30+ Years in Healthcare Risk Management President, Sorensen, Wilder and Associates Consultant to AzHCA, CAHF, UHCA, and several more Retired Fire Chief, Bradley, IL Author of monthly safety column, Long Term Living
magazine
Active Shooter Incidents…They’re Getting To Common
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2014 – 2015 FBI Figures
• 40 Incidents in 26 states• 20 in 2014• 20 in 2015
• 6 ended when armed citizens acted to end the threat
• 16 shooters committed suicide
• 14 killed by law enforcement
• 12 arrested
The prevailing attitude:“It won’t happen here.”
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Amish School ShootingNickel Mines, Pennsylvania
On October 2, 2006, Charles Robertsstormed a one-room schoolhouse inNickel Mines, Pennsylvania. He tookhostages and shot 10 Amish girls (ages6 to 13) before committing suicide.Five of the children died.
Even Hollywood is in on it…
Seminar ObjectivesUnderstand• A State of PreparednessReview• Terminology and Concepts• Case StudyLearn• The Value of Preparedness• Active Shooter Safety Action Plan• Safety Transition Adjustment Formula (STAF) ProtocolRemain• Safe and alive during an active-shooter incident
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Creating a State of Preparedness
Armed Intruder and Active Shooter in the Long Term Care Environment:Plan…Respond…and Survive the Unthinkable
Golden West Towers Senior CommunityNovember 20, 2012 • Torrance, CA
A male resident inhis 80s shot andkilled two females(a 54-year-oldfacility managerand 54-year-oldcaregiver) in thelobby beforeturning the gun onhimself.
Double Murder–Suicide:
Pablo Davis Elder Living CenterOctober 20, 2013 • Detroit, MI
A 65-year-old male residentshot and killed two femaleresidents at the center afterretrieving a rifle from hisroom. The shootingstemmed from a breakupwith his girlfriend that heblamed on the two women.
Double Murder:
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Abington ManorNovember 4, 2013 • South Abington, PA
Murder-Suicide:A 42-year-old staff nurseshot a resident to deathat a nursing home whereshe worked and thenturned the gun onherself.
Your Emergency Operations Plan
It probably addresses a lot of possibilities…
Greenbriar Nursing Care CenterMay 22, 2011 • Joplin, MO
EF-5 tornado:159 people killed,including 16 atGreenbriar
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West Fertilizer CompanyApril 17, 2013 • West, Texas
West Rest Haven Nursing Home
Reaction to Disaster or Crisis
It’s not what you think.
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Failure to Respond
• Subconscious need for normalcy• Overwhelming sense of denial• Unable to comprehend scope of event• Optimistic bias• Lack of safety culture• No planning or preparedness• Poor training• No practice or rehearsal
While an Armed Intruder or Active Shooter inYOUR facility may be
“UNTHINKABLE”It can be prepared for and mitigated!
Terminology and Concepts
Armed Intruder and Active Shooter in the Long Term Care Environment:Plan…Respond…and Survive the Unthinkable
Offender: The offender or perpetrator of anincident/event
Armed: The Offender carrying, displaying,and utilizing a weapon (primarily a firearm,but not always)
Caregiver: A healthcare worker (doctor,nurse, med tech, aide, social worker, etc.)
Clear: The methodical search of a facilityby law enforcement for additionalOffenders and threats
Crime scene: The exclusionary zone lawenforcement cordons off. Encapsulates thelocation of the crime and evidence to becollected
Domestic dispute: An emotionally chargeddispute between two or more persons engaged ina sexual, domicile, or family relationship;incident may have started off facility grounds
Evidence: Items that result from the planning,execution, and commission of a criminal act. Maybe material, electronic, statements, fluids, etc.
