University Village HHS LLC
Page 1 of 15
Effective: 9/01
SAFETY MANUAL
Review:
EMERGENCY PREPAREDNESS PLAN
Revisions: 12/02
Approved: 6/03
Applicable To: All employees
Reference: JCAHO EOC Standards
I.
SCOPE
The Emergency Preparedness Plan of University Village is a combination of plans and programs
designed to provide guidance to staff in responding to and managing the consequences of natural
disasters or other emergencies that disrupt the facility’s ability to provide resident care and/or enable
the facility to be ready to triage, treat or house should a disaster or unexpected event occur.
UV is not an active participant in the community emergency preparedness for the Tulsa Emergency
Management Agency (TEMA) who plans and coordinates community-wide emergency preparedness
due to the nature and scope of services available at this facility.
II.
GOALS AND OBJECTIVES
1.
2.
3.
4.
5.
III.
Triage, first aide and transfer of casualties as needed.
Continued care of the non-critically ill or non-critical casualties
Admissions or transfers from other facilities.
Rapid, efficient evacuation of casualties and others in the event of an internal disaster.
Cooperation and coordination of activities with the local, state and national agencies with
regards to major disasters.
ANNUAL EVALUATION
1.
The plan shall be evaluated annually with review for changes and improvements made based
on drills, changes in the facility mission or the capability of the facility. This review will be
made by the CQI Council. Implementation and evaluation of the plan is done to evaluate
facility preparedness, staff preparedness and resident management. Drills to evaluate the
plans components are required. This may include actual or simulated events to include at
least one implementation per year involving an influx of actual volunteers or simulated
residents.
2.
Instruction in the Emergency Preparedness Plan will be mandatory for all University Village
personnel:
a.
Upon orientation to the facility and department.
b.
Annually thereafter as a condition of continued employment.
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1
IV.
AUTHORITY AND DIRECTION OF PLAN
The licensed nurse on duty or the administrative officer or executive on call shall have the authority
to activate the plan and shall direct and coordinate all facility activities until relieved by a higherranking person. Ultimately, it is the responsibility of the CEO or designee to direct and coordinate all
facility activities.
V.
DEFINITIONS
Types of Disaster:
External Disaster
Community disasters involving casualties which could cause a transfer of persons from other
facilities due to local/state disasters (tornado, airplane wreck, explosion, etc.). UV is not
equipped to handle emergency triage or direct admissions via emergency rooms, therefore,
would be utilized only as a transferring facility rather than a direct admissions facility in times
of disaster for persons that meet the scope of care and services generally provided at this
facility.
Internal Disaster
A calamity inside UV which might cause the evacuation of residents from danger areas (fire,
explosion, etc.)
Disaster Threat
Disasters threatening the facility and/or the surrounding community requiring precautionary
evacuation procedures (exp: tornado warning, flooding).
Bomb Threat
Notification of threat of bomb placement at or near the facility.
Civil Disturbance
Group of individuals causing aggressive action, which places residents and facility staff and
visitors at risk.
Receipt of Information
All reports of a disaster will be forwarded to the Chief Executive Officer of University
Village or in his/her absence, to a representative, who will authorize all communications and
disaster instructions.
Alert
Should a disaster or mass casualty occur in the city or metropolitan area, University Village
would be notified by the civil authorities or other officials should the disaster affect the
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2
immediate area or require possible transfers. Any individual receiving information on a
disaster should make every effort to obtain as much information as possible regarding the
disaster (e.g., number of victims, types of injuries, Expected Time of Arrival (ETA), mode of
transportation, name and title of informant). This information should be recorded and given
to the Nursing Supervisor or Risk Manager who in turn will immediately defer to the
administrative head within the facility.
EMERGENCY PREPAREDNESS IMPLEMENTATION
NOTIFICATION SYSTEM
This level system will be determined by the severity of events.
LEVEL I. (Lowest – no need for Implementation of Incident Command Center)
A.
