EMPLOYEE
ORIENTATION
HANDBOOK
1
WELCOME !!!!!
We are glad you’re here! This orientation handbook was
designed to help familiarize you with our facility policies.
Please take time to look through this information. Again,
welcome to our family!
2
Table of Contents
WELCOME - 3
AGENDA - 7
ADMINISTRATION
•
Purpose, Vision, Values - 11
•
Organizational Structures - 13
HUMAN RESOURCES
•
Human Resource Department Contact - 17
•
Orientation of New Employees - 19
•
Harassment Policy - 20
•
Workplace Violence Policy - 23
•
Patient Care Philosophy - 28
•
Staff Rights - 29
•
Problem Solving Procedure - 30
•
Complaint Filing Procedures - 34
•
Ethics Information - 35
•
Employment Information - 36
•
Worker’s Compensation - 37
•
Employee Performance & Behavior Expectations - 40
•
Cariten Assist Employee Assistance Program - 43
•
Care of Equipment & Supplies - 44
•
Smoking Policy - 45
GENERAL INFORMATION
•
Frequently Called Numbers Phone List - 51
•
Badge FAQs - 52
•
Parking FAQs - 53
•
Time Clock Instructions - 54
•
Comment Box - 55
•
Lost and Found - 55
BENEFITS
•
Combined Time Off (CTO) for Full Time and Part Time Employees - 59
•
Cafeteria - 61
•
Employee Health Service – 61
RISK MANAGEMENT
•
Agenda - 65
•
2006 National Patient Safety Goals - 66
•
Systems Improvement Report - 67
•
Potential State Reportable Events - 69
•
Policy Overview – Elopement and Visitor Injuries - 71
3
Table of Contents Continued
•
Employee Incident Report - 72
•
Behavior Report - 74
•
Navigating the Intranet to Review Polices - 76
SAFETY
•
Information About Safety at Work - 81
•
Emergency Codes and Basic Staff Response – 83
•
Emergency Response Quick Reference Chart - 84
INFECTION CONTROL
•
Isolation Implementation - 88
•
Hepatitis B - 89
•
Hepatitis C - 90
•
HIV - 91
•
Clostridium Difficile - 92
•
Vancomcin-Resistant Enterococcus - 93
•
Methicillin-Resistant Staphylococcus Aureus (MRSA) - 94
•
Tuberculosis - 95
•
Needlestick/Body Fluid Exposure Policy - 96
SECURITY
•
Security Office Information – 99
•
Weapons Policy – 100
•
Patient Information Policy – 101
•
Patient Prisoners - 102
•
Abandoned Baby-Surrender of Infant – 103
•
Suicide Precautions - 110
ABUSE
•
How to Report - 113
CHAPLAIN
•
Chaplain Services - 117
HEALTHCARE PROFESSIONAL SUBSTANCE ABUSE
•
Characteristics of Substance Abuse of the Healthcare Professional – 121
CLINICAL SECTION
•
Standards of Care – 125
•
Age Specific Care – 127
FORMS

Restraints – 133

Clinical Post Test - 137

Infection Control Test – 139

Security – Safety Tests - 141
HUMAN RESOURCES CHECKLIST FOR NEW EMPLOYEES – 143
ACKNOWLEDGEMENT OF RECEIPT OF HANDBOOK – 145
4
Agenda
Fort Sanders Regional Medial Center
2006 New Employee Orientation
Welcome
8:00-8:15
President
8:15-8:35
HR
8:35-8:55
Risk Management
8:55-9:40
Safety
9:40-10:30
Break
10:30-10:45
Infection Control
10:45-11:30
Security
11:30-11:50
Abuse
11:50-12:15
Lunch
12:15-1:00
Patient Rights
1:00-1:15
Diversity
1:15-1:45
Chaplain
1:45-2:15
Facility Tour
2:15-3:00
Recognizing Impaired Employees
3:00-3:15
Employee Health
3:15-3:30
*These times are approximate and subject to change
5
ADMINISTRATION
6
Our Purpose
We serve the community by improving
the quality of life through better health.
