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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:center; "><span style="font-size:14pt; color:#00B050; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-size:14pt; text-decoration:underline ;">Some personal identifiers have been redacted for privacy purposes.</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">United States of America</span></p>
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							<p style="margin-top:0px; margin-bottom:0px; line-height:1; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">SECRETARY OF LABOR,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span></p>
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							<p style="margin-top:0px; margin-bottom:0px; line-height:1; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS OF CENTENNIAL PEAKS LLC, dba CENTENNIAL PEAKS HOSPITAL</span></p>
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							<p><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> OSHRC Docket No.:<span>
									</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">19-1579</span></p>
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				<p class="style_Default style_Default " style="text-align:justify; "><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">A</span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">ppearances:<span>
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				<p class="style_Default style_Default " style="text-align:justify; "><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">Alicia A. Truman</span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">, Esq.</span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; "><span><span></span>
						</span>and Beau Ellis, Esq.</span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">, Department of Labor, Office of the Solicitor, D</span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">enver</span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">,<span>
						</span></span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">CO</span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; "><span><span></span>
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				<p class="style_Default style_Default " style="text-align:justify; "><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">For Complainant<span>
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				<p class="style_Default style_Default " style="text-align:justify; "><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">Melanie Paul, Esq. and Dion<span>
						</span></span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">K</span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">ohler</span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">, Esq.,<span>
						</span></span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">Jackson Lewis, P.C.,<span>
						</span></span><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">Atlanta, GA</span></p>
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				<p class="style_Default style_Default " style="text-align:justify; "><span style="font-size:10pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:10pt; ">For Respondent<span>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:72px; text-indent:-1.27cm; "><span style="font-size:10pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">Before: First Judge Patrick B. Augustine – U. S. Administrative Law Judge</span></p>
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				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">I.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Introduction</span></p>
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				<p class="style_Default style_Default " style="line-height:2; text-align:justify; text-indent:1.27cm; ">Workplace violence<span>
					</span>is a unique hazard in the<span>
					</span>occupational safety and health<span><span></span>
					</span>arena. It is not governed by a specific standard,<span><span></span>
					</span>and many businesses do not have occasion to address it, or only need do so in the most cursory terms.<span><span></span>
					</span>But,<span>
					</span>in some industries,<span>
					</span>it is one of the most significant threats to the safety and health<span>
					</span>of employees covered by the Occupational Safety and Health Act, 29 U.S.C. §<span>
					</span>651<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">et seq.<span>
						</span></span>(Act).<span>
					</span>The hazard is particularly acute in the healthcare industry, where, according to the Bureau of Labor Statistics,<span>
					</span>U.S. healthcare workers suffered 15,000 to 20,000 workplace-violence-related injuries every year from 2011-2013<span><span></span>
					</span>and accounted<span>
					</span>“for nearly as many<span>
					</span>injuries as all other industries combined.”<span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref2" href="#ftn2">1</a></span><span><span></span>
					</span>(Ex. C-13 at 3; C-12<span><span></span>
					</span>at 2-3).<span>
					</span>The particular threat of violence faced by a healthcare facility<span>
					</span>depends on<span>
					</span>the type of services it provides,<span>
					</span>the patients it sees,<span>
					</span>and<span>
					</span>whether it is open to the public.<span><span></span>
					</span>(Ex. C-12)</p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Inpatient psychiatric hospitals, such as the one<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent operates<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Louisville, Colorado</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">deal almost exclusively with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">what is known as Type<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, or “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violence committed by patients upon staff members.” (Ex. C-14).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This is due, in no small part, to the population Respondent serves</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. According to Respondent,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">many of the patients it admits come<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">involuntarily<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">from</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>local</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">mergency<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">epartments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref3" href="#ftn3">2</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">These patients are typically at a low point</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in their psychiatric health and need assistance for any number of psychiatric or behavioral conditions, including depression, bipolar disorder, schizophrenia and other<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">schizo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-affective disorders</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lthough</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>data and Respondent’s own experience show</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>many of the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">se</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are not a threat to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the safety and health of its employees,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">some patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, especially those with a history of violen</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t behavior</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">will perpetrate violence on staff members responsible for providing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">them with care</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In light of this hazard, which Respondent admits is endemic to its workplace</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and the industry generally</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the operative issues in this case are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>whether</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adequately addressed the hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) Complainant established the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">feasibility of its proposed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">abatement measures.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant cited</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">failing to provide<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employment and a place of employment free f</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rom</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the recognized hazard of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>under the general duty<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">clause, 29</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>U.S.C. § 654(a)(1)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identifies multiple<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">aspects of Respondent’s current</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>workplace violence protection plan</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that are deficient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and makes an equivalent number of proposals<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to abate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While the case is complex in its particulars</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, at bottom</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">alleg</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">failed to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">address the hazard of workplace violence in a comprehensive</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>effective<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">way</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent, on the other hand, contends Complainant has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>shown</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent’s methods for addressing the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard were inadequate, nor has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">provided any competent evidence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the abatement methods he proposes would materially reduce the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In particular, Respondent contends<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the source of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard itself presents multiple difficulties</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, such as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">predicting who will perpetrate violence and when</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, as well as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assessing the effectiveness of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">particular abatement methods</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. As such, Respondent places significant emphasis on its clinical approach to workplace violence,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which it contends is outside the reach of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Occupational Safety and Health Administration (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">OSHA</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s task is a difficult one. It<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">must<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">account for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the difficulties inherent to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">provid</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a safe environment for psychologically and behaviorally</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>compromised<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to heal<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">while simultaneously</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>ensuring its employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>are provided with the most effective means to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">mitigate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">potential<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this is no doubt a difficult task</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in an environment where workplace violence is endemic</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is nonetheless obliged to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">take</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>all<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">necessary and appropriate steps to ensure its employees are provided with “employment and a place of employment<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which are free from recognized hazards . . . .” 29 U.S.C. § 654(a)(1)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ultimately, the Court finds Complainant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">established<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent failed to adequately address the hazard of workplace violence in multiple areas and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">simultaneously</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">prov</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">many of its abatement proposals<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">would be effective in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reducing the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Arcadian Corp.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">20 BNA OSHC<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2001</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2011</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(No.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">93-0628,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2004).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">failures<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">can be resolved through the intentional implementation of a comprehensive<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implements<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s abatement proposals insofar as the Court determines they are feasible.<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">II.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Jurisdiction & Stipulations</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">A.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>Stipulations</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The parties reached multiple stipulations, which they submitted to the Court prior to the trial in this matter.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Those stipulation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which the Court has accepted,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>provide as follows:</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">i.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent UHS of Centennial Peaks LLC dba Centennial Peaks Hospital (“Centennial Peaks”) is an employer engaged in a business affecting commerce within the meaning of Section 3(5) of the Occupational Safety and Health Act of 1970, 29 U.S.C. § 652(5).</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">ii.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Centennial Peaks is an in-patient psychiatric hospital.</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">iii.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Centennial Peaks has 5 units with a total of 104 beds.</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">iv.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Citation and Notification of Penalty underlying this proceeding was issued on May 31, 2019.</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">v.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent timely filed its Notice of Contest on June 4, 2019.</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">vi.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Employees at the worksite are exposed to the hazard of workplace violence, defined in this case as physical threats and assaults by patients toward staff.</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">vii.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The hazard of workplace violence as defined in this case was recognized by Centennial Peaks at the time of the alleged violation.</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">viii.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The hazard of workplace violence is recognized in the industry.</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">ix.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staff injuries from patient violence and/or assaults by patients against staff could result in serious injuries.<span>
					</span></span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">x.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Occupational Safety and Health Review Commission has jurisdiction in this proceeding pursuant to § 10(c) of the Occupational Safety and Health Act (“OSH Act”).</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">xi.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Nurse Manager/House Supervisor Shift Reports were produced by Respondent during discovery for 13 days in 2017, 65 days in 2018, and 57 days in 2019. (J-4)<span>
					</span></span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Joint Stipulations at 1-2.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref4" href="#ftn4">3</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "> </p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[Remainder of the page intentionally left blank]</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "> </p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">B.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Jurisdiction</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the stipulations</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref5" href="#ftn5">4</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent is an employer<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">engaged in interstate commerce and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">subject to the jurisdiction of the Act</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">United States v. Lopez</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 514 U.S. 549, 558 (1995).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See also</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Slingluff</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">v.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">OSHRC</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 425 F.3d 861 (10th Cir. 2005).</span><span style="font-size:11.5pt; color:#000000; font-family:Calibri; font-size:11pt; font-size:11.5pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court also finds</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Commission has jurisdiction over the matter pursuant to § 10(c) of the Act</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(JS No. 1)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Joel Yandel</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 18 BNA OSHC 1623, 1628 n.8 (No. 94-3080, 1999).</span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">III.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Procedural History</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is case began when one of Respondent’s employees filed an anonymous complaint with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">OSHA</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Denver Area Office</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, alleging employees were<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">routinel</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">y exposed to physical assaults by patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Respondent did not have a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">effective<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in place<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to address those assaults</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. On receipt of the complaint, Complainant designated Compliance Safety and Health Officer (CSHO)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Brian</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">O</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">b</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">erbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to perform<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>inspection</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>into the allegations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which began</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on December 7, 2018</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the results of his inspection, CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>recommended, and Complainant issued, a single-item Citation and Notification of Penalty</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which all</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">eged a violation of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the general duty clause (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">§</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>5(a)(1) of the Act</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and proposed a penalty of $10,229.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant filed a timely Notice of Contest,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">bringing the matter before the Commission.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The parties engaged in extensive motions practice during the pendency of this litigation.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Of particular importance to this case are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">two orders issued by the Court</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>during the course of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discovery</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: (1)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Order on Motion to Amend Citation and Complaint, d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Sept. 1, 2020; and (2)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Order on Complainant’s Motion for Sanctions and Entry of Sanctions, d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">April 19, 2021.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Regarding<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s Motion to Amend the Citation and Complaint</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Complainant sought to amend the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Citation and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complaint to add UHS</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Delaware as a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>party, based on Complainant’s assertion that UHS-Centennial Peaks and UHS-Delaware were a single entity for the purposes of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">establishing liability for the violation. Ultimately, the Court determined Complainant failed to properly<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and timely amend the Citation and Complaint pursuant to F</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">eral<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ule of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iv</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">il<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rocedure<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">15(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">c)(1)(C) and UHS-Delaware would be prejudiced by an</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>amendment at that stage in the proceedings.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Order on Complainant’s Motion<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to Amend Citatio</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Complaint</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Docket No. 19-1579 (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">September 1, 2020</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref6" href="#ftn6">5</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s Motion for Sanctions and Entry of Sanctions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court found Respondent failed to comply with its duty to preserve evidence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>once it was placed on notice of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pending litigation.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Court<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">imposed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>adverse inference</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that the unproduced evidence would have shown</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) a hazard of workplace violence was present in the work</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">place</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; (ii) Respondent recognized the presence of the workplace violence hazard; (iii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">had<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">actual<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">knowledge of the workplace violence hazard and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was aware its</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>employees were exposed to the recognized hazard of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iv)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">such exposure could result in seriously bodily harm or death.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Order on Motion for Sanctions and Entry of Sanctions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Docket No. 19-1579 (April 19, 2021).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he only remaining issue for trial<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">wa</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s whether Complainant established a feasible means of abatement.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>On that topic, however, the parties were limited to a defined time period</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and were<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">precluded from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inquiring into clinical/medical decisions, such as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">medication levels. (Tr. 194, 1774).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>At trial, the Court ruled on a motion to establish the timeframe for the admission of relevant evidence. The Court established the period of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">December 17, 2017</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>through May 30, 2020</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as the relevant period.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">After<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a period of delays owing to the COVID-19 pandemic, a trial in this matter was held<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">over the course of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nine</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>days, starting<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">September 13</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2021, in Denver, Colorado.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Both parties submitted post-trial briefs<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for the Court’s consideration.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition, on June 13, 2022, the Court ordered supplemental briefing to address the Commission’s March 3, 2022</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Decision and Order in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">UHS of Westwood Pembroke, Inc. and UHS of Delaware, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, No. 17-0727, 2022 WL 774272 (O</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">H</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Mar. 3, 2022)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">appeal docketed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, No.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">22-1845 (3d Cir. May 2, 2022)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The Commission’s decision</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was issued after the trial</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in this matter</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>had concluded and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">post-trial</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>briefs had been filed with the Court but before this Decision and Order was issued. The parties submitted their Supplemental Briefs on this issue certified to the parties</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref7" href="#ftn7">6</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">evidence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">presented at trial, the Court issues the following</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>findings of fact and conclusions of law</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">IV.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Factual Background</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">A.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">The Facility and Staff</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent runs a stand-alone</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, behavioral health facility, which provides acute</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, inpatient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>psychiatric treatment for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adults and adolescents. As noted earlier, p</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sychiatric patients come to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s facility, often involuntarily,</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref8" href="#ftn8">7</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for treatment and management of conditions such as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">depression, anxiety, psychosis, schizophrenia, bipolar disorder, and suicidal thoughts. (Tr. 349).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent, it admits nearly 4</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">000 patients each year</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which are treated and cared for by a staff of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">approximately 250 staff members</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">r. 1786, 2379).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Of particular interest to this case are the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>members of the hospital’s direct care staff,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which includes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>doctors, nurses, mental health technicians (MHTs),<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">social workers, and therapists. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">94).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The doctors, nurses, therapists, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">social workers make up the treatment team</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which is responsible for the clinical treatment of patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 1713-1714).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">treatment<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">team generates a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assessment of each patient and is responsible for the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ir</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>medical treatment<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and care<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">during</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>their stay at Centennial Peaks. (Tr. 233).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">MHT</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s work alongside the nurses and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">conduct<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient observation on a set schedule (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">observation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rounds)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>observing and managing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the milieu</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref9" href="#ftn9">8</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>transporting patients to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">meals, recreation, and group sessions; and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">facilitating group and recreational therapy. (Tr. 434).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Although doctors have</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>occasional,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>direct contact with patients,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nurses and MHTs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>work with and around patients throughout their entire 8-hour work shift.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The hospital<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">facility contains 104</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>beds that are split into five<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient care units</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: Castle, Torrey’s, Sunlight, Pike’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Peak</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and Crestone</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Peak</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref10" href="#ftn10">9</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">JS No. 3).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Castle</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">treats</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients for chemical dependency</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Torrey’s treats adult patients with severe anxiety or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">depression</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and represent potential suicide risks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Sunlight<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">treats adolescent patients. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1830, 2090, 2301). The remaining two units, Crestone</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(female)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Pike</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(male)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">known as intensive treatment units, or ITUs, where<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients with more severe mental disorders were treated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 94, 1119).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The ITUs became a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">principal focus of CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>inspection</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>because most of the workplace violence incidents occurred<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in those units or involved patients from those units. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2093</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">All</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">five<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">units<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">each<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">have</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patient rooms,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nursing station, common areas, a medication room, and a seclusion/quiet room</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for patients. (Tr. 96).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Administrators and executives<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>located throughout the building, adjacent to and within the units. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1766, 1770</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2120-2121; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-6</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent, e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ach</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>nurs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">es</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>station is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">centrally<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">located<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on the unit<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">provide a clear line of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sight<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was designed to permit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>easy communication between staff and patients.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 2123; Ex. C-5)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Patients come to the nurses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>station for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">many</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>reasons</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>other than medical care, including mundane, day-to-day concerns<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">like<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cups of coffee and telephone calls</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">269,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">377</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex. C-5). As the photographs and testimony illustrate, the nurse’s station<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is not enclosed,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has relatively short, narrow countertops,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and does not have</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a door to prevent access</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which Respondent contends is by design</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. 9</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">7</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-5).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ultiple employees identified the nurse’s station a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">location</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cluster of violent incidents, in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cluding jumping over the counter, grabbing/ripping the computer monitor from the desktop behind the counter,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and physical attacks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>by patients on staff. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr. 129, 583-85, 601-604 1634-36; Ex. C-7 at 12, C-19 at 13-16, Ex. C-72</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">B.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Intake and Admissions</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As noted above,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">many of the patients that come to Respondent’s facility are brought the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">re</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>involuntarily through a referral from a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">local emergency department (ED) or from the police.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Under ideal circumstances,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a patient is referred from a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>ED</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and a nurse from Centennial Peaks will communicate with the referring ED nurse<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">prior to the patient’s arrival. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1710</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This discussion includes information about the patient’s situation, background, treatment, and recommendations, which the nurses referred to as an SBAR. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">17</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">10</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-17</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Upon arriving at Centennial Peaks,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the prospective patient is separated from their personal belongings to ensure contraband is not brought onto the premises</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including drugs, weapons, or other items the patient could use to harm his/herself or others. (Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>2398; Ex. R-10).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">After the patient is screened for contraband, he/she meets with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">intake staff, who are trained social workers, in one of the four designated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">intake rooms</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">95-96</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">An intake staff member</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, often by themselves,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">typically performs a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n initial assessment of the patient to determine<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">whether they meet the admission criteria and whether Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">can provide</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>care that meets the patient’s needs.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref11" href="#ftn11">10</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">96,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1703-1711; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-87</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The assessment includes a review of a patient’s legal history, previous hospitalizations,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">diagnoses,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">medications,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and other pertinent medical history, as well as an assessment of the patient’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">risk of self-harm or harming others. (</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">If a determination is made</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a particular patient is high risk for assaultive behavior, a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">High-Risk</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Notification form is supposed to be placed in the patient’s file</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however, as will be discussed later, this did not always happen</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">597, 660, 1654</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-19, C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">23, C-20</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, R-79</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>assessment and other information contained in the fil</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is transmitted to the treatment team</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and to other treating staff members on subsequent shifts.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">95-96</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-87</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Though this is the typical process, administrators and staff testified there are occasions when a patient will be directly admitted to the unit<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">provide immediate medical care. (Tr. 1059, 1719).<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">C.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Day-to-Day Operations</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The workday at Centennial Peaks is split into three shifts of eight hours per shift.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Daytime shift runs from 7</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">:00</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">m</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>until<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">3:30 p.m.; night shift runs from 3:00 p.m. until 11:30 p.m.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; and overnight shift runs from 11:00 p.m. until 7:30 a.m.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 1731).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The shifts are designed with a 30</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">minute overlap, which permits the preceding shift to conduct a handoff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">report with the oncoming shift. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">167-68</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 717</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 1731</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). During the handoff, the oncoming and outgoing MHTs perform rounds t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ogether and discuss<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the status of each patient,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">incidents of aggression, and unit acuity.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref12" href="#ftn12">11</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1731-32</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). According to Respondent, the information contained in the handoff report is consolidated into the House</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Supervisor/Nurse Manager report, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">take</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a broader view of the events occurring at the hospital as a whole</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including patient census, staffing, discharge/admission</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and whether a Code had to be called</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. R-54; JS No. 4).<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">During a shift,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">direct care staff have multiple duties, including performing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rounds, handing out medicine, taking patients to group meetings, facilitating recreational therapy, and taking part in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">meetings. Typically, MHTs perform rounds every 15 minutes to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">observe patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however, doctors can issue special orders which increase the frequency of the rounds down to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">constant supervision</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, also known as one-to-ones.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref13" href="#ftn13">12</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1728-1730</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-20,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-82</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). According to Respondent,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">special orders are typically issued for patients<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>suicide risk. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. R-82</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As for recreational therapy and lunch, a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>MHT is typically assigned to transfer<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the patients in their unit to lunch, the gym, or outside<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">courtyard.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 435-436).</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref14" href="#ftn14">13</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">work performed directly with patients, some direct care staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>participate in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>daily and weekly meetings to discuss patient care</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Specifically, nurses, doctors, and social workers take part in daily treatment team meetings to discuss the status of each patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>their progress</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, as well as problems or issue</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including those related to aggression</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">681-682</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">MHTs<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">do</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">participate in treatment team meetings,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nor, for that matter, were they required or expected to review patient case files.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">542,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1615</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 1825</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Administrators also held meetings to discuss<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">various matters impacting patients and staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, these included the Performance Improvement Committee</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(PIC)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Patient Safety Council</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(PSC)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, flash meetings, and leadership meetings.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent, flash meetings occur every weekday, during which the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Chief Executive Officer (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CEO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Chief Nursing Officer (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CNO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, nurse managers, milieu managers,</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref15" href="#ftn15">14</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Risk Manager sit down to discuss<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">acts of patient aggression, as well as patients who, themselves, may pose a risk of assault. (Tr. 1748).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent’s WVPP,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he PIC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">oversees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the development and review of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“several different<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[active]<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">performance improvement initiatives</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, all with a focus on patient care.” (Ex. C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">14 at 2).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">One example of the PIC<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">development and review process was the Seclusion and Restraint Reduction<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Team</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which developed plans<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to reduce</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient restraints</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as part of the “Be Free” initiative instituted</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in 2018</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2110-2112</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">SC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which meets monthly</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">consists of a much larger group of administrators, including the CEO,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Chief Management Office</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">r</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CMO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, CNO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Director of Clinical Services, Director of Risk Management, milieu specialists</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, patient advocate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and nurse managers. (Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>2150</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex. C-47</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The PSC<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is used as a method for tracki</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ng risk trends through the review of various reports</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and action plans</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>developed in response. Respondent states the PSC is used for review of both patient and staff injuries.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr. 1699-1700</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex. C-47</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Although<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">they</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>were invited to PI</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C and PSC meetings,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">virtually no non-managerial direct care staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">attended. Respondent contends they were encouraged to attend meetings and provide input; however, according to the staff,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the primary obstacle to attendance was the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lack of adequate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staffing in the units to permit them to attend in the first place.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">544,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1145-46</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Some s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">taff also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">indicated they were unaware meetings were taking place at all. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">396, 528, 1145, 1172).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">attempted to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hold</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>town hall meetings, but they were also sparsely attended due, in part,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to staff either being at work in the units or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on their day off. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">529</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1146, 1807</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-1808).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>CNO Forster recommended replacing the town hall meetings with unit-based meetings; however, according to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, these meetings<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">did</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">tak</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>place.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 567-68; Ex. C-25).<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">D.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Staffing</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent, staffing decisions are made based on t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he needs of each of the hospital’s five units.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As noted above, each unit serves a different population of patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which have different care needs depending on the number of patients and the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">severity of their symptoms. Respondent uses a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staffing matrix, which sets staffing levels according to three factors: unit, shift, and number of patients.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on those factors, the matrix supplies a base level number of staff to be allocated.