| Course | HCR 264 Regulatory Essentials of Compliance Program Design |
|---|---|
| Module | Module 5 |
| Paper type | OSHA incident report and root cause analysis |
| Length | About 726 words, 5 pages |
| Format | APA 7 student paper |
| School | Arizona State University |
| Program | BS in Health Care Compliance and Regulations |
| Updated | October 2026 |
Free sample paper for HCR 264 Module 5
Incident Report and Root Cause Analysis: A Patient Assault on a Mental Health Technician
Student Name
BS in Health Care Compliance and Regulations, Arizona State University
HCR 264: Regulatory Essentials of Compliance Program Design
Instructor Name
Month Day, Year
Incident Report and Root Cause Analysis: A Patient Assault on a Mental Health Technician
Purpose
This report reconstructs an OSHA-recordable injury from public enforcement records, completes the information an employer must capture on an injury and illness incident report and analyzes why the event happened. The injured employee is not named; employer records would identify the worker, but a public analysis has no need to.
Part 1: Incident Report
The fields below follow OSHA's Form 301, the Injury and Illness Incident Report, which employers must complete within seven days of learning of a recordable case (Occupational Safety and Health Administration [OSHA], 2024).
| Form field | Entry |
|---|---|
| Employer | Circles of Care Inc., psychiatric and rehabilitation services, Melbourne, Florida |
| Establishment | Sheridan West Unit, 400 E. Sheridan Road, Melbourne, Florida |
| Employee job title | Mental health technician |
| Date of injury | November 7, 2023 |
| Where the event occurred | Nurse's workstation on the inpatient unit |
| What the employee was doing | Working at the nurse's workstation |
| What happened | A patient struck the technician with a metal hole punch |
| Injury | Serious injuries to the head, face, hands and arms |
| Object or substance that harmed the employee | Metal hole punch available at the workstation |
| Hospitalized as an in-patient | Yes |
| Reported to OSHA within 24 hours | No; OSHA cited the employer for late reporting |
Part 2: OSHA's Findings
OSHA cited the company with a repeat violation of the General Duty Clause, the catch-all duty to protect workers from serious hazards an employer knows about or should know about, because it had not shielded employees from patient violence. It also cited the company for not reporting the in-patient hospitalization within 24 hours, as the recordkeeping rule requires (29 U.S.C. § 654(a)(1); 29 C.F.R. § 1904.39). Proposed penalties totaled $101,397. The citation was a repeat because OSHA had investigated two serious incidents at another of the company's Melbourne facilities in 2020, including the fatal shooting of a counselor by a former patient (U.S. Department of Labor, 2024).
Part 3: Five Whys
1. Why was the technician injured? A patient attacked the technician at the nurse's workstation.
2. Why could the patient reach the technician with a weapon? The workstation was open to patients and held loose objects that could be used to strike someone.
3. Why was the workstation open and unsecured? The unit's design and supply practices had not been reviewed for violence risk, though patient aggression was a known hazard on psychiatric units.
4. Why had no review taken place? The organization lacked a functioning workplace violence prevention program with worksite analysis, despite earlier serious incidents at another of its facilities.
5. Why was there no functioning program? Leadership had not treated workplace violence as a hazard requiring the same systematic controls as other safety risks, so prior incidents produced no system-wide change.
Root cause: the absence of an organization-wide, management-led workplace violence prevention program, which allowed a known hazard to persist and also explains the missed 24-hour report.
Part 4: Research and Corrective Actions
Workplace violence is a recognized and common hazard in health care, with psychiatric and emergency settings at highest risk, and many assaults go unreported (Phillips, 2016). OSHA's workplace violence guidelines for hospitals, clinics and social service agencies describe the elements of a prevention program: management commitment and employee participation, worksite analysis, hazard prevention and control, training and recordkeeping with program evaluation (OSHA, 2016). Research supports the worksite analysis step. In a study of 21 hospital units, structured walkthroughs that combined each unit's violence data with a checklist of prevention strategies led most units to put environmental, behavioral or administrative changes in place within a year (Hamblin et al., 2017).
| Root cause or contributing factor | Corrective action | Owner |
|---|---|---|
| No prevention program | Written program with leadership commitment and staff on the committee | Chief executive and safety officer |
| Unsecured workstation | Enclosed or half-height protected workstation; remove loose heavy objects | Facilities |
| No worksite analysis | Annual unit walkthroughs using incident data | Safety committee |
| Late reporting | Reporting procedure with a 24-hour checklist for supervisors | Human resources |
| Prior incidents not acted on | Review of every serious incident across all sites by the safety committee | Compliance officer |
Conclusion
The injury was caused by a patient, but the conditions that allowed it were organizational. Completing the incident report makes the facts clear, and asking why five times shows that the missing piece was a prevention program that OSHA's own guidelines describe.