Facility: The structural location of employmentor physical location where an incident occurred
Terminology and Concepts
Definitions
Firearm: A gun; may be a handgun or long gun(shotgun or rifle)
Lockdown: An emergency safety procedureutilized by a facility to announce a threatwithin the facility, combined with a safetyaction plan to secure occupants until the threathas concluded
Mercy killing: A homicide committed toalleviate the suffering of the victim (usuallyfrom a medical condition)
Security: Persons tasked by the facility toensure the safety of employees, patients, andvisitors. Security may be a facility employee orcontracted staff (armed or unarmed)
SWAT: Special Weapons and Tactics. A highlytrained and equipped team of lawenforcement officers tasked to deal withhigh-risk threats
Threat: (v) Verbal, non-verbal, and otheractions expressing an intention to inflictfear, injury, or death; (n) the actual personcommitting the above
Unified Command: A shared incidentmanagement system in which two or moreofficers from different responding agenciesand functionality share managementresponsibilities from an establishedcommand post
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Terminology and Concepts
Definitions
Violent Crime: Defined by theDepartment of Justice as purse-snatching/pick-pocketing, assault(simple or aggravated), robbery,rape, and homicide
Weapon: Any item used to inflict fearin or cause injury to anotherindividual; may be defensive oroffensive (e.g., impact weapon,cutting weapon, weapon ofopportunity)
Witness: Any person having materialinformation about the planning orcommission of a crime. Statementsgathered from a witness during aninvestigation become evidence forprosecution or clearance of the crime
Characteristics of an Active Shooter
As with all aspects of human behavior, there is no 100percent “tried and true” characteristic of a shooter. Butwe still need to focus on behaviors, not profilesCommon characteristics include:
• A “brittle” personality• Feelings of persecution• Feelings of injustices• Sensitive to rejection• Self-perception (outsider)• Sees no other options
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Terminology and Concepts
Concepts
PHASE® Incident
CAVE® Incident
Rapid Response
Self Aid / Buddy Aid
PHASE® Incident
PHASE Incident
P: PersonalH: HostileA: AgendaS: SingularE: Event
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PHASE Incident
Personal: This incident is not random and occurs between knownpersons. The incident is driven by an emotional cause (passion, rage,love, revenge, etc.)
Hostile: The offender’s action toward the victim is driven by emotionand will be brutally violent
Agenda: The offender has a premeditated plan and has come to thefacility prepared to carry it out
Singular: The incident will be over once the agenda has beencompleted; not a continuous act
Continuous: The offender will continue the incident until (s)he isstopped by some outside forceActive: The offender’s agenda has no clear end point. (S)he mayhave an objective, but it is very broad and not clearly definedViolent: Because the objective is broad, the offender needs agrandiose method to carry it out (e.g., large quantities ofweapons, munitions, and possibly explosives). The method ofviolence delivery is usually well thought outEvent: The quantified incident
CAVE Incident Examples
• Mental illness• ‘Wrongful death’ (departmental-wide)• Resident mistreatment/abuse• Employee termination• Political agenda• Personal agenda
• Planned victim not there• Offender deep in building, might
shoot his way out• Murphy and his ruthless law
Rapid Response
Rapid Response
• A trained, coordinated law enforcement techniqueto respond to and mitigate the potentially highcasualty count from an active-shooter incident
• Developed after and due to the Columbine HighSchool mass shooting in 1999
• Primary objective: Enter the facility, proceed tothe sound of gunfire, stop the threat
• The initial entry team will bypass the woundedand those in need of help
• The second entry team is tasked with assistingthe wounded and directing evacuation
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Rapid Response
• Officers will be in different uniforms but will beclearly identifiable as police
• Follow law enforcement directions• Do not have any items in your hands• Keep your hands up. Try and remain calm• Do not run or make sudden movements toward
officers• Do not yell, scream, or speak with officers• Expect to be detained, searched, and questioned
Response to Law Enforcement Arrival
Self Aid / Buddy Aid (SABA)
Where will you be if it happens?
Self Aid / Buddy Aid (SABA)
A military and law enforcement technique now beingexpanded into the private sector that teaches care andtreatment basics for self survival and buddy survival. Topicsinclude:
• Controlling Bleeding• Direct Pressure or Pressure Bandage• Tourniquet Application and Use• Penetrating Chest Wound
Airway Management
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Individual SABA Trauma Kits
Case Study
Armed Intruder and Active Shooter in the Long Term Care Environment:Plan…Respond…and Survive the Unthinkable
Pinelake Health & RehabCarthage, NC
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Case Study:Pinelake Health & Rehab • Carthage, NC
• Skilled nursing, Alzheimer’s care, rehabilitation therapy,and hospice care
• 110 beds on campus• 90 resident beds• 20 special care (Alzheimer’s/dementia)
Facility Overview
Aerial View of Pinelake Health & RehabCarthage, NC
Case Study:Pinelake Health & Rehab • Carthage, NC
On Sunday, March 29, 2009, at approximately10:00 a.m., an act of violence at Pinelake Health &Rehab in Carthage, North Carolina ended several livesand wounded residents, staff, and a visitor—bothphysically and emotionally.
