As the nation is continuously impacted by acts of violence in schools, health care facilities, airports, shopping malls, and every type of property where people assemble, long term care providers must be particularly sensitive to this type of “unthinkable” peril. If violence of this nature can occur at a rural Amish schoolhouse in Pennsylvania like it did in 2006 where 10 innocent students were shot, what’s to stop it from happening in your nursing home or assisted living community? The horrific shooting that took place at a Kansas senior community in April 2014 answers that question. Long term and post-acute care providers, just like everyone else in our country, are vulnerable to an incident involving an “armed intruder” or “active shooter.”
Another important question that must be given serious consideration is this: How do long term care providers prepare for the types of potentially catastrophic incidents that typically have a low probability of occurrence? The starting point is of course the development of an “All Hazards” Emergency Operations Plan.
The first step in the development of an emergency plan that utilizes an “All Hazards” approach is to conduct a risk analysis, or Hazard Vulnerability Assessment, that helps providers determine the types of threats and perils that can impact their communities. Factoring in your facility’s proximity to schools, banks, commercial areas, military installations, and other potential risk exposures in the community-at-large will help determine the probability of occurrence at your facility.
Factors such as faith-based affiliations, labor-management issues, and other specific variables can help determine a provider’s vulnerability to an event involving an Armed Intruder or Active Shooter on its campus.

Maximize Security Measures, Set Up Training

Once the risk potential is assessed, it will be essential to develop procedures and protocols to address this highly dynamic type of event. Comprehensive systems must be integrated into a long term care provider’s operations and physical plant to help reduce the opportunity of occurrence. Items like access control systems, code-compliant locking equipment, and security technology that includes surveillance cameras and proper signage illustrating the presence of security measures need to be seriously considered.
Training employees to react appropriately to an event involving an armed intruder / active shooter is a serious challenge. A prevailing attitude in all types of occupancies is, “It will never happen here.” Embracing and promoting the All Hazards approach in every aspect of emergency planning, including training, is an essential component of preparedness.
Clearly defining the potential for such an event in a long term care facility is a critical step in developing a plan of action and a “culture of preparedness.”
Considering the intense and highly dynamic nature of this type of peril, it will be impossible to develop a procedure that provides staff with specific instructions on how to handle such an event. Training must focus on expectations and an understanding of the posture of law enforcement when they respond to a call for an armed intruder or active shooter at a facility. Additionally, personal protection must be considered on the premise that employees must protect themselves to be in a position to protect their patients.

A Reality Check

As a starting point, it is recommended that all occupants of every type of building view a video produced by the city of Houston and hosted on the FBI’s website entitled, “RUN, HIDE, FIGHT.”
While this short video training program is not specifically designed for a long term care facility, it will provide everyone who watches it with the critical concepts of immediate response during an active shooting situation. Providing staff with a level of “situational awareness” will help them develop a good understanding of this type of violent event.
Beyond the basics, long term care providers should consider providing employees with comprehensive training on armed intruder/active shooter.

Workshop Designed For Long Term Care

Recently, a team of consultants with specialized training and experience in emergency preparedness and law enforcement tactics conducted a workshop specifically designed for long term care providers for the County Commissioners Association of Pennsylvania. Approximately 60 attendees participated in a daylong workshop that was designed to promote awareness and set forth expectations for events involving deadly weapons.
Key components of the workshop included the introduction of the simple concept that, “bad things sometimes happen to good people.” The general elements of an All Hazards approach to emergency management, including integration of the Nursing Home Incident Command System (NHICS), was thoroughly reviewed, and participants were challenged to imagine this type of event occurring in their own community.
A significant portion of the training was devoted to case studies, including the tragic shooting that occurred in a nursing home in March 2009 and involved the deaths of six residents and one employee. In that case the deranged husband of one of the staff members on duty came into the facility and started shooting on a peaceful Sunday morning in a quiet, rural North Carolina community.

Facing ‘Kill Or Be Killed’ Situation

In addition to the procedure known as Run, Hide, Fight, participants were introduced to a procedure that the training team from Pendulum developed, known as The Four-outs:
  • Get Out
  • Hide Out
  • Keep Out
  • Take Out
This is a strategy that was developed by a Pendulum team that included subject matter experts from Sorensen Wilder and Associates and Fire and Life Safety working together as the Emergency Management Alliance. This concept illustrates the general actions that must be performed when a health care facility is confronted with an armed intruder/active shooter scenario.
While some employees may initially push back from the concept of “taking out” the offender as was promoted during the workshop, attendees were taught that this may be a true fight for life, including their own and the lives of their patients.

Working With The Police

Finally, attendees were exposed to the way law enforcement officials will respond to such an event. Gone are the days of a “pre-Columbine” world that utilized a tactical strategy where law enforcement officials would first assemble a team of specialized forces to address the threat. Instead, health care providers must now understand that police will be rapidly deploying inside of the facility when one or more first responders arrive on scene.
The first-in officers will be aggressively entering the facility with the main tactical mission of neutralizing the threat. Employees must be trained to understand the aggressive posture of these first-responders and know that they will need to follow commands and may be directed to place their hands in the air with fingers spread open to show that they are not a threat to the officers.
The information included in this article was designed to provide a very basic overview of an extremely complex situation involving an armed intruder/active shooter in a long term care facility. Clearly, there is a great deal of curriculum that needs to be developed and presented to employees to help them thoroughly understand the dynamic nature of this specific peril. One step that all providers should take is to reach out to their local law enforcement agencies to determine if any resource assistance is available. Another approach would be to work with industry associations to include educational programs on this important matter. Understand that there may be a number a consulting firms offering to provide assistance with this issue, but it will be imperative to engage a firm that specifically understands the complex operations of long term care facilities.
Raising the level of awareness by properly assessing the threat potential for an armed intruder / active shooter event in your facility will be a critical step in proactively addressing an unthinkable scenario. Understanding that anything is possible—and preparing your team to respond with an All Hazards approach to every type of emergency—is the responsibility of all providers.
Stan Szpytek is the president of Fire and Life ​Safety (FLS) and is the life safety/disaster planning consultant for the Arizona Health Care Association and California Association of Health Facilities. Szpytek is a former deputy fire chief and fire marshal with more than 35 years of experience in life safety compliance and emergency preparedness. FLS provides life safety and disaster planning consultative services to health care and senior living providers around the nation.
For more information, visit or email Szpytek at