Evaluation of Resident 

Aggression Toward 

Staff in a Center for 

the Developmentally 

Disabled – Michigan

Christine West, RN, MSN/MPH

Ellen Galloway, MA

Health Hazard Evaluation Report

HETA 2008-0046-3123

March 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific 

facility evaluated and may not be universally applicable. Any recommendations made are not to be 

considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE 

reports are available at http://www.cdc.gov/niosh/hhe/
The employer shall post a copy of this report 

for a period of 30 calendar days at or near 

the workplace(s) of affected employees. The 

employer shall take steps to insure that the 

posted determinations are not altered, defaced, 

or covered by other material during such 

period. [37 FR 23640, November 7, 1972, as 

amended at 45 FR 2653, January 14, 1980].
Health Hazard Evaluation Report 2008-0046-3123 Page i

Report Abbreviations.......................................................................ii

Highlights of the NIOSH Health Hazard Evaluation............ iii

Summary .............................................................................v

Introduction..........................................................................1

Assessment.........................................................................2

Results.................................................................................3

Discussion ...........................................................................8

Conclusions.......................................................................12

Recommendations.............................................................12

References ........................................................................15

Contents

A Acknowledgments and Availability of Report.....................19 cknowledgments
Page ii Health Hazard Evaluation Report 2008-0046-3123

BLS Bureau of Labor Statistics

HHE Health hazard evaluation

ICF/MR Intermediate Care Facility for the Mentally Retarded

IPP Individual Program Plan

NAICS North American Industry Classification System

NIOSH National Institute for Occupational Safety and Health

OSHA Occupational Safety and Health Administration

PPD Personal protective device

Abbreviations
Health Hazard Evaluation Report 2008-0046-3123 Page iii

What NIOSH Did

● We toured the center on July 8–9, 2008, and observed work 

areas. We talked with direct care staff about their health, 

their jobs, and resident aggression.

● We calculated injury rates based on Occupational Safety and 

Health Administration Logs for 2004–2008. These rates were 

then compared with national rates.

● We reviewed the Michigan Interpretive Guidelines for 

Intermediate Care Facilities for Persons with Mental 

Retardation. We also looked at the center’s plan for 

controlling exposures to bloodborne pathogens.

What NIOSH Found

● Center staff were at risk of injury from assault by residents. 

● Many staff thought that management lacked concern about 

their safety.

● Staff reported that most injuries occurred while physically 

restraining residents.

● The injury and illness incidence rate associated with assault 

was higher than national rates for healthcare and social 

assistance centers.

● The facility lacked policies and procedures to support a safe 

and nonviolent workplace.

● The plan for controlling exposures to bloodborne pathogens 

did not take into account the risk of infectious diseases 

associated with assaults by residents.

What Managers Can Do

● Form a safety committee that will develop a safety program to 

address safety issues at the facility. The program should also 

create a safety climate that is responsive to resident and staff 

needs.

● Create a human rights committee to address issues of 

resident aggression. This is required by the Michigan 

Interpretive Guidelines for Intermediate Care Facilities for 

Persons with Mental Retardation.

● Hire additional staff to provide a higher staff-to-resident ratio 

to help prevent incidents of aggression.

● Teach staff how to deal with resident aggression effectively.

The National Institute for 

Occupational Safety and 

Health (NIOSH) received 

a request for a health 

hazard evaluation from 

the management of an 

intermediate care facility 

for the mentally retarded 

(ICF/MR) in Michigan. 

The request was made 

because staff were being 

injured in assaults by 

residents. This center 

has closed since our 

evaluation.

Highlights of the

NIOSH Health

Hazard Evaluation
Page iv Health Hazard Evaluation Report 2008-0046-3123

Highlights of the

NIOSH Health

Hazard Evalution

(continued)

What Employees Can Do

● Wear clothing such as jeans and long sleeves to help protect 

from bites and other injuries.

● Remove objects in the environment that could be used as 

weapons.

● Report all injuries to a supervisor and seek care from a 

healthcare provider.

● Talk about aggression during program planning meetings for 

residents.

● Become active in safety and human rights committees.

● Take part in training on how to deal with resident aggression 

and strategies for self-care.
Health Hazard Evaluation Report 2008-0046-3123 Page v

In November 2007, NIOSH received an HHE request from 

management of an ICF/MR, a center for the developmentally 

disabled, in Michigan. The request was submitted because of a high 

number of injuries among staff from resident aggression.

On July 8–9, 2008, we visited the center, where we held an 

opening conference and met with management. We also held 

employee interviews, reviewed records and procedures, and toured 

each of the buildings at the center.