The initiation of the Emergency Preparedness Plan will be made by the Chief Executive
Officer and/or designee.
B.
Upon receiving the alert, these calls will be made to alert staff as to the current level of
disaster plan implementation.
PBX (Code called using 2 way-radios and/or phone list)
Chief Executive Officer
AL & Health Center Charge Nurses
Department Managers
Risk Manager
(Level III Only)
Medical Director
(Level II Only)
Contact those on Employee
Emergency Call Back Phone List
*Department Managers to be notified of type of disaster, anticipated casualties and damage or
interruption of services, if any.
Oklahoma State Health Department must be called within 12 hours of implementation of the disaster
plan. The phone number for the State Health Department is 405-271-6868.
LEVEL II.
A.
If a disaster occurs during the hours when department heads are not within the facility,
the PBX operator will initiate the emergency call back list to the Executive on Call
and Chief Executive Officer as noted above in Level I.
B.
All Department Managers or designees will be responsible for contacting the
appropriate number of personnel in their department. The employee emergency call
back list will be used.
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C.
The Director of Nursing and coordinators will assess staffing needs in their areas.
D.
The Incident Command Center will be implemented.
LEVEL III.
A.
This level of the notification system will be determined by the CEO or Incident
Command Center.
B.
The House Physician will be contacted.
C.
Disaster Medical Director/House Physician will determine physician staffing needs
and direct other physicians as needed.
Maintenance of Callback Lists
A current employee emergency phone call back list will be maintained by Administrative Staff,
Nursing, PBX operator and each Supervisor. This phone call back list will be approved and
reviewed and revised as needed with a copy sent to each of the above mentioned areas.
Notification Codes - (City-wide codes in effect at all Tulsa hospitals)
"Code Yellow"
=
External Disaster
"Code Black"
=
Tornado Weather Warning/Alert
"Code Red"
=
Fire
Employee Parking and Admittance
A.
Persons reporting for disaster assignments should leave their cars in the north employee
parking lots.
B.
The areas directly in front of the facility and the emergency ambulance entrance will be
closed to all traffic except emergency vehicles. Security will contact Tulsa Police Department
to assist with diverting traffic away from Emergency Entrances as needed.
C.
All doors will be secured by Security and Facility Maintenance. Entrance to the facility may
be gained through the front entrance only or the employee entrance in the North Parking lot.
D.
University Village employee identification will be required for admittance.
E.
Persons reporting for disaster assignments will receive the assignments in their department
area (Incident Command Center) at the time of arrival to the facility.
All Clear
The Incident Command Center Coordinator will notify the PBX operator of an all clear status on all
codes.
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ACTIVITY CENTERS
INCIDENT COMMAND CENTER
Location
Administrative offices
Personnel
Executive-on-Call (EOC) or designee
Medical Staff Representative as deemed necessary by Incident Command Center coordinator (ICC)
Media Representative as assigned by Executive-On-Call.
Risk Manager
Red Cross Volunteer – as applicable
Administrator
Messengers:
To Personnel Pool
Other as needed
Functions
 Direct and coordinate all facility and medical staff activities such as personnel
requirements, supply and equipment needs.
 Maintain list of casualties admitted, dismissed, and transferred and Dead On Arrival (DOA’s).
 Provide information to Red Cross only as appropriate.
 Provide information to media.
 Liaison with Tulsa Emergency Management Agency (TEMA). Phone# 596-9890
 Phone number for information line will be assigned.
 Assign resident room numbers if transfers are to be received.
 Assign coordinator of Personnel Pool until HR Director arrives.
 Maintain “Disaster Kit” including:
Flashlight
Pens
Markers
Disaster ID bracelets
Tags for facility staff (runner, transporter, etc.)
TRIAGE CENTER
Location
Only for extreme emergencies and only if staff available. – Doctors office entrance North of facility.
Personnel – Only as delegated by the Incident Command Center coordinator
 Nursing Triage officer
 Transporters as required: these should have resident care background.
