GENERAL INFORMATION AND DESIRED OUTCOME:

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1 PURPOSE: UNM Hospitals is committed to maintaining a safe and secure environment. UNM Hospitals strives to eliminate the occurrence of all workplace violence incidents. To coordinate a proper response that would minimize the risk and number of casualties in the event of a person using or brandishing a weapon on the University Hospitals premises and to assist law enforcement in locating and disarming the suspect. In the event of an individual on or in UNM Hospitals Clinic or facilities is using or displaying a weapon, UNM Hospital will institute procedures to minimize the risk to our patients, staff, faculty, researchers, students, visitors, and volunteers by evacuation, facility lock down and/or shelter in place procedures and by containing the incident as much as possible. To provide security and other personnel the procedure & guidelines to ensure the safety of patients, staff, faculty, researchers, students, visitors, and volunteers in the response and deployment, and handling of a person using or brandishing a weapon. SCOPE: This plan applies to all Off-Site Clinics UPC, CPC, ASAP, Out Patient Surgical & Imaging Services (OSIS), CTH Outpatient Center, and all Outpatient Clinics including Behavioral Health Clinics REFERENCES Emergency Management Plan for UNM Applies To: UNM Off-Site Clinics Including HOPE and Behavioral Health Responsible Department: Security Revised: 2/2016 Revised: -Emergency Plan Policy Patient Age Group: ( ) N/A (x) All Ages ( ) Newborns ( ) Pediatric ( ) Adult GENERAL INFORMATION AND DESIRED OUTCOME: To provide an organized response for off-site locations affected by a person using or brandishing a weapon. This emergency plan is designed for an immediate action response by UNM Hospitals personnel. This Emergency Plan will be distributed to key personnel who must familiarize themselves with the contents and inform others under their supervision. Advance familiarization with basic principles is necessary, as no time will be available to look up such a procedure in the event of a person using or brandishing a weapon. All Management Staff should be aware of the UNM Emergency Management Plan and procedures outlined within the plan The CEO, UNM Hospitals/Associate Vice President for Clinical Operations or his representative will monitor all publicity. It is the policy of the Health Sciences Center that the appropriate law enforcement agency will handle all matters related to a person using or brandishing a weapon. Page 1 of 5

2 The UNMH Security Department will provide assistance. In order to keep personnel, visitors and patients as safe as possible, all departments will cooperate with Police and the Security Department by following the procedures below. Maintaining the ability to address patient s medical needs will be a high priority for the police and security personnel. Exception or deviation to policy may be made in the best interest of Health Sciences Center/Clinical Operations, and their patient, provided the intent of this policy is observed. IMPLEMENTATION PROCEDURES 1. Initial Incident Declaration: Notification of a person using or brandishing a weapon: 1.1. Any individual, when it becomes known that any person is using or brandishing a weapon will immediately ensure you are in a safe location and notify: Police Department by dialing University Hospital Security by dialing Give the following information: Location of suspect (inside or outside) Number of Suspects Physical description of Suspect (include clothing description) Direction of travel Type of weapon displayed or using, i.e., gun, knife etc Number of people involved any casualties 2. Authority: 2.1. The UNM Hospitals Security Department has the responsibility for this Plan The University of New Mexico Police Department has Law Enforcement Jurisdiction. 3. Immediate Response Actions: 3.1. Hospital Employees: Upon receiving notification of a Code Silver, employees shall attempt to evacuate the building Quickly determine the most reasonable way to protect life Evacuate the building; ensure the escape path is accessible and safe ensure you are out of the armed persons view Evacuate regardless of whether others agree to follow Leave belongings behind Help others escape if possible Prevent individuals from entering an area where the armed person may be Once out of the building keep going, don t stop. Seek shelter or hide If evacuation is not possible, find a place where the armed person is less likely to find you Lock and or blockade the door with heavy furniture Page 2 of 5