Residents’ apartments appeared crowded with furniture. In some 

instances, residents would not be in clear sight of the staff when 

few staff were working. Staff reported that the personal alarms 

for alerting coworkers to respond to an incident site did not 

work in all locations. We observed no other alarm systems or 

communication devices on site.

We interviewed 24 direct care workers and nursing staff who 

reported being injured by a resident, and most reported being 

injured while physically restraining patients. These employees 

reported that an inadequate number of staff responded to events. 

They also reported that managers lacked concern about their safety 

and that they did not feel managers would heed their suggestions 

about how to handle resident aggression. In addition, they 

reported that they were not fully included in the residents’ IPP 

process. Half of the staff expressed a need for more comprehensive 

training on handling resident aggression.

The number of injuries and illnesses reported on the OSHA Form 

300 Log of Work-Related Injuries and Illnesses increased from 

2004 to 2006. Nonfatal injury and illness incidence rates were 

approximately three times higher than national rates in nursing 

and residential care facilities in 2004 and 2005. Most injuries were 

from assault, and the number of assault injuries increased over 

time. The incidence rates of assaults were higher than national 

rates for the nursing and social assistance sector from 2004 to 

2008, with the highest rate occurring in 2006. The most common 

injuries related to resident assaults were strains/sprains, bruises, 

and bites. Of the workers’ compensation claims, 13 (of 35) were 

filed by staff who assisted in physically restraining aggressive 

residents.

The facility provided no written policies or procedures on 

workplace violence. Managers reported that during new employee 

Direct care and nursing 

staff at this ICF/MR 

were at risk of injury 

from assault by 

residents. Although the 

center is now closed, 

we recommend that 

management at similar 

facilities develop a 

workplace violence 

program that has full 

participation of employees 

and managers and is 

evaluated periodically.

Summary
Page vi Health Hazard Evaluation Report 2008-0046-3123

Summary (continued) orientation and annually thereafter, direct care staff completed 

crisis intervention training, which focuses on handling agitated 

behaviors and applying physical restraint. Our review of the ICF/

MR regulations showed that in several instances, the center did not 

follow the regulations on staffing ratios, convening a human rights 

committee, proper use of medication to manage resident behavior, 

and staff training. The plan for controlling exposure to bloodborne 

pathogens did not take into account the risk of infectious diseases 

from resident assaults.

Although the center has closed since our evaluation, we feel that 

the results of this evaluation may benefit any ICF/MR or other 

similar facility. We encourage such facilities to develop a safety 

and health program that includes management and employee 

participation, hazard identification, safety and health training, 

and hazard prevention, control, and reporting. Employers should 

evaluate this program periodically. Our recommendations are 

based on the general violence-prevention strategies outlined in the 

document OSHA Guidelines for Preventing Workplace Violence 

for Health Care & Social Service Workers [OSHA 2004].

Keywords: NAICS 622210 (Psychiatric and Substance Abuse 

Hospitals), ICF/MR, workplace violence, injury
Health Hazard Evaluation Report 2008-0046-3123 Page 1

Introduction

On November 27, 2007, NIOSH received an HHE request 

from the management of a Michigan ICF/MR, a center for the 

developmentally disabled. NIOSH was asked to identify risk factors 

for resident aggressive and violent behavior toward direct care staff 

and to provide recommendations to decrease assaults. We visited 

the center on July 8–9, 2008, and met with managers, employees, 

and representatives from two unions; toured the facility; and 

interviewed staff.

Background 

The center was a Michigan-operated ICF/MR for persons with 

developmental disabilities and/or mental illness. After the 

evaluation, we were notified that the facility was closing and all 

residents were being transferred to family members’ homes, group 

homes, or other facilities. The center’s residents lived in a series of 

buildings split into four sex-segregated apartments. The apartments 

contained common areas for residents to eat, watch television, 

play games, and engage in other activities. Residents gathered for 

activities or participated in treatment in the common areas and 

in other buildings at the center. One building housed people with 

mental and physical disabilities who required extensive care and 

assistance with all activities of daily living. Many used wheelchairs 

and had substantial functional limitations. Two buildings housed 

able-bodied individuals with mental retardation and/or mental 

illness. A fourth building housed people who had been admitted to 

the center from the court system because they had pled not guilty 

by reason of insanity to a crime. These last three buildings included 

residents with mild mental retardation and/or mental illness who 

were able-bodied and moved freely around their apartments and 

the center’s grounds. Admission to the center was considered only 

when no local resources or less restrictive residential options were 

available. Some residents were placed at the center because of their 

aggressive behavior.

