The hospital manages security risks.

(1)

The hospital controls access to and from areas it identifies as security sensitive.

(2)

The hospital develops and implements written policies and procedures to follow in the event of a security incident, including an infant or pediatric abduction.

(3)

The hospital develops and implements a process(es) for continually monitoring, internally reporting, and investigating the following: - Injuries to patients or others within the hospital's facilities and grounds - Occupational illnesses and staff injuries - Incidents of damage to its property or the property of others - Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence - Hazardous materials and waste spills and exposures - Fire safety management problems, deficiencies, and failures - Medical or laboratory equipment management problems, failures, and use errors - Utility systems management problems, failures, or use errors Note 1: All the incidents and issues listed above may be reported to staff in quality assessment, improvement, or other functions. A summary of such incidents may also be shared with the person designated to coordinate safety management activities. Note 2: Review of incident reports often requires that legal processes be followed to preserve confidentiality. Opportunities to improve care, treatment, and services, or to prevent similar incidents, are not lost as a result of following the legal process.

(4)

The hospital coordinates administrative and clinical decisions for patients under legal or correctional restrictions on the following: - Use of seclusion and restraint for nonclinical purposes - Imposition of disciplinary restrictions - Restriction of rights - Plan for discharge and continuing care, treatment, and services - Length of stay