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref16" href="#ftn16">15</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent states it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adjusts<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the base number<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">up or down depending on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">additional factors, including admits/discharges,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adult/</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adolescent, and acuity. Acuity, as mentioned above, is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a metric<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for individuals, for units, and for the hospital as a whole. At bottom, acuity<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is a measure of the severity of an</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>individual patient’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">affliction</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">collective severity of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the unit or hospital as a whole.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">All staffing decisions start with the matrix.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Kevin<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Smith, Respondent’s staffing coordinator and CPI trainer,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he sets the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">initial schedule according to the matrix a few weeks in advance. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2355</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). From there, Smith testified he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adjusts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the schedule based on anticipated admits/discharges,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">skill/experience of staff, acuity of both individuals and units, and the medical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">needs of any individual patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2355-2357</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staffing meetings are held daily, and Smith and the House Supervisors assess staffing levels</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>periodically to assess whether staff should be called in or moved between units</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2354</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Smith testified if<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a staff member<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ask</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for additional staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, he would discuss<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the staff member, make his own observations to determine whether additional staff was needed, and seek approval from CNO Forster</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2262-2263</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Smith and Forster testified requests for additional staff were granted if sufficient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">grounds were identified for adding staff and staff was available to fill in.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1744</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>However, as discussed below</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staff was not always available.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Other than the matrix itself, there is no policy or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">set of standards to determine<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how adjustments are made, how acuity is taken into account, or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how skill/experience is allocated across the units.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">With respect to acuity, the Court notes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the matrices</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’ allocations of staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>are the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">same regardless<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of the unit, number of patients, or shift. (Ex. C-74, C-75, R-55). Th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e matrices</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>do not account for baseline acuity differences between the units, notwithstanding Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">squarely recognizes differences in acuity between the units</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Respondent contends<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the matrix<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">accounts for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">differences</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">other than acuity</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">between the units, such as the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">high volume of admits/discha</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">r</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ges from Torreys, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">additional hands needed to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">deal with a more active patient population in the adolescent unit,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and the importance of MHT support<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n the ITUs. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1850-1858).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Notwithstanding Respondent’s claims regarding<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how it allocated staff, Respondent’s employees repeatedly identified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">insufficient staffing as a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">recurring and significant problem. (Tr. 504, 573, 1031</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This included the employees who testified at trial, as well as numerous and repeated complaints about staffing in staff emails, surveys</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and reports. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">569-572,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1607-16</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">13</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 1830-1832</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-24,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-25,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-41, C-41,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-65</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-72</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Ashley Ma</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ncha</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified staff shortages</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—fewer staff than provided for in the matrix—o</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ccurred<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">daily</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">her requests for additional staff went un</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">heeded approximately 75% of the time, whereas Mancha testified her success rate was about 50%.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">504,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>509, 560,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>573).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Mancha,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff shortages impacted the available staff’s ability to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">properly and timely medicate their patients and initiate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">individual support plans,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are important elements o</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">f maintaining a healthy milieu. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">573-574</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition to having less staff than provided for in the matrix, a review of the matrices themselves illustrates Respondent reduced the number of staff available<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at certain census levels after the inspection occurred. (Ex. C-74, C-75, R-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">55).</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The problems experienced during the daytime<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>compounded<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">during the overnight and weekend shifts.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he presumption is that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">most of the patients are sleeping</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>during the overnight shift</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, so the matrix<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">allocates one fewer staff member during the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>11:00 p.m. to 7:30 a.m. shift. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1031</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-74</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">his presumption does not always hold, as patients in the ITUs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>can and do stay awake</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and, in some cases, can<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">escalate and agitate other patients. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1611).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further, patients can still be admitted to the hospital during the overnight shift, which can further affect<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the staff-patient ratio.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The overnight<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and weekend<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shift</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>also burdened by two additional considerations. First,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the weekday and daytime shifts have an abundance of managerial</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and administrative staff who are trained in both direct care of patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and in methods to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>de-escalate and restrain patients<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">should the need arise. Those<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff members are not included in the matrix and yet are available to assist. The weekend and overnight shifts do not have the same level of backup available to them, because most of the administration and managerial staff have gone home</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">448, 507, 1094</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On weekends and overnights, the only<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">person<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">usually available to fill in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is the house supervisor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who is not included on the matrix</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">572, 1030</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Erin<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ekholm</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who served as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">overnight house supervisor,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff shortages and a lack of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">back-up personnel resulted in the house<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">supervisor serving as a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">de facto</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>float staffer between the units. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1025-1027,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1031-1033</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). This</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>caused staff to miss</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">breaks,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and, in some cases,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">they were left</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>alone on the unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">849-50</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 1037</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent, it addressed staffing issues in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">several</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>different ways. In addition to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">procedure for staffing described above, Respondent identified staff members who were not included on the matrix but were nevertheless available to provide care and to assist in emergencies.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>set of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">outside-the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-matrix<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>included milieu managers, nurse managers, and house supervisors.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref17" href="#ftn17">16</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">When</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Forster</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>started as CNO,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Centennial Peaks had two milieu managers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, whose job was to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">monitoring unit acuity, patient precautions, and Individual Support Plans</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">At some point in 2018, Forster eliminated the milieu managers and replaced them with one nurse manager, which he believed would better<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">address patient care from a clinical perspective</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 1602, 1746-1747).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hough Respondent asserts these resources were available as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">outside-the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-matrix staff resources,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>milieu manager was not a relevant addition to the units until<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2020, long after the inspection occurred.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1601, 1602,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1748</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">N</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">either Mancha nor<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Eckholm</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>recalled having<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">milieu<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">managers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or resource nurses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>available to them<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as additional resources beyond the matrix.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 573, 1</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">030).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent also had other methods to address staffing shortages</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. According to Forster, employees would regularly call out sick</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which placed additional pressure on the scheduling staff to fill in the gaps in coverage. Kevin Smith, the staffing coordinator, testified he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sent out text and email blasts<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>additional coverage and, if the need was particularly acute,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was able to offer bonuses and other incentives to entice employees to come to work. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2460-2461</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). In addition,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Smith</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified employees could be “mandated” to stay past th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ir</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>originally scheduled hours in order to account for missing staff or late-admitted patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">These additional measures, in the Court’s experience, underscore the point that staffing was inadequate from the start to account for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">these situations.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court also observes having staff work back-to-back multiple shifts or being called in results in employee’s not being well</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rested</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>which</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in turn</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>impacts not only patient care but the alertness and stamina needed for staff to properly observed situations which could escalate as well as respond</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to those circumstances</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">claimed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shortages<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">impacted their ability to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adequately address the acuity of a unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including one-to-ones, five-minute checks, and patients on assault precautions. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1600). Further, staffing shortages also increased the likelihood an employee would be left alone<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to perform their regular duties</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">E</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">mployees testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">safety was impacted by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">short staffing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">insufficient staff to participate in patient restraints or de-escalation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">insufficient staff to even respond to a code during overnight shifts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In at least one instance,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients had to step in to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">help a staff member who</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">se head was being repeatedly smashed against the ground</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">even though a Code Green (emergency call) had been called over the PA system. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">449</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">These concerns were reported to Respondent’s Risk Manager, Kara<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">McArtor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and CNO Forster</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">E.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Workplace</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>Violence</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>Data and<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Employee Narratives</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e inspection<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n thi</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s matter<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was commenced<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of an anonymous employee complaint<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees at Centennial Peaks were subjected to physical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assaults<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">from patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>due, in part, to low staff-to-patient ratios in the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ITUs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-2).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Through his review of Respondent’s OSHA 300 logs, Employee Accident Reports (EARs),<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and employee interviews,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>confirmed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s employees were exposed to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ccording to the data CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>reviewed,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent experienced a substantial spike in workplace violence injuries in 2018</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 103-104; Ex. C-6</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). The OSHA 300 log, alone, indicated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s employees suffered<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">two</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">forty-four</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(44)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>days of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">job transfer/restricted duty</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and 0 days away from work</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in 2017<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as a result of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patient-on-employee violence.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-6).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Comparatively, Respondent’s employees suffered<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">twelve (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">12</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“reportable”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">two hundred eighty-seven (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">87</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>days of job transfer/restricted duty, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">twelve (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">12</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>days away from work</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in 2018</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for the same reason.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Ex. C-6).</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref18" href="#ftn18">17</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The OSHA 300 logs, however, only tell a portion of the story.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>research, he found<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">many of the injuries reported in the EARs did not find their way into the OSHA 300 log. (Tr. 108</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 123-125; Ex. C-11)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. In fact, based on his review, CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identified 46<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reports of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employee injuries<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that occurred</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in 2018.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref19" href="#ftn19">18</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-11).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The predominant number of these injuries involved a nurse or MHT</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">typically</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>occurred</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in the ITUs, Pike and Crestone. (Ex. C-11)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Of the assaults that led to employee injuries,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">twenty-five</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>involved police intervention</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>most of those involved</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>arrest</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, though it should be noted the injuries/assaults resulting in arrest<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">may implicate the same<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">multiple times. (Ex. C-11). In addition to the documented assaults and injuries in the EAR and OSHA 300</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>log, employees testified they were regularly exposed to violent, assaultive behaviors</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that resulted in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">minor (or no) injurie</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">such as being slapped, kicked, or spit on</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">but did not report such incidents because they accepted it as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">part of the job</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 496-497).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As noted above, employee</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">acceptance of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">minor violent behavior as “part of the job”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is well documented in the health care profession</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the inpatient mental health</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>arena, in particular</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-12, C-13</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As noted by Respondent, s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ome of the injuries occurred in clusters</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-11). For example, MC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who had a lengthy history of violent behavior was responsible for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">multiple</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>assaults over<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a few</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>days</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">353-356, 498,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">16</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">54</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-1681</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-7,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-20</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, C-72</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The same behaviors were also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">exhibited by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">RB</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">RS</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who both assaulted multiple staff members during the course of their stay at Centennial Peaks hospital. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">471- 481,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">478-482,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">599-608, 634-37</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-18, C-19</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s employees testified to several violent incidents to which they have been exposed during their tenure as employees at the Centennial Peaks Hospital.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">F</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">or the purposes of discussing the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">types of hazards to which Respondent’s employees were exposed and identifying feasible means of abatement to address those hazards, the Court finds the following examples illustrative:</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:48px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-family:Symbol; padding-right:20px;">·</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>was an MHC at Centennial Peaks from March 2016 to June 2021.<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">During his testimony,<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>identified three separate incidents where he was<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">injured. On one occasion,<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>was unexpectedly punched in the face by a patient, which resulted in a trip to the emergency room</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>and injuries that<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">kept him out of work for three months.<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 1117-1127).<span>
					</span></span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:48px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-family:Symbol; padding-right:20px;">·</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>was also injured at least three times she could recall during her testimony</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. In all three instances, a physical restraint was either being initiated or in progress</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Respondent contends the injuries were largely avoidable because<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>attempted to restrain when there were either not enough staff to init</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ate a hold or because<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">neither the patient nor staff were in immediate danger when<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>initiated the intervention.<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In at least one incident</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>where Respondent questioned<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s decision-making,<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>testified the patient in question had been involved in<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">three prior restraints on the same day and no additional precautions were taken to address the patient’s violent behavior. (Tr.<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">471-482; Ex. C-18).<span>
					</span></span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:48px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-family:Symbol; padding-right:20px;">·</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">One patient, RB, went behind the nurse’s station eight times<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">over the course of just under a month, during which he<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assaulted multiple employees and smashed multiple computer monitors. (Tr. 599-608, 634-637; Ex. C-19)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:48px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-family:Symbol; padding-right:20px;">·</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Another patient, MC, was restrained<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">multiple</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>times over the course of three days, during which time he was responsible for<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">no fewer than five EARs and multiple<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">verbal threats toward staff members. (Tr. 353, 356, 498; Ex.<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-7, C-20).<span>
					</span></span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The foregoing i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ncidents are archetypal examples of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the types of injuries to which Respondent’s employees were exposed, the situations during which employees were injured, the locations where injuries were likely to occur, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the source<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of the hazard, i.e., whether such events<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were isolated and unpredictable or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">whether<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">other information, such as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a patient’s immediate and long-term medical history</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>indicate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a propensity for violence.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">F.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Respondent’s<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Methods to Address Workplace Violence</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ultimately, this case is about abatement.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant has alleged Respondent failed to address workplace violence in a comprehensive and effective manner and proposed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">several methods by which Respondent can<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">abate the hazard more effectively.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent contends it</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policies and programs were</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>effective as possible<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>addressing workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in the context of an inpatient psychiatric hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The following</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is a recap of the relevant policies and procedures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">i.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Workplace Violence Prevention Plan</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant has proposed the develop</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ment and implementation of a WVPP as one of the proposed abatement methods, in reality a comprehensive WVPP will<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">include or touch upon all of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policies and procedures<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the parties have<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discussed during the course of this trial</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref20" href="#ftn20">19</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For example,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staffing is not, itself, a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP program or policy<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">per se</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the policy must consider</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">factors such as acuity, propensity for violence, special orders,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who is designated to respond to codes, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">experience of available staff,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">all of which</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>impact Respondent’s ability to address</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, deter, prevent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and respond to workplace violence.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">That<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“adequate staffing”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and other<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">complementary issues are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discussed in the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>guidance documents issued by OSHA</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Joint Commission</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(TJC)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and Respondent’s own<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">W</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">VP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>indicates the scope of a properly implemented WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>extends beyond<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">administrative and engineering controls designed to prevent a particular type of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violent interaction</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-12, C-13, C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">62).</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The initial<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">element to note in Respondent’s WVPP is the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">definition of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. According to Complainant’s expert, Dr. Jane Lipscomb,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the definition of “workplace violence” is the touchstone upon which a successful WVPP is built, because it guides</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>what needs to be reported, tracked, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ultimately how to address the hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-58</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at 15</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-16</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent’s WVPP<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">document<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">defines workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">quite broadly as Type II, or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“violence committed by patients on staff members.” (Ex. C-14 at 1).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The specific behaviors that would qualify as workplace violence are not described in the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>itsel</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">f; however, Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">contends its employees are provided with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a clear</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">er</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>definition of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>through</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>training</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>modules, including a PowerPoint presentation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which provides a more precise definition of workplace violence:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WPV is any physical assault, threatening behavior or verbal abuse occurring in the work</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">setting</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">” and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Physical assault is any attack ranging from slapping, hitting, biting, use of a weapon</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which results in any degree of injury from no injury to fatal injury</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.” (Ex. C-58 at 15-16).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For the purposes of this case, the parties stipulated the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">definition of workplace violence is “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">physical threats and assaults by patients toward staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.” (JS No.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">6).<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Beyond the initial definition</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the WVPP is broken down into<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">five main elements, as well as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">two<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">additional sections<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">allocating</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">responsibilities and mandating annual evaluation of the plan.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>itself, at least in format and title, mimic</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the basic elements of a WVPP as described in the OSHA and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">TJC guidance, which include: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Management Commitment; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) Employee Participation; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) Aggression Analysis & Surveillance; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iv</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) Hazard Identification and Control; and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">v</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staff Education, Training & Competency.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to the section entitled, “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Management Commitment</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>states generally that senior management will<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">commit<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sufficient capital an</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d resources to ensure the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is appropriately implemented and continuously updated. (Ex. C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">14). Respondent then identifies a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">series of initiatives</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which it contends are supportive of that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">commitment, including: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">15% reduction in staff injuries resulting from patient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">aggression in 2018; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">monitoring aggression through the use of reports and committees; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) encouraging staff to report injuries;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iv</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) providing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>post-incident access to medical and psychological care</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">v</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">additional shows of support, including management commitment to participating in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">emergency codes alongside staff. (Ex. C-14).</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Employee<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">articipation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>section</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>identifies some<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">strategic<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">committee’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staff are encouraged to participate in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but are not necessarily<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">members of. O</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">therwise</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, instead of a list of opportunities for employee engagement in the process, this section</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reads like a series of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient-based obligations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. For example,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the section states front line staff will be provided with “opportunities to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">participate in initiatives designed to minimize events of patient-to-staff aggression”,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">including</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">conducting thorough observation rounds, completing skin checks of patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>searching patient belongings</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-14 at 2-3).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While these<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">so-called</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">initiatives<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are certainly important aspects of a violence prevention program</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, they have little to do with employee participation and input into the development of a WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and instead have the appearance of a job description.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The remaining<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">elements</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of Respondent’s WVP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">address how Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">will track and trend acts of aggression</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, identify and respond to specific hazards, and the training it will provide to staff members</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to execute the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">elements of the plan.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Ex. C-14).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Court notes, as did Dr. Lipscomb, Respondent’s WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">focuses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on patient-centered interventions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, only</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>some of which have an ancillary impact on staff safety.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This tendency to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">focus on the patient side of the equation makes some degree of sense given Respondent’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>contemporaneous,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">yet occasionally conflicting, responsibility to ensure the safety of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and its employees; however,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">tension<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">between patient and staff safety</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>highlights<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">some of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the systemic problems with Respondent’s WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Principal among those problems is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the lack of a targeted definition of workplace violence, which, in turn, impacts Respondent’s ability to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">effectively<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">develop and implement the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>itself.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally, the program requires<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the designated responsible persons to perform an evaluation of the WVPP on an annual basis</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to ensure<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it remains effective. (Ex. C-14).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The only copy of the WVPP introduced into evidence was neither dated nor signed.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified there was no evidence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent performed an<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">annual<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">evaluation of the WVPP, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">neither<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CNO Forster</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>nor Kara<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">McArtor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were both</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>designated “responsible</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>persons” under the WVPP, could recall whether<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">y</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>had participated in an evaluation of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">ii.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Responding to Act</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>of Aggression</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">When patients become agitated and start acting out, Respondent has a series of codes its employees can call over the intercom system to ask for help.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The two codes discussed extensively at trial were</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Code Lavender and Code Green.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Depending on how agitated the patient has become, staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">will<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">request</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a Code Green or Code Lavender<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">either by calling out loud</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, now that walkie-talkies are carried<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">by staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at all times, by calling over the radio. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1348</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Once the code is called for, the call is repeated three times to ensure it is heard and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">designated staff respond. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2345</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">a. </span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Code Lavender</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent, the Lavender team was created by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">non-managerial MHT “managers”,</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref21" href="#ftn21">20</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Kevin Smith and Jordan Larson. (Tr. 2294)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The basic idea behind the Lavender team was to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">create</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a team of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who were particularly skilled at verbal de-escalation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">intervene<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">prior to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the point where physical intervention was necessary.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The goal was to reduce the number of restraints</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which was part of a mandate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">PIC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>called “Be Free”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2295-2298</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Lavender team is made up of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">MHTs and nurses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and is designated in advance of scheduling</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">When a Code Lavender is called, the designated members of the team are supposed to respond</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however, there are instances where immediate response may be delayed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>because members of the team may have patient care duties</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which they cannot leave. (T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">r. 326). In order to address this</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>problem, which is equally applicable to Code Green</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>calls</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Respondent has designated a Patient Management Leader, or PML. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1761</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The PML</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, though not a manager/supervisor<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">per se</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is charged with leading the response to a code</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which includes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">interacting with the agitated patient and ensuring continuity of care for the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>remaining patients on the unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including observation rounds and special orders</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1761</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2315</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). At any given time, there may b</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e multiple trained PMLs on the schedule; however, only one is designated per shift.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2318-2320</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to some employees, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">overabundance of PMLs sometimes led to confusion and disagreement as to who was in charge during the calling of a code. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">518, 1083).</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent tracked the Lavender team’s efforts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>over the course of a year (approximately April 2017 to mid-2018)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and determined the initiative showed “significant effectiveness”. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1209-1211; Ex. C-36, C-37).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>In particular, Respondent noted the Lavender team had a 100% success rate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in avoiding restraints over a six-month period in the Intake Department and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reduced the use of restraints overall over a period of months. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2297-2299). Notwithstanding the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">drop</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in the use of restraints</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in early 2018, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">number of employee injuries resulting from patient assaults increased dramatically during that period of time</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1219-1220</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-51</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "> </p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "> </p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">b. </span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Code Green</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">When<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n agitated patient becomes physical, or when it becomes clear the enhanced verbal de-escalation techniques are no longer<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">effective, staff members can call a Code Green</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A Code Green implies physical management of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the patient may be necessary; however, not every Code Green results in a physical restraint</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. In some cases, the patient can still be verbally de-escalated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">If they cannot, however,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Code Green is designed to ensure an adequate number of staff members come to assist</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in the physical management of the patient using restraint techniques learned in CPI (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Crisis Prevention Institute) training</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">During the relevant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">period</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for this case,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a staff member would typically call for a Code Green by verbally calling out<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to the closest<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">person available</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Ideally, this message would be relayed to someone who had access to the telecom/PA system</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at the nurse’s station</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who would, in turn,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">broadcast</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the call for a Code Green three times.