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Case Study:Pinelake Health & Rehab • Carthage, NC
• The gunman, Robert Stewart, arrives on location andparks in the front of the building
• Stewart fires multiple rounds into the PT Cruiser of hisestranged wife, who is an employee of the facility
• Before entering the building, Stewart shoots a visitor,Michael Cotton, in the shoulder
• Stewart enters the building to search for his estrangedwife, Wanda Stewart
• Unable to find her because she is in a locked dementiaunit, Stewart begins to shoot at residents and staff
Incident Overview
Case Study:Pinelake Health & Rehab • Carthage, NC
• Nurse Jerry Avant Jr. identifies the incident andmakes a facility-wide “lockdown” announcement
• Avant begins to move and secure residents but isshot by Stewart and later dies from the injuries
• A police officer arrives on scene and challengesStewart, who turns his gun at the officer
• The officer is shot, but returns fire, hitting andinjuring Stewart and stopping his attack
• The officer takes Stewart into custody
Incident Overview
Case Study:Pinelake Health & Rehab-Carthage, NC
Police Response: Cpl. Justin Garner
"He acted in nothing short of a heroic way today, and but for hisactions, we certainly could have had a worse tragedy," said Moore
County District Attorney Maureen Krueger. "We had an officer, a well-trained officer, who performed his job the way he was supposed to
and prevented this from getting even worse than it is now.“
www.wral.com/news/local/story/4837676/
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Case Study:Pinelake Health & Rehab • Carthage, NC
• 7 residents and 1 staff member killed• 3 injured, including the gunman• Stewart brought multiple firearms to
the facility and a bag of ammunition• 12-gauge shotgun• .22 caliber rifle• .22 Magnum semi-automatic pistol• .357 Magnum revolver
• The 12-gauge shotgun was Stewart’sprimary weapon of choice
Incident Discoveries and Aftermaths
Case Study:Pinelake Health & Rehab • Carthage, NC
LillianDunn, 89
JerryAvant Jr.,39, nurse
LouiseVocht De Kler, 98
Jessie V.Musser, 88
John W. Goldston, 78
Tessie Garner, 75
Bessie Hedrick, 78
Margaret Johnson, 89
“
”
Robert Stewart entered Pinelake thatday with a specific reason—to chasedown Wanda Stewart. He brought fourguns and a bag of ammunition with theintent of creating mass casualties.
Opening statement to jurors by Tiffany Bartholomew, Assistant DistrictAttorney for Moore County, North Carolina, at the homicide trial of RobertStewart on August 1, 2011
Motive
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“
”
Stewart doesn't recall what happened theday of the shooting and can't be held legallyresponsible for his actions. Stewartoverdosed on the sleep-aid Ambien the nightbefore the shootings and also was takingantidepressants at the time.
Attorney Jonathan Mergerian (defense attorney for Robert Stewart)
Defense Argument
Case Study:Pinelake Health & Rehab • Carthage, NC
On Saturday, September 3, 2011,Robert Stewart, 45, was foundguilty of second-degree murderfor killing eight individuals whilethe influence of antidepressantsand six (6) Ambien pills.
He was sentenced to 142 years in prison.
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Case Study:Pinelake Health & Rehab • Carthage, NC
Summary and Conclusions• A quick announcement of “Lockdown” by nurse Jerry Avant Jr. alerted
staff and residents, saving countless persons• Nurses and CNAs were able to secure and save many patients in locked
areas that were unable to be accessed by the gunman• A quick, composed response by a well-trained Carthage police officer
stopped the shooting rampage, preventing further casualties• Robert Stewart will spend the rest of his life in jail• Several families filed wrongful death civil suits against the parent company
of Pinelake Health & Rehab for lack of safety procedures and related issues
Active Shooter Safety Action Plan
Armed Intruder and Active Shooter in the Long Term Care Environment:Plan…Respond…and Survive the Unthinkable
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Active Shooter Safety Action Plan
Active Shooter Safety Action Plan
Active Shooter Safety Action Plan
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Active Shooter Safety Action Plan
• Exit the facility as quickly as possible• Leave personal belongings behind• Encourage people to go with you• Use the “bounding overwatch” technique to move
groups of people and yourself from point of cover tocover if you are not aware of the offender’s location
• Stay calm and quiet• When in a safe location, call 911• Follow police directions
Get Out
911
• Who should call 911?• Anyone and everyone!
• When should you call 911?• When it’s safe to do so!
• How should you call?• If possible, use a facility phone. This will allow the 911
operator to positively identify the address you are callingfrom without you having to give it
• If using a cell phone, the 911 operator may not be able toidentify your location unless you give them the address!
