, and until more scientific research is accomplished, it is better to take a wait-and-see attitude

Hey Tom… say hello to all my friends there in New Bern, home of the original Pepsi Cola.

“Take the Monkey Off My Back…”

I was recently in a meeting at a regional hospital where the CEO walked in, sat down, and started to address the group. She had this stuffed monkey on her shoulder and she proceeded to explain that the organization had a breakdown in accountability in the area of the Environment of Care (that is why I was there, as a consultant).

She said she wanted someone to step up to the plate and “take the monkey off my back”; meaning people had to start becoming accountable for doing their job. Needless to say, she got everyone’s attention, and nobody said a word for not knowing exactly how she meant the comment about the monkey. I looked around and I could tell nobody was going to move a muscle and they seemed nearly paralyzed with either fear or confusion.

I don’t really think she actually wanted the stuffed monkey removed from her back, but being the typical trouble maker that I am, I stepped up and took the monkey from her and she started to laugh, which set everyone at ease. I then had to sit through the remainder of the meeting with this damn monkey staring me in the eye.

I thought that was a very good object lesson by this CEO. It not only loosened up the conversation for the meeting after everyone had a good laugh, but it also drove a point home about accountability. All too often we sit in silos, defined by either our job description of the responsibilities assigned to us. As team-mates and fellow champions of healthcare, we need to remember to step outside of our silo (or comfort zone) and be accountable and responsible for ‘doing the right thing’. That’s the problem with ‘doing the right thing’… it is not always identified in our job description.

I’m sure I’m going to have bad dreams about that monkey….


Spontaneous Combustion

OK… I am not talking about spontaneous HUMAN combustion here, just the good ol’ garden variety type. You know… wet towels and blankets starting on fire?

Don’t think it doesn’t happen. It does happen, and more often than you would think. In my hospital career, I had it happen in my hospital twice, and in both situations our staff handled it rather poorly.

The first time, there was a laundry cart (not unlike the one to the left) parked in the back service hallway near the boiler room, which had sheets and blankets which were set aside because they had rips or holes. These sheets and blankets were clean and not soiled, but found to be defective in some way and were waiting for disposition. Somehow, water got into this cart and the sheets and blankets were allowed to be wet. Since the linen was technically ‘out-of-service’ and no decision had been made as to their disposal, they were not being accounted for, and no one was watching over them.

Looking back, I believe we decided it took about three days for the spontaneous combustion to occur, and when it did the sheets and blankets started smoldering. Once the source of the smoke was determined to be int he cart, a staff member decided it would be better to push the cart out of the building instead of pulling the fire alarm and leaving the cart where it was at. After all, it was just sheets and blankets smoldering a little bit, right? Wrong decision. As they pushed the cart they realized the only path to the outside was though the Receiving dock, which had plenty of combustible boxes on the dock. They couldn’t get the cart through the man-door to the outside, so they decided to push the cart off the receiving dock and allow it to spill onto the concrete. When the sheets and blankets fell out of the cart, enough oxygen was introduced and the linen burst into flames. Portable extinguishers were not enough to extinguish the fire and someone finally pulled the fire alarm and the fire department arrived. When we told them they needed to put of some sheets and blankets which were on fire on the Receiving dock, they looked at us like we were crazy (I guess wee were). We did a de-breifing of the situation and discussed what we did wrong.

The next time spontaneous combustion occurred, it happened in a storage room on a special nursing unit. This storage room was a former patient room which was converted for storage and still had the old style tilt-open windows. The season was summer-time and someone left the windows open for ventilation, and rain got into the room an left a puddle of water on the floor. A nurse threw a clean blanket on the water puddle and promptly forgot about it. Eventually, the wet blanket got kicked up against a baseboard heater, which was actually on and providing some heat for the room (in the summer?). After a couple days, the wet blanket built up enough heat until it eventually started to smolder, and staff started complaining of a burning smell. Did they pull the fire alarm station? No, they called engineering and said they smelled something burning. A maintenance man went up to investigate and when he finally opened the door to the storage room, it was completely filled up with smoke. Finally the fire alarm was pulled and more maintenance staff came running. A couple well intended, brave souls tried to enter the room to extinguish the blanket, but the smoke drove them back. Their action allowed more smoke to escape from the storage room and infiltrate into the nursing unit. In the meantime, nursing staff decided to evacuate the unit and 17 patients had to be relocated to other smoke compartments. The fire department arrived, and they put the fire out.

Lessons were learned from both incidents, not the least of which is spontaneous combustion does happen.

The Role of the Safety Officer

I frequently get asked to comment on the role of the Safety Officer in healthcare. Who should the Safety Officer report to? What qualifications or background should the Safety Officer have? I thought I would share these thoughts with you today.

Safety is a different issue in healthcare, as compared to general industry. In the general industry, OSHA compliance is king, and takes most of the efforts of the safety professional to ensure compliance. That isn’t the situation in healthcare. While OSHA compliance is still important, it doesn’t take nearly as much of the safety professional’s efforts as Life Safety does. The main reason why is you have patients that are nonambulatory and incapable of self preservation in the hospital in the event of a fire. You also have 5 or 6 different agencies (Joint Commission, CMS, State health departments, local fire marshal, state fire marshal and insurance companies) that expect you to comply with the NFPA 101 Life Safety Code, and they will frequently inspect your facility.

The whole concept of Life Safety pertains to getting out of the building alive if it is on fire. In other words, the Life Safety Code is primarily building oriented (with some exceptions). Therefore, I have always been a believer that the role of Life Safety Compliance is a role that belongs in Facilities Management, or at least report up to the VP in charge of facilities management. This way, if the Life Safety person needs assistance in changing something in the building, he/she already has a certain built-in cooperation because the facility person is directly involved with the Life Safety person.