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref22" href="#ftn22">21</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Depending on the situation, however, the individual needing the call may have to run to the nurse’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>station to make the call on their own. Once the Code is called, designated responders from each unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>are responsible for going to the unit where the Code originated. As</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>with Code Lavender,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Code Green responders may have duties which do not permit them to immediately respond, such as one-to-ones</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, providing medications, or taking patients off-unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In that instance</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">PMLs are responsible for ensuring the designated responder’s duties are covered</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>during the pendency of the Code</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Sometimes, this includes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">calling on administrative staff, if available, to fill in; however,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>this is less likely on the overnight shift</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because administrators are not typically available<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at that time.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Ashley Mancha,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CPI training required</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>four people to initiate a hold in order to maintain safety. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">562). This assessment was fairly consistent across the board.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>In some<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">instances, however, staff testified they found themselves in situations where<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">there were not enough people to respond to a Code</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>multiple Codes were called simultaneously</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">517,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">562,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1036-37</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 1134</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staff testified in those moments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it felt as if the Code response was insufficient in terms of the number of people responding, the amount of time it took<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a sufficient number of people to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">respond, or both. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1036, 1090, 1134</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Other than<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the staff’s subjective perceptions of how long it took other staff members to respond</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on some occasions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, however, there is very little evidence to indicate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how long it took for staff to respond</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, nor is there any indication in the available records that time of response was a problem</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or reported to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">upper management</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2197</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">W</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hile staff also expressed concerns about the number of staff responding to a Code event</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the documentation of those events indicates a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">robust</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and timely<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">response</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1762, 1765, 2342-2343</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Once the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">response team arrives at the site of the Code, the on-location staff inform the PML of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">what has happened to that point. (Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>1772,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2153, 2315</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Under ideal circumstances, the PML will<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">subsequently debrief each responder</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as they arrive</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2153, 2315</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). From there,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a nurse will supply any needed medication, and the PML will direct the staff on how to proper</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ly</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>restrain the patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1772, 2315-2317</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Once the patient has been restrained or de-escalated,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent says it performs debriefs of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the incident with all involved parties, including staff and the patient.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref23" href="#ftn23">22</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2310</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Acc</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ording to Respondent’s policy, debriefs and camera review of the incident are required after a restraint and/or seclusion</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however, it does not appear this policy was consistently followed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr. 1204-1205;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-39</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ultiple employees testified th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ey did not participate in a debrief or camera review after they were injured</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>during a restraint or other act of aggression</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">370,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1082-1090,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1128).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further, even when a camera review took place, employees testified t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he debriefings took the form<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a critique of employee performance instead of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an opportunity to both discuss what could be done better and to address employee concerns about what precipitated the incident and how it could have been handled differently. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">578-580</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Debriefing and camera review could also result in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">retraining or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">skills</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>update in CPI restraint techniques; however, as with the debrief itself, employees testified such follow-up training would not always occur.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">485</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">I</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n addition to the foregoing, the PML will perform a debrief and maintain a log of the code</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and its particulars so the data could be used for future trending, tracking, and response. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1780; Ex. R-68).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This information is also used in Respondent’s Good Catch program, which recognizes employees who<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are able to manage a potentially dangerous<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">situation,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and which provides an additional educational opportunity for other staff members to learn from.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 2136).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:132px; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">c. </span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Restraint Reduction, “Be Free”, and ITU Expansion</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Seclusion and Restraint Reduction Team</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(later renamed the Patient Aggressi</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Response Team</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, aka “PART”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was a subgroup of PIC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was tasked with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reducing restraints and seclusions as compared to the UHS corporate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">benchmark. (Tr. 1185; Ex. C-36).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This subgroup was charged with developing risk reduction plans, which, according to Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, “focused on reducing the number of staff injuries because of patient restraints.”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Br</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>36</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ostensibly, this program was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">designed to reduce<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff injuries by reducing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the type of incidents Respondent believed to be the most substantial source of staff injury.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Notwithstanding Respondent’s successful efforts to reduce</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the number of restraints</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the number of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employee<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">injuries went up.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This phenomenon coincided with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">two changes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at Centennial Peaks: (1) an increase in the number of patient beds in the ITUs, and (2)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">instituting the “Be Free” initiative.</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In 2017, Respondent added 32 beds to its facility</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which Respondent states<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were dedicated to the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>ITUs. (Tr. 99).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Jason<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Offen</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, of those 32 beds, eight were added to the Pike<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ITU. (Tr. 345). Interestingly, both<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent and Complainant rely on the exact same passages</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to support th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ese facts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iven that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">eight</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>beds were added to Pike, for a 30% increase in capacity, there was no explanation as to what happened to the remaining 24 beds. For the sake of clarity</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and expediency</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, however, the Court will accept Respondent’s representation that 32 beds were added to the facility, representing a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">thirty percent (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">30%</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>overall increase in capacity,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and that those beds were exclusively added to the ITUs.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>345</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Not long after</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the expansion,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in mid-2018,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent instituted a new initiative entitled, “Be Free”, as part of its<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">program to reduce seclusions and restraints. (Tr</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. 1797).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">philosophy</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>statement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of the Be Free initiative was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Centennial Peaks is a place of healing that is committed to delivering restraint-free services to every individual that [they] support.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Ex. C-36 at 8).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Notwithstanding the patient-centered philosophy behind “Be Free”, Respondent asserts the focus was still staff safety</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which is why it developed a presentation and training sessions to roll out the initiative</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent claims<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the initiative<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">came with several enhancements</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to the protocol for responding to patient-on-staff aggression</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">post-incident assessments, (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">risk investigation, including debrief and camera review, interviews, and determination of whether additional clinical intervention is needed;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) a second medical opinion for any patient who had multiple restraints.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref24" href="#ftn24">23</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr. 1800; Ex. C-39).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>CNO Forster also testified he added staff to the ITUs in order to account for the expansion and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Be Free initiative. (Tr. 1800-1801).<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CNO Forster testified he added staff after the expansion of the ITUs; however, the Matrices for 2017 and 2019 tell a different story. (Tr. 1800-1801). According to the Court’s analysis of the 2019 Matrix, as compared to 2017, Respondent reduced the number of required staff by one at the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">following census levels in the Pike Unit: 20 patients, 24-27 patients, and 28-30 patients. (Ex. C-74, C-75).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For example, i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n 2017, a census of 20 patients required<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">five</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staff during the day and evening shifts and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">four</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staff during the overnight shift. (Ex. C-74).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">I</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019, the same census required<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">four</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staff during the day and evening shifts and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">three</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>during the overnight. (</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Similar changes were imposed in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Crestone</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Torrey, and Sunlight</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>units</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-74,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-75).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As noted above in the discussion regarding Code Lavenders and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">PART, Respondent anticipated a reduction in staff injuries<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">through reducing the number of restraints. Unfortunately, as the data<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">illustrated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, that did not happen.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Employees testified there were a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">couple</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of explanations for the failure of the Be Free/Restraint Reduction initiatives</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. First, according to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">some employees, it was not clear the program was designed with staff safety in mind; rather, consistent with the philosophy statement, the program<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">had the appearance of focusing on patient safety with staff injuries being an ancillary consideration.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 575, 1099).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This understanding appeared to be<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">confirmed by meeting minutes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discussing the initiative. Specifically, the data presentations from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a Seclusion and Restraint Committee meeting indicate Respondent was tracking<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">seclusions, restraints, and special orders, but no data or analysis was presented on the topic of employee injuries resulting from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">such incidents. (Tr. 1213-1215; Ex. C-37).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Second, b</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">oth</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Mancha</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Wells</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified the Be Free program</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, as presented,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>created confusion</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">some staff were reluctant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">participate in restraints without prior permission from Forster,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">McArtor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, or Smith</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">his hesitation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, they believed,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>resulted in more injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">576-582).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identified a couple of reasons for the significant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>increase</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>employee injuries in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>2018</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. First, Respondent claims<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the unexpected rise was due, in part, to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nature of the patients who had to be restrained after enhanced de-escalation efforts were undertaken. Specifically, Respondent contends<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">these patients were more likely to be physically aggressive and, presumably,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cause more injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which is consistent with one of its primary arguments that staff injuries are the result of confrontations with a small population of outliers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 1799-1800).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Second, Respondent contends the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">increase in injuries was attributable to an increased emphasis on reporting employee injuries during the relevant time period.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on those conclusions, Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ended the Be Free initiative</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>around the same time it was determined the Lavender team was successful<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in its mission to reduce restraints—and, thus, stopped data tracking</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—and instead chose to focus its efforts on clinical management of patient aggression. (Tr. 1228; Ex. C-54).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:132px; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">d. </span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">CPI</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
						</span>and WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
						</span>Training</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As part of the new employee orientation,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">direct care<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff were required to take CPI training, which was spread out over the course of two days and included training in verbal de-escalation and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">physical restraint techniques.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref25" href="#ftn25">24</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">412, 2373-237</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">6</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-48</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Kevin Smith, the CPI coordinator and master trainer</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, was responsible for providing instruction, certifying<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">competencies, and tracking and providing follow-up training to ensure staff maintained their CPI certification. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2306-2307</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The basic gist of CPI training is to utilize<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">verbal de-escalation and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">only<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">if necessary, restraint maneuver</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s, which are based on the biomechanics of the human body</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2318</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2376</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-77</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-45</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). According to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Smith</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">premising the physical restraints<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on biomechanics means<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CPI</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-based</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>restraint<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">maneuvers are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>not dependent on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">size or strength</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of the person initiating the hold</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and should be able to be<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">performed with as few as two staff members.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2318, 2390</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">If performed correctly, the principles of CPI should serve to reduce the likelihood of injury for both staff and patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, whether through verbal de-escalation or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">using</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">physical holds</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">207).<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In 201</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">7</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a new curriculum was developed by the Crisis Prevention Institute, entitled Advanced CPI. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2381</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In June 2018, a UHS Clinical Training Coordinator<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">recommended implementation of Advanced CPI because Respondent was using a particular hold that was not from an approved curriculum. (Ex. C-46 at 2).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent began implementing the advanced CPI program in September 2018. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2380</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). By the time of the inspection, roughly one-half<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to three-quarters<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of Respondent’s employees had completed this training. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2378-79</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Although Complainant questions why all of Respondent’s staff had not been trained in Advanced CPI at the time of the inspection</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, there is no evidence to suggest<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the content of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">either regular CPI or Advanced CPI is insufficient in terms of pr</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">eventing injury vis-à-vis any other training program designed for the same purpose</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, nor was there any evidence to suggest the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">way</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent presented it was insufficient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">To support CPI training, as well as Code Green response</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Respondent instituted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Code Green drills and utilized actual Code Green</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">drills<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n avenue for training/retraining the concepts learned in orientation and refresher training.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Kevin Smith<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sought to improve upon the Code Green drills, and created a CPI drill</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>purportedly more structured, involved actual scenarios, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>done more frequently. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2115, 2308-2309; Ex. R-56).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Even though Smith testified the drills happened more frequently, there is only documentation of these drills happening in October and November 2018. (Ex. R-56).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staff members were not as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">complimentary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in their assessment of the effectiveness of CPI and the training regime that accompanied it.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">she did not believe the CPI techniques were sufficient when<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">attempting to restrain<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a patient of significant strength or size</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">457, 521).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Another complaint<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">levied against the program is the fact that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>some staff members could not properly utilize CPI techniques or simply refused to perform those duties. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">393, 1135).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally, employees testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">refresher training was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">often mandated but not usually provided</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr. 484-85).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent has a documented WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which it says was made available via its intranet site. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2262).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">None of the employees who testified at trial remembered seeing the WVPP document, nor did they recall ever receiving training specific to the WVPP, itself. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1096, 1145.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees were trained on the component pieces discussed in the WVPP; however, neither<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">McArtor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Smith,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or Forster<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">could recall whether Respondent ever held a training session discussing the WVPP<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and how it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">connects the disparate programs targeted towards reducing workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2300)</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:132px; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">e. </span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Incident and Injury Tracking</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">If an employee<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">injured during an encounter with an aggressive patient, Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>had<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a policy requiring reporting of all employee injuries, regardless of severity. (Ex. R-43).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The policy</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>lays out the respective responsibilities of the injured employee,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">supervisors, human resources, and loss control and preventi</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. R-43).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In the event of an accident, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WV</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>requires the injured employee to call<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Sedgwick hotline to report the injury</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref26" href="#ftn26">25</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Sedgwick is a claims management company, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">provides clinical consultation for the injured employee, including whether the employee should pursue medical care for the injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 2239, 3842). Sedgwick is also responsible for compiling the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">injuries into the OSHA 300 log. (Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>2239-2240</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">utilized<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">other methods for compiling information about employee assaults, including EARs,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Healthcare Peer Reviews (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">HPRs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(also referred to as MIDAS reports), and shift handoff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>reports.<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition to reporting the injury to Sedgwick, employees (or their supervisors) are expected to fill out an EAR</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">106</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-43</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In many instances, however, these reports were not filled out</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>did not perceive their injuries rose to the level of reporting. In other instances,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">EARs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>did not get filled out because employees did not receive training on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how, when, or whether to fill out an EAR. (Tr. 126-27, 584-86)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This was more or less confirmed by Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Education Coordinator, Carolyn Walker, in response to a query from the HR Director, Erika Donnellan. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr. 2257;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-83).<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent also had another series of reports called HPRs, which are also referred to as MIDAS reports</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The HPRs are primarily designed for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reporting patient-related incidents</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">McArtor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified they can also be used to collect data on employee injuries.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 1162, 2094</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). The MIDAS system did not have a data<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">entry point</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for employee injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1162, 2209</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Instead, HPRs had a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">narrative section where injuries could be described; however, as noted by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">McArtor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Mancha</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>depend</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on the individual filling out the report</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was not always done. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2209</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-72 at 32</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Those individual reports were then<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">compiled into a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">summary log. (Ex. C-72).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While Respondent claims the HPRs were filled out not only for restraints and seclusion, but also for acts and threats of violence, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">data and evidence show otherwise.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In particular</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the HPR</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>summaries show<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">general categories, such as “patient out of control” or “patient attacked staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—for which there was no discernible distinction</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—but do not necessarily indicate whether a staff member was injured, threatened, or otherwise unless included in the narrative</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As noted by Complainant, in one instance</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on July 6, 2018</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, four employees were injured during a restraint</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of patient SL, but the HPR summary entry does not include any information regarding the injuries. (Ex. 2209-2210; Ex. C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">72 at 32).<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">HR Director was responsible for tracking and trending all employee injuries, which she shared with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Risk Manager. This information, in turn, was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discussed at various meetings, including daily flash meetings</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and PIC meetings.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>35 (citing Tr. 2242-2243).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to the HR Director, Erika Donnellan</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, she was responsible for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">maintaining employee files and reporting employee injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but was not responsible for any portion of the WVPP or policies related to patient-on-employee violence. (Tr. 2260</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2262).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Instead, she testified she was responsible for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employee-on-employee violence. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2263</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Kara<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">McArtor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a designated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">responsible person under the WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, did not receive EARs (because they were sent to Donnellan)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>not formally notified of employee injuries, and did not know whether it was mandatory for employees to report all injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 1179, 1240</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex. C-14 at 5).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Nevertheless,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">McArtor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was responsible for data reporting in the PSC meetings</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">she culled from the HPRs, and Donnellan was responsible for EAR reporting at PIC meetings</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 1179-80,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2262).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>found the system of injury/incident reporting lacked consistency and Respondent’s system of review lacked cohesion, which he attributed to a confusing system of managerial responsibility for data collection and reporting, as well as the failure to train staff on accident reporting protocol. (Tr. 126, 158).</span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">V.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Analysis</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>facts of this case illustrate the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence in an inpatient psychiatric/behavioral facility</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">difficult to assess and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">wide-ranging</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in terms of the considerations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>an employer like Respondent must make to address it</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For this reason, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">guidance from OSHA, T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">JC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and the relevant scientific community</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>indicates</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the response to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard must be comprehensive in its scope</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, yet adaptable in its particulars</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">12 at 11).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This requires<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a systematic</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, process-based</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>approach<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to violence that goes beyond individual,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ad hoc</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>abatement strategies<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and, instead,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">establishes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a program through which all<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policies and procedures are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">developed and implemented</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">answer, according to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">industry guidance</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>W</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">VPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-12</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, C-13).<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court is mindful<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that, due to the nature of the problem, complete elimination of the hazard is an admirable, yet perhaps not entirely achievable, goal.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref27" href="#ftn27">26</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Indeed, even Complainant admits it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“is not proposing that employee injuries from patient aggression must be entirely eliminated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in order for Respondent to adequately protect employees from the hazard of workplace violence.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Compl’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">54</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>n.6.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">However,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">just</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">complete elimination of the hazard is not possible does not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lessen Respondent’s obligation under<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the general duty clause.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">29 U.S.C.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">§ 654(a)(1)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Crafting a response to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a multi-faceted hazard requires a multi-faceted approach</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Indeed, for as much as Respondent pounds its fist about the scientific reliability of any individual method of abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the science support</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a comprehensive and systematic approach to workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that is inclusive of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">many<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of the recommended abatement measures proposed by Complainant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Notwithstanding this fact,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, as it reiterated numerous times at trial and in its brief,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>focuses primarily on the clinical approach to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient-on-staff violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based upon these statements</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, it is not surprising Respondent’s WWVP<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">places its<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">focus on patient clinical care</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Unfortunately, as illustrated by this case, the clinical approach is not enough on its own to completely address the hazard, regardless of its importance to preventing patient aggression.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref28" href="#ftn28">27</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court finds Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policies as well as its<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">approach to workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">insufficient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. While Respondent undoubtedly has a policy document entitled</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“Workplace Violence Protection Plan”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the following analysis shows<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">neither the program itself, nor the initiatives purportedly<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">carried out under its banner,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are effective at abating the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Accordingly, the Court shall affirm the Citation in the manner discussed below.</span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">A.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">The General Duty Clause</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The general duty clause requires employers to “furnish to each of his<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>employment and a place of employment which are free from recognized hazards that are causing or likely to cause death or serious physical harm . . . .” 29 U.S.C. § 654(a)(1)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also referred to as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">§<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">5(a)(1)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Austin Bldg. Co. v. Occupational Safety<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">& Health Review Comm’n,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>647 F. 2d 1063, 1069 (10th Cir. 1981).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">I</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n order to prove a violation of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">§</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>5(a)(1) of the Act, Complainant must show: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) there was an activity or condition in the employer’s workplace that constituted a hazard to employees; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) either the cited employer or its industry recognized that the condition or activity was hazardous; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) the hazard was causing or was likely to cause death or serious physical harm; and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iv</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) there were feasible means to eliminate the hazard or materially reduce it.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Baroid</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Div. of NL Indus., Inc. v. Occupational Safety & Health Review Comm’n</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>660 F.2d 43</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">9</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 444 (10th Cir. 1981).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See also</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Waldon Health Care Ctr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 16 BNA OSHC 1052, 1058 (No. 89-3097, 1993). The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">evidence must also show the employer knew, or with the exercise of reasonable diligence, could have known of the hazardous condition.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Otis Elevator Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 21 BNA OSHC 2204, 2207 (No. 03- 1344, 2007).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Specifically, Complainant alleges Respondent violated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">§<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">5(a)(1) of the Act as follows:</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS of Centennial Peaks LLC., dba Centennial Peaks Hospital, at 2255 S 88th Street, Louisville, CO: On and proceeding 12/7/18, the employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely cause death or serious physical harm to employees in that employees were exposed to physical threats and assaults by patients. Employees, including nurses and mental health counselors, were exposed to incidents of violent behavior by patients that resulted in serious injuries<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">including bites, sprains,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lacerations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, bruising, scratches, concussion, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to the head, torso and legs from punches, kicks, forceful grabs, pushes, and tripping. Employees were exposed to the hazard of physical threats and assaults during routine interactions with patients who had known histories of violent behavior. The employer had not established or implemented effective measures to protect employees from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assaults or</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>other physical violence in the workplace.<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:96px; margin-right:96px; "> </p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-right:96px; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Citation and Notification of Penalty, Citation 1, Item 1. </span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As stated above, due to Respondent destroying videos which the Court found Respondent had an obligation to preserve as relevant evidence,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">issued<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sanction</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>against</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent and imposed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adverse inference</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the destroyed videos would have established all<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">elements of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">prima facie</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>case</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>including knowledge</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">except for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the feasibility prong of the general duty clause analysis</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the adverse<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inferences,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">only has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to prove<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s policies did not adequately address the hazard of workplace violence and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">whether there were feasible means to eliminate the hazard or materially reduce it.</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">Complainant must establish<span>
						</span></span><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">this<span>
						</span></span><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">element</span><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; "><span><span></span>
						</span>by preponderance of the evidence.<span>
						</span></span><span style="font-size:11.5pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; font-style:italic; ">See Hartford Roofing Co.</span><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">, 17 BNA OSHC 1361 (No. 92-3855, 1995). “Preponderance of the evidence” has been defined as:<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">The greater weight of the evidence, not necessarily established by the greater number of witnesses testifying to a fact but by evidence that has the most convincing force; superior evidentiary weight that, though not sufficient to free the mind wholly from all<span>
						</span></span><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">reasonable doubt, is still sufficient to incline a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>fair and impartial mind to one side of the issue rather than the other.</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:102px; margin-right:48px; "> </p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:11.5pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; font-style:italic; ">Preponderance of the Evidence</span><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">, B</span><span style="font-size:10pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">LACK’S<span>
						</span></span><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">L</span><span style="font-size:10pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">AW<span>
						</span></span><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">D</span><span style="font-size:10pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">ICTIONARY<span>
						</span></span><span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; ">(10th ed. 2014).</span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">i.</span><span style="font-size:11.5pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:11.5pt; font-weight:bold; ">Respondent Was Aware of the Hazard</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Though the parties did not stipulate to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">issue of knowledge, the Court’s adverse inference applies to each element of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">prima facie</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">case, with the exception of the element of feasibility.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Specifically, the Court’s adverse inference on knowledge found the destroyed videos would have provided Respondent with actual knowledge.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Additionally, the Court finds this element is not</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>subject to reasonable dispute. Everyone from the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">MHTs to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CNO, COO, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CEO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(which were supervisors/managers)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of Centennial Peaks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>w</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>aware of the workplace violence hazard, which is memor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ialized in the testimony presented in this case, the reports submitted to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Centennial Peaks administration, the employee surveys,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">EARs, HPRs,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">many other documents recounting the same.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The question in this case is not whether anyone was aware of the hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but whether Respondent’s response to the hazard was adequate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Thus, it is unnecessary for the Court to engage in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a lengthy analysis about whether<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a particular individual was aware or could have been aware</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of the hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, whether that person was a supervisor, or whether it was foreseeable<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">person in question<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">would engage in unsafe conduct.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See, e.g.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Mountain States Tele. & Tele.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">v</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">. OSHRC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>623 F.2d 155 (10th Cir. 1980).</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref29" href="#ftn29">28</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Accordingly, the Court finds Respondent had actual knowledge of the hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and such knowledge can be imputed to Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "> </p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">ii.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Feasibility Prong<span>