At the time of our evaluation, the center employed 251 resident 

care aides and nursing, medical, and therapy staff; and 158 

administrative, housekeeping, and maintenance staff. The largest 

groups of employees at the center were resident care aides, licensed 

practical nurses, and registered nurses. The U.S. Department of 

Labor defines direct care workers as nursing aides, orderlies, and 

attendants in any setting (institutional or residential). Similarly, 

in this evaluation, we refer to resident care aides as direct care 
Page 2 Health Hazard Evaluation Report 2008-0046-3123

Introduction 

(continued)

Assessment

workers. Because of the nature of their work, nurses and direct care 

workers had the most contact with residents; they provided for the 

residents’ physical, medical, and habilitation needs as specified in 

their IPPs. Nurses and direct care employees worked one of three 

8-hour shifts to provide 24-hour staffing of the center. Overtime 

was needed to cover understaffed shifts. Those who wished to 

volunteer for overtime used a sign-up sheet in the break room, but 

supervisors assigned mandatory overtime to staff for uncovered 

shifts. Typically, staff worked one 8-hour overtime shift per week.

We visited the center July 8–9, 2008. We toured the buildings; 

observed the settings and staff interactions with residents in 

buildings 405, 608, 609, and 610; and interviewed nurses and 

direct care workers. Before our visit, we obtained copies of the 

OSHA Form 300 Log of Work-Related Injuries and Illnesses from 

the period 2004–2008 and a list of employees who received assaultrelated workers’ compensation during the period of June 2006 to 

May 2008.

Health Interviews 

From a staffing list of direct care workers, licensed practical nurses, 

and registered nurses from all three shifts, we serially selected 

employees for interviews. In addition, employees who were 

interested in an interview were invited to participate. We collected 

the following information: name, age, job duration, usual shift, 

medical history, extent of overtime, injuries from resident assault, 

circumstances that led to acts of aggression and possible injury, 

management perceptions of resident aggression, existing policies, 

and training programs designed to reduce resident aggression.

OSHA Logs and Workers’ Compensation 

Claims 

From the OSHA Log data, we calculated nonfatal injury and illness 

incidence rates and compared them with national incidence rates 

for nursing and residential care facilities for 2004–2008 (NAICS 

code: 623000). On the basis of incident reports, management 

identified injuries on the OSHA Logs that were caused by assault. 

We also calculated the incidence rate of injuries due to assault and 

compared these to rates for the healthcare and social assistance 

sector for 2004–2008 (NAICS code: 62). National assault 
Health Hazard Evaluation Report 2008-0046-3123 Page 3

Assessment (continued) incidence rates were not available for nursing and residential 

care facilities. For these calculations and comparisons, we used a 

formula available on the BLS website, at http://data.bls.gov/IIRC/

calculate.do. Incidence rates represent the number of injuries 

and/or illnesses per 100 full-time workers and were calculated as 

follows:

N/EH × 200,000

where 

N = number of injuries and illnesses/injuries due to 

assault,

EH = total number of hours worked by all center employees 

during the calendar year, and 

200,000 = base for 100 full-time-equivalent workers 

(working 40 hours per week, 50 weeks per year).

Policy and Training Document Review 

We reviewed the Michigan Interpretive Guidelines for 

Intermediate Care Facilities for Persons with Mental Retardation 

and the center’s control plan for bloodborne pathogen exposure. 

We also reviewed employee training requirements for intervening 

in and managing inappropriate resident behavior.

Observations 

In buildings 405, 609, and 610, male and female residents lived 

in separate apartments with communal bedrooms, living room, 

kitchen, and small activity room. Residents engaged in scheduled 

activities in nonresidential building 608, which had a large 

common area. The apartments were adequately lit and contained 

few loose objects that could be used as weapons. We observed 

no sharp objects or items that contained glass other than a few 

wall clocks. The apartments contained plastic or heavy wooden 

furniture, and some rooms appeared crowded. We observed several 

rooms and hallways where residents would not be in clear sight 

of the staff when few staff were working. Staff carried a PPD, a 

personal alarm that if activated would signal other staff to respond 

to that location during an incident. Staff reported that the PPDs 

did not work in all locations inside and outside the buildings and 

that, at times, not enough people responded to the incident for 

assistance. We observed no other alarm system or communication 

devices on site.

Results
Page 4 Health Hazard Evaluation Report 2008-0046-3123

Results (continued) Staff Interviews 

We interviewed 20 direct care workers, two licensed practical 

nurses, one registered nurse, and one direct care supervisor. Table 

1 summarizes the demographics and responses of the interviewees.

All staff members interviewed reported that they had been injured 

by residents and that work-related injuries from resident aggression 

had been increasing; 20 (83%) reported being injured while 

engaged in physical restraint of a resident. Half reported needing to 

see a healthcare provider for their injuries, and slightly fewer than 

half requested time off work for their injuries. Several staff showed 

us lacerations and bruises from resident aggression. When asked to 

identify factors that contributed to injury from patient aggression, 

10 staff (42%) said that the number of staff responding to an 

incident was typically insufficient, and 20 staff (83%) reported 

that managers lacked concern about their safety and would not 

consider their suggestions about how to handle resident aggression. 

