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October 2020: Claims & Risk Reduction Newsletter

Prevention or Payout: Injuries in Behavioral Health Units

Alan Daigrepont, CWCP, CMSP

Sr. Claims Consultant

Employee injuries incurred while working in Behavioral Health Units are a growing concern in our industry. LHA Trust Funds has seen a significant increase in the number of claims involving employees, from CNAs and nurses to cleaning staff, who have sustained injuries from the actions of a behavioral health patient.

Consider these claims:

Claim #1

A 61-year-old Mental Health Technician was followed by a patient into the laundry area and attacked. She sustained injuries to the head, right wrist and right arm along with cervical complaints. Due to the violent nature of the incident, the employee has obtained counsel to pursue benefits although it is doubtful that any claim can be pursued against the patient due to their mental health status.

Treatment for the employee’s injuries may include physical therapy, epidural injections, medical branch blocks and radiofrequency ablations. If these treatments do not offer relief, surgery may be required. The likelihood of a return to gainful employment is minimal in this case.


Claim #2

A nurse Assessment Coordinator was attacked, grabbed by the throat and thrown against the wall by a patient who had been restrained. For reasons unknown, the employee removed the restraints before she was assaulted. She suffered injuries to the neck and lower back. The employee also claimed Post Traumatic Stress Disorder as a result of the incident.

This employee also obtained counsel to represent her. While her physician indicated that the physical complaints of the neck and lower back did not require surgery, she vigorously pursued the PTSD claim. The treating psychologist initially concluded that the employee’s PTSD was due to the incident. However, our resulting investigation found that she had a history of psychiatric treatment stemming back to her childhood that was not divulged on the post-hire medical questionnaire. A second medical opinion (SMO) indicated that the employee could return to gainful employment with the restriction of choosing an alternate career away from the mental health arena.

Unfortunately, this employee returned to work with a different employer in the capacity of a Mental Health Technician. While the claim was suspended at this point, the claimant suffered another incident while working for the new employer. Her attorney then attempted to incorporate the new complaints into the existing claim. The added claim of the employee’s worsening PTSD as a result of this second incident has complicated the resolution to the case.


As these two claims demonstrate, treating behavioral health patients is not without risk. When incidents happen, they can have a long-lasting impact on both employee and employer. We recommend implementing best practices to help minimize altercations between patients and staff to reduce this type of claim.

Glenn Eiserloh, CHSP

Sr. Risk Consultant

The statistics related to workplace violence in healthcare are sobering. OSHA reports that healthcare workers in the United States suffered 15,000 to 20,000 serious workplace violence-related injuries from 2011 to 2013. According to the Bureau of Labor Statistics, healthcare workers suffer four times the worker assault rate as compared to private industry. This is 16.2 per 10,000 worker assault rate in healthcare as compared to private industry’s 4.2 per 10,000.

Behavioral health disorders alter the way individuals act, think and react to situations. Many patients are not aggressive at all, some may have the potential to become aggressive and others act out without any prior indication. It is imperative that leadership develop processes in the following three areas to ensure the safety and security of patients, staff and others in behavioral health organizations:

  • Foster strong communication skills among staff with the patients.
  • Facilitate staff ability to identify and manage escalating aggressive behaviors competently.
  • Implement preventive measures that may help reduce patient aggression.

Behavioral health organizations should invest in training that will allow staff to identify and manage aggressive patient behavior. The training’s goal is to identify and de-escalate these behaviors so the situation does not turn into a physical altercation between staff member and patient. A good program will address both verbal and non-verbal communication, addressing characteristics and interventions to manage each stage of aggression. While dealing with any aggressive patient can be challenging, applying proactive techniques can significantly reduce exposure to an attack like those described above. Several training courses are available. Management of Aggressive Behavior (MOAB) is an example of such a course.

Educating staff in dealing with this unique population is also key. A comprehensive orientation program should be developed that supports staff with continued training to improve their skills over time. Communication and interaction with patients is a critical area to focus on. Depending on the job position of the staff member, they may have minimal to no prior experience in interacting with behavioral health patients along with minimal to no prior knowledge of therapeutic communication skills. Some ideas for incorporating communication training into orientation include educational communication videos, in-service training using scenarios and discussion, and role-playing between educator and staff members to practice skills.

These additional tips can also help employees maintain their safety while caring for patients. Facilities should consider adding or reinforcing these concepts during employee training.

  • Maintain personal space distance from patients.
  • Do not allow patients to walk behind you. Do not turn your back to patients.
  • Maintain situational awareness of your surroundings.
  • Speak to patients in a kind, respectful manner.
  • Be aware of your non-verbal communication as well as that of the patient.
  • Pay attention to the signs of agitation and potentially escalating behavior. (Wringing of hands, rocking, aggressive language, pacing, etc.)
  • Call for help if patient behavior escalates.
  • Conduct post-incident debriefings for educational purposes.

While it is unknown why the patient in the second claims scenario was released from restraint, there must have been a good reason for the patient to have been restrained in the first place. A decision to discontinue restraint should only be made after the patient’s behavior has been determined to no longer represent a threat to self, staff or others. Staff must document their assessment of the patient’s readiness for a trial release. CMS interpretive guidelines specify that staff should be trained and demonstrate competency in their ability to identify patient behavioral changes that may indicate that restraint is no longer necessary and can be safely discontinued. Organizations should have very specific policies to address restraint in response to behavior that coincide with CMS regulations that apply to the facility. If the patient was in restraint for reasons related to behavior, caution must be taken when doing any type of release.

Following violent events such as those presented above, leadership should conduct a thorough investigation utilizing a Root Cause Analysis (RCA) process to review the events that lead to the restraint episode all the way through when the event occurred. This is a quality improvement tool that helps organizations identify opportunities for improvement in policies, procedures and education to reduce the risk of recurrence.

Attacks by aggressive patients are not uncommon in behavioral health facilities and sometimes cause extensive bodily harm to staff members and patients. By taking a proactive approach, both behavioral health organizations and their employees can help minimize the risks of incidents taking place.

For more resources to help prevent incidents between staff and behavioral health patients, view the LHA Trust Funds Behavioral Health toolkit.

If you have any questions related to this newsletter, please contact:

Jesse P. Eusay, MBA
Vice President, Claims
225.368.3840
jesseeusay@hsli.com
Alan Daigrepont, CWCP, CMSP
Senior Risk Consultant
Steve Johnson, COSS, CHSP, COEE
Senior Risk Consultant
Glenn Eiserloh, CHSP
Senior Risk Consultant