References
Duties of employers and employees, 29 U.S.C. § 654 (2024).
Hamblin, L. E., Essenmacher, L., Luborsky, M., Russell, J., Janisse, J., Upfal, M., & Arnetz, J. (2017). Worksite walkthrough intervention: Data-driven prevention of workplace violence on hospital units. Journal of Occupational and Environmental Medicine, 59(9), 875-884. https://doi.org/10.1097/JOM.0000000000001081
Occupational Safety and Health Administration. (2016). Guidelines for preventing workplace violence for healthcare and social service workers (OSHA 3148-06R). U.S. Department of Labor.
Occupational Safety and Health Administration. (2024). Injury and illness incident report (OSHA Form 301). U.S. Department of Labor. https://www.osha.gov/recordkeeping/forms
Phillips, J. P. (2016). Workplace violence against health care workers in the United States. New England Journal of Medicine, 374(17), 1661-1669. https://doi.org/10.1056/NEJMra1501998
Reporting fatalities, hospitalizations, amputations, and losses of an eye as a result of work-related incidents to OSHA, 29 C.F.R. § 1904.39 (2024).
U.S. Department of Labor. (2024, May 9). Department of Labor investigation into worker's serious injuries finds Florida behavioral health facility again failed to protect employees from workplace violence [News release]. https://www.dol.gov/newsroom/releases/osha/osha20240509
What the HCR 264 Module 5 instructions ask for
The third writing assignment in HCR 264 falls in Week 5, the module on the Occupational Safety and Health Act. Instead of an essay, the syllabus asks you to complete an OSHA Incident Report Form template for a real OSHA case and support your analysis with outside research, which is why it is called a Root Cause Analysis Paper. A real case means one OSHA or the Department of Labor has made public, usually through a news release announcing citations, so the facts you enter on the form should come from that record. The form captures who was hurt, where, how and with what; the analysis explains why it happened and what would prevent it. Health care cases on workplace violence, needlesticks, patient handling and chemical exposure are well documented. The assignment shares the course's 300 writing points with the other three papers.
Inside the HCR 264 Module 5 example
After a two-sentence purpose statement, Part 1 completes the incident report as a two-column table of form fields and entries, using only facts the Department of Labor published and leaving out the worker's name. Part 2 summarizes what OSHA cited, the penalty and why the violation was a repeat. Part 3 asks why five times, moving from the patient's act to the missing prevention program, and states the root cause in one sentence. Part 4 brings in research on workplace violence in health care, OSHA's own prevention guidelines and a hospital study of worksite walkthroughs, then lists corrective actions in a table that names an owner for each. A short conclusion separates the patient's act from the organizational conditions that allowed it.
Where the marks sit in the HCR 264 Module 5 rubric
Canvas holds the rubric for this assignment, part of the 300 points for writing. A strong submission completes the form accurately from a real, identifiable OSHA case, separates facts from interpretation, reaches a root cause that is organizational rather than "the employee was careless" or "the patient was violent," supports the analysis with research and OSHA guidance and proposes corrective actions that match the causes. Points go when form fields are filled with guesses, when the five whys stop at the first answer, when the root cause blames an individual, when recommendations do not follow from the analysis and when sources are missing. Graders also look for respect for the injured worker's privacy; a public analysis should not name the person.
HCR 264 Module 5 help with common mistakes
Find your case first; a Department of Labor news release about a health care employer is the easiest starting point, and the newer the better. Copy only facts the release states into the form, and leave fields blank rather than inventing details. Ask "why" until you reach something management controls, such as a missing program, policy or design choice. Check the regulation the employer was cited under. Use OSHA's guidance for your industry to frame corrective actions, and give each one an owner. Keep the injured worker anonymous. If you cannot find a case with enough detail, the desk can suggest public sources that list recent health care citations.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Arizona State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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HCR 264 Module 5 questions, answered
Where can I find a free HCR 264 Module 5 sample paper?
On this page: a finished OSHA incident report and five-whys root cause analysis of a patient assault on a mental health technician.
What is OSHA Form 301?
The Injury and Illness Incident Report employers complete within seven days for each recordable work injury or illness.
How fast must an employer report a work-related hospitalization to OSHA?
Within 24 hours of learning of an in-patient hospitalization, under 29 C.F.R. § 1904.39.
What is the General Duty Clause?
The OSH Act's catch-all rule, section 5(a)(1), used when no specific standard covers a serious hazard the employer knew or should have known about.
How do I find a real OSHA case for HCR 264?
Department of Labor and OSHA news releases announce citations with dates, places, injuries, violations and penalties.