Of the staff interviewed, 13 (54%) reported that they were not fully 

included in the residents’ IPP process, including providing input 

to the medical provider about behavior that might warrant changes 

in the residents’ medication. They reported that medication 

reductions seemed to result in resident aggression. Half of the staff 

expressed a need for more comprehensive training on handling 

resident aggression.
Health Hazard Evaluation Report 2008-0046-3123 Page 5

Results (continued)

OSHA Logs and Workers’ Compensation 

Claims 

Table 2 presents the number of injuries and illnesses recorded in 

the OSHA Log and compares incidence rates of nonfatal injuries 

and illnesses at the center with national incidence rates for nursing 

and residential care facilities from 2004 to 2008. OSHA Log data 

were available for the first 6 months of 2008. The number of 

injuries and illnesses increased from 2004 to 2007. Incidence rates 

for injuries and illnesses increased from 2004 to 2006, with a slight 

decrease in 2007. Nonfatal injury and illness incidence rates were 

approximately three times higher than national rates in nursing 

and residential care facilities in 2004 and 2005. In 2006 and 2007, 

rates at the center were approximately four to five times higher 

than national rates.

Table 1. Demographics and responses of the center’s direct care staff who were interviewed (N = 24)

Characteristic Variable No. %

Sex Women 19 79

Job title Resident Care Aide 21 88

Licensed Practical Nurse 2 8

Registered Nurse 1 4

Work shift Morning 11 46

Afternoon 10 42

Midnight 3 13

Work duration < 5 years 5 21

5–10 years 13 54

>10 years 6 25

Overtime Yes 20 83

Mandatory 12 50

Voluntary 8 33

No 4 17

Injured in assault by resident Yes 24 100

Consulted healthcare provider 12 50

 Time off work 11 46

No 0 0

Injured during physical restraint of resident Yes 20 83

Inadequate staff responding to 

incident

10 42

Lack of concern about staff 

safety

20 83

Lack of input into resident IPP 13 54

Inadequate training on handling 

resident aggression

12 50
Page 6 Health Hazard Evaluation Report 2008-0046-3123

Results (continued)

Table 3 presents the number of injuries due to assault, assault 

incidence rates at the center, and national incidence rates in the 

healthcare and social assistance sector. Most injuries represented 

in Table 2 were caused by assault; injuries due to assault increased 

over time except for a slight decrease in 2007. Assault incidence 

rates were higher than national assault rates for the nursing and 

social assistance sector during the period 2004–2008, with the 

highest rate occurring in 2006. Most assault injuries resulted in no 

missed work days from 2004 through 2008. For those injuries due 

to assault that did result in days lost, a total of 3,382 lost work days 

were recorded during the 2004–2008 period.

Table 2. Number of nonfatal injury and illness cases and incidence rates from OSHA logs for 2004–2008 at the 

center, compared with national rates

Variable 2004 2005 2006 2007 2008*

No. of injury and illness cases at the 

center 

131 143 204 162 54

Injury and illness incidence rates† at the 

center

26 31 41.3 37.5 13

National incidence rates† for nursing and 

residential care facilities

9.7 9.1 8.9 8.8 8.4

*Data available for January–June 2008.

†Per 100 full-time employees.

Table 3. Number of injuries from assault cases and incidence rates from OSHA logs for 2004–2008 at the 

center, compared with national rates

Variable 2004 2005 2006 2007 2008*

No. of cases due to assault at the center 85 92 140 121 40

Assault incidence rates† at the center 17 20 32.4 29 9.3

National incidence rates† of assaults in 

health care and social assistance

0.11 0.84 0.83 0.83 0.82

*Data available for January–June 2008.

†Per 100 full-time employees.
Health Hazard Evaluation Report 2008-0046-3123 Page 7

Results (continued)

From June 2006 to May 2008, 35 workers’ compensation claims 

were paid for injuries involving a resident assault encounter. Of 

these, 22 injuries occurred as a result of resident aggression and 13 

occurred to staff who assisted in physically restraining aggressive 

residents. Ten injuries were to the lower extremities, 15 to upper 

extremities, 8 to the head or neck, and 2 to the back. Four of the 

injury claims were for bites.

Review of Policies 

The center provided no written policies or procedures on 

workplace violence. Managers reported that direct care staff 

completed training during new employee orientation and annual 

training on crisis intervention, which focused on handling agitated 

behaviors and applying physical restraint. Direct care workers 

were also required to complete annual training on the following 

topics: personal safety techniques, behavior management, resident 

communication skills, and nonviolent crisis management, which 

included a restraint-reduction effort.

