Could your aides be at risk for violence?

Safe working conditions can help you retain staff

No matter how superior your home health aides are, nothing will ruin an employer-employee relationship quicker than a patient or family caregivers who are prone to violence. As director of a hospital-affiliated home health agency, your staff looks to you for protection. Are you prepared to help?

Judy Jacobs, RN, MA, president of Professional Healthcare Systems in Troy, MI, tells the story of a home health aide who had recently become engaged. When the aide arrived at her patient’s house, she slipped off her engagement ring and placed it in the pocket of her jacket — a commonplace action in what seemed an ordinary day. But here the story takes a tragic turn.

During the time she was in the home, a relative of the patient came in and tried to steal the ring, says Jacobs. Unfortunately for the aide, she caught the would-be thief red-handed, and says Jacobs, "The thief beat her so badly that she has been in a vegetative state for years."

A frightening story for anyone, especially home health aides whose jobs require them to enter other people’s homes alone. What went wrong? And perhaps just as importantly, what can home health agencies do to prevent tragedies like this from ever happening again?

Take a good look around

Jacobs, who with her partner Wayne D. Porter, MS, a special agent and criminal investigative analyst with the Florida Department of Law Enforcement in Tampa and co-author of the book Workplace Violence in Healthcare Toolkit, says there are quite a few things that agencies should be doing but all too often aren’t. Porter also is a senior vice president with Professional Healthcare Systems consultants in Troy, MI.

First, an agency "needs to teach its employees to recognize and assess the patient and the environment for potential signs of violence. This needs to be done on the initial visit," she says, "and at every subsequent trip to the home."

Much of the initial assessment and information gathering (such as whether the patient has a criminal record or a history of past abuse) should be done by the nurse during the initial patient assessment visit, before an agency has even agreed to take on a patient. Also, check to see if there have been sudden and multiple changes in caregivers, recommends Jacobs. "If a caregiver says he or she is afraid of a patient, you know you have a problem."

Assessing for violence can get complicated

Trying to evaluate an individual’s potential for violence can get a little complicated, Jacobs admits. Just about anyone would agree that a patient who is pacing the room, fists clenched and face flushed, as he swears loudly is angry. However, the signs aren’t always so easy to read, "because it’s not always something as overt as someone screaming," says Jacobs. Still, there are some significant clues to be had if only the aide knows where to look.

Among the more obvious are "weapons in the caregiving area and any drug paraphernalia that might be out," says Jacobs. Should either of those items be found — at any stage in the case — the agency should require the patient to sign a contract agreeing to remove the items from the home and lock them up elsewhere while the aide is there. Oftentimes, the items in question don’t belong to the patient but to a family member. That, says Jacobs, poses just as much of a threat to the aide as if they were the patient’s personal property.

Some less apparent threats to an aide’s safety are blocked egresses, she says. "Any time that ways out of the home are blocked, the agency can ask to have them cleared. If the patient refuses, the agency has the right to determine the place as unsafe and not admit the patient," Jacobs explains.

Just because a patient has been accepted into an agency’s home care program is no reason to relax, warns Jacobs. Aides should continue to monitor the situation and patient environment on a visit-by-visit basis.

For example, "When you’re changing the sheets look under the mattress. Check to see if there is alcohol beneath the bed," she advises, pointing out some of the other hiding spots for weapons. Granted, Jacobs says, if you find a 9 mm Glock under the pillow, it’s a pretty good chance that you may be in danger, but the problem arises even when the threat isn’t right under your nose, she adds.

Physical, psychological, and psychosocial factors can all point to a potential for harm, says Jacobs. Aides should pay attention to whether prescriptions are getting filled, and if not, why. Has the patient’s power or water been cut off? "Sometimes, the patient doesn’t have the money to pay bills or refill prescriptions perhaps because he lost his job," she says.

Nor is a lack of money always the issue. Sometimes a patient’s deteriorating mental health can also be the source, especially patients in the latter stages of AIDS and Alzheimer’s. Added together, those factors can combine with deadly force, she explains.

At any time, if an aide determines the threat of violence exists, says Jacobs, reporting it is critical. Tragically, all too seldom do aides follow through.

The refrain that Jacobs hears the most is "Aides aren’t reporting incidents of violent behavior; therefore, no one knows what’s going on." The reasons behind this are numerous, she says, but cites self-blame on the part of the aide as one of the leading factors.

Encourage aides to report incidents

"In nursing, you’re taught that if you can’t deal with someone, then you’re not good. I think the aides put the blame on themselves," she says. "Added to that is the possibility that they have reported an incident before and were rebuffed or even written up by the management. Sometimes the administration takes it very lightly when someone comes back and says there’s something wrong."

The last reason, and one of the easiest to remedy, is that few agencies have a reporting process in place.

Once managers have been educated on how to be aware of and handle reports of violence, the agency needs to set up very specific procedures for handling threats and workplace violence, she says. To do so, staff from all levels of the agency need to be involved — anyone who may come into contact with the patient in question.

"The legal department or lawyer needs to be involved, and the entire agency team, not just nurses and aides but occupational therapists and social workers, need to know what the plan is," she says.

All agencies should have incident reports on hand that allow space for the aide to "write down verbatim what was said, what happened, and who was there. You need to put it in quotes and include the report in the patient’s chart because if the agency is ever sued and an attorney shows up, an agency can say, Hey, this is what we did. We provided reasonable accommodation, but they were noncompliant and posed a threat,’" Jacobs explains.

Formal policies are required

Once documented, the agency needs to decide how to continue. "You may decide you have to send an armed escort with the health care workers," she says. "You need to put the patient and family on notice and put in the patient’s bill of rights that there must be a safe work environment for the aide, and if it doesn’t happen, that the family will be notified and the place deemed unsafe. Spell out exactly what the consequences will be."

Medicare-certified agencies are required by the Americans with Disabilities Act and civil rights laws to provide care to patients without discrimination as long as the patient provides no significant risk to the third party," explains Jacobs.

"That third party is the home health aide. The agency has to provide reasonable accommodation for the patient’s treatment and care, but the patients have the responsibility to comply and cooperate. If they don’t, the agency can discharge the patient."

Document everything

Without documentation, an agency might have a hard time proving it had discharged a patient over a legitimate concern. Still, says Jacobs, agencies often don’t want to report incidents of threats or violence because they don’t want to open themselves up to investigation by the regulatory agencies.

What those agencies don’t understand, she adds, is that by failing to do so they are hurting only themselves, and maybe their employees, she explains.

"Agencies need to understand that without these formal policies they haven’t created a safe harbor for themselves and they can be sued by their employees," she says.

"One incident of workplace violence can put an agency out of business. A critical incident could cost as much as $250,000 in legal fees alone. If it’s homicide, double it, and if it goes to trial, then triple that figure.

"You just can’t afford to have something happen at your agency. What’s more, could you really live with yourself if something did?" Jacobs asks.


Judy Jacobs, RN, MA, President, Professional Healthcare Systems, 3911 Rochester Road, Troy, MI 48083. Telephone: (248) 740-7888.

Wayne D. Porter, MS, Senior Vice President, Professional Healthcare Systems, 3911 Rochester Road, Troy, MI 48083. Telephone: (248) 740-7888.