					</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Prior to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assessing a particular abatement proposal</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, however, Complainant must show “as a threshold matter, that the methods undertaken by the employer to address the alleged hazard were inadequate.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra Health M</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">gmt.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>No. 13-1124,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *12 n.14 (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">O</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">H</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ar. 4,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">see also Sea World of Fl</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">a.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">, LLC v. Perez</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 748 F.3d 1202 (D.C. Cir. 2014) (holding adequacy of employer’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>precautions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>measured against precautions taken by “a reasonably prudent employer familiar with the circumstances of the industry”).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In making the threshold determination that Respondent’s existing abatement regime is insufficient, the Court is guided by the D.C. Circuit’s analysis in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC N</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">w.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Psychiatric Hosp</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>LLC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 951 F.3d 558, 564</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(D.C. Cir. 2020). In that case, the employer challenged the ALJ’s conclusion that “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the recommended measures would materially reduce the hazard of patient violence beyond what Brooke Glen’s existing safety program already achieved.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 951 F.3d at 564. In particular, the employer asserted the ALJ should have placed more emphasis on its expert’s testimony, which, for the most part, focused on whether the hospital’s existing abatement measures were consistent with the industry’s response to workplace violence.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>In response, the D.C. Circuit reiterated its prior holdings, which state, “‘[A] safety precaution’ that ‘is recognized by safety experts’<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">need not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">‘</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find general usage in an industry</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or have<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">‘</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">become customary</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">‘</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its absence [to] give[ ] rise to a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>violation of the General Duty Clause.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(citing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Nat’l</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Realty</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 489 F.2d<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1257,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1266 n.37</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(D.C. Cir. 1973).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">If Respondent’s existing means of abatement are determined to be inadequate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, or plain absent,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as compared to precautions taken by a reasonably prudent employer, Complainant must then show: (1)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>proposed measures are capable of being put into effect, and (2) those methods would be effective in materially reducing the incidence of the hazard.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Integra.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2019 WL<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1142920</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *12 (citing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Beverly Enters., Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 19 BNA OSHC 1161, 1190 (No. 91-3344, 2000) (consolidated)).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Indeed, in many of the recent Commission and circuit court cases discussing the general duty clause, one of the primary considerations was whether OSHA established the effectiveness of the proposed method of abatement. For example, in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the employer argued the Secretary failed to produce evidence of how the proposed abatement measures would reduce the employer’s “already low rate of patient aggression.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">951 F.3d at 564</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The D.C. Circuit noted two problems with the employer’s argument—one factual and the other legal. First, the circuit court cited with approval the ALJ’s conclusion that Respondent’s reporting process was flawed and thus “diminish[ed] the significance of its recorded rate of patient aggression.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Second, the court noted that, even were it to accept the incidence rate documented by the employer, “[A] low rate of workplace accidents cannot alone establish compliance with the General Duty Clause.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Rather, as it articulated previously in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">National Realty</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">‘</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[H]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">azardous</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>conduct need not actually have occurred,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or have occurred at any particular rate, for an employer to be liable.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(quoting</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Nat’l</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Realty</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 489 F.2d at 1267</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Instead, the key question will always be “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">whether the Secretary’s measures would appropriately safeguard employees by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">‘</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">materially<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reduc</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">] the hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of patient-on-staff violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at 565 (quoting</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">SeaWorld</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 748 F.3d<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1202,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>1215</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(D.C. Cir. 2014))</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Ultimately, the court determined the employer’s existing safety protocols were incomplete and/or inconsistently implemented and that a “comprehensively considered and applied program would materially reduce the hazard.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The standard for assessing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the effectiveness of a particular abatement proposal</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is not necessarily mathematical. In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the D.C. Circuit held:</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:16px; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Contrary to Brooke Glen’s assertions . . . , the Secretary need not quantify the extent to which that program and its component parts “would have materially reduced the likelihood” of patient-on-staff violence,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Nat’l</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Realty</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 489 F.2d at 1267. Instead, the Secretary satisfied the General Duty Clause’s test by establishing that a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">comprehensive workplace safety program would more effectively and consistently apply measures designed to reduce patient-on-staff violence than Brooke Glen’s present system did.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 951 F.3d at 565. In that respect, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Commission</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>ha</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>found expert testimony, insofar as it is reliable, is sufficient to establish a particular abatement method would materially reduce the hazard.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ee Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *13-14 (finding expert testimony regarding material reduction of hazard of workplace violence sufficient without requiring expert to quantify extent of reduction).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The e</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ffectiveness of a particular abatement proposal can also be established through</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the identification of the</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>successful use of a similar approach elsewhere and compliance with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">industry standards.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref30" href="#ftn30">29</a></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Pepperidge Farm Inc.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 17 BNA OSHC 1993 (No. 89-265, 1997).</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">iii.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Abatement as Process<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">vs. Alternative Abatement Proposals</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">One<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">final<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">issue</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the Court<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">must</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>dispose of before addressing the details of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s abatement proposals is the manner in which Complainant has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposed them.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Relying on the Commission’s recent decision in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">A.H. Sturgill</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Roofing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Respondent contends</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Complainant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has couched these abatement proposals as alternative forms of abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See A.H. Sturgill Roofing</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">No. 13-0224, 2019 WL 1099857 (O</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">H</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Feb. 28, 2019)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Specifically, Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">suggests<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it need not implement every proposed abatement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">measure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because just</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>one of Complainant’s proposals would be sufficient to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">materially reduce the hazard.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant, on the other hand, argues the abatement measures proposed in the Citation are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">elements of a process-based approach to abatement.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Compl’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">61. The Court agrees with Complainant.</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to the Commission,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“[W]here actual injury is present and substantial causation has been shown, the Secretary may require [an employer] to engage in an abatement process, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">goal of which is to determine what action or combination of actions will eliminate or materially reduce the hazard.”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Pepperidge Farm Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">17 BNA OSHC 1993,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>2034</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(No. 89-0265, 1997)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This approach has been recognized in recent cases addressing the same subject matter as the present case.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">, e.g.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">UHS of Westwood</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>No.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">17</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-0737,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2022 WL 774272</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>*8</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary’s approach in this regard aligns with the nature of workplace violence, which as alleged here arises in different contexts and conditions at Pembroke, necessitating different abatement measures.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">but see Sturgill</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1099857</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">*9 (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">finding abatement measures to be alternatives where “any one of them would constitute abatement of the alleged violation”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On the flip side</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of this coin, if abatement measures are proposed as alternatives</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, then proof<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent implemented any<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>individual</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>proposal</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>constitutes abatement of the violation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant made clear</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>propose</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the suggested abatement measures<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as a process by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which Respondent could achieve a material reduction in the hazard of workplace violence.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>In fact,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">much of Complainant’s case was premised on the concept of a thoroughgoing and comprehensive<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence prevention plan that incorporated most, if not all, of the proposed measures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The primary thrust</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Lipscomb’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testimony and report</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, upon which Complainant substantially relied,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was the importance of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a comprehensive, process-based approach to workplace violence prevention</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1310-1311</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>C-58</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Although Respondent argues</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Complainant’s proposals were alleged as alternatives, the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">re is no evidence to support this.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This matter was tried by Complainant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as a process by which Respondent could achieve a material reduction in the hazard of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">addressed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>through direct</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and cross</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">examination testimony and exhibits.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Accordingly, the Court finds Complainant has properly proposed the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">abatement proposals as a process-based approach to workplace violence.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The characterization of the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>abatement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposals</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">either<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">alternatives</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">components of a process of abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>dictates</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Complainant’s burden of proof with respect to this element.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>As noted above, if a set of proposals</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is couched in the alte</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rnative, then<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant must prove Respondent has implemented none of the measures.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Sturgill</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1099857</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *9</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">However,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">where Complainant has proposed a series of abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>measures as a process</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or as components of a single means of abatement,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant need only show Respondent failed to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implement one of them</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">see also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">UHS</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, No. 17-0737, 2022 WL 774272,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>*8<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[T]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Secretary need only prove that at least one of the measures he proposed was not implemented and that the same measure is both effective and feasible in addressing the alleged hazard.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC N</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">w.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 951 F.3d<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">564 (Secretary proposed “menu” of abatement options to materially reduce workplace violence hazard alleged under general duty clause)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Thus, in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Commission</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>limited its analysis to two abatement proposals—equipment for summoning assistance and equipment for de-escalation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when it determined UHS Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violated the general duty clause.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">UHS</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, No. 17-0737, 2022 WL 774272,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">*9,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>n.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>11.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Notwithstanding the Commission’s holding, the Court will<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">address each of the proposed forms of abatement below</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Section<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">V.d.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">B.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Credibility/Persuasiveness of Experts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A substantial<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">amount of time, roughly<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">three days, was dedicated to expert testimony in this matter.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s noted above,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Commission has held reliable expert testimony is sufficient itself to establish a particular abatement method<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">would materially reduce the hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>even if the expert cannot specifically quantify the extent of the reduction.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ee Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *13-14</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court analyzed the credibility of each expert<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">based on</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>their demeanor, motivation, clarity, and reliability</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Although each<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was properly qualified as an expert in this matter, the Court finds their opinions are not entitled to equal weight</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">i4i Ltd. Partnership v. Microsoft Corp.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 598<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">F.3d 831, 852 (</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Fed. Cir. 2010) (“When the methodology is sound, and the evidence relied upon sufficiently related to the case at hand, disputes about the degree of relevance or accuracy<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(above this minimum threshold) may go to the testimony’s weight, but not its admissibility.”)</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">564 U.S. 91 (2011)</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">i.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Dr. Jane Lipscomb</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">, PhD</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Lipscomb</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was qualified as an expert<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>workplace violence in healthcare and behavioral health settings.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">She</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>has been<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">studying workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for over<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">thirty (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">30</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>years, including independent research, publications, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">consultation with both government and private entities. (Ex. C-57).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Her career started<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when she worked as a staff nurse at University Hospital in Boston from 1976-78</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which she followed up with a stint a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s an Epidemic Intelligence Service Officer and Nurse Epidemiologist</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the National Institute</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of Safety and Health (NIOSH)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">from 1981-1984</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 1288).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Lipscomb earned her<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ph.D.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in epidemiology</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>from</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the University of California, Berkeley</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, during which time she also taught epidemiology at the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">University of California, San Francisco</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(UCSF)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 1290).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">After her stint at UCSF</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, she returned to NIOSH</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, where she advised the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">D</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">irector on a host of issues, including workplace violence, which she had<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">written about during her time in California. (Tr. 1291).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">After NIOSH, Dr. Lipscomb went back to teaching at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the University of Maryland, where she stayed for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">twenty (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">20</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>years, during which time she<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">spent the better part of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ten</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>years studying workplace violence full time and even developed a course entitled “Violence as a Public Health Problem”. (Tr. 1292).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to her<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Curriculum<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">V</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">itae</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Dr. Lipscomb has published<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">over<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">twenty-five (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">25</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>articles addressing the issue of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in the healthcare setting</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">including a handful<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">dealing specifically with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violence in a behavioral healthcare context. (Ex. C-57).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition, Dr. Lipscomb has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">served as principal investigator</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, co-investigator, or consultant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">seven</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>different<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">research and evaluation studies</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">presented<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">papers/speeches</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on workplace violence at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ten</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>conferences/seminars;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and has been honored multiple times for her work in that area. (Ex. C-57). Dr. Lipscomb’s research was also instrumental in developing the OSHA Guidelines for Workplace Violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">subsequent publications related thereto. (Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-12, C-13).</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In this Court’s opinion, Dr. Lipscomb’s testimony credibly and directly addressed the sufficiency of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s abatement methods and the feasibility of Complainant’s proposed measures.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further, with perhaps one exception, Dr. Lipscomb’s testimony went<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">largely<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">unrebutted by</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>fact witnesses or</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent’s expert, Dr. Marc Cohen</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, whose testimony was largely based on personal experience and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>research he found for the purposes of this<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">case,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but which is not related to his primary field of study</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, forensics</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Lipscomb’s opinions, on the other hand, are not only based on studies she personally performed but also upon<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">studies that are within her field of expertise. This, above all, sets her apart from Dr. Cohen</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, whose testimony<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">wa</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s largely dependent upon<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">their individual,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">personal experience</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and studies they found<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">but do not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">relate specifically to their field of study.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Lipscomb’s testimony</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was based on an intimate understanding of the problem of workplace violence due to a career spent studying it. As such the Court has relied extensively on her conclusions in this matter.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Accordingly, the Court assigned the testimony of Dr. Lipscomb controlling weight except for the one instance noted below.<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">ii.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Dr. Monica<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Argumedo</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was qualified as an expert in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">evaluating and clinical management of psychiatric patients and in the efficacy of abatement measures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to address workplace violence. (Tr. 777-779). She<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has been practicing psychiatry for over<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">seventeen (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">17</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>years</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including receiving board certification in general psychiatry in 2010 and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">forensic psychiatry in 2011. (Tr. 758-59; Ex. C-27).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>received her medical degree from the Illinois College of Medicine in 2004<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and completed a four-year residency program at Georgetown University Medical Center</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, during which time she became chief resident in charge of the hospital’s inpatient psychiatry unit.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 755-56).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Since that time</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>has</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>primarily</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>worked in the field of forensic psychiatry</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, performing assessments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of those charged with crimes to determine whether they are fit to stand trial, as well as serving as an expert witness</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 761-62; Ex. C-27).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">However</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, in addition to her forensic practice, Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>has intermittently served<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at inpatient psychiatric facilities, in which she has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">served as director of intake</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and provided general psychiatric services.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 763-69; Ex. C-27).</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For the most part, Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testimony was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">based on her personal experiences as a psychiatrist in inpatient facilities; she has not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">engaged in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">independent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>research on the topic of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>other than studies she found for the purposes of this case.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>That said, to the extent Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>opinions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">whether based on research or her own experience</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">align with Dr. Lipscomb’s, the Court finds such agreement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">should be due</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">substantial</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, but not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">controlling, weight</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">iii.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Dr.<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Marc Cohen</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Cohen<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was qualified as an expert</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in the field of psychiatry</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1895</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">He received his medical degree from the University of Southern California in 2003</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and did his residency at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the UCLA</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">/San Fernando<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Valley Psychiatry Residency Program, during which time he became chief resident from 2006 to 2007. (Ex. R-1).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">He also took part in the UCLA/VA Forensic Psychiatry Fellowship program.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Like Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Cohen is board certified in general psychiatry and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">forensic psychiatry. (Ex. R-1).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">During his career, Dr. Cohen has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">served as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an Associate Clinical Professor at the UCLA<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">School of Medicine in the Department of Psychiatry and Biobehavioral Sciences</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff psychiatrist for the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Twin Towers Correctional Facility, the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>VA</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Olive View-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UCLA Medical Center</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">psychiatry expert in mental health court; and as a forensic psychiatrist. (Ex. R-1).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">He has also given two presentations on workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to the Employment Law Institute and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Practicing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Law Institute</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however, neither<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">addressed the specific issue of workplace violence in an inpatient psychiatric unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. R-1).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Like Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Dr. Cohen’s testimony was premised, in large part, on his personal experiences and on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">studies he found specifically for the purposes of this litigation.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On those bases, Dr. Cohen</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>opined that the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>efficacy of the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>proposed abatements, taken individually,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were not supported by peer-reviewed studies</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s will be shown in more detail below,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>many of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the studies Dr. Cohen relies on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are either<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">limited in their scope, such as the nurse’s station<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">study</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">focused on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">single nurse’s station in a single inpatient unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(ii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">anecdotal, such as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Due article, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">consisted of 34 total hours of the researchers’ recorded observations;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">dependent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>limited</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">self-reporting</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, like the Shannon article, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">looked at only 19 reports over the course of 4 years</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and based its conclusion about the counter-therapeutic effect of security presence on a single anecdote</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 2028</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2047-20</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">60</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-2</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This stands in stark contrast to the peer-reviewed studies Dr. Lipscomb relied upon, which showed that a comprehensive WVPP, consisting of many of Complainant’s proposed measures,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">would be materially effective at reducing the hazard by up to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sixty percent (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">60%</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-58</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further undermining Dr. Cohen’s opinion is the fact that he admitted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he neither reviewed, nor was he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">charged with offering</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>opinions on, the elements of Respondent’s WVPP.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 2074-75). To the extent he offered an opinion on such matters,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>limited to a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">conclusory statement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that the existing regime was consistent with his understanding of industry practice</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and was based on his review of deposition testimony</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1895</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In some cases, however, Dr. Cohen readily admitted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">certain proposals would have a positive<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">effect on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence, such as personal alarms or walkie-talkies</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>limiting access to nurse’s stations (without fully enclosing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>them).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While there are areas where the Court relied on Dr. Cohen’s assessment, particularly<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">with respect to the question of hazard transference from staff to security, the Court<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">did not place significant weight on Dr. Cohen’s testimony</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>with respect to the effectiveness of Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policies and procedures or with respect to his assessment of the effectiveness of Complainant’s proposals</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for the reasons stated below</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">C.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">The<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">OSHA Guidelines</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>& Roadmap</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">for</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>Healthcare Facilities</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Most, if not all, of Complainant’s proposals can be<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">found in, or are at least based on,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a set of three publications:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">OSHA’s Guidelines for Preventing Workplace Violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Guidelines)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Preventing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Workplace Violence: A Road Map for Healthcare Facilities</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Road</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ap)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Joint Commission’s Sentinel Event Alert</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: Physical and Verbal Violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Against Health Care Workers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Sentinel Alert)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-12,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-13,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-62)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As noted by the parties, neither of the foregoing documents present mandatory standards</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, nor do they<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">create new legal obligations. (Ex. C-12 at 4)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Nevertheless, r</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">egardless of whether the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">uidelines are mandatory standards or not</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">they</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>recognize</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employers are bound by the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">general duty clause</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and by its reasonable and prudent employer standard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-12 at 4</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Guidelines</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>were<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">originally produced in 1996, were updated again in 2004</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and updated most recently in 2018. (Ex. C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-12).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">They were devised<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">specifically for health care and social service settings, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">psychiatric facilities. (Ex. C-12 at 7)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. According to the Overview, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">uidelines were developed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">based on “industry best practices and feedback from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">stakeholders and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>provide recommendations for developing policies and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">procedures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to eliminate or reduce workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in a range of healthcare . . . settings</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.” (Ex. C-12 at 7).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Those recommendations ultimately<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">form the basis of a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">model<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence protection program</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which is broken down into its constituent parts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shows</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>how it would apply in various settings using charts and checklists.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Ex. C-12 at 20, 24).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">uideline</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the recommendations<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reflect the variations that exist in different settings and incorporate the latest and most effective ways to reduce the risk of violence in the workplace.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">” (Ex. C-12<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at 7).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Guideline</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">recommendations are informed by</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>an extensive bibliography of workplace violence studies</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including studies by the C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">enter for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">D</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">isease<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ontrol (CDC)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, international standards</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>associations,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>state departments of health,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>multiple publications from Dr. Lipscomb, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Sentinel Event Alert from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">TJC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-12 at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">40-45).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Road Map</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>essentially provides the same framework as the Guidelines, upon which it is based. (Ex. C-13). The difference, however, is the Road Map uses concrete examples of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how various healthcare facilities, including inpatient psychiatric facilities,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">have</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>successfully</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>utilized workplace violence policies and procedures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>like those discussed in the Guidelines and Road Map</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-13).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e exemplar facilities were selected, in part, from publications; however,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in most cases, OSHA performed site visits</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, held meetings, and conducted interviews. (Ex. C-13). Of those facilities, they all acknowledged<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a WVPP were works in progress subject to continuous improvement. (Ex. C-13</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at 4).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The third document is the Sentinel Event Alert</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>workplace violence against healthcare workers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is published by</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Joint Commission (TJC)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">JC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on-profit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>accrediting and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">standards-setting body</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of which Respondent is a member. (Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>1315, 1499; Ex.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-62</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). TJC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>produce</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Sentinel Event Alert</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s, which</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identifies specific types of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sentinel and adverse events</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">high-risk</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>conditions,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">describes their common</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">underlying causes, and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">recommends steps to reduce</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">risk and prevent future</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">occurrences.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">” (Ex. C-62).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In response, “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Accredited organizations should</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">consider information in a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Sentinel Event Alert when</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">designing or redesigning</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">processes and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">consider</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implementing relevant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">suggestions contained in the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">alert or reasonable alternatives.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">” (Ex. C-62).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Sentinel Event Alert<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">does not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">explicitly</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>adopt the five-part breakdown of a WVPP<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discussed in the Guidelines and Road Map; however,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a closer inspection of the recommendations reflects a near-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identical set of expectations, including</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">management commitment</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(ii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employee participation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">tracking and trending of workplace violence data</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iv)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identifying source(s) of the hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and developing a response</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(v)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">providing training</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on de-escalation, self-defense, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">responding to emergency codes. (Tr. C-62).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition, the Sentinel Event Alert<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identifies<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">factors associated with violence, including, as is relevant to this case</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">:</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">understaffing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(ii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inadequate security</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff working in isolation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iv)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lack of emergency communication<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">devices</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-62 at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">3).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">There is a substantial amount of overlap between these publications, including cross-references to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">each within the respective bibliographies or reference pages</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which shows</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the abatement measures proposed by Complainant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(which are based, in significant part, on these publications)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are not merely<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ad hoc</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>responses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to workplace violence but are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">industry-recognized methods for addressing a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">complex<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard. The overlap not only includes internal cross-references to the documents themselves, but<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Sentinel Alert, for example</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">includes references to the same exemplar hospital systems<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">referenced in the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Road Map<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that use the WVPP<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">uidelines generated by OSHA. (Ex. C-62 at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">4).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">claims</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>neither the Guidelines nor the Road Map are applicable to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>facility. This argument is rejected. Not only do the Guidelines specifically reference inpatient psychiatric facilities, but the Road Map uses inpatient psychiatric/behavioral facilities as examples to illustrate the effectiveness of the guidelines. (Ex. C-12, C-13). Further, Respondent has</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">o</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t elucidated any cogent distinction between itself and other in-patient facilities to suggest the engineering and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">administrative controls suggested by the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">uidelines, TJC Sentinel Alert, or Roadmap would not be effective. Nor, for that matter, does it explain why it chose to model its WVPP after the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">uidelines’ recommendations.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition to the above, the Court<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">notes Dr. Lipscomb testified the Sentinel Event Alert</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>introduced into evidence “really very closely follows the OSHA Guidelines”. (Tr. 1316).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Indeed, looking at the Sentinel Event Alert itself, the Court notes it repeatedly references<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the OSHA Guidelines, as well as other OSHA publications related to the topic of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence. (Ex. C-62 at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">8)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">D.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Evaluation of Individual<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Abatement Proposals</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In this section, the Court will address the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>abatement proposals Complainant included in the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Citation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Although the Court will discuss them individually, as noted above, the entire list constitutes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>an abatement process, of which each numbered proposal is a part.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In lieu of addressing these proposals in the order in which Respondent lists them in the Citation, the Court<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">starts with Complainant’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>WVPP proposal</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>since, according to expert testimony,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it is the touchstone from which other abatement proposals naturally flow.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">1.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Respondent’s WVPP.<span>