Our review of the ICF/MR regulations showed that the center 

did not consistently follow these regulations in areas such as 

Table 4 presents the types of injuries resulting from assault for 

2004–2008. Overall, the most common injuries related to resident 

assaults over the 4-year period were strains/sprains, bruises, bites, 

head trauma, broken bones, and lacerations. Some recorded 

incidents involved multiple injuries. Resident care aide was the 

most common job type reported with injuries due to assault.

Table 4. Types (numbers) of injuries related to resident assaults at the center, from OSHA logs, 2004–2008

Variable 2004 2005 2006 2007 2008*

Strains/sprains 52 30 45 38 20

Contusions 17 31 36 26 6

Bites 9 10 34 36 9

Head trauma/injury 5 4 4 7 2

Fractures 3 2 1 4 1

Lacerations/scratches/abrasions 2 5 8 6 2

Facial injuries 2 5 8 2 4

Other 3 6 5 5 1

*Data available for January–June 2008.
Page 8 Health Hazard Evaluation Report 2008-0046-3123

Results (continued) staffing ratios, convening a human rights committee, proper use of 

medication to manage resident behavior, and staff training.

We reviewed the control plan for bloodborne pathogen exposure 

because of the bites and other potential exposures to body fluids that 

direct care workers reported in the interviews and on the OSHA 

Logs. The plan for controlling exposure to bloodborne pathogens 

included the basic elements of OSHA’s bloodborne pathogen 

standard, such as for needlestick injuries and handling resident 

laundry [29 CFR 1910.1030]. Hepatitis B vaccination series were 

made available for new employees. The plan did not include an 

evaluation of or prevention strategies related to the infectious disease 

transmission risk resulting from resident assaults.

Incidence rates of overall injury and illness and injury due to assault 

at the center were higher than national rates in the healthcare and 

social assistance sector. In addition, the incidence rates of injury 

and illness increased from 2004 to 2006, with a slight decrease in 

2007. Most injuries were from resident assault. The Department of 

Justice National Crime Victimization Survey Report for 1993–1999 

reported rates of simple assault by occupational category, which can 

offer some comparison [DOJ 2001]. Of the occupational groups in 

healthcare with the highest average annual rate of simple assault, the 

survey found that mental health staff experienced 4.3 assaults per 100 

workers and nursing staff experienced 2.2 assaults per 100 workers. 

At 24.7 per 100 workers, the average rate of injury from assault at the 

center for 2004–2007 was much higher than these rates. However, 

incidence rates of injuries due to assault were below rates found in a 

2004 study at a public ICF/MR in Idaho. In that facility, the average 

rate of injury among direct healthcare staff was 32.7 per 100 workers 

[Manning 2005]. We found that most staff did not take days off work 

after assaults, but of those staff who did, the total amount of lost 

work time from 2004 through 2008 was more than 3,000 days. Staff 

who required time off had typically experienced severe injuries that 

may have required prolonged recovery and treatment.

Every staff member interviewed reported being repeatedly injured by 

residents and that work-related injuries from resident aggression had 

been increasing. The types of assaults that staff reported are typical 

of those documented in other social service and healthcare settings, 

such as being kicked, hit, bitten, and scratched [NIOSH 2002a]. Most 

staff reported being injured while physically restraining a resident. 

Discussion
Health Hazard Evaluation Report 2008-0046-3123 Page 9

Discussion (continued) Research has demonstrated that a common adverse consequence of 

using physical restraint is agitation and that combative residents often 

become more combative when restrained [Tinetti et al. 1991; Mion 

and Strumpf 1994; Driscoll 1999; Castle and Engberg 2009].

Workplace violence against staff is common in healthcare and social 

service settings [Islam et al. 2003; Gerberich et al. 2004; McPhaul 

2004; Gerberich et al. 2005; Nachreiner et al. 2007]. Healthcare 

leads all other industries in the number of nonfatal assaults resulting 

in lost work days in the United States, accounting for 60% of all 

such assaults. Nurses, nurse aides, and orderlies had the highest 

proportion of these injuries [BLS 2007]. However, little is known 

specifically about the extent of workplace violence against healthcare 

staff who care for residents with developmental disabilities in longterm care facilities. Most ICF/MRs in the United States, including 

this center, serve a mix of developmentally disabled, mentally ill, or 

dually diagnosed residents. Many of these facilities serve residents 

who have no other placement option because of severe behavioral or 

medical issues. This situation places direct care workers at higher risk 

for injury than other healthcare professionals.