Our Vision
Through its people
Covenant Health will be recognized
as the premier health services system in Tennessee
Our Values
Working together in service to God, our values are:
Integrity
Quality
Service
Caring
Developing People
Using Resources Wisely
7
Patient
Representative
Administrative
Supervisors
IC – Infection Control
EST – Enterostomal Therapy
* Ft.P – Float Pool
Employee Health
Nursing Education
Respiratory Therapy
*Ft.P/IC/EST
Women Services
Transitional Care Unit
CC/COU/Tele/ED
Cath Lab/Card Dx.
Med Surg Units
Informatics/Volunteer Svrs.
Chaplains/Gift Shop
Ruth Crawley
VP/CNO
Rehabilitation Services
Clinical Effectiveness
Quality Improvement
Materials Management
Finance/Accounting
Outpatient Services
Neuro Diagnostics
Laboratory
KBOS & IS
Liaison
Physician Recruitment
Facility Services
Food/Nutrition Services
Pharmacy
Environmental Services
Beverly Graham
VP/Support Services
(PT, CROP/PROP, Diabetes)
Imaging
Health Information
Management
Wound Care
Registration/Scheduling
David McReynolds
VP/CFO
Perinatal Center
Julie Dougherty
Marketing
Medical Staff Office
Phillip Hipps
Risk Management
Colleen Andrews
Human Resources
Mavis Rioux
Executive Assistant
Keith N. Altshuler
President/CAO
FORT SANDERS REGIONAL MEDICAL CENTER
Surgical Services
Endo Lab
8
Marketing
Vacant
9
HIM
Valerie Capps,
Supervisor
Centralized Coding &
Registration
Janet Love, Mgr
Business Office
Judy Ridenour, Mgr.
Accounting
Dominic Moro,
Supervisor
Chief Financial Officer
Traci McCullough
Medical Director
Rick Grapski, MD
Laser Center
Masoud Panjehpour,
Manager
Chief
Administrative Officer
Phil Johnson
Sharon Mullens,
Manager
Foundation
Practice Mgr
Rob Sanders
Thompson Oncology
Group
Patient & Family Services
Clinical Dieticians
Social Services
Genetic Counseling
Radiation Oncology
Linda Linn, Mgr
Downtown & West
Breast Center
Cancer Outreach Services
Shelia Baucum, Manager
PET Imaging
Karen Woten, Mgr
Cancer Registry
Anita Thompson, Mgr
Clinical Trials
Josie Stanga, Manager
Director of Clinical
Services
Ann Henderlight
Multidisciplinary
Cancer Care
Coordination
Victoria Spry
Quality Mgmt
Deloris
Wittenbarger
Sandra Marshall
SVP, Organizational
Effectiveness/Clinical
Outcomes
THOMPSON CANCER SURVIVAL CENTER ORGANIZATION CHART
COVENANT HEALTH
HUMAN RESOURCES
10
Human Resources
Department
Laurel Plaza, Suite 106
Knoxville, Tennessee 37916
(865) 541-1247
Director
Colleen Andrews
541-2817
Sr. Generalist
Susan Thompson
541-1891
Sr. Generalist
Teresa Harris
541-1339
Coordinator
Catherine Okhuysen
541-1888
Associate
Diane Shelton
541-1247
We want your employment and/or clinical rotation here to
be satisfactory for both you and your manager. We are
here to help you with any concerns or problems.
11
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Compensation,
Benefits & Employee Programs
Subject:
ORIENTATION OF NEW
EMPLOYEES
Policy Number: HR.CB.020
Page: 1 of 1
Approved by: President & CAO, FSRMC
Generated by: Human Resources
Approved by: Director, Human Resources
Effective date: 08/93
Approved by:
Revised date: 02/04
SCOPE:
This policy applies to all Ft. Sanders Regional Medical Center, Ft. Sanders
Foundation, Thompson Cancer Survival Center, Thompson Oncology
Group, and Ft. Sanders Perinatal Center employees.
PURPOSE:
To ensure high quality care, competency, and patient and employee safety,
individuals hired by Covenant Health must receive proper orientation to the
facility, to their departments, to relevant policies and procedures, and to all
facets of the job duties they are expected to perform.
POLICY:
All newly hired employees will attend a New Hire Celebration/Orientation
session covering Covenant Health Purpose, Vision, Values; Integrity and
Compliance; and Employee Benefits before reporting to work. In addition
to this general celebration/orientation, newly hired employees will also
receive orientation to their facility and department; and a complete
assessment of individual competency to perform the duties of the position
will be conducted by the Department Manager or designee. General
follow-up sessions designed to gather employee feedback are conducted
frequently during the first year of employment in an effort to improve the
orientation process and increase retention. Refer to facility specific policy
for more details.