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 Messenger.
Functions








Receive and sort casualties.
Transport to designated areas.
Tag patients/residents and initiate disaster admitting form.
Burn victims – Transfer to Hillcrest Medical Center Burns Unit.
First Aid/Observation – Doctors clinic across from nursing station in Health Center
Expired casualties – morgue as designated by University Village Risk Manager
Immediate trauma treatment – Doctors clinic across from nursing station in Health Center
Maintain “Disaster Kit” including:
flashlight
pens
markers
disaster ID Bracelets
name tags for extra staff or volunteers (runner, transporter, etc.)
disaster admitting form
copy of Emergency Preparedness Plan
nursing assessment forms
 Serve as triage and initial first aide treatment as needed.
FIRST AID/OBSERVATION AREA
Location
Doctors Office areas as identified when needed.
Personnel
 Physicians as needed.
 Nursing staff as needed.
Functions
 Provide minor care for casualties who can be treated and released.
Observe residents/patients who may need further treatment or status is in question.
PERSONNEL POOL
Location
Theater area – main building.
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Personnel
 Coordinator (Manager of Human Resources or as designated by Incident Command Center.)
 The Coordinator will bring a facility phone directory and employee emergency call back list to
keep at the personnel pool.
 Staff not needed in departments will be sent by manager to personnel pool to await assignment.
Functions
 Log in personnel and assignments.
 Assign staff to areas needed as dictated by plan and directed by Command Center.
 Monitor staff available for service.
VISITORS/RELATIVES
Location
Resident Main Dining Room or as otherwise designated by the Command Center.
Personnel
 Social Services
 Chaplains
 Others as needed
Function
 Waiting area for relatives who cannot remain with residents.
 Social Worker or Chaplain will coordinate transmitting information to relatives of victims and to
assist them as needed.
PRESS ROOM
Location
To be assigned only as needed. (Suggested area to be West Wing Conference Room).
Personnel
 Media Representative as designated by CEO or Incident Commander.
Function
 Holding area for press to receive information.
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CHILD CARE
Location
Location as designated when deemed needed – (suggested area - Shuffleboard Room)
Personnel
 Activities Person(s) as coordinator.
 Others as needed
Function
 Care for children of called back staff until other arrangements can be made.
DEPARTMENTAL FUNCTIONS
All Employees
Take direction from supervisor.
 If called to report to facility:
Wear usual uniform attire (if possible).
Wear ID badge.
Bring children only if necessary or needed as teen volunteers for child
care.
Clock in and report to Department.
Accept assignment of duties other than usual job function as needed.
All Physician Staff
Report in to Incident Command Center for assignment as needed.
Maintenance/Security
 Implement Security Plan for External or Internal Disaster.
 Maintain Utilities.
 Other duties as needed.
Business Office
 Assist with admitting and discharging residents as necessary.
 Other duties as needed.
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Food and Nutrition Services
 Prepare and serve food to residents, employees, physicians and volunteers.
 Kitchen/Dining Room – First Floor
Nursing Units
 Determine medical status of current residents.
 Provide essential nursing care to current residents and disaster casualties as needed.
 Staff First Aid and Triage Area – Doctors clinic area – across from nursing station in Health
Center.
 Initiate medical records and documentation of treatments rendered.
Materials Management – Provided by the Tulsa Regional Medical Center Materials
Management and Other Contracted Vendors
 Obtain and provide supplies and equipment as requested by areas.
Managers/Area Supervisors
 Suspend routine departmental functions and provide only essential services until the immediate
disaster status has ended.
 Assess staffing needs for next 24 hours as per type and volume of residents and current census.
Initiate call back as needed and communicate needs to Command Center.
 Notify Personnel Pool in Theater, Ext. 387.
 Assess supply and equipment needs and communicate to Incident Command Center.
 Assign area staff and direct activities for the area with overall direction from Command Center.