3 If confronted by law enforcement stay calm, show your hands. Do not make any sudden movements. Calmly listen for instructions. Provide law enforcement with information available At no time will an employee offer information to the news media. All queries will be referred to the Public Affairs Office or to the Administrator on Call In-Patient Units If the incident occurs in a location where there are in-patients. The unit staff will immediately and simultaneously take action to ensure safety by: Ensure doors to the unit are closed and locked. Security will lock doors via access system if applicable Check the status of all patients and ensure that all patients are accounted for Instruct and insist that all patients and visitors remain in their room. Keep patients away from windows. Assign nursing personnel to enforce this order. Patients (and personnel) can make excellent targets for snipers Initiate unit emergency plans when instructed Be alert to the presence of unauthorized people or loiterers in your area. Contact Security if you observe anyone. NOTE: Visiting Regulations: If notified no inpatient visitors will be permitted, unless the condition of the patient necessitates a visit by family, the nursing staff will contact the Control Center and the Security Office for instructions if necessary. Pediatrics may allow parents to stay. 4. Security Personnel: 4.1. Security Charge Officer will take charge of the situation until relieved by the Security Director or his/her designee The security officer(s) assigned to the security monitoring room will shelter in Place. The security officer(s) assigned to the monitoring room will immediately and simultaneously notify UNM Police by dialing 911 and attempt to locate and track the suspect via UNM Hospitals Security Closed Circuit Television System and provide continuous information to 911 and Security Officers on duty 4.3. If the event occurs near UNMH Main Hospitals the security charge officer will immediately notify PBX Operator to overhead page Code Silver three times and provide the general location of the incident Security will immediately lock down all Access Controlled exterior & interior doors to the facility. Page 3 of 5

4 4.5. Security Officers will respond to the general vicinity at a safe distance (Security Officers Discretion) to observe and report suspect information to security dispatch/monitoring room Security Officers will communicate with as many people possible to alert them of the potential danger and instruct them to take Shelter in Place A security officer should be immediately assigned to meet arriving police personnel. Security Officers should provide direction to police to the incident. Security Director or his/her designee will prepare to provide law enforcement with hospital floor plans from the security office or designated staging area Administrative Supervisor: 5.1.Will notify the Administrator on Call 5.2.Will maintain close liaison with the Director of Security or his designee. 5.3.Will quietly, and confidentially, alert all head nurses/charge nurses inhouse by telephone if it becomes necessary to evacuate patients. 5.4.Make all possible preparation, short of actual evacuation. 5.5.Remain in contact with head nurses/charge nurses and evacuate ONLY when orders to do so are received from Hospital Administration. 5.6.Make every effort not to alarm patients and visitors. 5.7.Nursing personnel on duty will ensure that, in the event of an evacuation from one area or the entire hospital, no patient will be left unattended in an evacuated area Staff Administrator, Public Relations, and Risk Management: 6.1.Will direct the release of information to the news media. 6.2.Risk Management will handle all legal issues related to Health Sciences Center and patient confidentiality. 6.3.Reporters arriving on the scene will be directed to a pressroom Notifications: 7.1.The Individual Facility Emergency Call Tree shall be activated. 8.0.Reentry and Recovery: 8.1.Reentry is only to be executed by emergency responders under the authorization of the Incident Commander. 8.2.The Incident Commander has sole authority to disengage the participating units/services or to notify participants that the emergency mode no longer exists and the recovery phase has been implemented. 8.3.When the Incident Commander or the Director of Security gives the "all clear", the PBX Operator will notify radio personnel Review procedure and update plans as necessary. Additional recommendations from APD may be beneficial at this time. 8.4.After statements, reports, etc. are completed, all key personnel who were involved will meet the Associate Vice President for HSC Clinical Operations or his/her designee to review and critique the operation. Page 4 of 5

5 8.5.Arrange to reassure all patients, employees, and anxious visitors that there is no longer any danger. 8.6.Determine public information release, if any. 8.7.At the termination of the incident a debriefing session with all participants will be held to critique the management of the incident. DEFINITIONS Armed Person using or brandishing a weapon is defined as "... an armed person who has used deadly physical force on other persons and continues to do so while having unrestricted access to additional victims and is a criminal offense. In the event that hospital personnel are involved in a situation or believe that there is a person brandishing a weapon and potential for violence to erupt, notification to law enforcement shall be made immediately. Brandishing a weapon is defined as to point, shake, and or wave a weapon in a menacing manner. Shelter in Place is defined as a process for taking immediate shelter in a location readily accessible to the affected individual by sealing an area that can be secured from outside the location affected. The law enforcement agency will take charge of the investigation and resolution of the situation. SUMMARY OF CHANGES Reviews/Revisions created 2/2016 Format change RESOURCES/TRAINING Resource/Dept. UNMH Security Department Contact Information FFunes@salud.unm.edu and RTalley@salud.unm.edu DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Manager, UNMH Security or Biosecurity, UNM/HSC Select Agent Program Official Approver Administrator, Human Resources Y Official Signature Date: 1/21/2011 Effective Date 2/2016 Origination Date 5/2010 Issue Date Clinical Operations Policy Coordinator 2/2016 ATTACHMENTS None Page 5 of 5