Some hospitals have the role of Safety Officer be a manager’s position and report directly to the Director of Facilities management, which I think is a good situation. But if the facility person is not a director, then the Safety Officer person could report to the VP in charge of facilities. I believe the role of Safety Officer should not be higher than a manager’s position, because if it was a Director (or heaven forbid, a VP) then that person would have a tendency to stay in their office. The Safety Officer needs to be a person who walks around and is visible to the rest of the staff in the hospital. It needs to be a person who is willing to “get his hands dirty” and be frequently seen on the floors. He/she needs to build a positive relationship with others who will come to see him/her as a resource.

Some hospitals have the Safety Officer report up through Risk Management, but I don’t see that. If the Safety Officer is not in the same camp as the facilities person then there is too much of a possibility of silos being built and the cooperation level between Safety and facilities diminishes. I would advise you to not make the position of Safety Officer anything less than manager. He/she needs to be at least a manager to have a certain level of authority and access to administration.

Abandoned Items

When I travel around the country and conduct building inspections at hospitals for compliance with the Life Safety Code, I seem to always find things that surprise me. Just when I think I’ve seen it all, something different and strange pops up and smacks me in the face.

Abandoned items in place are not that uncommon in hospitals. One of the most common abandoned items in place is fire or smoke dampers. Once a hospital smoke compartment becomes fully sprinklered, section permits smoke dampers to be removed from smoke compartment barriers, provided the ductwork served by the smoke damper is fully ducted (meaning there is no open return air plenum ceiling). [NOTE: This is permitted under the NFPA 101 Life Safety Code, but it is not permitted under the IBC codes and standards. For hospitals that must comply with IBC codes, this is not an option. Check with your local and state authorities before attempting the removal of a damper.]  It is quite common to disconnect the power source from the actuator of the smoke damper and secure the damper blades in the open position, and place a tag or label on the damper explaining it is disconnected and abandoned in place. Likewise, when a fire damper is no longer required in a ductwork, it too can be disconnected and abandoned in place.

However, other items that are abandoned may need a more demolition than that. Take a look at the top picture. That is a gas line that was disconnected from the main supply. The main supply was capped off, but the disconnected branch was left without a cap or a plug, and some paper towels were placed over the open end, probably to catch the few drips of cutting oil. This is a perceived safety risk, as someone may come along and hook up the other end of the abandoned pipe to a gas source, and the open end would allow gas to escape into the mechanical room. Is that a likely situation? Probably not, but hospitals are required to manage their risks, and allowing an open abandoned gas pipe to remain is a risk that needs to be address. The best mitigation for that risk is to simply remove the abandoned pipe.

The next picture shows an abandoned HVAC ductwork that was allowed to be left open for a long time until some enterprising refrigeration mechanic decided to use the register boot as an access up through the floor for his refrigeration lines. I looked at this modification and there was no fire-stopping installed to preserve the 2-hour fire rating integrity of the floor. Now, if you’re thinking there should have been a fire damper in the floor where the HVAC duct penetrated, you would be partially correct. Fire dampers in HVAC ductwork that penetrate fire rated floors were not a NFPA requirement until the late 1950’s. Facilities that were constructed prior to that did not have to retroactively go back and install fire dampers. However, if any modification of the ductwork were to occur, then it would be required to bring it up to current codes and standards. Well, running refrigeration lines through an abandoned HVAC opening in the fire rated floor is a modification, and proper fire stopping material would have to be installed.

These are examples that show that abandoned items need to be removed all the way back to the source (or equipment that they are connected to), to eliminate safety risks. It may take a little more time and resources to do this, but it prevents a serious problem from occurring in the future if they are removed.






I’m a big believer in ‘MBWA’… Management By Walking Around. I think more good can be done if the person who is in charge of Life Safety compliance walks around the hospital frequently, looking for problems, and turn them into an opportunity for improvement. Take the situation in these pictures… Somebody placed a cart or a plant in front of the fire alarm pull station, and nobody thought that it was a problem.

You really cannot blame the patient-care staff, if they haven’t been instructed not to place items in front of pull stations. What is obvious to you and me, is not so obvious to someone who takes care of patients. Have you stopped to observe how much information a new-hire nurse has to learn during orientation? The nurse gets the regular 2 or 3 days of regular orientation that all new employees receive, then they have to go through another couple of days for specialized nursing orientation.

Was there ever enough time in new employee orientation to cover all the little nuances pertaining to Life Safety? Not if your hospital was like the one I worked in. I did the Safety orientation for new employees, and I was only given 45 minutes to cover all of the basics. I seem to remember that we did not discuss the issue of obstructing pull stations, because there simply wasn’t enough time to cover all the ‘little’ Life Safety issues.

That’s why it is so important to be up on the floors, walking around, talking with as many staff as possible. I frequently introduced myself and let them know who I was so they got familiar with me and comfortable around me. That way, when there was an opportunity for improvement, then we discussed it and they were not threatened by the conversation.

How often should you make your rounds? I tried to do it once a week, and our hospital was around 450 beds. It would take me about an hour to do the entire hospital. Can you spare an hour per week? At times I had another individual do it on my behalf. These rounds are not intended to be the Hazardous Surveillance Rounds that are required twice per year in patient care areas. These are quicker rounds to do some quick observations. Its partly to let the staff know that we’ll be by every so often and it keeps the less diligent ones on their toes.

Management By Walking Around…. It’s sort of like being a politician. Get out there; see and be seen. Stop and talk with a few people. Smile. Shake hands. Let them know what you’re doing. Pretty soon they’ll be looking out for the same things you are.

You’ll find more problems like the ones in the pictures by ‘MBWA’, long before the surveyor finds them. And its the right thing to do.