12
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Standards of Conduct
Subject:
HARASSMENT
Approved by: President & CAO, FSRMC
Generated by: Human Resources
Approved by: Director, Human Resources
Effective date: 08/91
Approved by:
Revised date: 02/04
Policy Number: HR.SC.009
Page: 1 of 3
SCOPE:
This policy applies to Fort Sanders Regional Medical Center, Thompson Cancer Survival
Center, Thompson Oncology Group, and Ft. Sanders Perinatal Center employees.
PURPOSE:
To maintain a productive work environment free from all forms of harassment, including
sexual harassment. Furthermore, this policy defines harassment and provides a mechanism
that is available to all employees to make complaints of harassment that will be handled in a
prompt and confidential manner.
POLICY:
Covenant Health is committed to providing a work environment free of all forms of
harassment. Accordingly, all forms of harassment are prohibited, including but not limited to,
sexual harassment and harassment because of an individual’s race, color, sex (including
pregnancy), national origin, ancestry, religion, marital status, age, and physical or mental
disability. Covenant Health will not tolerate verbal or physical conduct by any employee,
patient, physician, visitor, vendor, contractor, or any other affiliate that harasses or degrades
any individual or that interferes with work performance, including the creation of an
intimidating, offensive, or hostile work environment.
Definitions:
Harassment is any verbal, physical, or visual conduct that tends to belittle or provoke, and
includes but is not limited to “jokes”, gestures, and derogatory remarks. Federal, state, and
local laws prohibit sexual harassment and harassment based on a certain individual’s
personal characteristics including an individual’s race, color, sex (including pregnancy),
national origin, ancestry, religion, marital status, age, and physical or mental ability.
Covenant Health will not tolerate any harassment.
Sexual Harassment is any unwelcome sexual advance, request for sexual favors, or other
verbal or physical conduct of a sexual nature, including but not limited to sexual jokes,
sexual innuendoes, obscenities, and the display of sexually suggestive photographs and
photographs of nude or partially nude men and women
13
Sexual harassment is also committed if:
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Standards of Conduct
Subject:
HARASSMENT
Policy Number: HR.SC.009
Page: 2 of 3
Submission to the unwelcome sexual advance or request for sexual favor is made either an
express or implied condition of employment; or
Submission to or rejection of the unwelcome sexual advance or request for sexual favor is used as
the basis for an employment decision; or
The unwelcome sexual advance, request for sexual favor, or other verbal or physical conduct has
the purpose or effect of interfering with the employees’ work performance or creates an
intimidating, hostile, or offensive work environment.
It is important to remember that an individual need not be propositioned, touched offensively, or
directly subject to sexual innuendo to be sexually harassed. Any demeaning, intimidating, or
hostile conduct toward an individual based on his or her sex can constitute sexual harassment.
Reporting Requirements
It is essential that employees immediately report all suspected instances of harassment, including
sexual harassment. Any employee who feels that he/she has been or is being harassed, or who
believes that another individual has been or is being harassed, must immediately report such
harassment to his/her immediate supervisor or department director/manager, to Human Resources,
or to any other department director/manager of his/her choosing. If a complaint of harassment is
being made against the employee’s immediate supervisor, the employee should file the complaint
directly with the Director of Human Resources or any department director/manager.
This reporting requirement applies to harassment, which occurs off-site as well. (For example, if an
employee is given a work assignment that takes him/her to a patient’s home or any other off-site
location.) Employees are not required to endure insulting, degrading, intimidating, hostile, or
offensive treatment on the job when their work duties take them away from Covenant Health
premises.
Any delay in reporting incidents of harassment inhibits Covenant Health’s commitment to prevent
and, when necessary, promptly remedy such incidents. Any failure to report or delay in reporting
incidents of harassment may be deemed unreasonable.
Any supervisor or department director/manager who observes or is made aware of an alleged
instance of harassment is required to intervene as appropriate and report the incident to the
Director of Human Resources, even if no formal complaint of harassment is filed.