A survey that examined the distribution of residents in several U.S. 

public ICF/MRs showed that 80% of these facilities characterized a 

portion of their resident population as being dangerous or aggressive 

and reported that this portion is increasing [Manning 2005]. Working 

with patients or clients with a known history of assaultive behavior 

has been identified as a risk factor for hospital employees [NIOSH 

2002a]. Persons with mental and physical disabilities may become 

agitated by certain stressors—including lack of privacy, minimal 

control over daily activities, and noise level—and have reduced 

impulse control, which may result in agitation and aggression [Myers 

et al. 2005; Privitera et al. 2005].

We observed certain aspects of the physical environment and 

deficiencies in the security system that placed staff at increased risk 

for injury from assault. Furniture placement was crowded, which 

could have led to entrapment of staff and inability to observe 

residents in all areas of the room. Residents could have used some 

moveable items to assault staff. PPDs were not reliable, so other staff 

members would not always know to assist in a crisis. Inadequate 

security and poor environmental controls are associated with 

increased risk of assault in hospitals and may be significant factors in 

social services workplaces as well [NIOSH 2002a].
Page 10 Health Hazard Evaluation Report 2008-0046-3123

Discussion (continued) Understaffing may have led to fewer staff being available to assist 

with resident care and respond in a crisis. In addition, most direct 

care workers and nurses interviewed reported working overtime (an 

additional 8-hour shift) during each 1-week period, and 50% reported 

that overtime was mandatory. Facilities employing healthcare 

workers are mainly 24-hour, 7-day operations that require working 

more than 8 hours a day and working night shifts [Lipscomb et 

al. 2002; Lamberg 2004; NIOSH 2004]. Studies have found that 

overtime increases fatigue and stress and decreases alertness and job 

performance, putting employees at greater risk of resident assault 

and injury [Rogers 1997; Simpson and Severson 2000; Lamberg 

2004; Gerberich et al. 2004; Dembe et al. 2005]. Risk of injury 

has been found to increase every hour after 8 hours of work, and 

injury risk in the 12th hour of work is twice that in the first 8 hours 

[Lamberg 2004]. Employees may be less able to react to a resident 

assault and quickly manage the situation when they are fatigued. 

Mandatory overtime may limit the worker’s ability to plan for sleep 

and recuperation and to arrange for child care and other family 

responsibilities. In addition, it has been associated with increased 

risk of somatic complaints, poor recovery, burnout, and work-home 

imbalances [Van Der Hulst and Geurts 2001; Golden and Jorgensen 

2002; NIOSH 2004]. Direct care staff may be more at risk for injury 

during the evening, when other staff members—such as psychologists, 

case managers, and doctors who work traditional business hours—are 

unavailable to help; however, we did not examine whether work shift 

was a contributing factor to injury due to assault.

Most staff reported that managers lacked concern about their 

safety and did not listen to their suggestions about how to handle 

resident aggression or their input in residents’ IPPs. Research has 

determined that direct care workers have less control over their 

work environment, fewer opportunities to make independent 

decisions, and higher levels of job strain than other occupational 

groups [Karasek and Theorell 1990; Sullivan et al. 1999; Morgan 

et al. 2002]. In another NIOSH HHE, investigators examined job 

stress characteristics in employees of a developmental center and 

found that staff reported one of their most common stressors was 

having no supervisory support and little control over treatment 

decisions [NIOSH 2002b]. Organizational factors such as high job 

strain and low decision latitude have been associated with injuries, 

cardiovascular disease, and adverse mental health outcomes [Corrigan 

1993; Sanne et al. 2005; Schoenfisch and Lipscomb 2009; Rodwell et 

al. 2009].
Health Hazard Evaluation Report 2008-0046-3123 Page 11

Discussion (continued) We found that staff are being assaulted in ways (i.e., bites, scratches, 

and other injuries that result in broken skin) that could increase risk 

of bloodborne pathogen transmission, but this was not addressed in 

the plan for controlling bloodborne pathogen exposure. Hepatitis B 

virus, human immunodeficiency virus, and hepatitis C virus are the 

bloodborne pathogens most frequently associated with occupational 

exposures. In developmental centers, reported staff exposures 

have been primarily via residents’ bites, fingernail scratches, body 

fluids, and (occasionally) injury from sharp instruments. Staff who 

are vaccinated are protected from hepatitis B infection, but those 

assaulted with objects are at risk of tetanus if the assault results in a 

deep puncture wound or the object is contaminated. The risk that a 

bloodborne pathogen might be transmitted via fingernail scratches 

has been reported as minimal, but hepatitis B and hepatitis C can be 

transmitted via saliva. Transmission of these pathogens to hospital 

staff with occupational exposure to needlesticks and injuries from 

other sharps is well documented. A bite poses a risk of infection 

transmission from the resident to the staff person who is bitten but 

also vice versa [Lohiya et al. 2001].