Things to remember regarding 911
911
• Facility name and location• Your name• Nature of the event• Description of the subject or shooter (if known)• Type of weapon(s)• Persons injured—number and extent
Information to give the 911 Operator
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Handgun Long gunWeapon Types
Active Shooter Safety Action Plan
Get Out: The faster and smarter youmove to “Get Out,” the lower theprobability you will be shot by thebad guy. Moving targets are hardtargets to hit.
Active Shooter Safety Action Plan
Statistically, trained and prepared lawenforcement officers involved in a gunfightonly hit 18 to 27% of targets.
The likelihood of being hit by a bullet firedby the offender during an Active ShooterEvent is low if you move quickly!
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Active Shooter Safety Action Plan
Active Shooter Safety Action Plan
• Inconspicuous place• Cover yourself• Call 911 if able and safe to do so• Be QUIET• Silence cell phones, pagers, etc.• Be still• Elevator or stairwell?• Hide in ‘plain sight’• Play dead
Hide Out
ANAWARENESS
TEST!
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Active Shooter Safety Action Plan
• Hiding in Plain Sight• The bad guy is looking for targets of
convenience and opportunity• If you can hide out of the bad guy’s Line of
Sight, chances are low (s)he will not see you• Can be utilized to hide residents• Because of the police Rapid Response, the bad
guy will be moving quickly and not take timeto search for victims
Hide Out: It’s easy to miss somethingyou’re not looking for!
Two volunteers, please!!!
Active Shooter Safety Action Plan
Hide OutHide in plain sight: deep corner
BadGuy’s
Line ofSight
Hallway
PatientRoom
1
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Active Shooter Safety Action Plan
COVER
• Hides you• STOPS Bullets
CONCEALMENT
• Hides you• DOES NOT STOP Bullets
VS.
Active Shooter Safety Action Plan
Active Shooter Safety Action Plan
• Lock/deadbolt• Big, heavy things
• Furniture (desks, bookshelves, etc.)• Medical equipment• Hospital beds
• Lots of smaller things• Body fluids: fecal matter???• Once secure, call 911
Keep Out
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Active Shooter Safety Action Plan
Active Shooter Safety Action Plan
Take Out
• The FIGHT of—and for—your LIFE• Commit to the act…• …and do not stop until the threat has ended• Misery LOVES company—strength in numbers• Weapons of opportunity in the workplace• Position of Tactical Advantage• Diversion and confusion prior to the fight• Surprise, Aggression, Speed
Active Shooter Safety Action Plan
Take Out
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Bay County School Board Meeting • Panama City, FLTuesday, December 14, 2010 (approximately 2:00 p.m.)
Weapons of Opportunity
Safety Transition Adjustment Formula ProtocolSTAF-P
Armed Intruder and Active Shooter in the Long Term Care Environment:Plan…Respond…and Survive the Unthinkable
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The Dilemma—What about my residents?!?!
Resident Safety and Personal Safety Duringa PHASE® or CAVE® Incident
• How do I protect myself?• How can I protect my residents?• When should I act?• How should I react?
Introducing the(STAF-P)
SAFETY
EMPLOYEES
STAF-P
RESIDENTS
Safety Transition Adjustment Formula Protocol (STAF-P)“...balancing the safety of residents and employees”
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JM5
Safety Transition Adjustment Formula Protocol(STAF-P)
Response
ActiveThreat
Resident Safety Personal Safety
Distant Immediate
ActiveShooter
Safety ActionPlan
Safety Transition Adjustment Formula Protocol(STAF-P)
Time of Recognition• Employee awareness and recognition of a PHASE® or CAVE®
incident needs to be immediate• Employees need to identify and announce to the facility the
Offender’s location and intention• Employees need to move residents and visiting family members to
and secure them in areas of safety per the STAF protocol• When the offender breaches your area/wing/floor, transition from
resident safety to personal safety utilizing the Active ShooterSafety Action Plan
Slide 91
JM5 11:19am Time of recognition by Nielson, 11:25am 911 call fromNielson 11:29am shooters enter the library 11:29am to 11:37amshooters in library4:30 seconds in the library….on the phone with 911 heard at aminimum 22 shots and 2 explosions There were 56 people in thelibrary: 10 deaths and 12 injuries occurred in 7 minutes.Over 10 minutes of ‘time’ between Time of Recognition and libraryexecutions…What could you do in 10 minutes to secure residentsor patients?James Minninger, 4/22/2014
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Safety Transition Adjustment Formula Protocol(STAF-P)
• You are making decisions for the residents• Are you able to lockdown the entire unit/wing/floor and barricade
it?• If not, whom do I attend to first?