14
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Standards of Conduct
Subject:
HARASSMENT
Policy Number: HR.SC.009
Page: 3 of 3
Investigations
Covenant Health will promptly investigate all allegations of harassment and take whatever
measures are necessary to initiate investigation, promptly remedy any incidents of harassment it
determines to have occurred, and prevent further incidents from occurring. The investigation will
be conducted in as confidential a manner as possible; however, Covenant Health reserves the
right to disclose the substance of the complaint to the extent necessary to conduct a meaningful
and accurate investigation.
The results of Covenant Health’s investigation will be communicated to the employee filing the
complaint and to any employee accused of harassment. The Director of Human Resources will
keep any documentation related to the results of the investigation. Any corrective action forms
that arise out of a complaint of harassment will be placed in the disciplined employee’s personnel
record.
Anti-Retaliation
Covenant Health will not tolerate any retaliation against an employee who makes a good faith
report of harassment or cooperates with those persons investigating the allegation of harassment,
regardless of the outcome of the investigation, and will take immediate corrective action against
any individual who threatens or engages in such retaliation.
Covenant Health will not tolerate false accusations of harassment, and employees making false
claims of harassment in bad-faith intended to harass or embarrass the alleged harasser, will be
subject to corrective action, up to and including termination.
Corrective Action:
Any individual found to have violated this harassment policy, including its anti-retaliation
provisions will be subject to corrective actions, up to and including immediate termination.
Any employee who has questions about this policy is encouraged to discuss the matter
with his/her supervisor, department director/manager, Director of Human Resources or any
member of management with whom he/she feels comfortable.
15
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Human Resources
Subject: Workplace Violence
Policy Number: HR.SC.251
Page: 1 of 5
Approved by: Human Resources Director
Generated by: Human Resources
Approved by: President / CAO
Effective date: October 2003
Approved by:
Revised date: January 2004
Review date:
Scope:
This policy covers all employees of Fort Sanders Sevier Medical Center.
Purpose:
The purpose of this Covenant Health Workplace Violence Policy is to ensure a safe, nonviolent
environment for all employees, patients, visitors, and clients, and to reduce the risk of violence through
crisis intervention.
Policy:
The safety and security of employees, patients, and visitors is of vital importance to Covenant Health.
Overt acts of violence, threats of physical harm and/or behaviors that are harassing, threatening, and/or
considered violent will not be tolerated within Covenant Health facilities nor, by extension, at any
location where business is conducted on behalf of Covenant Health. Any employee who engages in a
violent act, as defined within this policy, or who makes any threat to engage in a violent act, directed
toward the person or property of any employee, patient, physician, visitor, or client within a Covenant
Health facility may be subject to immediate termination of employment.
Possession of any item within Covenant Health facilities which may be defined as a weapon in
accordance with Tennessee law, except in the instance of authorized law enforcement agents, may
likewise constitute a basis for termination of employment (see Weapons Possession policy). Specific
examples of weapons include firearms, explosive devices, clubbing instruments, and knives with fixed
blades or blades longer than four (4) inches.
“Violence” And Specifically Prohibited Activities Defined:
Following are examples of violent acts and specifically prohibited activities within the context of this
policy. These examples are not regarded as all-inclusive but are provided as a means to illustrate the
intent of the policy. Covenant Health retains the prerogative to specify and/or define additional acts as
violations of the policy. Such acts are specifically prohibited and employees engaging in such acts may
be subject to disciplinary action up to and including termination of employment.
16
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Human Resources
Subject: Workplace Violence
Policy Number: HR.SC.251
Page: 2 of 5
§
Commission of, or threat to commit, any violent act prohibited by Tennessee state
criminal statutes in facilities operated by or on the property of Covenant Health or at any
other location where business is conducted on behalf of Covenant Health;
§
Refusal to participate in an investigation pertaining to allegations or suspicion that a
policy violation has or is likely to occur;
§
Some examples of “violent acts” and prohibited activities are:
a.
Murder, voluntary manslaughter, aggravated rape, rape, mayhem, especially
aggravated robbery, armed robbery, robbery, burglary, aggravated assault,
assault, and battery;
b.
Verbal threats against an individual or personal property, verbal abuse, or any
form of harassment;
c.
Intentional damage, defacement, or destruction of personal or facility property;
d.
