The Supreme Court of New York, Kings County teaches us in Wyckoff Heights Med. Ctr. v. Rodriguez that healthcare facilities and individual providers have the right to protect themselves against violent and noncompliant patients. Mr. Rodriguez was a quadriplegic patient who also suffered from Type 2 diabetes mellitus. Prior to his inpatient admission, he was being treated in his home by the Visiting Nurse Association (VNA) of Brooklyn. Due to Mr. Rodriguez's violent, abusive, and harassing behavior, the VNA abandoned his care, whereupon he was admitted to Wyckoff Heights Medical Center. Wyckoff treated and stabilized the patient and then determined he no longer required hospital care. He was issued a discharge notice on March 20, 2002. Both the VNA and patient opposed this discharge notice. The VNA argued that the hospital had no standing to force the patient to leave the hospital. Mr. Rodriguez opposed the discharge because he did not want to go to the adult home that accepted him. He appealed the discharge to the Island Peer Review Organization (IPRO). IPRO upheld Wyckoff's discharge decision, determining that there was no medical necessity to keep Mr. Rodriguez. A proper plan to discharge him to an adult home or his own home with appropriate home healthcare had been established. Home healthcare was immediately ruled out since the VNA refused to provide care. Mr. Rodriguez did not want to go to the adult home recommended by Wyckoff, so an injunction was filed by the hospital to have the patient removed to the adult home.

In deciding this case, our court determined that there were no cases in New York, which addressed the use of injunctions to discharge a patient following a proper discharge notice. In looking to other jurisdictions, however, it learned that there was a recognized injunctive in New Jersey to eject a hospital patient who refused to leave following a discharge (Jersey City Med. Ctr. v Halstead, 169 NJ Super 22, 404 A2d 44 [1979]). Additionally, this right had also been recognized by the federal court in Lucy Webb Hayes Natl. Training School for Deaconesses & Missionaries v Goeghegan, 281 F Supp 116 [D DC 1967]). Lastly, Our court determined that North Carolina makes patients liable for criminal trespass when refusing to leave a hospital once a proper discharge plan has been issued to the patient (NC Gen Stat Ann [S] 131E-90). Lucy Webb instructs that hospitals have no duty to allow their facilities to be used for purposes other than what they are intended (Lucy Webb, supra at 117). The conclusion from these cases was that where a hospital complies with the required patient discharge guidelines, a patient's failure to comply may result in a mandatory injunction requiring the patient to leave (Wyckoff Heights Med. Ctr. v. Rodriguez, 2002).

Our court applied case precedence and state law to Mr. Rodriguez's facts, and determined that the New York guidelines were meticulously followed. Specifically, Mr. Rodriguez received a written notice of his discharge, which was based on numerous medical examinations. Mr. Rodriguez was given the opportunity to appeal the discharge determination. Further, he was included in the release arrangements from the hospital. Our court ruled that it did not matter that Mr. Rodriguez was not satisfied with the adult home that had agreed to accept him. His violent behavior, which included harassment, cursing, and biting attending healthcare professionals, caused him to forfeit his right to demand a discharge placement of his choice. The court granted the mandatory injunction, ordering Mr. Rodriguez to leave the hospital. It further ruled that should Mr. Rodriguez not leave, the hospital could use any appropriate means to carry out the injunction (Wyckoff Heights Med. Ctr. v. Rodriguez, 2002).

The rulings from this 2002 case and those relied on to make this decision have been upheld. The current position of the American Nurses Association on Incivility, Bullying and Workplace Violence is that nurses must, "create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect" (American Nurses Association [ANA], 2015). The ANA also says that nurses must be afforded similar treatment. "The nursing profession will no longer tolerate violence of any kind from any source" (ANA). Best practices must be developed and implemented to prevent these behaviors while ensuring the safety and wellness of nurses to allow optimal healthcare outcomes to the patients (ANA).

In 2007, Protecting our Caregivers from Workplace Violence was published by the Norfolk District Attorney's office and includes contributions from the Brockton Visiting Nurse Association. The document highlights the prevalence of workplace violence in healthcare. Staggering statistics are that, "health care workers experience violent assaults at a rate four times higher than other industries; for nurses and other personal care workers, this rate jumps to 12 times higher" (Norfolk District Attorney's Office, 2007, p. 8). It was learned from a 2004 survey that half of the nurses who responded were punched at least one time in the previous 2 years. A study focusing on emergency department care reported 75% of the physicians had been threatened in the last year, with 28% being assaulted (Norfolk District Attorney's Office, p. 8).

Protecting Our Caregivers offers violence risk assessment strategies and ideas for prevention programs and incident reporting mechanisms. It also shares valuable recommendations for a workplace violence prevention plan, regardless of the healthcare facility type or point of care:

* "Educate employees about workplace violence prevention policies and plans;

* Communicate a clear definition of workplace violence;

* Solicit input from frontline employees to help identify risk factors, Report problems, and suggest improvements and interventions;

* Require employees to report all incidents of workplace violence;

* Develop communication systems that alert staff to a patient's history of violent behavior;

* Track all reports of violence to identify trends that can be addressed;

* Identify steps for employees and managers to take when violence occurs;

* Focus on ways to make the physical environment safer; and

* Provide prompt and comprehensive assistance for victims and witnesses of violence" (Norfolk District Attorney's Office, 2007, p. 5).

Recognizing that home healthcare providers are at more risk, a separate section is devoted to the special precautions that must be taken, like requiring security to accompany caregivers on visits, and refusing to provide services until the safety of caregivers can be assured. The document outlines the need for refusal to provide services and treatment contracts and notification of who will be in the home during a visit administrative policies to further protect home healthcare providers. Lastly, Exhibit 5 accessible at http://faculty.uml.edu/jbyrne/44.327/ProtectingOurCaregivers.pdf is a contribution from the Brockton VNA, which outlines the Safety Precautions for Home Care Staff that should be followed. It is a worthwhile 5-minute review of lifesaving reminders that good judgment and common sense prevail over walking into bad situations.

REFERENCES