POLICY #:
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APPROVED BY: / DATE:
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POLICY
College Hospital is committed to ensuring that its workplace is safe for all of its employees and that it is free from recognized hazards including those likely to cause physical harm or death. In keeping with this commitment, and in compliance with all applicable sections of the California Health & Safety Code, along with the Cal/OSHA healthcare workplace violence prevention regulation, College Hospital has established the following Workplace Violence Prevention policy.
Definition of Workplace Violence
Workplace violence means any act of violence or threat of violence that occurs at the work site. Workplace violence includes: (1) the threat or use of physical force against an employee that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury; (2) an incident involving the threat or use of a firearm or other dangerous weapon, including the use of common objects as weapons, regardless of whether the employee sustains an injury.
College Hospital recognizes that there are four types of workplace violence:
- Type 1 violence means workplace violence committed by a person who has no legitimate business at the work site, and includes violent acts by anyone who enters the workplace with the intent to commit a crime.
- Type 2 violence means workplace violence directed at employees by customers, clients, patients, students, inmates or any others for whom an organization provides services.
- Type 3 violence means workplace violence against an employee by a present or former employee, supervisor or manager.
- Type 4 violence means workplace violence committed in the workplace by someone who does not work there, but has or is known to have had a personal relationship with an employee.
Workplace Violence Prevention Plan
College Hospital will maintain a Workplace Violence Prevention Plan (the “WPV Plan”) that is reviewed annually by the Workplace Violence Committee. Each employee will be provided with a copy of the WPV Plan at the time of hire. Additional copies of the WPV Plan will be made available to any employee at any time.
Training
At the time of hire, and at a minimum of once annually thereafter, each employee will receive training that addresses the workplace violence risks that the employee is reasonably anticipated to encounter in his/her job, the workplace violence hazards identified in the facility, and the corrective measures that have been implemented. Employees whose job duties include responding to alarms or other notifications of violent incidents will receive additional, interactive training that is specific to confronting or controlling persons exhibiting aggressive or violent behaviors.
College Hospital will provide additional training if/when new equipment or work practices are introduced, or when a new or previously unrecognized workplace violence hazard has been identified.
Documentation
Information about each incident of workplace violence will be assigned a case number and recorded in a violent incident log, which will be retained for at least five (5) years.
Investigation records for each incident of workplace violence will be created and maintained for five (5) years.
Workplace violence education and training records will be created and maintained for five (5) years.
Records of workplace violence hazard identification, evaluation and correction will be created and maintained for one (1) year.
Reporting Requirements
Telephone Reports to Cal/OSHA District Office
College Hospital will report immediatelyby telephone to the nearest Cal/OSHA District Office any serious work-connected injury, illness or death requiring inpatient hospitalization, or where an employee suffers a loss of any member of the body, or suffers any serious degree of permanent disfigurement.
Reports to Cal/OSHA via the Online Reporting Portal
College Hospital will use the Cal/OSHAonline reporting portal to report:
(1)any incident involving the use of a firearm or other dangerous weapon regardless of whether the employee sustains an injury; or
(2) the use of physical force against an employee that results in, or has a high likelihood of resulting in, injury requiring more than first aid, psychological trauma, or stress regardless of whether the employee sustains an injury.
Reports to Cal/OSHA must be made within 24 hours after the Hospital knows of the incident if the incident involves:
(1)a fatality or injury that requires inpatient hospitalization
(2)the use of a firearm or other dangerous weapon
(3)presents an urgent or emergent threat to the welfare, health or safety of hospital personnel.
All other reports to Cal/OSHA must be made within 72 hours.
Reports to Law Enforcement
Within 72 hours of an incident, College Hospital must report acts of assault or battery against on-duty hospital personnel to the local law enforcement agency if the incident results in injury or involves the use of a firearm or other dangerous weapon, even if there is no injury.
Reports to the California Department of Public Health (CDPH)
The death or significant injury of a staff member resulting from a physical assault that occurs within or on the grounds of a facility is an adverse event that must be reported to CDPH no later than five days after the adverse event has been detected. If the event is an ongoing urgent or emergent threat to the welfare, health or safety of patients, personnel or visitors, the report must be made no t later than 24 hours after the adverse event has been detected.
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