Flagrant or impudent disregard of health and safety policies;
e.
Illegal use, possession, or sale of any weapon, as defined by Tennessee state
law, in facilities or premises owned or operated under the auspices of Covenant
Health, or at any location where business is conducted on behalf of Covenant
Health;
f.
Refusal to consent to a search for the presence of a weapon when requested by
an authorized agent of Covenant Health; and,
g.
Conviction under any criminal statute for the illegal possession of a weapon or for
the commission of a violent act against the person or property of another.
Facility Responsibilities:
It is the responsibility of each facility’s Risk Management Department or representative to
ensure compliance with the Workplace Violence policy. The actual policy administration may
be assigned to the Safety Committee or an Employee Safety subcommittee. The Safety
Committee or Employee Safety subcommittee will be typically comprised of at least one
management level representative from Security, Worker’s Compensation, Risk Management,
and Human Resources. The composition may vary by location contingent upon facility size,
staffing, and organization. In those instances where a specific expertise may not be
17
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Human Resources
Subject: Workplace Violence
Policy Number: HR.SC.251
Page: 3 of 5
available within the facility, a representative with the required expertise may be appointed
from another facility.
A primary function of the Safety Committee or Employee Safety subcommittee is to
improve and promote each facility’s ability to address workplace violence. Specific
responsibilities include, but are not necessarily limited to:
§Develop, implement, and monitor a Workplace Violence Prevention plan;
§Review incidents of violence at the facility, and recommend preventive measures as
appropriate;
§Review the facility’s readiness to respond to issues or incidents associated with
workplace violence;
§Develop an expertise regarding issues of workplace violence within the Committee and
other appropriate members of management;
§Appoint and establish the responsibilities for a “response team” designed to respond to
and assess any incidents of violence, or potential violence, which may occur (the
“response team” may be defined as a responsibility of the Safety Committee or
Employee Safety subcommittee);
§Develop and help disseminate workplace violence prevention information for facility
personnel; and
§Establish and monitor procedural mechanisms for application of the Workplace Violence
policy to employees classified as contract, temporary, and “occasional”, whether
employed directly by the facility or through an agency or outside vendor.
Responsibilities of Management and Supervisory Personnel:
Staff members whose positions incorporate management and supervisory responsibilities
will have the following obligations to support this policy:
Assure that staff under their supervision receive workplace violence prevention
information;
Assist the Safety Committee/Employee Safety subcommittee in the implementation and
maintenance of the Workplace Violence Prevention Plan;
18
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Human Resources
Subject: Workplace Violence
Policy Number: HR.SC.251
Page: 4 of 5
§Communicate all approved workplace violence prevention policies to staff under their
supervision, including communication to any third party employees working within their
unit/division or otherwise under their administrative auspices; and,
§Comply with proper reporting procedures with regard to any overt policy violations or
observations of potential warning signs.
Responsibility of Employees:
Maintenance of a safe workplace is regarded as the responsibility of all employees.
An employee who feels that he or she has been a victim of any act in violation of this policy,
or who is aware of violations which may have victimized other persons, should report the
circumstances immediately. In addition to reporting any overt violations of the policy,
employees are likewise expected to report possible warning signs of violence they may
observe (e.g., verbal abuse, aggressive behavior, loitering, and so forth).
REPORTING PROCEDURE:
Violations And Potential Warning Signs Should Be Reported To The Security
Department.
The Security Department will notify Human Resources of any confirmed
incidents.
An employee who has knowledge of a violation of this policy but fails to report the violation
may be subject to disciplinary action. No employee will be disciplined or discharged for
truthfully reporting a policy violation.
Applicability to Non-Employees and Off-Site Incidents:
It is not the intent of this policy to be intrusive or to infringe upon the private lives of
individuals employed by or associated with Covenant Health. However, the policy may be
considered applicable to certain incidents involving employees and non-employees which
may occur off-site. This would generally involve issues which may originate at the facility
and culminate in an off-site incident or which have a direct bearing on the individual’s ability
19
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Human Resources
Subject: Workplace Violence
Policy Number: HR.SC.251
Page: 5 of 5
to perform their job or is inconsistent with the mission and values of Covenant Health.
Limitations on Employee Benefits:
If an employee is injured as a result of instigating a violation of this policy, or while engaged
as a willing participant in a policy violation, entitlement to Worker’s Compensation benefits
may be denied.