					</span></span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court starts with its evaluation of Complainant’s recommended abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>by examining Respondent’s WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it is linked to nearly every other proposal<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at issue in this case</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is the umbrella under which any<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">serious attempt to address workplace violence must fall</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Indeed,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as noted by Complainant, one of Respondent’s key problems is the failure to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">connect its various efforts to address workplace violence under the comprehensive</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>rubric of a WVPP.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>uses the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">terminology</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>discussed in the Guidelines, Road Map, and Sentine</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">l<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Alert, and even provides a list of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">connected programming,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">neither it, nor many of Respondent’s other efforts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, were materially effective at reducing the hazard of workplace violence.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“effectiveness” of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>approach to workplace</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">primarily</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>focus</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on clinical, patient-based solutions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">indicated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a significant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rise in workplace violence events and injuries<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in 2018. At or around that time, Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>increased the capacity of its facility by roughly 30 percent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; (ii)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>implemented an initiative to reduce<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">restraints</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at certain census levels, reduced the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">number of staff required under the matrix.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While none of these<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">actions are problematic when viewed individually, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">manner and timing of their implementation<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">highlights<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s failure to approach<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the problem of workplace violence in a comprehensive manner</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which Dr. Lipscomb,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Guidelines, Road Map</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and the studies<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">they<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rel</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">y</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>upon<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">show i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s effective at reducing the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent contends the rise in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reported injuries and incidents is likely due to an emphasis on increased reporting</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref31" href="#ftn31">30</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the patients that had to be restrained tended to be more aggressive</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">179</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">9-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1800</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1863</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While that may be true at a base level for those injuries actually reported on the OSHA 300</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the reporting explanation<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">does<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">account for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the incident and injury<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">numbers reported<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">by CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">culled</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>multiple data sources</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to find a more accurate picture of accident/injury data<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that more closely aligned with the interviews he took.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">His findings</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>highlighted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">unreliability of the data collected and relied upon by Respondent and the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lack of a centralized system of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">data collection<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for employee injuries.</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "> </p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">i.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Develop and Implement a Comprehensive WVPP</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Dr. Lipscomb, an effective WVPP starts with a clear definition of workplace violence. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1331</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-58</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to the Guidelines, NIOSH defines workplace violence as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Ex. C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">12 at 8). The parties have stipulated to this definition for the purposes of this case.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition, a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>WVPP contains five key<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">building blocks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) Management Commitment</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">/</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Employee Participation, (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) Worksite Analysis, (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) Hazard prevention and control, (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iv</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) safety and health training, and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">v</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) Recordkeeping and program evaluation.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Guidelines state:<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The components are interdependent and require regular reassessment and adjustment to respond to changes occurring within an organization, such as expanding a facility or changes in managers, clients, or procedures. And, as with any occupational safety and health program, it should be evaluated and reassessed on a regular basis.</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Ex. C-12 at 11)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This interdependency underscores the importance of a comprehensive approach to workplace violence: a failure in one aspect of the program<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a trickle-down effect on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">other elements. For example,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>definition of “violence” impacts what events are reported and when they should be reported</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1332</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The events that are reported, in turn,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">impacts data collection</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>which impacts employer’s ability to fashion a targeted and effective response</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant characterize</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent’s WVPP as a “paper<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">exercise</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that contain</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>some elements of a proper WVPP but<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was otherwise incomplete</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in both its content and implementation.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent contends it has developed and implemented an effective WVPP and Complainant’s concerns are directed to the form, not the substance, of its WVPP. Specifically, Respondent points out its program is based on the Guidelines and incorporated numerous clinical and non-clinical policies and practices, which address the hazard of workplace violence at least as effectively as Complainant’s proposals.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The Court finds</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Complainant established Respondent’s WVPP was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">effective in some of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">subitems</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>identified in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">batement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">I</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">tem #5 of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the Citation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and, therefore,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">needs to be changed consistent with the proposed abatement.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">To the extent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant failed to meet its burden with respect the other subitems, the Court has noted those as well.<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Subitem 1:</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">E</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">valuation and assessment of WPV incidents or trends, including a worksite-specific hazard analysis that analyzes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the worksite for risks, including but not limited to, potential weapons, potential for employees to be cut off from communication</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, delays in activating alarm systems, potential for physical entrapment of employees.” (Ex. C-1 at 7).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">There are a couple of layers to this subitem</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>which bear discussion.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">First, Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>has policies and procedures related to the collection of incident/injury data</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Respondent utilizes a committee system through which it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">collects and analyzes the data, and it performs hazard analyses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of the facility</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and activities occurring therein. Th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">us, the question with respect to this subitem is whether Respondent’s system was effective</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Court finds</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was a mixed bag.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>At the most basic level, the Court finds Respondent’s system of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">data collection, upon which its system of evaluation and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assessment</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is based,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is flawed. As<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">noted,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a couple of times above,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s injury data<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was contained in multiple sources (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">OSHA 300 logs,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">EARs,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">HPRs), each of which were under the purview of a different<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">manager.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The HR Manager, who is not responsible for patient-on-employee violence, is nonetheless responsible for gathering<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employee accident reports and supplying that data to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Risk Manager, who is responsible for patient-on-employee violence but only reviews HPR</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s, which are patient-focused<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">documents</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In the end, as illustrated by the testimony of CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, this led to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inaccurate data and inconsistent reports.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court finds there was no central</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>point of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>collection</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence data, nor was there a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>responsible person<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">designated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to analyze</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, summarize</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and disseminate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the conclusions reached<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on the basis of that data.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>underscores the lack of a “coordinated approach” required under the Guidelines, the Roadmap, Dr. Lipscomb’s expert testimony and cited publications. </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">That said, the Cou</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rt finds Respondent performed environmental</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and data-driven</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>assessments of the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>facility for hazards, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how furniture or other items could become potential weapons.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1492</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2475, 2477</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). In response to incidents involving furniture</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as weapons</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Respondent purchased new, weighted furniture</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to reduce the possibility</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a patient would be able to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pick it up, and in response to an incident where a patient threw computer monitors, Respondent bolted them down. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2475-2477</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">When that barrier was overcome, Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">purchased smaller monitors that could fit under the overhang of the station desk</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2496</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This illustrates Respondent, at least with respect to this issue,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was already implementing the proposed abatement measures.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>As to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">potential for employees to be alone, cut off from communication</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, delays in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">code activation, and possible entrapment, the Court finds Respondent had a blind spot</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Whether through<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">surveys, shift reports, HPRs, EARs, or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">even policy</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Respondent was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at least constructively</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>aware<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its employees w</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ould be left to cover a unit alone due to understaffing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and, based on their responsibilities, could be cut off from communication because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">portable communications devices were not required</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>unless off unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2127</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2213-14</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">At the least</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Respondent was aware MHTs were alone when they transferred patients off-unit for recreation or meals and that intake personnel<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were often alone, without surveillance, with potentially violent patients during the intake process.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2127-28</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Each of these situations, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when staff had to enter patients’ rooms for rounds or special orders,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">presented the possibility of staff entrapment and subsequent delay in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">initiating a Code.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Subitem 2:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“Provide clear written procedures for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how employees should respond to patients making threats, showing aggression, and assaults.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">With respect to this item, the Court<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">recognizes Respondent had policies covering Code Lavender and Code Green and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the use of CPI techniques, all of which are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">effective and, to an extent, necessary aspects of a successful WVPP. However, there were three areas in which Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">procedure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>were not clear:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when to call police</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(ii)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>when to report an incident of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">establishing a chain of command</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>during a Code involving multiple PMLs. As to the procedures for calling police,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff members on the whole felt as if they were discouraged from calling the police.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 482, 712, 1047, 1101</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Management did not do much to dispel this notion when they second-guessed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an assaulted employee’s decision to press charges</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>chang</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>policy to create additional barriers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to contacting police</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">questioned<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the wisdom of calling police</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, despite the extreme danger, because “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">encouraging police involvement is not where we need the analysis of the incident to be directed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.” (Ex. C-44). Thus,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">there was a fair amount of confusion amongst staff members regarding the policy</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Regarding<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the question of when to report an incident of workplace violence, the WVPP is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">silent.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Indeed, the WVPP talks about encouraging employees to submit EARs and that EARs, HPRs, and other data points will be used to inform policy; however, the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">re is no discussion about when or under what conditions an employee should report an incident of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including those not resulting in injury.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref32" href="#ftn32">31</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This, as mentioned above, has a lot to do with the lack of clear definition of workplace violence. While the parties agreed to a definition of workplace violence which includes threats of violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the policy’s definition is an overly broad</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>relational description: “violence committed by patients upon staff members”. (Ex. C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">14 at 1).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">contends it gives a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">more precise definition during training, which is found in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>PowerPoint presentation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-58). According to Dr. Lipscomb, while the definitions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>provided in the PowerPoint</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">give</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a clear</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">er</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>understanding of workplace violence, her review</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Risk Management Worksheets described numerous incidents fitting the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">definition</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but no corresponding reports in any of the known data sources</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which she believed undermined the assertion these definitions were understood by or known to staff members.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref33" href="#ftn33">32</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-58 at 15-16).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Given the reporting discrepancies noted above, as well as the testimony of employees, who<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to accepting some level of violence as “normal</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Court finds employees were given little,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">or at least inconsistent, guidance on when to report an incident of workplace violence.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This is especially so for incidents of violence not rising to the level of an injury, so-called, for which there appears to be no system of reporting or information gathering.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff members testified the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">re were<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">occasions during Code Greens and Lavenders</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>where conflicts arose amongst responders as to who should lead the code</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr. 518,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1083, 1091</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Emmett Wells, who worked as a social worker at Centennial Peaks, testified he believed the breakdown in communication in these circumstances led to three of his injuries during responses to codes and, ultimately, caused him to opt out of responding to codes.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref34" href="#ftn34">33</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr. 1083, 1091).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>As noted above, PMLs are either nurses or MHTs designated to lead crisis/code response</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Smith</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">there<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>designated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">PMLs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for code greens, but</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, due to their training,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>more than one of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>designated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>responders<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">re</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>likely to be trained as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>PMLs.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr. 2318-2319).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Considering the PMLs also had<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">duties</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that might prevent prompt response, such as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">one-to-ones or other special patient care responsibilities</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the ground was ripe for conflict based on who responded first.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">did not present any evidence, nor could the Court find any, to indicate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a pro</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cedure<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to prevent clashes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">over<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who should lead the code</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Subitem 3</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“The WVPP must also provide for the participation of direct care staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>such as MHCs and RNs, e.g., through the committees that discuss WPV incidents.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>has two</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>complaint</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>about this element</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">section of the WVPP entitled “Employee Participation”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">primarily consisted of tasks<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for staff to complete</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that are part of patient care, not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">initiatives to participate in; and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) direct care staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>did not have a standing seat on any</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of the committees discussed above—PIC, PSC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—or even knew they existed. (Tr. 528, 1145, 1175).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">argues;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>however, its direct care employees have a standing invitation to participate in both PSC and PIC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>meeting</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Respondent highlighted initiatives</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, policies, and procedures, which were initiated at the suggestion of direct care staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Patient Management Leads (PMLs)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Lavender Response Team,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and even the WVPP was developed with the assistance of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Kevin Smith and Jordan Larsen, who were MHTs/non-managerial milieu managers at the time. (Tr. 2099, 2299; Ex. C-14)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">see<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">72</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Even Mancha and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified to occasions where their suggestions were adopted.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While the Court finds Respondent provided its employees with opportunities to participate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in developing initiatives to address workplace violence, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Employee Participation program of Respondent’s WVPP is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, for the most part, a set of responsibilities and duties employees owe to patients.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">his is not just a criticism of form</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, but the WVPP’s current construction suggests a misunderstanding of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">role</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>direct care staff have<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>identifying, assessing, and implementing policies and procedures to prevent workplace violence.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Ex. C-12 at 13</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>This conclusion is made stronger by the fact that most of the employees who testified stated they had never seen the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">document before</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">394, 1095,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1145).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The WVPP<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">should be amended to reflect the purpose of employee participation in its<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">continuing development.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Subitem 4:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Implement administrative and engineering controls to reduce or eliminate WPV hazards, including an assessment<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of appropriate staffing levels for each unit.” The Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the substance of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">subitem</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">addressed in multiple other sections, from the modification of the nurse’s station and the use of walkie-talkies or panic alarms to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s assessments of proper staffing levels. While Complainant’s criticism as to this item is directed to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">contents of the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>physical</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">plan itself,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court finds</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>these sub-proposals are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ultimately duplicative of other proposals specifically targeted at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">engineering controls and administrative procedures, such as staffing levels.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Thus, the Court will<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discuss those specific abatement proposals elsewhere.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Subitem 5:</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Annually review the WVPP and update as necessary</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Solicit employee feedback during the process.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, there was no evidence the WVPP had been reviewed or updated since its creation.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 166).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Neither<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Forster nor<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">McArtor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>recalled participating in an annual review of the WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, even though both are designated as responsible persons under the plan</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1219, 1693</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex. C-14</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Respondent contends the policies and procedures set forth in the plan</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“were constantly being revised and new mitigation efforts were developed and implemented on a continuous basis.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">72 (citing Tr. 1340).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policies and procedures may have been addressed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on an individual basis, the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">re is no sense—indeed, no evidence—Respondent reviewed any of those policies<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">collectively as part of its WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The fact that two of the primary responsible parties under the WVPP had no recollection of participating in a review of the program</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, even after the need for such a review was identified by UHS Corporate Loss Control in a site visit at the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">beginning of 2019,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">suggests the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP program</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is ultimately a list of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">duties and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patient-based</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>programs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or, as Complainant put it, a “paper<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">exercise</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Through the foregoing discussion, the Court has addressed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">many of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Guidelines’ so-called building blocks of a WVPP,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">including Employee Participation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">/Management Commitment</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Hazard Analysis,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Injury Tracking,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Evaluation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref35" href="#ftn35">34</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Court identified areas where Respondent’s WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>complied with the letter and spirit<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Guidelines and also where<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s existing regime was ineffective at addressing the hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. At bottom, however,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court finds Respondent’s WVPP, taken as a collective whole, is ineffective at its primary role.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">There is no sense in which the various programs and/or initiatives that purportedly make up the WVPP are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">connected to one another</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Further, there appears to be a lack of buy-in into the program from either side of the employment coin:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">designated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">responsible parties in management are not aware<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of when or even whether a review of the WVPP took place</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and most of the employees who testified are not aware of the existence of an overarching WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, let alone their ability to participate in initiatives and programs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>created under its guise.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In that way, the Court agrees Respondent’s WVPP, in its current form, is little more than a paper exercise</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>therefore</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">deficient,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and ineffective at preventing workplace violence.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:156px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:162px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">ii.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Feasibility</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">of Complainant’s Proposal</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>Regarding WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>and Analysis of Whether it Would Result in Material Reduction of the Hazard<span>
					</span></span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">There</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is little debate over the feasibility or effectiveness of this</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>particular</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>proposal</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>indeed, Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">developed a WVPP with at least a nominal nod to the components discussed in the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">uidelines.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Nor, for that matter, does Respondent contend a WVPP would not be effective. Instead,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent spent significant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">time arguing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant could not prove any of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">individual abatements</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, or specific combination<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">thereof</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>would be effective at reducing the hazard.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">approach<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is contrary to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">current state of workplace violence research, which is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, in the words of Dr. Lipscomb, a “multi-factorial” problem</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr. 1322-23).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">What researchers discovered is that a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>multi-factorial problem</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">requires a multi-factorial</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, yet adaptable, solution</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-58, C-59</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; C-61 at 2-3</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>In the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">study</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>relied upon by Dr. Lipscomb,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">researchers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>conducted a randomized</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, controlled intervention study (the so-called “gold standard”)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implementing a “data-driven, worksite-based intervention based on the OSHA Guidelines.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-58 at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">12).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The study<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">found<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hospital units, including psychiatric units, that implemented<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a comprehensive program based on the Guidelines</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and adapted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">according to the data,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was effective at reducing patient-to-worker violence-related injuries by 60% within 2 years of implementation. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1324</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-58</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at 21).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This conclusion was borne out in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>other contexts, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">examples highlighted in both the Road Map and Sentinel Event Alert. (Ex. C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-13, C-62).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Lipscomb highlighted Aria Jefferson hospital, which is referenced in the TJC<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">publication,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and a trade journal called<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Healthcare Executive</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-61,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-62 at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">4)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to these sources, Aria Jefferson was able to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">use a data-driven, comprehensive approach to workplace violence to reduce<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violence related injuries by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">70 percent over the course of four years.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref36" href="#ftn36">35</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Indeed, throughout the Road Map, there were multiple examples of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">healthcare facilities that experienced success in reducing workplace violence through the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implementation of a comprehensive program to address workplace violence. (Ex. C-13).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>Respondent’s attempts to undermine these conclusions are not persuasive. In particular, Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">points out the size of the hospital system, perhaps to suggest<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its conclusions are not applicable to a small, stand-alone facility like Respondent’s;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>however, Respondent has not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identified</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>anything about the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">42 individual units studied within that system<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">highlight a meaningful difference between<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">them and Respondent. Respondent also points out the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">researchers tracked a more broadly defined hazard, which included verbal abuse, bullying, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">harassment</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however, the problem for Respondent is the study may have used a more inclusive definition</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of workplace violence, but the ultimate effect was a reduction in patient-to-staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In other words, a more inclusive definition<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">arguably made the program more successful not in the identification and reduction of workplace violence generally, but<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in the reduction of injuries, which data<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">likely showed was the result of a broad range of violent encounters.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally, Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">points out the study was not specific “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which interventions were used on which units and it cannot be determined from the study which</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">interventions improved reducing the rate of workplace violence incidents.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">64.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">last<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">argument misses the point:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">what matters<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at the approach be based on the data, specific to the worksite, and comprehensive in its scope</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The fact the authors of the study could not specify some magic formula of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">interventions culled from the Guidelines makes sense considering the assessment<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is data-driven and site-specific.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">What t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hese studies<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">show</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is the importance of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">process</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>driven by the Guidelines.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s position, though incorrect, makes sense given its reliance on Dr. Cohen’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testimony, which focuses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on evidence-based<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">analyses of individual interventions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. This focus also</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>highlights one of the reasons why the Court placed more weight on Dr. Lipscomb’s testimony</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: she is more attuned to the state of the science with respect to workplace violence. Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Cohen is clearly a qualified clinical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and forensic psychiatrist,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">but he, like Respondent, is focused on clinical interventions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at an individual level</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which are more easily controlled</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>than<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">changes to administrative or engineering controls impacting a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">large population of patients with differing diagnoses and levels of acuity implemented by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">healthcare professionals in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">different<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">settings.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Lipscomb, on the other hand, has made the study of workplace violence a significant part of her life’s work; she is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not only familiar with the state of the research but was also instrumental in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">conducting studies supporting the comprehensive approach described above.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court finds Complainant, through Dr. Lipscomb’s testimony, established the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposed comprehensive WVPP would be materially effective at reducing workplace violence in Respondent’s hospital.</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally, Respondent also attempts to undermine<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s claim<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">regarding effectiveness by suggesting many of the incidents of workplace violence were “unpredictable” and, thus, no amount of intervention, comprehensive or otherwise, would be adequate to address the hazard.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">goes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as far as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to claim</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[a]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ggression</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>which is caused by mental illness rather than bad intent is by its very nature unpredictable and preventing it is not feasible because it is almost always unforeseeable.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">64 (citing</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>2019 WL 1142920, at *24</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (MacDougall, H., concurring) (Workplace violence is a “condition that results from the acts of third parties, engaged in unpredictable human behavior, and outside of an employer’s control; no matter how sound an employer’s safety program might be for the particular circumstances in its workplace, it is possible the employer cannot free the workplace of the hazard.”)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While the Court agrees there were example</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s of staff being injured by patients without<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">warning</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, this made up a small portion of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cases discussed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Further, the Court finds Respondent overstates the case regarding the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">predictability of incidents of aggression.</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">J</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ust because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a small universe of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>outbursts may be “unpredictable</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, such does not justify the refusal to implement strategies that have been successfully implemented by others and are recommended<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">based on</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>joint efforts between OSHA, NIOSH, and the Joint Commission, which itself approves of the Guidelines/Roadmap as a starting point for an effective WVPP. Further,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">if<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court were to accept Respondent’s characterization of workplace violence,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it begs the question as to why Respondent uses tools to assess violence risk</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and implement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">initiatives to reduce that risk</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>if they serve no purpos</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref37" href="#ftn37">36</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The fact is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, while<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">individual acts viewed in isolation may appear unpredictable, the evidence presented at trial<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shows there were multiple data points available to Respondent, which would have illustrated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the existence of injury clusters related to a location, activity, or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">type of patient.<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent lamented the characterization of its facility as a hazardous workplace</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>because of the presence of mentally ill patients when, it claims, the data shows<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a substantial amount of the workplace violence incidents was connected to a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discrete</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>population of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">high acuity patients with a substantial history of prior violent acts.