• Residents who are able to act without assistance following caregiverdirective
Safety Transition Adjustment Formula Protocol(STAF-P)
Active Shooter Rule of Thumb:
In the midst of a CAVE® incident, the active shooter will belooking for targets of convenience and opportunity. The shooteris looking for mass casualties. As (s)he moves from area to areain your facility, (s)he is not likely to take time to breech a dooror do a room-by-room search looking for victims. The shooterknows (s)he must move quickly before police intervene.
Washington, DC Navy Yard Shooting Surveillance Footage (September 16, 2013)
Source: FBI
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Safety Transition Adjustment Formula Protocol(STAF-P)
• Know your facility• Are you able to lock your wing or floor and keep the
Offender from gaining access?• Can you secure residents in their rooms?• Is there a room where you can ‘stash’ numerous residents
and lock the door?• Supply/janitor’s closet• Medication room• Records room• Bathrooms
• Hide ‘in plain sight’
Protocol: Hide Out/Keep Out
Program Developmentand Staff Training
Armed Intruder and Active Shooter in the Long Term Care Environment:Plan…Respond…and Survive the Unthinkable
Program Development and Staff Training
1. Conduct Security Vulnerability Assessment2. Develop An Active Shooter Emergency Response Plan3. Develop an Active Shooter Training Program4. Train Staff on How to Respond to an Active Shooter
Event5. Plan for Recovery
Five Steps to Protect Our Stakeholders
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Even if this is a good depiction of your maintenancedirector, this does NOT represent a good site securityplan…...
Program Development and Staff Training
Answers several key questions:1. From what and from whom should the healthcare
facility be protecting itself? (What are the THREATS)2. Where are the “chinks in the armor” that could allow
the event to occur (What are the VULNERABILITIES)3. What are the likely consequences in the event the
vulnerabilities are recognized and compromised? (Whatare the RISKS)
4. What can we do to minimize the vulnerability?
Step 1: Conduct a Security Vulnerability Assessment (SVA)
Program Development and Staff Training
Make it realistic to the threat:• PHASE® Event: Shooter has a specific target• CAVE® Event: Shooter looks for high body/casualty counts;
shoots as many as possible• There will be no “Code Team” responding• Chaos will reign• It may be only you and a colleague to get through this…alive
Step 2: Develop An Active Shooter Emergency Response Plan
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Program Development and Staff Training
• Develop plan with employees and residents in mind• Active Shooter Safety Action Plan• STAF-P
• Denial has no survival value It won’t happen here…
• Develop a plan with a survival mindset• Lines of survival: exits, hiding places, barriers, weapons of opportunities
Step 2: Develop An Active Shooter Emergency Response Plan
Program Development and Staff Training
• Your training strategy:• Provide a range of options and choices for occupants to make decisions
• Survival is not a random outcome— survival is the result of trainingand preparedness!!!
• The four-step approach to training Awareness
• Preparedness• Drills and exercises
• Evaluations and improvements
Step 3: Active Shooter Training
Program Development and Staff Training
Training should be multilevel. Atnew employee orientation, all
new employees should go throughthe facility-wide program. Oncethey get to the particular unit inwhich they will be working, theyshould go through department-
specific orientation as on-the-jobtraining
Step 3: Active Shooter Training
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Program Development and Staff Training
• How do we practice and train?• Seminars• Tabletop exercises• Practical exercises
• How often do we need to practice and train?• Frequency should be clearly defined in policy• Biannual seminars/tabletop exercises• Annual practical exercises
Drills
Program Development and Staff Training
• The first response to an active event is the same for TRAINED andUNTRAINED (and UNPREPARED) people …
Step 4: Active Shooter Response
Program Development and Staff Training
Trained and Prepared:• Anxiety• Recall what they
have learned• Ready to act as they have been trained
Step 4: Active Shooter Response
Untrained and Unprepared:• Panic• Frozen with fear; disbelief and
denial• Stay frozen in shock and denial
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Program Development and Staff Training
Step 5: Post-incident Recovery
Program Development and Staff Training
Step 5: Post-incident Recovery
Recovery• Initiate the facility Crisis Management Plan• Takes place after the event is over• Return to normal or safer state of affairs as
quickly as possible• May take days, months, or years• Key is evaluation of event and a recovery plan
in place BEFORE the event occurs
Review
• PHASE® Incident/CAVE® Incident• Decision making/Stress Control• Active Shooter Safety Action Plan
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