Employees whose employment may be terminated as a result of policy violation(s) will not
be eligible for rehire.
Authority To Conduct Searches:
Covenant Health reserves the right to conduct searches of company-owned property,
furnishings, lockers, and other similar articles which may be provided for employee use in
the event of reasonable suspicion that a weapon may be present or concealed.
Covenant Health also reserves the right to request to search personal property, with the
employee’s approval, in the event of reasonable suspicion that a weapon may be present
or concealed.
An employee’s refusal to permit or cooperate in a search based on reasonable suspicion
will be considered a basis for disciplinary action, up to and including termination of
employment.
20
PATIENT CARE PHILOSOPHY
Every patient who enters a Covenant Health facility is to be treated with courtesy,
compassion, respect, and dignity. As an employee or student, you have accepted the
high and special challenge of providing advanced technological care while maintaining
a personal and close awareness of the individual human needs of our patients. In any
activity conducted by, for, or in the organization affecting care and treatment of
patients, there will be no separation, discrimination or other distinction on the basis of
race, color, disability, or national origin. All cultural diversity is acknowledged and
incorporated into the patient plan of care.
In working with the sick and injured, it is important to remember that you are dealing with
persons in exceptional circumstances. You will discover that many patients have
fears and resentments that may manifest themselves as irritability, lack of cooperation
and apprehension. Courtesy, kindness, and above all, sincere understanding are
important steps in overcoming these problems. Always remember that what is routine
for you may be a great emergency in the mind of the patient and his/her family. Your
thoughtful consideration will often be remembered long after the medical services
performed have been forgotten.
When a patient requests to Opt Out of the Hospital Directory they are considered to
become NO INFORMATION status. The patient and/or the patient’s personal
representative will be advised by the registrar that as a No Information patient, all
telephone calls, visitors, florists, etc., will be informed there is no listing for the patient.
Only the room # and the MD’s name will appear on the front of the chart
STAFF RIGHTS
Requests by a staff member not to participate in any aspect of patient care where there is
perceived conflict with the staff member’s cultural values or religious beliefs will be
addressed in the following manner:
1. The Ethics Committee is available to employees as a forum and source of ideas
for resolution of ethical conflict.
2. Employees may transfer to a position in another department, if available.
3. If the ethical conflict occurs when the employee is on duty, and the patient’s
need for care or treatment is imminent, the staff on duty should decide who will
care for the patient. If no decision can be reached, the staff member in charge
should refer the issue to the manager, Director, Administrative Supervisor, or
Administrator On-call to render a decision to ensure that the patient receives
appropriate care.
21
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Standards of Conduct
Subject:
STAFF RIGHTS
Policy Number: HR.SC.014
Page: 1 of 1
Approved by: President & CAO, FSRMC
Generated by: Human Resources
Approved by: Director, Human Resources
Effective date: 12/94
Approved by:
Revised date: 02/04
SCOPE:
This policy applies to all Ft. Sanders Regional Medical Center, Ft. Sanders Foundation, Thompson
Cancer Survival Center, Thompson Oncology Group, and Ft. Sanders Perinatal Center employees.
PURPOSE:
To provide guidelines to address any request by a staff member not to participate in any aspect of
patient care, including treatment. The guidelines ensure that a patient’s care will not be negatively
affected if the request is granted.
POLICY:
Requests by a staff member not to participate in any aspect of patient care where there is perceived
conflict with the staff member’s cultural values or religious beliefs will be addressed as indicated
below. Examples of this include therapeutic abortions and “do not resuscitate.”
The Ethics Committee is available to employees as a forum and source of ideas for resolution of
ethical conflict.
Employees may transfer to a position in another hospital service, if available.
If the ethical conflict occurs when the employee is on duty and the patient’s need for care or
treatment is imminent, the staff on duty should decide who will provide care to the patient. If no
decision can be reached, the staff member in charge should refer the issue to the Manager, Director,
House Supervisor, or Administrator On-call to render a decision to ensure that the patient receives
appropriate care.
