accountability

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

Posted on May 30, 2018 10:50 pm by Caroline Ramsey-Hamilton Comment

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..

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©For more information and a free subscription: write to: caroline@riskandsecurityllc.com

We provide the best Active Shooter Training, Workplace Violence Assessments, and & CMS Facility All-
Hazards Risk Assessments, Drills & Training Programs.

www.riskandsecurityllc.com and www.caroline-hamilton.com

62-Year Old Bumblebee Tuna Worker Killed in Oven with Six Tons of Canned Tuna

Posted on May 28, 2015 9:19 am by Caroline Ramsey-Hamilton Comment

RISK Alert Report #710 – May 27, 2015

The Los Angeles District Attorney announced felony charges Monday against
Bumblebee Tuna’s San Diego Plant, alleging that a worker, Jose Melena,
entered a thirty-five foot cylindrical oven that sterilizes cans of tuna. Melena’s
co-workers closed the door and started the oven. The oven temperature rose to
270 degrees in the next two hours, and when the doors were opened, they found
the severely burned remains of Jose Melena.

According to District Attorney Jackie Lacey, “We take worker safety very seriously”,
according to a published statement. “Our goal is to enhance the criminal of workplace
safety violations. Although the Bumble Bee investigation began in 2012, this case
represents our commitment to protecting workers from illegal – and, potentially,
deadly – on-the-job practices.”

Two plant employees, former Safety Manager Saul Florez, 42, of Whittier,
California, and the current Director of Plant Operations Angel Rodriguez, 63, of
Riverside, California, with three felony counts each of an Cal-OSHA (State of
California ) violation causing death.

Both men face arraignment on May 27 at the Foltz Criminal Justice Center in
downtown Los Angeles. If convicted, the individuals could serve three years in
state prison and a fine of up to $250,000. Bumble Bee faces a maximum fine
of $1.5 million.

Lessons Learned:

1. Strong safety controls should be put in place to protect workers in High Risk
Occupations.

2. Employees should make sure that all employees are aware of the
company’s safety and security rules to prevent incidents like this.

RISKAlert® is a publication of Risk & Security LLC

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Tags:
man dies in tuna oven
workplace safety

DOD moves military bases to a higher alert status

Posted on May 8, 2015 6:37 pm by Caroline Ramsey-Hamilton Comment

In an unusual move today, the U.S. Department of Defense (DOD) raised the security level at
U.S. military bases because of the increasing concerns about possible attacks by ISIS (ISIL).

While the DOD cited no specific threat, they did refer to the recent attack in Garland, Texas,
(last Tuesday), after ISIS claimed responsibility for the Prophet Mohammed cartoon contest
featuring cartoons about “the Prophet”.

The threat level was raised to ‘Bravo’ level, and it’s worth noting that it’s the first time the
threat level has been that high since the anniversary of the 911 attacks on September 11,
2011, which was the 10th anniversary of the 2001 attacks.

A higher threat level could mean 100% ID checks at the entrance to all military bases, including
air force bases, army bases, navy and marine bases. It also puts base military police on alert
to be highly situationally aware, including investigating anything they see that might be
terms “suspicious”. The FBI will also increase surveillance of suspected pro-ISIS individuals.

Persistent stories have been focusing on the Texas border, which may be harboring an
ISIS camp, and the right wing media has reported that an ISIS camp may be sending their
soldiers into the US on specific missions. Although this has been widely discredited by
officials, some circles are reporting a link to the Army’s Operation Jade Helm, a massive
military drill across nine states, which is slated for July 15th, to September 15th, 2015.

We encourage individuals to be situationally alert AT ALL TIMES, and a increase
in military alert levels would certainly be something to note.

How to Build a New, Risk-Based Police Model that Really Works

Posted on December 5, 2014 11:19 am by Caroline Ramsey-Hamilton Comment

Law Enforcement Can Transform Itself by Turning to a Risk-Based Policing Model

Watching the protests across the country over the last few months, the two groups, the Citizens and the Police, as polarized as the US Congress, I think, we can do BETTER than this. We can make police officers RISK OFFICERS for their communities.