Volunteers
 Provide support and assistance to residents and/or visitors, staff, such as staffing childcare area,
relatives waiting area, and messenger functions as available and as needed.
Administration
 Report to Personnel Pool for assignments.
Security
1.
2.
Upon activation of the disaster plan, the ORU Security Staff, maintenance and/or
housekeeping staff will be called into service for security as needed.
 They will be responsible for locking all entrances to the building.
 Additional security personnel will be posted at other entrances and outside as needed.
A security officer will be posted at the front entrance.
 To allow employees to enter the building upon presentation of ID badges.
 Employees will accompany their children to the child care area.
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

Employees will report to the individual departments for check in and assignments.
Relatives of casualties who are not minors will be directed to the Chapel area.
ADMISSION, TRANSFER, DISCHARGE
Initial Identification
1.
2.
3.
4.
Should persons be admitted, they will receive an ID bracelet with the number on the
corresponding Admission Report, and the persons name, if available. Include list of
Allergies Identified.
The tagging clerk will complete the top portion of the Admitting Report as completely and
accurately as possible in the situation. If necessary, estimate age, race and sex.
When the disposition and condition of the person has been established, tear off or copy and
send to Command Center.
The original Admitting Report stays with the patient as the initial medical record.
Admissions
1.
2.
3.
4.
Elective transfers or admissions (non-casualty) will be suspended for the duration of the
disaster (except in drill situations).
Residents may be admitted from other facilities - information received by phone, fax or
verbal triage. The Command Center will assign room numbers and submit information to
admitting personnel.
After the crisis subsides, admitting clerks (as assigned by Incident Command Center) will
interview the admitted residents or their next of kin to obtain full admitting data and complete
the admission process.
A medical record will be initiated on all patients/residents.
Transfers and Discharges
1.
2.
3.
4.
5.
The Medical Director, in conjunction with the nursing staff and persons attending physicians,
if available, will determine which persons may safely be transferred to other healthcare
facility or discharged home.
Residents to be transferred will have completed transfer forms and be accepted by the
receiving facility. Tulsa Emergency Management Agency may be contacted to assist with
transportation.
Resident to be discharged will be facilitated through the admitting area.
Residents being transferred into University Village from other facilities will be coordinated
by the Charge Nurse or Director of Nursing. This will be communicated to the Incident
Command Center Coordinator as often as possible.
Check Emergency Transfer Agreement for List of Contracted facilities to facilitate transfer.
(List attached)
TOTAL EVACUATION PLAN
The decision to evacuate the facility shall be made by the Chief Executive Officer or Administrator
on Call in his/her absence or the Risk Manager.
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The Tulsa Emergency Management Agency (TEMA) (596-9899) will be contacted to provide
transportation, communications and utilities to facilitate a total evacuation.
The alternative care sites will be Hillcrest Medical Center or Tulsa Regional Medical Center or any
Hillcrest Healthcare Facility unless other facilities are determined and utilized per Tulsa Emergency
Management Agency (TEMA) recommendations and the hospital Chief Executive Officer. Also
refer to the Emergency Transfer Agreement List to facilitate transfers to other facilities.
(List Attached)
Evacuation Priority
Residents will be evacuated according to the following priority levels with the level indicating the
order of evacuation:
Level I – Resident’s medical condition is stable and the physician agrees that the resident can be
discharged to a family member. These residents will have priority for readmission when the facility
may be reopened for business.
Level II – Resident’s medical condition is stable but the resident requires further medical care to
prevent a serious threat to their health. The resident is ambulatory or wheelchair bound and requires
no major medical equipment.
Level III – Resident’s medical condition is stable enough to be transferred without assistance of
licensed personnel but requires minor medical equipment (i.e., oxygen, stretcher support, etc.).
Level IV – Resident’s medical condition requires attendance of licensed personnel and major medical
equipment (i.e., ventilator, cardiac monitor/defibrillator, etc.).