This evaluation has several limitations. The injury rates calculated 

from the OSHA Logs may overestimate or underestimate the extent 

of this problem. The rates are based on OSHA’s basic requirements 

of recording and reporting only occupational injury and illness events 

that are severe enough to cause lost work time, require treatment 

beyond first aid, cause loss of consciousness, or result in restricted 

work duties or transfer to another job [29 CFR 1904.7]. The rates 

of less severe injuries and assaults are likely to be much higher; 

underreporting of injuries and assaults has been reported in other 

studies [Bensely et al. 1997; Erikson and Williams-Evans 2000; Islam 

et al. 2003; Myers et al. 2005]. However, some overestimation of 

rates also may have occurred because the number of overtime hours 

was not reflected in the formula. To allow comparison with other 

facilities with the same NAICS code throughout the United States, 

we used the standard formula number of 200,000 hours, which 

reflects a standard 40-hour work week. The national incidence rates 

for nursing and residential facilities and the healthcare and social 

assistance sector offered the closest comparison with incidence rates 

of work-related injury and illness and assault at the center, but the 

industry rate includes employees working in all occupations, some 

of whom may have lower exposures to the more hazardous aspects of 

healthcare.
Page 12 Health Hazard Evaluation Report 2008-0046-3123

Discussion (continued) In addition, findings from this evaluation apply to this center 

and may not reflect the injury/assault experiences at other ICF/

MRs nationwide. The information from the interviews may not be 

representative of all direct care staff at this entire facility. The staff 

members volunteering to participate in our interviews may have been 

more concerned about resident aggression and as a result may have 

overestimated the concerns of all direct care staff. We attempted to 

overcome this issue by serially selecting staff to interview; however, 

interviews were voluntary, and a few staff declined participation.

Direct care and nursing staff at this ICF/MR were at risk of injury 

from assault by residents. Nonfatal injury and illness rates for direct 

care staff and nurses were much higher than national rates, and 

injury assault rates were higher than for other healthcare worker 

groups.

The following recommendations are based on the findings of our 

site visit to this center. Although the center is now closed, consistent 

application of these actions should help prevent or reduce resident 

assault and create a more healthful workplace at any ICF/MR or 

other similar facility.

Policies 

● Develop a proactive safety and health program. This 

comprehensive program should include management and 

employee participation; hazard identification; safety and health 

training; and hazard prevention, control, and reporting.

● To develop a safety and health program, use the State 

Operations Manual, Interpretive Guidelines—Responsibilities 

of Intermediate Care Facilities for Persons with Mental 

Retardation (“Interpretive Guidelines for ICF/MR”) and 

OSHA’s Guidelines for Preventing Workplace Violence for 

Health Care & Social Service Workers (“OSHA Workplace 

Violence Guidelines”), which are available on the OSHA 

website at http://www.osha.gov/Publications/OSHA3148/

osha3148.html [42 CFR 440.150–480; OSHA 2004].

● Develop a workplace violence prevention policy, using the 

OSHA Workplace Violence Guidelines. Use this policy to 

Recommendations

Conclusions
Health Hazard Evaluation Report 2008-0046-3123 Page 13

Recommendations

(continued) create a culture of safety (including a clear policy of zero 

tolerance for workplace violence). Once all levels of staff work 

together to develop this policy, the safety committee should 

take charge of maintaining safety and promoting the policy.

● Ensure that the bloodborne pathogen policy includes an 

evaluation of all occupational exposures that could result in 

infectious disease transmission. This includes all assaults such 

as bites or puncture wounds in which staff are at risk for disease 

transmission from infectious body fluids. Explain possible 

controls to reduce or eliminate such exposures in the exposure 

control plan, to comply with OSHA’s bloodborne pathogen 

standard [29 CFR 1910.1030].

Physical Environment and Security 

Measures

● Ensure that staff have access to alarm devices or cell phones 

where risk is apparent or may be anticipated. Ensure that an 

adequate number of trained personnel are available to respond 

to incidents when an alarm is triggered.

Healthcare Management

● Encourage employees to report assaults to their supervisors and 

seek a prompt referral to a healthcare provider if injury occurs; 

ensure the provider is experienced in evaluating and treating 

work-related injuries.