The current stereotypes of police with military-style weapons and protective gear, is counterproductive, just like the stereotype of poor, uneducated, violent, drug-using citizens is also counterproductive to progress.

Most departments are still working with the historical model of law enforcement that is still followed religiously around the country, even though it is over 100 years old. This model is totally ” Enforcement ” oriented. Something bad happens, police go find the perpetrator and arrest them.

At the same time, cities and counties are having a hard time enlisting new officers, in fact, in Police Chief Magazine in the December 2014 issue, they point out that 80% of departments are having major recruitment problems. Young men don’t want to become ‘traditional’ police officers. The role needs to change.

The model of law enforcement is at a point when it needs to change, and to evolve into a risk-based, crime-preventive model, instead of a total arrest and subdue model.

The benefit would be a different kind of police force, one that is more educated, more tech-savvy, and problem solving, and focused heavy on prevention.

Instead of educating police officers on some goofy model of how to talk to people, they need to get educated on threat-risk techniques. They need to be able to go to a neighborhood, pro-actively and come up with a risk assessment for that neighborhood, followed by a plan to improve the lives of the people who live
there. Just like we use interviews and surveys for our high-tech risk assessments, these officers could do the same thing.

Police officers today perform only a narrow range of activities. This great group of ethical professional officers COULD DO SO MUCH MORE.

In the next article, we’ll include suggestions on how to make the change.

Tags:
#Ferguson
#Garner
#HandsUp
#RiskBased
Erik Garner Choked
Law Enforcement
Police

White House Security Breach -WHO DIDN’T LET THE DOGS OUT!]

Posted on September 22, 2014 1:18 pm by Caroline Ramsey-Hamilton Comment

**RISK Alert Alert #590 – White House Security BREACHED**

UPDATED Dateline: Sept 23, 2014

White House Attacker had been ARRESTED TWICE BEFORE, INCLUDING ON
AT THE WHITE HOUSE, CARRYING A MACHETE!

In Federal court, prosecutors said the Gonzalez car contained 500 rounds of ammo,
guns, assault rifles, a hatchet and a machete!

AND HE HAD BEEN ARRESTED TWICE BEFORE, including in August 2014, carrying a
hatchet on the White House Lawn. And on July 19, after being spotted driving recklessly
in a gray Ford Bronco, Gonzalez was charged in Wythe County, Virginia, with evading arrest
and possession of a weapon after he was found in possession of 11 weapons, including a
sawed-off shotgun, assault rifles and knives, and map — with the White House circled!

The Nation Was Shocked on Sept. 19 when an intruder not only jumped the fence,
but was ABLE TO ENTER THE FRONT DOOR of the White House. Controls that should
have been in place were apparently not ready for an actual security incident.

When even elementary schools have access control and card key systems, it is really hard
to believe that there is NO CARD KEY SYSTEM for the White House.

SECURITY IS A PROCESS, and that’s why Security Plan, Security Policies, and Security

Procedures are in place for every U.S. Federal Building. Obviously, at the White House, the
process is broken, or agents are willfully ignoring the security controls which should be in place
100% of the time. Every government building should have strong access control systems in place.

The intruder, Omar Gonzalez did the unthinkable, according to the
Washington Post. They reported that the 42-year-old ex-veteran from
Texas climbed over the north fence line along Pennsylvania Avenue,
toward the eastern side of the house’s circular driveway. His breach
set off the standard security alarm across the compound. Officers
rushed to the North Lawn but were unable to reach him on foot as
he ran, arms pumping, threading the needle between the fountain
and a security guard booth and ignoring their commands that he stop.
Gonzalez actually entered the White House because the door was UNLOCKED!