Preparation for Evacuation
1.
2.
3.
The Director of Nursing will designate a staff member to keep a log to include residents
identification and resident’s disposition and equipment transported with the resident/patient.
For Level II – IV resident/patients, the medical record or a copy will be sent with the person
to the receiving medical facility as well as any medical equipment necessary to facilitate a
safe transfer. The log will note that medical records were sent with the resident/patient. (All
information pertinent to the continued care of the resident in another facility for a short stay or
permanent transfer will be required.)
Each person will be properly badged with name, physician and location of assignment.
Evacuation Procedure
1.
2.
Level I – Residents/Patients who are discharged will be evacuated from the building via the
safest exit as designated by the Incident Command Center coordinator.
Level II – IV – Residents/Patients will be evacuated from the building with a facility
representative, a Tulsa Emergency Management Agency member or EMSA medical
personnel assigned to accompany the resident/patient(s) to the receiving medical facility. The
Incident Command Center will designate the exit route and arrange for transportation of
residents/patients.
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3.
4.
Prior to leaving a unit unoccupied, the employee in charge will secure all drugs and narcotics
and turn in the keys to the DON.
Rounds by licensed nursing staff or social services or chaplain staff will be made at least daily
at each facility where residents/patients have been transferred to:
 Assure resident/patients condition.
 Obtain lists of resident/patients who will be able to be discharged and identify
where those resident/patients will be sent.
 Provide any assistance to University Village physicians.
 Provide support to residents/patients and family members.
 Determine resident/patient needs and assessment for return to University Village
when conditions are appropriate.
INTERNAL RELOCATION
External Disaster/Disaster Threat
1.
2.
3.
4.
The Incident Command Center will determine where residents will be relocated and assign
staff to accomplish the move.
The charge nurse will direct the quickest and safest plan for relocation of residents.
Resident equipment, medical records and medication will be transported to the new area.
A log of residents relocated, including pre- and post- move location, will be sent to the
Incident Command Center.
Internal Disaster/Disaster Threat
Residents will be removed from areas of potential danger or areas with loss of services as designated
by the Incident Command Center Coordinator, Chief Executive Officer, Administrator-on-Call, or
Risk Manager on premises until such danger or threat is removed.
Tornado Warnings
If a tornado warning (Code Black) is issued for the immediate vicinity, residents, staff and visitors
will be relocated as follows:
With imminent need to protect when time is emergent, residents will be moved as far away from
windows as possible. Blinds and curtains will be closed. Residents may be covered with blankets for
protection.
When time permits, residents may be moved into the internal small rooms, bathrooms, computer
room on first floor or other residents’ closets.
Residents unable to be moved to lower floors will be placed in interior closets of their room.
Non-clinical staff and visitors may assist with resident movement or will proceed to internal rooms
on the first floor. The elevators should not be used during Code Black.
COMMUNICATION
General
1.
Communication will be limited to messages essential to the emergency operation.
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2.
3.
 Telephone usage is restricted to essential calls. Employees should not attempt to make
calls to family or friends, but wait until the alert is over. Then such calls can be made.
In case of telephone service failure, cell phones, two-way radio equipment and runners will be
utilized.
 In the event the phone system is inoperative, the Chief Executive Officer or Designee will
obtain radio emergency services via ham radio operators as needed and the runners will be
utilized for communication.
Should Tulsa Emergency Management Agency (TEMA) feel that UV’s Incident Command
Center needs to communicate with other areas facilities TEMA will be issued a two-way radio
to the facility to assist with communications with city wide TEMA representatives.
Resident/Patient Information
1.
2.
3.
4.
Resident/Patient information will be released only through the Red Cross or specifically
identified staff assigned by the Incident Command Center. The Incident Command Center
Coordinator will identify a qualified person to staff the information line and an Ext. for the
purpose of communication of resident/patient information. If available a Red Cross volunteer
will be placed in this capacity.