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Looked at another way, however,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent had data available to it indicating a specific subset of patients was responsible for an outsized</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>number of incidents, which presented an opportunity for assessment and evaluation of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policies and procedures related to this subset of patients, which Respondent did not do</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The individual files of MC, RB, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">LJ</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">illustrate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>failure: there was a lack of documentation (or at least a lack of notification/warning) about a patient’s prior history of violence even though the information was available</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at intake</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>C-19, C-20</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, C-23</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Further, with respect to Respondent’s claims regarding the efficacy of a clinical approach to violence from this select subset of patients, the Court finds such interventions were insufficient, on their own, to address the hazard, as illustrated by the number of attacks towards staff occurring in close succession</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>despite clinical interventions occurring in the interim</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Along similar lines, the Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proper implementation of a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">comprehensive program, driven by data, would also have revealed the cluster of incidents occurring at the nurse’s station</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and presented opportunities for prophylactic measures to prevent these “unpredictable”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">acts of aggression.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">H</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ad Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">properly<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">analyzed its own data,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>whether with respect to high acuity patients or the nurse’s station,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the next logical step would have been for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent to take appropriate actions to eliminate or substantially reduce this risk through proper planning and implementation of a comprehensive WWVP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>focused<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>such populations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and locations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent cannot<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">simply</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>put its head in the sand, plead a certain class of patients are more prone to such conduct and unpredictable, and then do nothing. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Court can rely on expert testimony to determine the feasibility of proposed abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as well as whether it would materially reduce the hazard if implemented</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Commission</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>ha</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>found expert testimony, insofar as it is reliable, is sufficient to establish a particular abatement method would materially reduce the hazard.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ee Integra.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *13-14 (finding expert testimony regarding material reduction of hazard of workplace violence sufficient without requiring expert to quantify extent of reduction).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Court</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>previously found</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Dr. Lipscomb</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testimony<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was entitled to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">controlling weight</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Dr. Lipscomb</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified Respondent’s WVPP was flawed and provided reasons for her conclusions as well as studies which supported her testimony that a comprehensive, linked WVPP would result in a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">material</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>reduction of workplace violence instances in R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">spondent’s workplace. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the foregoing, the Court finds Complainant established the feasibility of Complainant’s abatement proposal<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">#5</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, recommending the implementation of a comprehensive WVPP.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Court also finds the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testimony<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">supports Dr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Lipscomb’s conclusion<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that implementation of a comprehensive</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and coordinated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>WVPP would result in a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">material reduction</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of workplace violence incidents</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>therefore,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">would<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">materially</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>reduc</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>overall</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>hazard of workplace violence as recognized by both Respondent and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">industry.</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court could stop its analysis at this point and end the discussion. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As discussed above, t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Court<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">found<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant proposed a series of abatement measures as a process. Thus, Complainant need only show Respondent failed to implement one of them.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Sturgill</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1099857</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *9</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">see also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">UHS Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>2022 WL 774272</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>*8</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(“[T]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Secretary need only prove that at least one of the measures he proposed was not implemented and that the same measure is both effective and feasible in addressing the alleged hazard.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC N</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">w.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 951 F.3d<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">564 (Secretary proposed “menu” of abatement options to materially reduce workplace violence hazard alleged under general duty clause)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. However,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for the purposes of clarity</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and completeness,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court will continue its analysis on the remaining proposed abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>measures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_cf01 style_cf01 " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Segoe UI; font-size:9pt; font-family:Times New Roman; font-size:12pt; ">in light of the pending appeal of the Commission's decision in UHS Pembroke.</span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">2.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Reliable and readily available communications devices</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Prior to the inspection</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s employees<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">only carried communication devices when they transported patients off-unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. When they were on unit, staff only had two radios available</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which were kept at the nurse’s station, along with the telephone, which served as the primary device by which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">c</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">odes were<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">broadcasted to the rest of the hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">97, 389).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Otherwise, while on unit, staff would have to verbally call for a code</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. At full staffing capacity, this might not be a problem; however, there were numerous examples provided by employees<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">where they were alone or could not immediately be heard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. This included intake personnel, who are typically alone while performing their assessment and are not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">usually monitored remotely, even though cameras were available.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court finds Respondent’s prior regime</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which relied on calling out to other employees in the hopes of getting a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">message relayed to the PA system, was ineffective.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Under the best of circumstances</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">response time could be delayed by the logistics of the situation:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the individual calling the code<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">needs to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>be heard by someone physically occupying the nurse’s station (though Respondent apparently frowned on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">remaining behind the desk), who could relay the message out to the hospital as a whole.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Any potential delay in response can, and did, result in employees receiving serious injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. For example,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified she and a co-worker were repeatedly assaulted during the pendency of a Code Green call</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>because they could not easily make the call for a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">code, which resulted in other patients intervening to prevent further injury. (Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">448-49</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s Corporate Loss Control recognized this shortcoming, at least with respect to the intake process, and recommended the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implementation of panic alarms during the intake process. (Ex. C-51 at 2).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court also finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implementing the use of walkie-talkies and/or personal panic alarms would be feasible and effective.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">First, Respondent already had two walkie-talkies present on each unit at the time of the inspection</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which its staff used in specific circumstances</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, indicating its employees were fa</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">miliar with using the walkie-talkies for this purpose.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Integra<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *12</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Second,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">after the inspection occurred, Respondent increased the number of radios<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on unit to make them available to each employee</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both Forster and Smith testified improved response time</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s to Code Greens and had the ancillary effect of allowing codes to be called<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at night without disturbing sleeping patients on the unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and unnecessarily<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">affecting acuity of the milieu</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">r</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. 234</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">7-48)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See SeaWorld</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 748 F.3d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1215;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">FMC Corp.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 12 BNA OSHC 2008 (No</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. 83-488</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 83-489</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>1986).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Third, each of the experts, including Dr. Cohen, testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the use of walkie-talkies and/or panic alarms would be effective<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in reducing the likelihood or severity of the injury</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>resulting<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">from an act of patient aggression. (Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1520,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Fourth, the Guidelines refer to using<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">communication devices, such as panic alarms or cellular phones<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">summon assistance more effectively</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>C-12</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">All three experts testified the use of walkie-talkies would result in a material reduction in the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identified</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>hazard.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ee Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *13-14 (finding expert testimony regarding material reduction of hazard of workplace violence sufficient without requiring expert to quantify extent of reduction).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Accordingly, the Court finds Complainant proved the use of personal communication devices and/or panic alarms would be</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a feasible and effective method to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">materially<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reduce the hazard.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref38" href="#ftn38">37</a></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">3.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Reconfiguring</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>the</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>Nurses</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">tation</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the testimony</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>nurses’ station was a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">locus for patient aggression</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-72</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">With<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">no door to prevent entry, and a fairly low and narrow countertop, the nurse’s station</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">provided virtually no barrier between direct care staff and patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">5</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The incidents described<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">by employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>include</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients reaching over the top of the counter to rip<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">computer<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">monitors<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">off</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the desk</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>even when they were bolted down</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; (ii)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients walking</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>behind the nurses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>desk and physically assaulting staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; (iii)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a patient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">attempting to barricade a staff member</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>behind the station</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>numerous threats</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(iv)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>destruction of property in the area of staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">129, 583-85</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>601-604</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>1634-36</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex. C-7 at 12</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, C-19 at 13-16</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Ex. C-72</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">any of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">these incidents<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">could have been prevented by modest improvements at creating an actual barrier to entry</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">If<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the behavior of psychiatric patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is so unpredictable</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as Respondent has argued,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees should be afforded<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">more substantial protection when working behind the desk, during which time their<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">focus may be on paperwork or other duties which may divert attention from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an unpredictable source of harm.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The recurrence of these types of incidents at the nurse</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>station during the relevant period<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">indicates</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">current layout is not effective</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and the Court so finds.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant proposes a performance</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">oriented<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">solution to the nurse’s station</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Contrary to Respondent’s characterization of the abatement proposal</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Citation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>does not</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>mention a particular solution; instead,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent is expected to reconfigure the station to prevent the types of incidents described above:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">jumping ove</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">r the counter</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; (ii)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>walking through the door</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">grabbing items that could be used as weapons.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-1 at 7).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>At trial, of course, this idea was fleshed out to include solutions such as a locking door</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>higher and deeper countertops</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 145).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The employees who were attacked at the nurses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>station all testified they believed a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">more substantial barrier</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, such as a door or higher counter,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>would have prevented the types of attacks described above</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s did the experts, including Dr. Cohen. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1352-56</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2032</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>This consensus is reflected in the Guidelines</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Road Map</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">recommend deep counters at the nurses’ stations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>up to enclosure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as a means of barrier protection</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, but also</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>states employers and workers<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">must</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>determine the appropriate balance<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">between creating a suitable atmosphere for the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">services provided at the hospital and the type of barrier being used.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">12 at 21).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent contends the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">number of injuries and incidents at the station is overblown,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">citing only two injuries at the station in 2018.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 143). Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">downplays incidents where patients entered the station without injury, including when one patient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“pulled a monitor from its base” without mentioning what happened to the monitor afterwards</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or when another patient “grabbed a badge and keys”, which just so happened to be attached to a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff member</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; or when<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a patient enter</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d the station and “grabbed a bin of pens/paperclips”, which she subsequently used to throw<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-63, C-72</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at 33</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">casts this proposal as a straw man and suggests Complainant is requiring it to fully enclose the station</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. While the Road Map mentions<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">enclosure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as an option, Complainant did not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">include it among the options it was pursuing.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">argues it previously attempted to modify<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>nurses’ station</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but notes it was poorly received by staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who claimed it interfered with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">performing their duties</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This argument is equally unconvincing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because it only suggests th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>particular iteration of the nurses’ station was inconvenient; however,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>there was no evidence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent attempted</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to address this, and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, for that matter, inconvenience is not a defense to the element of feasibility.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Tri-State Roofing & Sheet Metal, Inc. v. OSHRC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 685 F.2d 878, 881 (4th Cir. 1982) (“The particular views of workmen are not necessarily, and often times are not, the best determination as to what is safe and what is unsafe. Convenience rather than safety considerations often dictates a worker's perspective.”).</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally, Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">yet again relies on a fatalist perspective on patient-on-staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violence, when</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it argues, “[W]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hen dealing with patients with emotional disorders, enclosing the nurses’ station does not prevent an assault; it simply changes its location as the patient will commit the assault elsewhere if not clinically addressed.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">68.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Simply because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the possibility of a future assault exists does not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">justify failing to respond in a concrete way to an easily identifiable problem.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reventing an assault in the moment can give the staff member a moment to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">prepare and the patient an opportunity to decompress, depending on the nature of the “dispute”.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In this instance, something as simple as a door<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">or making the counters higher and deeper<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">would likely have prevented<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at least a handful of the encounters described.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>All three experts testified that the reconfiguration of the nurse’s station would result in a material reduction of the identified hazard.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ee Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *13-14 (finding expert testimony regarding material reduction of hazard of workplace violence sufficient without<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">requiring expert to quantify extent of reduction).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court finds the foregoing abatement feasible and effective</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at materially reducing the identified hazard.<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">4.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Staffing Issues</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In this section, the Court will address two separate, but interrelated abatement proposals:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) designating staff, with no<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">duties to prevent immediate response to a code, to res</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pond to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violent incidents; and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) ensuring staffing adequate for census and acuity, taking into account<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient aggression and history of violence.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref39" href="#ftn39">38</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As the following will show,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court finds Respondent has already implemented<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s proposal to designate a response team for acts of patient aggression.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant failed to show</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent’s current<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">protocol</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for Code Green<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">or Code Lavend</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">r<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">response is insufficient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in terms of time or adequacy of response.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In nearly ever</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">y</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>report of a Code Green, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">treatment records indicate a robust response in terms of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the number of employees responding.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See e.g.,</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr. 1762, 1765, 2342-2343</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-18 at 2</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 8</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 14</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; C-19 at 9</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 23,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">31,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">38</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; C-20 at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">15</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 24,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">29</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">That said,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the evidence also shows Respondent failed to properly staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the units, whether at a baseline level or in consideration of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">acuity. These two problems go hand-in-hand</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. In an ideal scenario, Respondent’s designated responder system, inclusive of PMLs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, would be able to both respond to a code and account for a reshuffling of required, patient-centered responsibilities</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. However, given the restraints imposed by a lack of sufficient staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the response may not be as smooth, or, more problematically</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, leaves staff members alone on a unit.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">What the following will show is abatement of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">overarching<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staffing problem will, albeit indirectly, solve<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">issues with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s code response protocol.<span>
						</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "> </p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">i.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Designating Staff to Monitor and Respond</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ostensibly, Complainant’s proposal could be effectuated in one of two ways: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) designating<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a response team of staff members with no patient care duties<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that would prevent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>an immediate response; or (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) designating a single security guard for the facility<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on per-shift basis, who would respond to codes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span><span></span>
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The exact nature of Complainant’s proposal was not made clear until the issue was discussed during Dr. Lipscomb’s testimony. Dr. Lipscomb drafted her report with the understanding the proposed security force would include four additional staff per shift. (Tr. 1554). During a colloquy with the Court, counsel for Complainant clarified Respondent was not expected to have someone on every unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for every shift</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 1410). Instead, Complainant stated, “[W]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hatever</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the employer decides will abate the hazard, just making sure there is either designated staff or a security shift that could respond to it.” (Tr. 1410).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The Court finds Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">code response system, which designates responders and PMLs in advance of a shift,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">achieves this in an effective way, albeit not in the manner Complainant intends.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Thus, Dr. Lipscomb’s report provides no assistance on this issue. </span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s primary concerns appear to be the num</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ber of people responding to codes and the amount of time it takes them to respond.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Compl’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">67</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref40" href="#ftn40">39</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Indeed, some staff testified they believed there were not always enough people to respond to codes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, but these were limited in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">number,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and, in at least some cases, the problem was not with the protocol for response but with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the availability of staff as a general proposition. For example</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Erin<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Eckholm</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">they</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>did not believe there was sufficient staff on the overnight shift</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to adequately respond<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff would rotate out to take breaks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which created temporary staff shortages</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and especially when the shift was already short-staffed. (Tr. 1036-37</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 1134</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Situations such as this do not necessarily highlight issues with Respondent’s system of designated responders</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, but with the fallout of not having enough staff to fill in after the responders have left.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Similarly, Complainant also points t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">o testimony by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Emmett Wells, who attributed his injury to a failure of communication and lack of response; however, even he noted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“a lot” of people responded</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. He merely expressed his</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>belief the response was inadequate.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 1090-1091).<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While the Court agrees with Complainant that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">having unfettered staff would likely reduce the response time</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and, thus,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">preventing injury or minimizing its severity</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Complainant has failed to show Respondent’s current system of designated responders<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was not effective</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to deal with calling of Codes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. As to this proposal, we are not discussing the prevention o</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">f incidents leading to Code Greens; instead, the Court is being asked to assess a proposal</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the principal goal of which is to minimize response time and maximize response numbers.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In order to reach the question as to the efficacy of Complainant’s proposal, Complainant must show Respondent’s existing methods are inadequate to the task</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *12 n.14<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[A]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s a threshold matter, that the methods undertaken by the employer to address the alleged hazard were inadequate.”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The problem for Complainant, though, is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it has not produced</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>sufficient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>evidence to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">prove</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Code Green<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">response</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>system</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>insufficient in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">terms of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">time</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it took to respond</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">number</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>responding to a Code Green</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>In fact, according to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s own internal study, its response<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to Code Greens was adequate in that there was always a PML and at least 3 to 4 designated code responders for each<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">incident. (Tr. 2140).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The evidence on that topic, as discussed above, is equivocal at best.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Making matters more confusing is Complainant’s proposal, clarified at trial, that a single, dedicated responder</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on each shift would be sufficient to abate the hazard. While the Guidelines, Road Map, and Sentinel Event Alert all recommend</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the use of a dedicated response/security force</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and former employees as well as the experts testified to the use of security at other places of employment,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">such a recommendation is predicated on the existence of a force of security officers present at a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">time. (Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-12, C-13, C-62).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This, of course, explains the assumption made by Dr. Lipscomb in her expert report</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that each unit would be covered by a security officer. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-58)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In this instance, the Court agrees with the assessment of Dr. Cohen, who opined<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the use of a single security guard would simply transfer the hazard from direct care staff to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">guard, who would be in no better position than an individual MHT responding to a code. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1952</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">What is unclear, based on Complainant’s proposal, is whether the security guard is expected to respond alone, or whether<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he/she is simply a first responder designated to respond more quickly to codes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who would be followed by other staff members either designated or otherwise available to respond</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Also, if the intent of Complainant was to have the security guard respond alone to Codes, the Complainant also failed to address how this proposal would be effective if the security personnel<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>already responding to a Code and another Code was called at the same time.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Because the nature of the proposal, at least with respect to the hiring of professional security is concern</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed, is so vague, the Court finds Complainant failed to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">establish its proposal<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for one dedicated security personnel per shift for the entire hospital<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">would materially reduce the hazard.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref41" href="#ftn41">40</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "> </p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "> </p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:192px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">ii.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Ensuring Adequate Staffing</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Guidelines, Road Map, and Sentinel Alert all refer to adequate staffing as a factor associated with workplace violence, but none of them provide specific guidance as to how to make that assessment. (Ex. C-12, C-13, C-62). For that matter, there is no specific standard or regulation that indicates a minimum staffing threshold. Notwithstanding the lack of any concrete standard for compliance, Complainant contends</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the evidence shows</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent understaffed the units according to its own<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staffing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">matrix and further argues the matrix itself, at least in certain circumstances, does not establish a sufficient baseline for staffing. Respondent contends the matrix and subsequent staffing decisions account for changes in acuity, including special orders, to ensure adequate staffing, and accuses Complainant of establishing a “subjective, unquantifiable” standard against which this and all future staffing will be measured by OSHA.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court finds the weight of the evidence shows Respondent (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) failed to account for acuity in either the matrix itself or in its staffing decisions; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) failed to consider the consequences<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staffing at the levels provided in the matrix would have when staff was confronted with Code Greens, or even mundane activities like taking lunch breaks, especially during the overnight shift; and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) failed to respond to regular, recurrent complaints regarding staffing from the staff itself, which regularly identified hazardous situations created by understaffing.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Court also finds Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ultimately confessed feasibility by adding<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, after the inspection,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who are not counted towards the matrix baseline but are still available to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">engage in Code Greens and/or fill in the voids in staffing left behind by designated responders.<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:240px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:222px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-weight:bold; padding-right:20px;">a.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Respondent’s Program Was Not Effective</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>does not have<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a polic</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">y<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for assessing and responding to acuity<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to ensure adequate staffing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Forster and Smith both testified it is considered, but<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">no one testified as to how<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff allocations are made because of it</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Whether due to a failure of policy or simply a failure to consider acuity, there is an</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>un</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">expect</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed similarity between baseline staffing levels in the matrix</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, irrespective of which unit is under consideration</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and the relative acuity of the respective units</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. To be sure, Respondent discussed how staffing decisions were made in the weeks prior to a given shift and that modifications were made up to and even during the shift itself. Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also presented evidence about how it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">address</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">es</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>unforeseen staff shortages<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when staff call out sick, including reassigning staff, utilizing staff (such as the house supervisor) not included in the matrix,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">providing financial incentives for filling in, and holding over staff onto the following shift until<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a replacement can be found. (Tr. 1978)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court was not convinced by these explanations.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">At trial, the Court attempted to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discern why the staffing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>levels provided in the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>matrix<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>essentially the same across the board, irrespective of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">unique characteristics</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of the unit in question.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr. 1849-1853).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">E</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ach unit is different</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Crestone and Pike units are designated as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">intensive treatment units</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">each of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which house</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>adult patients with severe psychiatric and behavioral disorders</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In fact, the lion’s share of violent patient-staff encounters<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">occurs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in these units</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however, their baseline staffing levels are no different than the Torrey’s unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which houses lower acuity adult patients, or the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Sunlight unit, which houses adolescent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients. (Ex.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>C-74, C-75)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court was not convinced by Respondent’s explanation at trial, nor is it any more convinced of Respondent’s argument here.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">First,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court is not convinced by the explanation given by CNO Forster that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discharges</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in Torrey’s and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a more active population in Sunlight justify<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staffing th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ose</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>units at virtually the same levels</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as the ITUs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>across the board.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Lipscomb<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and Dr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testified t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">similarity did not make sense</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1000-1002, 1366).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Second,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the data presented at trial showed Crestone and Pike were the locus for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a highest proportion of the assaults occurring at Centennial Peaks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Forster and Smith, who<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">oversaw</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staffing, testified they increased the baseline numbers of the matrix</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in Crestone and Pike; however, according to the matrices presented at trial, Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>actually reduced<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the number of staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Crestone, Pike, Torrey, and Sunligh</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in 2019<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">even<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">after i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t reviewed the data showing a drastic spike in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employee injuries resulting from patient assaults.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr. 1800-1801</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2357-2359</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-74, C-75</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Forster testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he reduced staff numbers in the ITUs because they were overstaffed during the relevant period; however, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">data regarding assaults, coupled with</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>repeated employee complaints regarding the lack of adequate staff,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">indicates<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">otherwise</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent says it considers a host of factors, from experience to acuity, when making staffing decisions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including the development of the staffing matrix.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">It is unclear, however,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how those decisions are made and whether</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>they have any real effect.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Forster testified he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">always considered requests for additional staff and would attempt to fulfill the request if he deemed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>there was a need.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testimony from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Mancha, however, their requests were</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>usually left unmet about 50% of the time or more</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and it was unclear as to why requests were denied</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">509, 560</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Not only did Respondent not have a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">written<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policy or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">guidance</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assigning staff,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">but there was also</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>no sense from either Smith or Forster</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, other than a vague statement about considering factors impacting acuity,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as to how they<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">allocated staff when<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>were</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on one-to-ones, five-minute checks, or assault precautions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. And, as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">recounted</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>above, all objective indications</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>suggest Respondent had a hard enough time meeting the minimum requirements under the matrix</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to staff, u</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nderstaffing was a chronic problem</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; however, this was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">particularly acute during the overnight shift.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">During the daytime</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">administration and management, many of whom were trained in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ode<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reen response and CPI, were available to respond to codes or to fill in on the backend<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when designated responders went to a code. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">448, 507,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">572, 1030,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1094</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">addition, during the relevant period, Respondent staffed the hospital with additional</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staff, who were not counted against the matrix</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, such as the A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">dministrator-on-call (AOC) and milieu and nurse managers.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Those extra-matrix staff were not typically available on the overnight shift, where staffing is typically lower due to the assumption that most patients will be sleeping during that time.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1195</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). In fact, according to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Mancha and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ekholm</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, they do not recall having<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">milieu managers<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">or resources nurses<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">available to them<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on the overnight shift<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">during the relevant time period. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">508, 572,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1030). As it turns out, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">milieu manager<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">position was eliminated in 2018 and was not renewed until 2020</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, after the inspection concluded. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1601, 1748). Thus, other than the House Supervisor, the overnight shift did not have extra-matrix staff available to fill in when necessary</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 572, 1030). For that matter, the House Supervisor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was regularly relied upon to fill</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in when units were short-staffed due to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">callouts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or unexpected admissions. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. R-54 at 1).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Having non-matrix staff having to fill in when units were short staffed, in and of itself, establishes that staffing ratios were inadequate.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent contends Complainant’s concerns about understaffing, especially on the night shift, are overblown. In particular, Respondent notes Dr. Lipscomb could not assess<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how often situations arose where there was not sufficient staff to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both respond to a code and provide adequate staffing of the unit during<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pendency of the code</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified codes were only called on overnight shift about once every two weeks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1132,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1478-1479)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. While th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ere may be no<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">explicit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>data to assess how often a staff member could be left alone<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">during a code, the Court finds there was ample information available to Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to ascertain it was not a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>unique occurrence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">callouts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>being a regular occurrence and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">overnight shifts already starting with one less staff member and limited extra-matrix staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staff submitted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">m</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ultiple</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>reports<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to management<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">describing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the impact of working short-staffed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and the challenges faced during th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ose</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>time</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. These challenges included</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inability to take breaks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">trying to account for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patient who is on a one-to-one observation “while awake”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but is awake during a period of time when th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e staffing levels assume the patient will be sleeping.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Terry<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Bierweiler</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>submitted multiple reports</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">/emails to management illustrating<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how his unit was short-staffed and discussing the potential impacts if<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a code was called, which, contrary to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[redacted]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testimony</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, he believed “were not uncommon</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”. (Ex. C-25, C-65). In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">one email</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Bierweiler</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">noted he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">only had</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">two</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>nurses and 2 MHTs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in the Pike unit for a 26-patient census. (Ex. C-25)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to the matrix, Pike was already short one employee.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref42" href="#ftn42">41</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-74).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">To make matters worse, one<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">MHT was covering<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a one-to-one</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and another was performing five-minute checks in addition to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the normal 15-minute rounds</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which meant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a code or even a scheduled break would result in only two staff members covering a 26-patient unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-25).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Mancha testified she had experience similar scenarios<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when she worked overnight shifts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, as did many other staff members</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 571-72</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1031-1033,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1040,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1053,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>1139,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1618-1619; Ex.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>C-24,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>C-40,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>C-41, C-42,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>C-68, C-70</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent contends many of the instances where the unit was left short-staffed was due to staff calling out unexpectedly</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which it attempts to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cure through<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">incentivizing staff who pick up additional shifts or through holding staff over.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The problem, as noted by Forster, is that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">callouts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">happen “quite frequently”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 2457). In one month, alone, Forster noted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">seventy-five</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>employees who called out sick</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, or a little more than two employees per day</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 2457).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In other words, while individual call outs might be hard to predict</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the possibility of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">short staffing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>resulting from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">callouts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">appears to be an ever-present concern</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and one which Respond</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ent should account for, but does not, in its staffing decisions.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the foregoing analysis, and the facts described earlier in this opinion, the Court finds Respondent’s staffing protocol was not sufficient to address<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the hazard of workplace violence.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Through reports</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, surveys,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and emails to management, staff repeatedly<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">short staffing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as a chronic problem that exposed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">them to acts of workplace violence or, at the very least, left staff members in situations (such as working alone</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) where the possibility of being attacked<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was substantially higher.<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:240px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:216px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">b.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Complainant’s Proposed Abatement is Feasible</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>and Would Materially Reduce the Hazard</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court finds Complainant established its proposed abatement is feasible and would materially reduce the hazard.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As to feasibility, the Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent essentially admitted to feasibility</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, if not effectiveness,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>when it added back the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">milieu manager position as a non-matrix staff member</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and ensure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>one would be available on each shift.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The addition of non-matrix staff members</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">will not only alleviate the problems with short staffing generally but will also shore up the ancillary problem of having an adequate work force to cover units when designated responders respond to a code. This conclusion is supported by the opinions of both Dr. Lipscomb and Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">more staff means</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>quicker response to codes and increased availability to handle the needs of patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">837-39, 919,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1001,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1369;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-58 at 33). As to the latter, Dr. Lipscomb</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>pointed to a focus group she participated in where patients reported acting out aggressively when they perceive their needs are not being met, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">often accompanies a shortage of staff. (Ex. C-58 at 33).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">levelled two primary criticisms a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>this form of abatement. First, Respondent contends</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposed an unduly vague requirement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that Respondent “maintain<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staffing that is adequate for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">census and patient acuity, taking into consideration patient aggression and history of violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-1).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>While Complainant has not proposed a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">specific number of staff that would be appropriate based on census and acuity, the Court finds this is not fatal.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Given the differences between unit acuity at a baseline level<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">within Respondent’s own facility,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court finds establishing a specific number<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is not achievable in a vacuum</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Instead,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>must, as stated in the Citation, take certain factors into account when making staffing decisions both in terms of the baseline levels established in the matrix and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when setting/revising the staffing schedule for the coming weeks.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">claims it considers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>acuity</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but, in reality</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has not elucidated a process by which it makes such decisions and, ultimately,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>failed in many cases to meet its own minimum level of staffing per the matrix.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The numerous complaints from staff in reports, emails, and surveys over the years solidify this fact</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">At a minimum</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, not only should staffing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">be<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">increase</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to prevent the sort of shortages identified in this case, but Respondent should also be able to articulate how it considered acuity</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, patient aggression, and history of violence when making staffing decisions.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Second, Respondent tried to question the effectiveness of additional staff through the testimony<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of Dr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Cohen</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who cited<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">studies<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">written by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Vincent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Staggs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he believed stood for the proposition that higher staffing levels do not necessarily equate to a safer workplace. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1979-1981; Ex. R-2 at 15.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">First, Dr. Cohen admitted the study had self-reported limitations, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the lack of a conclusion about causation. (Tr. 2064-2066). In other words,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">way</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>data was collected,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staggs could not conclude whether<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the increase in violent acts he discovered<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the result of increased staffing levels or whether</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the increased staffing levels were imposed in response to an increase in violent behavior.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Second, the Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s concern</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>go to something more basic</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; namely, whether Respondent had a sufficient number of staff to safely<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">accomplish the duties assigned to them</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including code response</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>According to Dr. Lipscomb</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">there are studies, such as Staggs, which purport to show a negative relationship between staffing levels and patient violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and there are also studies which show a positive relationship between staffing levels and patient violence. (Tr. 1477-1478).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Lipscomb</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>noted</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Staggs article<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">should</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>be read<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">carefully to understand there is a level<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>which adding staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">results in equivocal findings<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as to its effect on patient violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 1477).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">However, a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ccording to Lipscomb, “I don’t think any expert or practitioner would agree that having staff levels where one or two people are left alone on a unit with psychiatric patients that are admitted because they’re a danger to themselves or others that that is safe.” (Tr. 1476-1477).</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The Court finds the testimony<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of Dr. Lipscomb<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argu</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">m</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">edo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>are entitled to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">controlling</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>weight for the reasons set forth above.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *13-14 (finding expert testimony regarding material reduction of hazard of workplace violence sufficient without requiring expert to quantify extent of reduction).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The opinion of Dr. Cohen is given little weight since the study he cited and relied upon has been identified as flawed and discounted by Dr. Lipscomb and Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the foregoing, the Court finds Complainant established the feasibility and effectiveness of this abatement proposal</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and that it would material</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ly</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>reduce exposure to the hazard of workplace violence.<span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">5.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Communication<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">to All Affected Staff</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>Incidents of Workplace Violence</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span><span></span>
					</span>and<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Escalating Behavior</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant contends Respondent failed to properly communicate vital information about<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients’ previous history of violence and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">indications of escalating behavior, which have the potential to lead to violence.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>In particular, Complainant contends Respondent’s system of communication failed in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at least four</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>respects, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) incomplete information provided by intake department prior to admitting the patient to a unit; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inadequate information exchange<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">during shift change</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, such as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>information about prior violent acts or indicators of violence occurring while at the facility;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sharing information about a patient responsible for a code being called; and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iv</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not sharing information with ancillary staff, such as housekeeping, about potentially assaultive patients.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ultimately, the Court finds Complainant failed to prove Respondent’s existing system was ineffective</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Although Complainant identified discrete instances where information was not properly transmitted</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, on the whole the Court finds Respondent had systems in place to ensure that information<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">about violent incidents and indicators of violence was communicated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, or made available to, direct care staff.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The Court also finds Complainant failed to present evidence which proved</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent failed to communicate relevant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">warnings to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>ancillary staff, such as housekeepers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and cafeteria workers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Mere statements in the Citation or Complai</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>not acceptable proof</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of a violation. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">asserts<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>intake procedures<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were insufficient because some employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>expressed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">concern,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">they did not always receive adequate information from the intake department about new patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and sometimes they did not have sufficient time to review the information they received. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">366,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">563; Ex. C-24).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While there were occasions when<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients were transferred to units without a complete assessment, the Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this was not a failure of policy or procedure but, instead,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the result of emergent circumstances and/or<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discrete failures to include a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">High-Risk</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Notification for patients assessed to be a violence risk.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A review of the intake assessment form shows Respondent’s intake clinicians typically perform a thorough assessment of incoming patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which is transferred to the unit when the patient is admitted. (Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-79</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>opined the assessment was deficient due to the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>manner in which it was collected in the file, the Court finds this was a criticism of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">form over substance. There was no indication the information gathered was irrelevant or inaccurate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. There were occasions when the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">High-Risk Notification form was not included in the assessment; however,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">there was no indication the information gathered in the assessment was deficient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or could not be used to assess violence risk.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further, although there were occasions where intake would do a direct admission to the unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which made effective transfer of information difficult (if not impossible), both Dr. Lipscomb and Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified there are times when direct admits<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are appropriate to initiate medical interventions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>when a recently admitted or transferred patient cannot be de-escalated through other means. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1059, 1517).<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For similar reasons, the Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant failed to prove Respondent’s system of information at shift change, including information about a patient’s prior act</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of violence,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was ineffective.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Administrators and staff alike testified each shift<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">overlaps by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">20-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">30 minutes to permit the exchange of information during observation rounds.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">During the rounds, staff discuss<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the current state of all patients, including whether<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a particular patient has engaged in concerning behavior or has assaulted a staff member. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">366-67</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). This information is also transmitted to the Treatment Team, which uses that information to inform<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">treatment decisions. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">681,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1737</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Although there may have been occasions where conducting handoff reports at shift change was complicated by extraneous factors, like staffing,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">such criticisms are properly leveled at staffing concerns, not the manner of information exchange.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further, though Complainant criticizes Respondent for not requiring<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">MHTs to review patient records or attend treatment meetings, the Court finds this does not suggest anything deficient about the program.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Patient files were not off-limits to MHTs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who could review them if they chose to do so.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ome of Complainant’s suggestions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>do not address a significant concern or are otherwise impractical to implement.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">First, h</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ousekeeping and food service workers do not provide direct care</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and there was no testimony or other evidence to suggest<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">supplying these<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees with patient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">information would be effective at addressing the workplace violence hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">There is no evidence in the record which indicated any acts of violence against the housekeeping or cafeteria staff.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Indeed, without a clinical or patient care background, it is unclear to the Court what housekeeping employees would conceivably do with this information.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Instead, Respondent provides such staff with a modified version of CPI training</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Court</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>finds is a more practical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and effective way to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">address the potential for workplace violence. (Tr. 2145).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Second, the Court finds Complainant’s criticism that employees did not have adequate information about a patient prior to responding to a Code Green is largely impractical.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Respondent, staff members typically stick to a single unit, which means they are more familiar with the patients they regularly work with.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">At Centennial Peaks, there are four inpatient units, which can have more than<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">one hundred</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients at a time.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">It is wholly impractical to provide every staff member with information about each patient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and simultaneously expect them to review such information</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>MHTs have patient files available to them, but do not typically review the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">m</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. More practical</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and just as effective,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is Respondent’s current Code Green regime, which uses a PML to guide the code response</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and inform the participants of relevant information.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the foregoin</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">g, the Court finds Complainant failed to prove Respondent’s existing system of information exchange is insufficient to address the hazard of workplace violence. Accordingly, Complainant’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">abatement proposal is rejected.</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">6.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Training on WVPP</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant contends Respondent failed to provide adequate training<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in all elements of the WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and identified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">five</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>areas</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in particular</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that should be included in such training</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. These include:</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how to call for assistance;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(ii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">uniform methods for responding to codes;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hands-on code drills;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(iv)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how to contribute to a post-incident debrief/root cause analysis; and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(v)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">preventing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">badges and/or communication devices from being taken by patients. (Ex. C-1).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent contends Complainant is yet again elevating form over substance</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and points to the numerous training modules it requires in order to address the problem of workplace violence, including CPI training, code green drills,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and verbal de-escalation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Respondent oversimplifies what Complainant seeks in this abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which is targeted toward the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">comprehensive nature of the WVPP.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As much as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">any proposal</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>discussed thus far</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, training on the WVPP is a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">necessary</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>part of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">creating and implementing a comprehensive WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Understanding the plan</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and, consequently, how to define and prevent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>are crucial<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to engaging in an all-encompassing process to prevent workplace violence.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. C-58 at 37-38).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The important aspect of this abatement proposal is to ensure all training related to acts of aggression or used as abatement measures therefor is connected under a single umbrella</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the WVPP. In other words, employees need to be<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">instructed in more than CPI techniques</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and the lik</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e; employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>must also be<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shown how<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">each of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">training elements listed in the WVPP are connected to one another and, ultimately, toward the goal of reducing workplace violence.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant’s criticism o</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">f Respondent’s training program is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>about ensuring the disparate elements<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">listed within Respondent’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>WVPP are adequately sewn together as part of a comprehensive whole</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>not</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>about whether</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it has provided training on</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">individual</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>elements of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>program.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The evidence shows<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent provides training in numerous areas, including a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rigorous</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>approach to CPI, de-escalation, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an on-the-job shadowing program</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">However,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the overwhelming weight of the evidence shows Respondent did not provide training on the program itself.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Employees testified they did not recall receiving training about the WVPP, and administration officials could not remember whether such training had ever been provided.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>failure to connect the disparate elements of Respondent’s plan<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">played out in numerous ways. For<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">example, employees expressed confusion<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">over the proper protocol for restraint and seclusion under the Be Free program</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which aimed to reduce restraints and rely on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">verbal de-escalation techniques. This confusion, in the opinion of many employees, led to injuries<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because they were unsure whether and when to institute a restraint.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Confusion spread to other areas of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">training that should have been connected through the WVPP, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">chain of command under the PML program</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">understanding when to report a workplace violence injury.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to Dr. Lipscomb, confusion could be remedied by training not only on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">programs under the umbrella of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the WVPP, but<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">training on the core elements of the WVPP itself, including the Management Commitment and Employee Participation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>building blocks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which the Guidelines note are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">vital to ensuring<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the success of the program. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1377-78</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C-58</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Dr. Cohen<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">did not opine on the content or sufficiency of the program; rather, he relied on deposition testimony merely to assert such training had taken place. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2068-69; Ex. R-2 at 17).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Because Respondent failed to provide training on the plan as a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">whole and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>considering the confusion that resulted from failing to connect major initiatives to the purpose of the plan, the Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant established Respondent’s existing training regime was ineffective at addressing the hazard of workplace violence.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The Court finds Dr. Lipscomb’s testimony</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>shows</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that implementation of training on Respondent’s comprehensive WVPP is feasible and such training would result in a material reduction of the workplace violence hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ee Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *13-14 (finding expert testimony regarding material reduction of hazard of workplace violence sufficient without requiring expert to quantify extent of reduction).</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">That said, the Court does not find</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>all elements of Respondent’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">WVPP,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or its training program were deficient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. With respect to Code Green Dri</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lls recommended by Complainant, the Court finds such drills were occurring based on the testimony of Kevin Smith, who w</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as responsible<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for initiating them. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2308</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">). Complainant contends the lack of documentation—only three drills in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">November 2018</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">suggests the drills were not occurring on the schedule suggested by Respondent; however, employees testified they had participated in drills on at least a semi-frequent basis, which the Court finds is sufficient to overcome the dearth of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">documentation of those drills.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr. 519-520,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1378;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex. R-56)</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As for the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">argument about Respondent’s failure to ensure its employees were adequately trained in CPI/advanced CPI, the Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the distinction between the two, at least with respect to the relevant time period, is much ado about nothing. All of Respondent’s direct care staff had received<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the full two-day training on CPI. Whether the employees felt comfortable utilizing CPI</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or questioned its effectiveness under certain circumstances, there was no competent evidence to suggest CPI training was ineffective as a means to de-escalate and/or restrain an aggressive patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, nor did the evidence show</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>advanced CPI was required because of such deficiency.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further, as it relates to advanced CPI, the Court finds Respondent was in the process of ensuring its employees received<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the training at the time the inspection occurred</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and further finds Complainant failed to prove</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>CPI was ineffective such that additional training was necessary</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. According to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Smith</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, nearly 50% of Respondent’s employees had received advanced CPI training<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at the ti</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">me of the inspection.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Part of the reason for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this, according to Smith, is that advanced CPI</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>had only recently been introduced as an alternative to CPI training.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court concludes it would be punitive to hold Respondent liable for not implementing advanced CPI training when it had commenced a schedule for such training</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and there was no discernable evidence to indicate that CPI</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>alone</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was deficient.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">his proposed abatement method could have been subsumed under abatement item #</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">5, which addressed the need for a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">comprehensive</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>WVPP. As noted in the Guidelines, Road Map, and Sentinel Alert,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">one of the five building blocks for a WVPP is a robust safety and health training<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">program</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Ex. C-12). At the top of the list of topics<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for such training: the workplace violence prevention policy. (Ex. C-12 at 32).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the foregoing, the Court finds<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">:</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">established<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">significant shortcomings in Respondent’s training regime as it relates to the WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; (ii) has established the feasibility of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">training on the WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; and (iii) training in the WVPP would materially reduce the hazard of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">7.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Conducting Investigations & Debriefings</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><a name="ftnref43" href="#ftn43">42</a></span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The discussion around this abatement item highlights one of the key principles of a comprehensive WVPP:<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">failures and/or shortcomings in one area of the plan invariably impacts the other elements of the plan.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">That is particularly the case here, where</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>how you define workplace violence will dictate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">what type of events are reported and, subsequently, which events<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">will be investigated and analyzed.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Guidelines stress the importance of post-incident evaluations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and appear to suggest casting a wide net to include “near misses”, which it defines as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">incidents that “could have potentially resulted in death</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>injury, or illness.”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Ex. C-12 at 30).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This would be consistent with the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">parties’ stipulation defining workplace violence as including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not only assaults but also threats</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, even if it is inconsistent with Respondent’s definition in practice, in the WVPP, and in the events it chooses to analyze and debrief.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Guidelines state</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">I</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nvestigating incidents of workplace violence thoroughly will provide a roadmap to avoiding fatalities and injuries associated with future incidents.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Ex. C-12 at 28).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">To get an accurate road map, however, you need good data.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant contends Respondent’s policy, or lack thereof,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">regarding post-incident debriefing and camera review did not account<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for all<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence injuries.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In support of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this claim, Complainant relies<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on the testimony of multiple employee witnesses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who testified they did not typically participate in debriefs or camera reviews, even for incidents involving seclusion and restraint</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(S&R)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">370, 1128</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1052, 1082-86,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1670-72</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-16</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further, though camera reviews are mandated for both S&R and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">"all reported staff injuries”, staff testified camera reviews were rare, and, to the extent they occurred,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were focused on evaluating CPI technique</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">served more as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an opportunity for management to critique performance<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">more<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">than as a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n opportunity to review what happened</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and seek input</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">158,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">578-580.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1101</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; Ex.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R-16</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent, on the other hand,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">argues it performed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">debriefings consistent with the WVPP, maintained accurate records of patient assaults on staff,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">tracked and trended employee injuries, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discusses<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“near misses” in the context of successful Team Lavender interventions and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Code Greens not resulting in restraint.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent claims both Dr. Lipscomb and CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>reached inaccurate conclusions when it came to issues like maintaining accurate records of assaults, tracking and trending injuries, and whether debriefings were occurring after incidents other than<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S&R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The problems for Respondent are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">three</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-fold. First, it failed to put forth convincing, countervailing evidence to suggest it performed debriefs or reviews of incidents other than<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S&R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The only documentation of debriefings was found in the S&R packets, and the only evidence employees were debriefed when a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S&R<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was not involved is the word of its administrators and management, who could not remember whether they performed training on the WVPP or the results of a root cause analysis of a particularly gruesome incident involving a patient with a knife. (Tr. 2158)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Smith testified he kept a spreadsheet on codes, indicating information about the code and providing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the name of who led the debrief, but none of this documentation was submitted at trial.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref44" href="#ftn44">43</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Tr. 2313).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The limited focus of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">documented<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">debriefs and investigations, in turn, limited</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the universe of potential incidents subject to review and potentially creat</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>blind spots in any future hazard or trend analysis.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Second, as discussed repeatedly above, Respondent’s record of assaults and injury<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are inaccurate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Employees did not report every injury</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and Respondent did not have an accurate record of those injuries as illustrated by CSHO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oberbeck’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>analysis of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">EARs, HPRs, and OSHA 300s.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The same is the case here with respect to debriefs and follow-up investigations.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>testified her review<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of incident reports and patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>files revealed no documentation of camera reviews. (Tr. 866).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Cohen’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s review of case files does not counter this analysis, as he relied on management depositions and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policy to assert debriefing and camera reviews were occurring.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 2074; Ex. R-2 at 17-18).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The debriefs performed were limited in scope</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and did not always include all parties to the incident</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which Dr. Lipscomb testified is vital to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an accurate determination of what occurred</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and how to prevent those events going forward</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1380</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent claims</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>some</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>members are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>unwilling to participate for various reasons, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">be</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>traumatized by revisiting the incident. There is no way for this to be verified</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, but the weight of employee testimony suggests they were simply not included, not that they chose not to participate.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Complainant argues Respondent should conduct a review and debrief of near-miss incidents in the same manner as it reviews incidents resulting in injury, which is consistent with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the recommendation from the Guidelines</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>discussed above.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondent argues</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant never defines “near-miss”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in the context of an in-patient behavioral health facility, when it is not predictable when violence or an assault would happen, this is not even practical.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>89.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Court is confused by this line of argument. Complainant seeks to define “near miss” in the same way as the Guidelines. While a staff member may not be able to assess a near-miss incident<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he/she</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is not aware of because it never came to fruition, they are all-too-aware of incidents<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that could have result</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in serious injur</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">y, including a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient who makes physical threats and postures before being verbally de-escalated or patients who throw computer monitors or other items</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>turned into weapons.