What We Learned:

Security Procedures and Policies MUST BE FOLLOWED 100% of the Time
for Security to be Effective. In this incident, the major problems included:

Front Doors MUST BE LOCKED to keep intruders out.
Canine that was on the job should have been released.
Active Monitoring of cameras was not effective. Was the intruder missed?
The perimeter fence is obviously not up to the job. In fact, a 2^nd jumper
breached the fence again on the same day,RISKAlertis a publication of Risk & Security LLC

RISKAlertis a publication of Risk & Security LLC

Inmate Patient Takes Sheriff’s Deputy’s Gun, Shoots Deputy and Kills Himself

Posted on August 25, 2014 10:23 am by Caroline Ramsey-Hamilton Comment

Prisoner Grabs Deputy’s Gun at a West Union, Iowa Hospital, Shoots Deputy & Turns Firearm on Himself.

At Palmer Lutheran Health Center, a full service hospital in West Union, Iowa, an inmate who was brought from Fayette County Jail on Saturday morning, August 23, at 8:30 am, grabbed the County Sheriff Deputy’s gun and demanded he be released, the deputy used a non-lethal device on the inmate, who then shot the deputy at close range. The inmate then killed himself with the handgun.

The deputy, who was wearing a bulletproof vest, was shot in the stomach, but was treated and released at the site of the incident. The inmate, still unidentified, grabbed the gun when one of his hands was released for his medical treatment.

LESSONS LEARNED:

1. Forensic patients (prisoners) know it’s easier to escape
from the hospital room, or hospital bed, than it is to
escape from the County Jail! Security should be
present to support law enforcement. One deputy is
a minimum. Deputy with security officer present is
better.

2. Wearing a bulletproof vest saved the deputy’s life during the incident. Security officers should
consider having bulletproof vests available when dealing with this type of patient.

According to research in the Journal of Injury Prevention, “Shootings in U.S. Hospitals 2000 – 2011,
in 23% of shootings within hospital emergency departments, the weapon was a security officer’s gun taken by the perpetrator. https://www.llis.dhs.gov/sites/default/files/FA-gdkelen.pdf

IAHSS (International Association of Hospital Safety and Security), has policy guidelines for security departments that deal with forensic (inmate) patients. IAHSS members can access the Healthcare Security: Basic Industry Guidelines at www.iahss.org.

Security managers and hospital management need to make sure that All Hospital Staff including Clinical Staff
Are Warned to Use Extreme Caution When Working with or Near Forensic Patients!

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

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Psychiatrist Shoots Mental Patient who Killed His Caseworker at Mercy Fitzgerald Hospital

Posted on July 25, 2014 7:07 pm by Caroline Ramsey-Hamilton Comment

Psychiatrist Draws Gun in Mercy Fitzgerald Hospital and Shoots the Mental Health Patient who Killed his Caseworker by Shooting Her in the Face. Witnesses near the scene reported hearing screaming and gunfire, as suspect and mental health patient Richard Plotts confronted his caseworker, Theresa Hunt, and then drew his gun, and killed her. Another bullet grazed a doctor, adjacent to the scene, but the doctor had a gun of his own, and he shot Plotts 3 times in the torso.

The doctor, identified as Lee Silverman, was treated was treated for a head wound and released after being taken to the Hospital of the University of Pennsylvania. The shooter, Richard Plotts, of Upper Darby, Pennsylvania, who had a long criminal record, was undergoing surgery Thursday night at the Hospital of the University of Pennsylvania. If he survives, he will be charged Friday with murder, said Delaware County District Attorney Jack Whelan.

There is a Lesson Here — KEEP POTENTIAL SHOOTERS WITH WEAPONS OUT OF HOSPITALS.

A is for Access Control! Once a potential shooter brings a weapon into a hospital, everything is much more difficult to control. Keep them out.

Weapons should be checked at the hospital entry points and no-weapons signage should clearly indicate that weapons are not allowed, and that should be followed up with either stand-alone, or wand metal detectors which give staff members a initial level of protection.

usa-shooting-pennsylvania

Bernice Ho, a spokeswoman for Mercy Fitzgerald Hospital, said Thursday it was against hospital policy for anyone other than security guards to carry weapons, so there are questions about why this doctor disregarded the policy, although Donald Molineux, chief of the Yeadon Police Department, said “If Silverman returned fire and wounded Plotts, he without a doubt saved lives.”

