PATIENT VIOLEN NCE RISK ASSESSME A ENT ADDRESSOGRA APH PA ART A: Obs served Behaviours (Sc core 1 for eac ch of the obs served behav viour catego ories below). SCOR RE HIS STORY OF VIO OLENCE - Sco ore 1 for past occurrence off any of the fo ollowing: E Exercising phys sical force, in an ny setting, towarrds any person including i a care egiver that caussed or could havve caused injuryy A Attempting to ex xercise physical force, in any se etting, towards any person incl uding a caregivver that could ca ause injury S Statement or be ehaviours that could c reasonably y be interpreted d as threatening to exercise phyysical force, in a any setting, against a any person inclu uding a caregive er that could cause injury OB BSERVED BEH HAVIOURS - Score S 1 for eac ch of the obse erved behavio our categories s below: C Confused (Diso oriented - e.g., unaware u of time e, place, person) IIrritable (Easily y annoyed or angered; Unable to t tolerate the presence of othe ers; Unwilling to o follow instructio ons) B Boisterous (Ov vertly loud or no oisy - e.g., slamm ming doors, sho outing, etc.) V Verbal Threats s (Raises voice in i an intimidatin ng or threatening g way; Shouts a angrily, insulting g others or swea aring; M Makes aggressiive sounds) P Physical Threa ats (Raises arms/legs in an agg gressive or agita ated way; Make es a fist; Takes a an aggressive sstance; Moves/lu unges fforcefully toward d others) A Attacking Obje ects (Throws ob bjects; Bangs orr breaks window ws; Kicks object;; Smashes furniiture) A Agitate/Impulsive (Unable to remain r compose ed; Quick to ove erreact to real a and imagined dissappointments; Troubled, nervvous, rrestless or upse et; Spontaneous s, hasty, or emotional) P Paranoid/Susp picious (Unreas sonably or obses ssively anxious; Overly suspici ous or mistrustfful - e.g., belief of being spied o on or cconspiring to hu urt them) S Substance Into oxication/Withd drawal (Intoxica ated or in withdrrawal from alcoh hol or drugs) S Socially Inapprropriate/Disrup ptive Behaviour (Makes disrup ptive noises; Sccreams; Engage es in self-abusivve acts, sexual b behaviour or ina appropriate behaviour - e.g., ho oarding, smearin ng feces, food, e etc.) B Body Languag ge (Torso shield - arms/objects acting as a barrrier; Puffed up cchest - territoria l dominance; Deep b breathing/pantin ng; Arm domina ance - arms sprread behind hea ad, on hips; Eye es - pupil dilation n/constriction, ra apid blinking; L Lips - compress sion, sneering, blushing/blanch b ing) To otal Score Pa atient’s Risk Rating: R Co ompleted By: Lo ow (0) Moderate (1-3 3) High h (4-5) Very High (6+ +) __ __________________ __________________ __________________ ____________________________________ _ NAM ME/DESIGNATION Date/Tim me: _________________________________ YYYY/MM M/DD HH:MM PA ART B: VIO OLENT PATIIENT IDENT TIFICATION PROCESS ACTIONS T TO BE COM MPLETED B BY RHP OVERALL SC CORE Low w Sccore of 0 Mo oderate to Very y High Sccore of ≥ 1 ACT TIONS TO TAK KE Continue to monittor and remain alert for any p potential increasse in risk. Com mmunicate anyy changes in beh haviours that may m put others at risk to Leade er/After-hours Coordinator (A AHC) and during transfer of acc countability. En nsure commun nication devicess are in place ((e.g. panic alarrms). Required Action ns:  Apply Be ehaviour Safety Alert (BSA) tto the patient’s electronic chart  Apply vissual alerts:  Discuss ide entification of riisk with patientt/family when ssafe to do so  Appropriate e armband app plied when safe e to do so  Signage ovver bed and on door to patient room  Label on sp pine of patient cchart  Add violentt patient attribu ute in Capacity Management  Kardex sticcker      NS6 6393 (Rev. 2018/01/23 3) Side 1 Notify Le eader/AHC if needed Scan en nvironment for potential p risks a and remove if p possible Use effe ective therapeu utic communica ation Ensure communication c n devices are in n place according to unit protocol (e.g. panicc alarms) Communicate any changes in behaviiours, that mayy put others at risk to Leader/A AHC See Over → Patient Name/PIN: LHSC Patient Violence Risk Assessment Continued _____________________________________________________________ PART B: VIOLENT PATIENT IDENTIFICATION PROCESS ACTIONS TO BE COMPLETED BY RHP continued  Alert Security and request assistance as needed Additional actions  Inform security of contributing factors and de-escalation techniques to be taken for  Initiate applicable referrals (e.g., Social Work, Spiritual Care) High to Very High Score of > 4      If a violent episode occurs Ensure personal safety and the safety of others Call 55555 and initiate Code White, as indicated Notify Leader/AHC of all violent episodes Notify MRP Complete AEMS report Completed By: ________________________________________________________________________________________ Date/Time: NAME/DESIGNATION ________________________________ YYYY/MM/DD HH:MM PART C: CONTRIBUTING FACTORS Physical, psychological, environmental, and activity triggers can lead to or escalate violent, aggressive, or responsive behaviours. Documenting known triggers and behaviours and asking your patient or substitute decision maker (SDM) to help identify them can help you manage the patient more effectively and safely. Use the information collected and intervention resources on this document to develop an individualized patient plan of care and a staff safety plan to protect workers at risk. Question for Patient/ Substitute Decision Maker (SDM): CONSIDERATIONS (select any that apply) To help us provide the best care possible, please describe if there is anything during your stay that could cause you to become agitated, upset, or angry. e.g., I am agitated when … Physical Psychological           What works to prevent or reduce the behavior(s)? e.g., When I am agitated, it helps if I …       hunger pain infection new medication other ________________ ____________________________ ____________________________ ____________________________   fear uncertainty feeling neglected loss of control being told to calm down being lectured other ________________ ____________________________ ___________________________ ____________________________ ___________________________  go for a walk listen to music watch TV draw read have space and alone time talk 1:1 with _______________________  participate in  activities consult a family member or friend Environmental  noise  lighting  temperature  scents  privacy  time of day  days of the week  visitors  small spaces/ overcrowding  other ________________ Activity        bathing medication past experiences toileting changes in routine resistance to case other _________________ ____________________________ ____________________________ ____________________________ Potential De-Escalation Techniques Identify potential de-escalation strategies using above information actively listen such as: respect personal space offer choices use humour give eye contact 2 staff members present during patient interactions __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Completed By: ________________________________________________________________________________________ NAME/DESIGNATION Date/Time: _______________________________ YYYY/MM/DD HH:MM GUIDELINES FOR USE The purpose of this form is to identify the risk of violent or threatening behaviour and initiate appropriate safety actions. USE OF PATIENT VIOLENCE RISK ASSESSMENT: To be completed on admission for all patients over 10 years of age, and with any changes. CHART HIERARCHY: This document should be placed at the front of the patient chart. INITIATION OF THE ASSESSMENT: Whenever possible, it is recommended that two Regulated Health Professional (RHP) or one RHP and Security complete the assessment. COMPLETING THE ASSESSMENT: The RHP completes Part A on admission and calculates a Risk Score for the patient. If all questions in Part A are answered with NO, the assessor signs the form and no further action is required at that time. For scores of 1 or more, sections B and C must be completed and signed accordingly. NS6393 (Rev. 2018/01/23) Side 2