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">To the extent Respondent is relying on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its documented “success” in the early days of the Lavender Team, the Court notes these documented successes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>shows how Respondent’s employees were able to avoid restraint in a particular situation, but there is nothing to suggest<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">documenting<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this limited universe of interactions was effective</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at reducing injuries</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. During this same<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">period</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>employee injuries went up substantially</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The testimony of Dr. Lipscomb, Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Argumedo</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discussion of post-incident debriefings and investigations, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">near misses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, all attest to the effectiveness of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a robust system of review that relies on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">accurate recordkeeping of injuries and incidents</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a clear and consistent definition of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and commitment to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">providing staff with opportunities to engage in the process in a constructive manner. The foregoing establishes Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s existing regime was not effective because</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it did not have accurate records due to the limited universe of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">incidents where it performed documented briefings and review</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. This<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is due to a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lack of clear policy as to what constitutes an act of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and, subsequently, what should be documented.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See, e.g.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">UHS of Delaware, Inc. and Premier Behavioral Health Solutions of Florida, Inc. dba Suncoast Behavioral Health Center</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 18-0731,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at 101-102</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">OSHRC ALJ<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2021)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pending<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Commission review on other issues</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(“[I]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ncident</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">investigations and debriefings were [] hampered by their scope</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>. . . .”);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Accordingly, the Court finds Complainant established</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) significant shortcomings in Respondent’s incident investigations and debriefing regime; (ii) the feasibility of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">abatement; and (iii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">strengthening<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>incident investigation and debriefing policies<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">would materially reduce the hazard of workplace violence.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">S</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ee Integra.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2019 WL 1142920</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at *13-14 (finding expert testimony regarding material reduction of hazard of workplace violence sufficient without requiring expert to quantify extent of reduction).</span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:120px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">8.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Economic Feasibility</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Beverly Enterprises</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Commission defined “feasible” as economically and technologically<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">capable of being</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>done.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Beverly Enter</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">s.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">, Inc.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">19 BNA OSHC<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1190 (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">citing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Baroid</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Div. of NL Indus., Inc. v. OSHRC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 660 F.2d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>447.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The obligation to prove economic feasibility under the general duty clause falls to Complainant.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Waldon Health Care Ctr.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 16 BNA OSHC<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1063 (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">finding the Secretary failed to fulfill his burden of establishing that it was economically feasible for the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer to have made the HBV vaccine available to their employees on a preexposure basis)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">presented compelling evidence indicating its proposed abatement measures would be economically feasible.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Specifically, Complainant<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pointed to three bases upon which all of the proposed abatements would be feasible: (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) many of the proposed abatements only require a change in policy, documentation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, or practice, such as implementing a comprehensive WVPP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(ii)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">communication of incidents of workplace violence;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adequate training, and conducting debriefings; (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent implemented, in some form or fashion, some of the proposed abatements</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>after the inspection occurred</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">purchasing additional radios</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, redesigning another reception area in the ECT department to be fully enclosed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and adding additional staff (milieu managers), whose<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">job was to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">monitor acuity, patient precautions, and individual support plans</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; and (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">v</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent failed to introduce any evidence to suggest the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">bottom-line revenue testified to by Respondent’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>acting C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hief<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">F</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inancial<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">O</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">fficer</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was either inaccurate or insufficient to pay for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>additional staff or updates to the nurse’s station, two abatements i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t either implemented or performed in other areas (the ECT reception area) after the inspection occurred.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 1584-1586; Ex. C-79). Furthermore, as illustrated in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Road Map, most, if not all, of the foregoing abatement measures have been implemented in facilities</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>like Respondent’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>thr</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">oughout the country.<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the foregoing,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Court finds Complainant established the economic feasibility of the proposed abatement measures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which the Court has found would be<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">technolog</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ically feasible of being implemented and effective at addressing the hazard of workplace violence.</span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">VI.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Affirmative Defenses</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent advanced<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">four affirmative defenses in its Answer.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Answer, August 9, 2019. At trial, the Respondent indicated it was pursing all of the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">m</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Tr</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>20</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In Respondent’s Post-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">trial</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">B</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rief, it failed to brief any affirmative defenses as instructed by</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the Notice of Receipt of Trial Transcript and Briefing Order dated November 2, 2022. A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ccordingly, a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ny affirmative defenses raised in Respondent’s Answer are deemed abandoned.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">a.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">-Pac</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Corp.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 15 BNA OSHC 1127, 1130 (No. 89-2713, 1991). </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">VII.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Penalty</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Under the Act, the Secretary has the authority to propose a penalty according to Section 17 of the Act.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">29 U.S.C. §§ 659(a), 666. The amount proposed, however, merely becomes</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>advisory when an employer timely contests the matter.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Brennan v. OSHRC</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Interstate Glass</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 487 F.2d 438, 441–42 (8th Cir. 1973);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Revoli</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Constr. Co.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 19 BNA OSHC 1682, 1686 n. 5 (No. 00-0315, 2001). Ultimately, it is the province of the Commission to “assess all civil penalties provided<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in [Section 17]”, which it determines<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">de novo</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. 29 U.S.C. § 666(j);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">see also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Valdak</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Corp.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 17 BNA OSHC 1135 (No. 93-0239, 1995)</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 73 F.3d 1466 (8</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">th</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Cir. 1996)</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“Regarding penalty, the Act requires that “due consideration” be given to the employer’s size, the gravity of the violation, the good faith of the employer, and any prior history of violations.”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Briones Util. Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 26 BNA OSHC 1218, 1222 (No. 10-1372, 2016) (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">citing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>29 U.S.C. § 666(j).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">These factors are not necessarily accorded equal weight.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">J.A. Jones Constr.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 15 BNA OSHC 2201, 2216 (No. 87-2059, 1993) (</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">citation omitted</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Rather, the Commission assigns the weight that is reasonable under the circumstances.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Eric K. Ho,</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>20 BNA OSHC 1361, 1379 (No. 98-1645, 2003) (</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">c</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">onso</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lidated</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">),<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff'd sub nom.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Chao v. OSHRC</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 401 F.3d 355 (5th Cir. 2005)</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">overruled on other grounds</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">E.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Smalis</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Painting</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 22 BNA OSHC 1553 (No. 94-1979)</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. It is the Secretary’s burden to introduce evidence bearing on the factors and explain how he arrived at the penalty he proposed.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Valdak</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Corp</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 17 BNA OSHC at 1138.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“The gravity of the violation is the ‘principal factor in a penalty determination.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Assessing gravity involves considering: (</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) the number of employees exposed to the hazard; (</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ii</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) the duration of exposure; (</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iii</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) whether any precautions have been taken against injury; (</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">iv</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) the degree of probability that an accident would occur; and (</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">v</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) the likelihood of injury. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See, e.g.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Capform</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 19 BNA OSHC 1374, 1378 (No. 99-0322, 2001),<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_cf01 style_cf01 " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Segoe UI; font-size:9pt; font-family:Times New Roman; font-size:12pt; ">No. 01-60417, 2002 WL 35650276 (5th Cir. Mar. 20, 2002)</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_cf01 style_cf01 " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Segoe UI; font-size:9pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant proposed a penalty of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">$10,229</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which includes in its calculation<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a 10% reduction in the original penalty due to Respondent’s size.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The foregoing analysis shows<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nearly all of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent’s direct</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>care staff, and even some of the ancillary staff, are exposed to the hazard of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on a daily basis. Respondent has taken some precautions against injury, but as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has been shown, many of those measures were ineffective.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally, based on the testimony of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">all employee witnesses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the likelihood of being injured is substantial. Accordingly, the Court finds the penalty proposed by Complainant is approp</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">riate.</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on the entirety of the foregoing decision, the Court<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">finds Complainant met its burden to establish a violation of 29 U.S.C. § 654(a)(1)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Accordingly, Citation 1, Item 1 shall be AFFIRMED and a penalty of $10,229 shall be ASSESSED.</span></p>
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			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:72px; text-indent:-1.27cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">VIII.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Conclusion</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In the end, the most important takeaway from this case is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the importance of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an all-encompassing, systematic approach to workplace violence.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Consistent with Dr. Cohen’s concern that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">interventions should be evidence-based, a comprehensive<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence protection plan</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is data-driven</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, but the program will only be as good as the data collected. This requires a clear definition of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence that guides what is reported, how it is tracked, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how to respond.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Management needs to ensure the programs are carried out</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and, perhaps most importantly, needs to take seriously the concerns of its staff, who are intimately connected to the problem of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. While the Court has noted areas where Respondent has been successful and where the existing program has proved deficient,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the foregoing should<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nonetheless<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">serve as a starting point and road map towards developing a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">truly comprehensive<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence protection plan</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Areas of success, just as much as areas of failure, should be reviewed and serve as additional data</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to shape and form the workplace violence protection plan.<span>
						</span></span></p>
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				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; padding-right:20px;">IX.</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">O</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">rder</span></p>
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				<p style="line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>The foregoing Decision constitutes the Findings of Fact and Conclusions of Law in accordance with Rule 52(a) of the Federal Rules of Civil Procedure. Based upon the foregoing Findings of Fact and Conclusions of Law, it is ORDERED that:</span></p>
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			<p style="margin-left:48px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:48px; text-indent:-.635cm; margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;">1.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Citation 1, Item 1 is AFFIRMED as serious, and<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">penalty of $</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">10,229</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>is ASSESSED.<span>
					</span></span></p>
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				<p style="text-align:justify; margin-left:24px; "> </p>
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				<p style="line-height:2; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>SO ORDERED</span></p>
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				<p><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:20pt; font-family:Brush Script MT; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Brush Script MT; font-size:20pt; text-decoration:underline ;">/s/ Patrick B. Augustine</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Patrick B. Augustine</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>Judge, OSHRC</span></p>
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				<p style="text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Date:</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>July 26, 2022</span></p>
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				<p style="text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Denver, Colorado</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span></p>
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					<a name="ftn0" href="#ftnref0"></a> </p>
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					<a name="ftn1" href="#ftnref1"></a> </p>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn2" href="#ftnref2"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">1 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">According to studies conducted on workplace violence, these numbers drastically underestimate the extent of the problem by a factor of three or more, which the studies attribute to employees’ understanding that violence perpetrated by patients/customers on staff is simply “part of the job.” (Ex. C-62 at 2).</span></p>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn3" href="#ftnref3"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">2 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Respondent also has patients who self-admit</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn4" href="#ftnref4"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">3 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Subsequent references to the Joint Stipulations will<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">appear as follows: “(JS No. ___)”.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn5" href="#ftnref5"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">4 </span></a><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">See Armstrong Utils., Inc.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, N</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">o</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. 18-0034, 2021 WL 4592200, at *2 n.2 (O.S.H.R.C</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Sept. 24, 2021)<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">(finding it was “plain error” to not accept the parties’ stipulation);<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">CF & T Available Concrete Pumping, Inc.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, 15 BNA OSHC 2195, 2199 (No. 90-329, 1993) (Commission accepted the parties’ stipulation that the alleged violation, if any, was serious).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">The Court also notes the parties stipulated to all but<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">two</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>element</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">s</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>of the Complainant’s<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">prima facie</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>case.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>The parties did not stipulate to the issues of knowledge and feasibility.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">In reality, the stipulations as to the elements of Complainant’s case are surplusage, because the Court already sanctioned Respondent for destroying video recordings of the worksite during the relevant period by imposing adverse inference</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">s</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>and finding the destroyed videos would have established all but the feasibility prong of the general duty clause analysis.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">See Order on Complainant’s Motion for Sanctions and Entry of Sanctions</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, Docket No. 19-1579 (April 19, 2021).</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">The stipulations were not submitted to the Court until nearly five months after the Court entered sanctions against Respondent.<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">See<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Joint Stipulations</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, Docket No. 18-1579 (September 3, 2021).</span></p>
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					<a name="ftn6" href="#ftnref6"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">5 </span></a><span><span></span>
					</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Complaint did not request a reconsideration of this Order</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>nor did he raise it in his post-trial brief. As such, it is now the law of the case.<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">Ariz</span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">.</span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; "><span><span></span>
						</span>v. Cal</span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">.</span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">460 U.S. 605 (1983) (law of the case doctrine requires that when a court decides on a rule, it should ordinarily follow that rule during the pendency of the matter).</span></p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn7" href="#ftnref7"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">6 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Parties essentially argued the same points they argued in their original post-trial briefs just in more detail. While<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Respondent has argued that<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">Westwood Pembroke</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>was wrongfully decided by the Commission and the case is currently on appeal to the Third Circuit Court of Appeals, the Commission</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">’s</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">Westwood Pembroke</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Decision and Order is a Final Order of the Commission</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>as of this writing</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. As a Final Order of the Commission, the Court is bound to follow its precedent</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "> </span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">Gulf & W. Food Prods. Co.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, 4 BNA OSHC 1436, 1439 (No. 6804, 1976)</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "> (consolidated) (“[T]he orderly administration of [the OSH Act] requires that the Commission's administrative law judges follow precedents established by the Commission.”); </span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">see </span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">McDevitt Street Bovis, Inc.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">19 BNA OSHC 1108</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, 1110 (No. 97-1918</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, 2000) (noting that Commission generally applies law of circuit to which appeal is likely, but concluding judge properly applied Commission precedent where pertinent circuit “neither decided nor directly addressed” issue).</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn8" href="#ftnref8"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">7 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Involuntary admissions come from area emergency rooms, as well as from local police.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">(Tr. 95).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn9" href="#ftnref9"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">8 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>The parties repeatedly referred to the “milieu” when discussing the state<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">of a particular unit in the hospital.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">(Ex. R-52)</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.<span>
						</span></span></p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn10" href="#ftnref10"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">9 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Respondent also has an Electroconvulsive Therapy unit</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, which provides services on an outpatient basis and is not a focus of the current matter.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">(Tr. 94, 347).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn11" href="#ftnref11"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">10 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Under the Emergency Medical Treatment and Labor<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Act</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>(EMTALA), hospitals like Respondent are required to treat and<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">stabilize patients under emergency conditions.<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">See<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">42 U.S.C. §</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>1395dd</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>H</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">ospitals are only allowed to<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">reject a patient under very limited circumstances; namely, lack of capacity and<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">lack of ability to treat.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">(Tr. 420, 2149).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn12" href="#ftnref12"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">11 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Acuity is a concept that can refer to<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">the severity of an individual’s condition, as well as the psychiatric condition of the unit as a whole.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn13" href="#ftnref13"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">12 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">The frequency and purpose of the special observation rounds may change</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">during the overnight shift, during which time most of the patients are sleeping. (Tr.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">1481</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn14" href="#ftnref14"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">13 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Not all patients travel to lunch, as some do not want to leave the unit and others are restricted to the unit, so the remaining nurses and MHTs remain on unit for the remaining patients and to do charting.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn15" href="#ftnref15"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">14 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>As will be discussed in more detail<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">later</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>in this decision, the milieu manager was<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">created back in<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">2017, removed for a period of time, and then reinstituted<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">after the inspection. Initially, the milieu manager was charged with monitoring unit acuity, patient precautions, and Individual Support Plans.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>(Tr.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">1602</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">). When the position was brought back, Respondent imbued the milieu manager with manager-level responsibilities. (Tr.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">1601, 1747).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn16" href="#ftnref16"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">15 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>For example, according to the matrix in place at the time of the inspection, if Pike</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">’</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">s Peak had a census of 20 patients, Respondent should allocate 5 staff members (2 nurses and 3 MH</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">T</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">s) to the 3 p</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">m</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>to 11 p</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">m</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>shift. (Ex. C-74).<span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn17" href="#ftnref17"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">16 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Intake personnel were also trained and available to respond to<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">emergencies</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">; however,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">they were not required</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>to do so. (Tr.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">1077</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">).<span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn18" href="#ftnref18"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">17 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Both the 2017 and 2018<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">OSHA<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">300<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">logs<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">include injuries from sources other than patient violence, and the Court was mindful to remove those entries<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">from the total referenced above.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn19" href="#ftnref19"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">18 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Of further interest is the fact that<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">the EAR report numbers, which were added to the OSHA 300 log numbers,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">only represent the five-month period between July 5, 2018</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>and November 29, 2018. (Ex. C-11).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Likewise, the police report numbers only represent the calls made in the second half of the year. (Ex. C-11).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn20" href="#ftnref20"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">19 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">As discuss</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">ed</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>in greater detail later in this decision,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">one of the key</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">failures identified by Complainant is th</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">at Respondent’s WVPP is not comprehensive in its scope</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>but is instead a<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">paper program and a series of disjointed policies</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>with no discernible connection.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn21" href="#ftnref21"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">20 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Though they were not managers at the time of the program’s creation, Kevin Smith has become an actual “manager</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">” due to his promotion to milieu manager. (Tr.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>2387</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn22" href="#ftnref22"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">21 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>During the overnight shift,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">the staff member initiating the call would separately call the other nurse’s stations<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">instead of calling over the PA system<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">to avoid waking up/agitating the other patients in the hospital</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.<span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn23" href="#ftnref23"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">22 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>According to Respondent</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, the debriefs required by its policy are also required by Colorado law.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn24" href="#ftnref24"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">23 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Respondent noted some of these policies were in place prior to the implementation of the Be Free initiative, which might explain why the document it relies on to illustrate the “new” protocol does not have any mention of the Be Free initiative on it</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, nor does it include an effective date. (Ex. C-39).</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">
					</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn25" href="#ftnref25"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">24 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Staff with no direct care responsibilities, such as cafeteria workers and janitorial staff, received an abbreviated form of the training. (Tr. 2154).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn26" href="#ftnref26"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">25 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Of course, there are instances where the employee cannot self-report</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>due to the nature of their injuries</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, in which case the supervisor makes the call to Sedgwick</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. (Ex. R-43).<span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn27" href="#ftnref27"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">26 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>At trial, Complainant placed significant emphasis on<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">the stated purpose of Respondent’s WVPP, which<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">“recognizes and establishes a ‘Zero Tolerance Policy’ for all types of workplace violence . . . .”</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">(Ex. C-</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">14). This is not entirely surprising</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">—The Joint Commission’s “Sentinel Event Alert”</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>includes as one of its recommendations that “leadership<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">should establish a goal of zero harm to patients and staff”</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. (Ex.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">C-62). That Respondent and TJC express a goal of zero</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>harm is not surprising</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>given what is at stake</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. Rather, of bigger concern is the manner in which that goal is sought, which is the subject of the current case.</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn28" href="#ftnref28"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">27 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">At trial, Respondent argued repeatedly that certain proposed abatement measures could not be implemented because it impacted patient care. Respondent argued TJC and state statute prevents implementation of some of the proposed abatement measures, without identifying the activity and providing the specific statutory provision for the Court to analyze. Without specifics, Respondent’s argument cannot stand.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Respondent’s argument is further undermined as it relates to TJC. TJC issued publications in which in-patient psychiatric hospitals, such as Respondent, were encouraged to follow the OSHA Guidelines and Roadmap in charting its course to address workplace violence. (Ex. C-12, C-13, C-62). In fact, the OSHA Guidelines reference TJC publications as a resource relied on the development of the Guidelines and Roadmap. (Ex. C-12). It is highly unlikely TJC would have taken the above position if it concluded that patient care would be significantly impacted or that state statutes were contravened.</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn29" href="#ftnref29"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">28 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">In general, “[w]here it is highly probable that a Commission decision would be appealed to a particular circuit, the Commission has . . . applied the precedent of that circuit in deciding the case—even though it may differ from the Commission’s precedent.”<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">Kerns Bros. Tree Serv</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">., 18 BNA OSHC 2064, 2067 (No. 96-1719, 2000) (citation omitted).</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn30" href="#ftnref30"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">29 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. </span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">It is also important to note that, to the extent an employer has implemented some of the Secretary’s proposed abatement measures, those measures should, at the very least, satisfy the first prong of the feasibility analysis: whether the abatement proposals are capable of being put into effect.<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">See SeaWorld of Fl</span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">a.</span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; "><span><span></span>
						</span>LLC v. Perez</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">748 F.3d 1202, 1215 (D.C. Cir. 2014);<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">FMC Corp</span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, 12 BNA OSHC 2008 (No. 83-488 et al., 1986)</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.<span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn31" href="#ftnref31"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">30 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span><span></span>
					</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">I</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">f the increase in reportable injuries<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">was due to this factor (which the Court does not find), the Court<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">would still</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>conclude that</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>prior to<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">this drastic increase in reported injuries</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, the WV</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">P</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">P, its implementation</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>and reporting w</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">ere</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>ineffective</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, because</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>prior to<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">the increase,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>injuries were not being reported<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">accurately</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>This illustrates both the primacy of a comprehensive WVPP as an abatement measure</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>and the impact the failure of any of its individual elements can have on the WVPP as a whole.<span>
						</span></span>
				</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn32" href="#ftnref32"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">31 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. The EAR form itself indicates what should be reported</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, but i</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">t is a general form related to any injury suffered by an employee, not necessarily injuries resulting from workplace violence</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">(Ex. R-43).</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn33" href="#ftnref33"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">32 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. Dr. Lipscomb also noted the PowerPoint presentation</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>also had “San Marco Behavioral Health” on the title of the slides,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">which calls into question the provenance of the document</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>and may explain why Respondent’s employees do not recall ever seeing it. (</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Ex. C-58</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn34" href="#ftnref34"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">33 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. According to Wells, it was optional for social workers to respond to codes. (Tr. 1077). </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn35" href="#ftnref35"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">34 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. Because Complainant has identified a separate abatement proposal for training, the Court will address that building block in Section<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">V.d.vi</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">infra</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn36" href="#ftnref36"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">35 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. The Sentinel Event Alert indicates a 55% reduction by 201</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">5, which represented year three of the program. (Ex. C-62).<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn37" href="#ftnref37"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">36 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>If the Court were to accept Respondent’s invitation on this point, then the Court must find that any hospital where conduct may be unpredictable is exempt from implementing any policies on workplace violence since such conduct is unforeseeable. The Court must decline Respondent’s invitation. Data has established—and especially Respondent’s data to the extent it can be relied on—the incidents of workplace place violence were not unpredictable or unforeseeable. In fact, the increased frequency of workplace violence incidents which occurred in 2018 after the aforementioned changes at Respondent’s facility shows workplace violence was no longer unforeseeable.</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn38" href="#ftnref38"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">37 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. The Court<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">was not provided with convincing evidence that one method/device would be substantially more effective<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">than the other under the circumstances presented here. Thus, the Court finds the use of either device, or both, would be materially effective at reducing the hazard.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">This is consistent with the wording of the proposed abatement which identified options for Respondent’s consideration. Thus, while there was testimony on the use of panic alarms and bracelets, there is no need to discuss this testimony since Respondent, after the inspection, chose the method it implemented to improve communication and call for Codes. By doing so, Respondent effectively established<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">such a method could be feasibility implemented and its implementation would materially reduce the hazard. </span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">
					</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn39" href="#ftnref39"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">38 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. Abatement Item No. 4</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>also includes a requirement to train direct care staff in advanced CPI. Since this proposal is<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">not directly related to staffing, and considering these proposals are being considered as part of a collective process, the Court shall address the question of training in advanced CPI in the section on training.<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">See<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Section<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">V.d.vi,<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">infra</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn40" href="#ftnref40"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">39 </span></a>.<span><span></span>
					</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">By all accounts</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, response time improved after Respondent provided every staff member on a unit per shift with walkie-talkies.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Both<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Forster and Smith testified of improved response times to Code Greens. (Tr. 2347-48).</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>Thus, Complainant’s concern regarding response times has been abated as such method has been found to substantially reduce workplace violence injuries due to improved response times.</span><span><span></span>
					</span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">See infra</span><span><span></span>
					</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">V.D.2</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span><span><span></span>
					</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Also, each of the experts, including Dr. Cohen, testified the use of walkie-talkies and/or panic alarms would be effective in reducing the likelihood or severity of the injury resulting from an act of patient aggression. (Tr. 1520, 2019).</span>
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					<a name="ftn41" href="#ftnref41"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">40 </span></a><span><span></span>
					</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Since the Court has found Respondent’s current response protocol<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">adequate and</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>given Complainant’s clarification at trial that it is Respondent’s choice</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>of the method to abate the workplace violence hazard, it is not necessary to further evaluate the use, number</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>and type of security personnel Complainant envisioned but did not adequately communicate to the Court.</span><span><span></span>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn42" href="#ftnref42"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">41 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. Respondent accused<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Bierweiler of “catastrophizing”</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>scenarios like the one described above by looking at worst-case<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">outcomes</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">. Considering many other staff members expressed similar concerns in reports, emails, and survey responses, the Court finds<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">Respondent is minimizing a legitimate concern about the hazards of understaffing.</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span></p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn43" href="#ftnref43"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">42 </span></a><span><span></span>
					</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">The Court notes that debriefing and investigations are also the focus of the<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">t</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">raining abatement</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">recommendation<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">previously</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>discussed. Much of the analysis in this section is equally applicable to what should be included in WVPP training as it relates to conducting investigations and<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">debriefing</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>of impacted<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">employees</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span>
				</p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="text-align:justify; ">
					<a name="ftn44" href="#ftnref44"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">43 </span></a><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>It is well established that when one party has it peculiarly within its power to produce evidence which would elucidate the situation and fails to do so, it gives rise to the presumption that the evidence would be unfavorable to that party or is not available.<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">Graves v. United States</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, 150 U.S. 118, 121 (1893). The Commission has also noted when one party has evidence but does not present it, it is reasonable to draw a negative or adverse inference against that party, i.e., that the evidence would not help that party's case.<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">CCI, Inc.,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>9 BNA</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>OSHC</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>1169, 1174 (No. 76-1228, 1980),<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">aff'd</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, 688 F.2d 88 (10th Cir. 1982). See also<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">Woolston Constr. Co</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">., 15 BNA OSHC 1114, 1122 n.9 (No. 88-1877, 1991) (citing<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">Baxter v. Palmigiano,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>425 U.S. 308, 316-18 (1976)),<span>
						</span></span><span style="font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; font-style:italic; ">aff'd</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, No. 91-1413</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">, 1992 WL 117669</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>(D.C. Cir. May 22, 1992)</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; "><span><span></span>
						</span>(unpublished)</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-size:10pt; font-family:Times New Roman; ">.</span></p>
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