District Attorney Whelan described how the meeting among Plotts, Silverman, and Hunt abruptly took a violent turn. Plotts and Hunt went to Silverman’s third-floor office shortly before 2:30 p.m., Whelan said. Plotts was apparently armed, and people near the room soon heard shouting.

Concerned, a hospital employee “actually opened the door, saw him pointing a gun at the doctor,” Whelan said. The worker shut the door quietly and immediately called 911. Plotts then opened fire. According to Whelan, he shot Hunt two times in the face. The psychiatrist then ducked under his desk, retrieved his gun, and came up shooting, striking Plotts three times.

Keep Weapons Out of the Hospital to Dramatically Reduce Violent Incidents!

RISKAlert – May 2014 Shooting at VA Medical Center, Dayton, Ohio

Posted on May 15, 2014 11:01 am by Caroline Ramsey-Hamilton Comment

RiskAlert INCIDENT REPORT 552 – HOSPITAL SHOOTER

Terminated Employee Shoots Staff Member during Card Game
at Veterans Affairs Medical Center in Dayton, Ohio

Allowing terminated employees to have access to a hospital or facility where they
worked before is a questionable decision, because not only anger at the organization,
but also anger at individuals and former co-workers may turn into an incident as this report
explains.

In early May, a terminated housekeeper at the Veterans Affairs Medical Center in Dayton, Ohio came back to the hospital to play cards in a hospital break room with a group of current VA staff. The perpetrator, Neil Moore, had also brought a handgun to the hospital. Neil was upset because he thought another VA staff member was having a relationship with his wife, so he pulled out the gun, and as a result, one person was shot in the ankle.

It was not a typical active shooter scenario, but it does point out
the access control problem in hospitals, and also questions the
ability for anyone to walk into a hospital with a loaded gun.

LESSONS LEARNED:

1. Access to former employees should be prohibited or at
least limited on a case by case basis.

2. Visitors should not be allowed to bring guns into a hospital.
Metal detectors should be used to screen for weapons.

Moore, a former employee at the Veterans Affairs hospital, told police that he was going to a regular card game with
his former co-workers. He said he went to the hospital Monday intending to brandish the handgun to intimidate two former co-workers he believed were involved in relationships with his wife and daughter, both of whom reportedly work at the hospital. Moore planned to “hold the ex-co-workers at gunpoint while he punched them with his right hand,” according to court documents.

The hospital complex has beds for about 450 people and provides veterans with medical, mental health and nursing home care. It doesn’t have metal detectors at its entrances, but it does have its own security force.

VA spokesman Ted Froats said the force conducts active shooter training four times a year and showed outstanding response Monday. He said in a statement Tuesday that the hospital will consider additional steps to ensure safety, while making sure that any new measures won’t impede the hospital from providing care to veterans as quickly as possible.

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

Two Nurses Stabbed on Easter Sunday in Different SoCal Hospitals

Posted on April 21, 2014 7:17 pm by Caroline Ramsey-Hamilton Comment

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

Why We Need to Switch to a Risk-Based Security Model – School Stabbing at Franklin Regional, Active Shooter Incidents at Fort Hood (twice), LAX, and The Washington Navy Yard.

Posted on April 15, 2014 8:42 pm by Caroline Ramsey-Hamilton Comment

When I turned on the news today, I was in the middle of writing an article on the 2^nd Shooting
at Ft. Hood from last week, and then saw that there had been a violent knife attack at a
Pennsylvania high school, with 20 casualties and at least eight injured critically, the next day,
there was a hate crime shooting at the Jewish community center in Overland Park, Kansas.

Once again, we see violence on a mass scale, the FBI has been brought in, and next will come
information on the victims. With two major events, in two weeks, what can we deduce about the
security in place at both Franklin Regional High School, Pennsylvania, and Fort Hood, Texas.

NEWS FLASH: THE CURRENT SECURITY MODEL IS NOT WORKING!

CURRENT SECURITY MODELS

Disaster preparedness is improving, Emergency Management is working, but security is
still not where it needs to be. It is a systemic problem based on the fact that security around
the U.S. is still locked in a REACTIVE mode, not a PROACTIVE mode.