Casualty logs will be supplied to the Red Cross by the Incident Control Center and requests
for resident/patient information will be referred to the Red Cross.
Casualty logs will include patient name, age, sex, diagnosis and condition, address and
disposition or location of resident/patient.
In the triage area, each resident/patient will be badged and an Admitting form initiated. One
copy of the form will be sent to the Command Center.
Media
All information to the media will be coordinated by the Media Representative as directed by the
Chief Executive Officer or Incident Command center coordinator. Any facility media representative
must communicate through Hillcrest Healthcare System marketing.
SUPPLIES AND EQUIPMENT
1.
2.
Since University Village does not have a materials management department on campus, UV
will have to request additional supplies from the Tulsa Regional Medical Center or Hillcrest
Medical Center (HMC) Materials Management Department or Contracted Vendors.
The Tulsa Regional Medical Center or Hillcrest Medical Center Materials Management
Department shall obtain equipment and supplies from vendors or other healthcare facilities as
approved by the system Incident Command Center Coordinator.
UTILITIES
Emergency Water Supply
1.
The U.S. Army Reserves (744-6095) may be utilized to request use of the 450-gallon water
trailer.
2.
The Tulsa Fire Department (582-3131) will dispatch a pumper unit upon request as able.
3.
Flushing:
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a.
4.
5.
6.
7.
8.
9.
Water to all toilets will be manually turned off by maintenance staff except where
specifically identified.
b.
Staff will use water from external sources and portable water containers (buckets) to
flush toilets that need flushing.
c.
Pour water in toilet bowl while pushing handle.
e.
Have liners available to use in toilets, if necessary.
f.
Put signs on public restrooms.
Handwashing:
a.
A supply of liquid hand sanitizer may be requested from Vendors or Materials
Management.
b.
Hand sanitizers will be distributed to each area.
c.
Use gloves until sanitizers can be distributed.
Covered containers will be made available to dispense drinking water to each unit.
Distribution of covered containers for water or bottled water will be distributed according to
the following priority:
a.
Nursing Units
b.
Kitchen
c.
Housekeeping
d.
Public Restrooms
e.
For maintenance of emergency power generator.
f.
Offices
Food
a.
Consider other sources for food supply (Fadler Food Service, Tulsa Regional,
catering, etc.)
Tulsa Emergency Management Agency (TEMA)
a.
Contact TEMA for other sources of water.
b.
Phone Number: 596-9890
Recovery of Water Loss
a.
Make sure faucets and toilets are turned off.
b.
Notify Maintenance of any repairs that need to be made.
Electricity
1.
2.
3.
4.
In the event of power failure, power to the facility emergency generator will automatically
start within 30 – 45 seconds and supply emergency circuits only.
Fuel levels will be monitored by maintenance staff to ensure continued essential services.
Water is needed to facilitate the function of the natural gas powered emergency generator.
Maintenance will coordinate with utility companies whatever is needed to facilitate sources of
water or natural gas (other utilities) should they be needed in extended outages.
Battery operated flashlights and lanterns will be supplied to areas as needed.
For all Utility Outages:
1.
Communication
a.
Maintenance to contact directors/area supervisors to communicate identified problems,
give estimated length of time for disruption, other pertinent information.
b.
The incident command center would be set up should utility outages be expected for
extended periods of time.
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c.
After hours, the nurse supervisor would keep the clinical areas updated.
CIVIL DISTURBANCE
In the event of a civil disturbance in the vicinity or a threat in the vicinity of the facility, the following
procedure will be followed in addition to the general procedures:
1.
2.
3.
4.
5.
All doors will be locked by security, maintenance, or housekeeping staff.
The front entrance will be manned by a security person to prevent entrance by unauthorized
persons.
Security personnel or personnel as designated will maintain a check on all entrances.
Only authorized personnel will be allowed entrance into the building. Facility personnel will
be identified by security or facility personnel or name badges.
Personnel will be alerted to watch for possible agitation in the facility.
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