● Require staff to report every incident of assault, even if the 

event is unlikely to recur or seems minor. Consistently record 

and follow up cases of injuries from assaults on OSHA Logs 

and other incident reporting systems as appropriate, to analyze 

trends and to track the magnitude and seriousness of resident 

assaults. Incident reporting should include details of the 

characteristics of attacker and victims, an account of what 

happened before and during the incident, and the relevant 

details of the situation and its outcome. Use these findings to 

look for patterns of incidents and to revise safety procedures 

when needed.
Page 14 Health Hazard Evaluation Report 2008-0046-3123

Recommendations

(continued) Safety Committee

● Create a permanent safety committee that uses the OSHA 

Workplace Violence Guidelines to guide its actions. The 

committee should consist of all levels and types of staff 

(especially management, direct care staff, and maintenance 

employees), who work together to proactively address safety 

concerns that affect staff and residents. Provide this committee 

with the resources and management support it needs to 

implement its recommendations.

Human Rights 

● Create a permanent human rights committee in accordance 

with standard 483.440(f)(3) of the Interpretive Guidelines for 

ICF/MR [42 CFR 440.15–480].

● Ensure that the committee reviews and approves any resident 

programs that use restrictive techniques such as restraints/

physical interventions and medications to manage behavior. 

In addition, ensure that the committee periodically reviews/

monitors such programs to determine whether continued use is 

justified.

● Re-evaluate the behavior medication policy to ensure that 

it is being implemented in accordance with the Interpretive 

Guidelines for ICF/MR [42 CFR 440.15–480].

Staff Scheduling

● Maintain staff–to-resident ratios that meet all applicable 

requirements (e.g., Interpretive Guidelines for ICF/MR, OSHA 

requirements, best practices), and exceed these requirements 

where indicated by residents’ IPPs, staff and resident safety 

requirements, and other relevant concerns.

● Decrease the amount of overtime for direct care workers and 

nurses, and consider developing a system to reward employees 

who volunteer for overtime when it is needed.

Training

● Conduct a comprehensive needs assessment to determine 

training needs.
Health Hazard Evaluation Report 2008-0046-3123 Page 15

Recommendations

(continued) ● Provide regular, ongoing, interactive training as indicated by the 

needs assessment, Interpretive Guidelines for ICF/MR, and the 

OSHA Workplace Violence Guidelines for direct care workers 

and nurses.

Employee Health and Wellness 

● Encourage and emphasize employee positive health and wellness 

programs such as stress management, weight control, smoking 

cessation, and healthy eating habits.

● Publicize the Employee Service Program; ensure that employees 

know that this confidential, free program is available to them, 

and encourage them to use it.

● Develop an effective post-incident response and evaluation 

program to assist direct care staff and others in dealing with 

psychological trauma, fear of returning to work, and other 

consequences of being assaulted and/or injured at work [OSHA 

2004].

● Hold monthly group discussions for staff to encourage them 

to discuss their concerns about residents’ day-to-day care and 

aggressive behavior, as well concerns about their own health 

and safety.

● Continue to offer crisis intervention services, such as the 

Traumatic Incident Stress Management Program offered 

through the state of Michigan for employees who have recently 

experienced an assault.

● Provide tetanus/diphtheria vaccination to employees in 

accordance with the Advisory Committee on Immunization 

Practices.

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Acknowledgments and

Availability of Report

The Hazard Evaluations and Technical Assistance Branch 

(HETAB) of the National Institute for Occupational Safety and 

Health (NIOSH) conducts field investigations of possible health 

hazards in the workplace. These investigations are conducted 

under the authority of Section 20(a)(6) of the Occupational Safety 

and Health (OSHA) Act of 1970, 29 U.S.C. 669(a)(6), which 

authorizes the Secretary of Health and Human Services, following 

a written request from any employer or authorized representative 

of employees, to determine whether any substance normally found 

in the place of employment has potentially toxic effects in such 

concentrations as used or found. HETAB also provides, upon 

request, technical and consultative assistance to federal, state, and 

local agencies; labor; industry; and other groups or individuals to 

control occupational health hazards and to prevent related trauma 

and disease.

The findings and conclusions in this report are those of the 

authors and do not necessarily represent the views of NIOSH. 

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement of 

the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these 

websites. All Web addresses referenced in this document were 

accessible as of the publication date.

This report was prepared by Christine West and Ellen Galloway 

of HETAB, Division of Surveillance, Hazard Evaluations and 

Field Studies. Field assistance was provided by Gricelda Gomez. 

Health communication assistance was provided by Stefanie Evans. 

Editorial assistance was provided by Seleen Collins. Desktop 

publishing was performed by Robin Smith.

Copies of this report have been sent to employee and management 

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Below is a recommended citation for this report:

NIOSH [2011]. Health hazard evaluation report: evaluation of resident aggression 

toward staff in a center for the developmentally disabled – Michigan. By West C, 

Galloway E. Cincinnati, OH: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National Institute for Occupational 

Safety and Health, NIOSH HETA No. 2008-0046-3123.

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