The main reason for this reactive mode in security organizations, is because most security
officers come from a law enforcement background, with a model which is based on crimes
and arrests, and it is totally REACTIVE. A crime happens and police officers go into action
and arrest the perpetrator(s).

CRIME HAPPENS = PERP IS IDENTIFIED = PERP IS ARRESTED

Unfortunately, this reactive model does not work for preventing security incidents and mass violence
because it is INCIDENT DRIVEN, not Risk-Driven. It focuses on individuals, not on a more holistic,
generalized view of Threats, and it totally leaves Solutions (Controls) out of the equation.

After studying pages of after action reviews, post-incident analyses and media sources, the one
recommendation that makes sense is that organizations need to switch to a RISK-BASED,
PROACTIVE mode for security to work.

This was highlighted in a remark made by a Pentagon official, commenting on the 2^ndFort Hood
Shooting on April 2, and the fact that new DOD recommendations for security, had just been released.

“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 that the new
recommendations had not yet been put into effect at Fort Hood. At Fort Hood, very little had
changed from 2009 regarding security procedures for soldiers at the entrance gates.”

The question for the Department of Defense is “how could this happen again at the same military
base? I took extra time to study the 89-page document called An Independent Review “Protecting
the Force”, one of 3 reports created after the initial Fort Hood Shooting, whene 13 were killed, and
43 injured.

If you look at the recommendations, they are very bureaucratic and procedural. They could have
been written by an efficiency expert, not by anyone with a background in security, and covered things
like policy changes, and having screening for clergy and psychologists, and improved mental health
programs. These are all important, but they do not provide a secure environment.

The LAX after action analysis’ Number One recommendation was to change
the security focus to a Risk-Based approach.

RISK-BASED SECURITY

The problem with a reactive approach is that you can’t screen and lock down everyone. At Fort
Hood, for example, there are 80,000 individuals living on the base, and probably hundreds of
visitors who go in and out every day. It’s impossible to assess the mental health, and the
‘intentions’ of all of them.

That’s why a Risk-Based Approach works – because it focuses on the potential threats and then evaluates the existing controls to see whether they offer the required amount of protection based on the likelihood of the threat occurring.

You stop violent events by controlling access and by controlling weapons. No matter how unpopular they are, you use metal detectors at certain points, you use security officers at key entrances, you control entrances and exits.

Once the event starts, you can improve security by having faster notification (panic alarms), ability
to block, or disable weapons and attackers, adequate transport, better emergency response, but to
avoid the violence, you need to have strong access control.

The Risk-Based approach makes use of annual risk assessments that are holistic in nature. They
are not done in stovepipes, they include the entire organizations, they include input from staff
members, visitors, students, vendors, soldiers, patients on how they see security from their point
of view, which is always dramatically different from management or administration.

A risk-based approach requires an organization to:

Define potential security risks.
Develop standardized risk assessment processes, for gathering and
analyzing information, and use of analytical technology
Risk-Based Security focuses on PREVENTION OF NEW INCIDENTS
whether they are active shooter, general violence, etc.
Enhances security’s ability to rapidly respond to changes in the threat environment.

MORE BANG FOR THE BUCK

According the LAX (LAWA) after action report, “Simply adding more security does not
necessarily provide better security. Determining priorities and where to achieve great
value for the dollars invested requires regular, systematic assessment of the likelihood
and consequences (risks) associated with a range of threat scenarios that morph and
change more quickly now than ever before.

Collaborative engagement in a security risk assessment process across the community builds
the buy-in needed to develop and sustain a holistic security program over time. Leaders must
be open to challenging established practices and demonstrate a willingness to change direction”.

Making the switch to a Risk-Based security program is the best recommendation for those who
want to protect their staff, students, patients, vendors, clients, soldiers, and visitors from a mass
casualty event, or for all the organizations who don’t want to have a terrible incident happen in
the first place!

Caroline Ramsey-Hamilton

President, Risk and Security LLC

Caroline@riskandsecurityllc.com

www.securityinfowatch.com/blogs

www.riskandsecurityllc.com