22
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Standards of Conduct
Subject:
PROBLEM SOLVING
PROCEDURE
Policy Number: HR.SC.011
Page: 1 of 4
Approved by: President & CAO, FSRMC
Generated by: Human Resources
Approved by: Director, Human Resources
Effective date: 08/91
Approved by:
Revised date: 02/04
SCOPE:
This policy applies to all Ft. Sanders Regional Medical Center, Ft. Sanders Foundation,
Thompson Cancer Survival Center, Thompson Oncology Group, and Ft. Sanders Perinatal Center
employees.
POLICY:
In work situations, complaints and disagreements may arise over work-related issues or incidents.
Covenant Health has developed a problem-solving procedure as a method for employees to
register complaints concerning their working conditions, administration of policies, or a disciplinary
action an employee believes is unjust. The problem-solving procedure is available to all
employees who have completed their initial employment period.
Terminations are not subject to the problem-solving procedure. Terminated employees who wish
to discuss the circumstances of their termination are encouraged to contact their Director of
Human Resources.
Covenant Health is committed to preserving positive relations between management and
employees. To fulfill this commitment, Covenant Health sets the following standards:
1.
Each employee shall be guaranteed fair and honest treatment in all aspects of his or her
employment. Supervisors and managers shall treat each employee with respect, shall not
demonstrate personal prejudice, or grant unfair advantage to one employee over another.
2.
Each employee has the right to express his or her views concerning company policies and
practices to management. Each employee is responsible, however, for expressing those
views in a fair and honest manner. Every employee should be committed to making positive
and constructive criticism.
3.
Each employee is responsible for following company rules of conduct, policies, and practices.
Should an employee disagree with a company policy or practice, the employee is invited to
express that disagreement through the Problem-Solving Procedure. An employee is
expected to comply with the disputed policy or practice until the disagreement has been
heard and the disagreement is addressed.
23
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Standards of Conduct
Subject:
PROBLEM SOLVING
PROCEDURE
Policy Number: HR.SC.011
Page: 2 of 4
4.
No employee shall be penalized, formally or informally, for voicing a disagreement with
company policies and practices or for using the problem-solving procedure to voice such
disagreement.
5.
Every complaint, question, problem, or suggestion shall be considered and answered as
quickly as possible. In the case of formal action by an employee, the answer and an
explanation shall be given in writing.
6.
An employee shall present his or her own case.
PROCEDURE:
An employee should generally initiate the problem-solving procedure with his or her
immediate supervisor but may initiate the problem-solving procedure at later steps if the
immediate supervisor is the subject of the grievance. When an employee initiates use of the
problem-solving procedure, he/she should be provided with a copy of this policy. The
employee or the manager may request a delay between steps if more time is needed to
gather or present additional information. At any step of the problem-solving procedure, a
Human Resources Department representative is available to assist either the employee or
the manager with the process.
Step 1:
An employee has five (5) working days from the time an incident occurs to file a complaint.
Employee
First, an employee should discuss the issue with his or her immediate supervisor in private.
To initiate the problem-solving procedure, a statement must be presented in written or typed
form, dated, and signed by the employee. This statement should include an explanation of
the employee's concern and what action the employee requests to satisfy the concern. If
the problem or complaint is with the direct supervisor, the employee may omit Step 1 and go
directly to Step 2.
Department Manager
Department Manager will discuss the problem with the employee and provide the employee
with a written response within three (3) working days from the date he/she receives the
statement. If this is not possible, the supervisor will inform the employee in writing of the
projected response date. The supervisor will review the complaint based on facts, company
policy, and investigative findings.
24
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Standards of Conduct
Subject:
PROBLEM SOLVING
PROCEDURE
Policy Number: HR.SC.011
Page: 3 of 4
Step 2:
Employee
If the employee is not satisfied with the answer from the immediate supervisor or if the complaint is with
the immediate supervisor, he/she may submit the statement to the Department Director. The employee's
statement must be submitted within three (3) working days of the date the written response in Step 1 is
received.
Department Director
The Department Director will discuss the problem with the employee and provide the employee with a
written response within three (3) working days from the date he/she receives the statement.
If this is not possible, the Department Director will inform the employee in writing of the projected
response date.
Step 3:
Employee
If an employee is not satisfied with the Department Director's response, the employee may submit the
statement to the Vice President. The statement must be submitted within three (3) working days of the
date the written response in Step 2 is received.
Vice President:
The Vice President will review the statement and provide a written response within five (5) working days
from the date the statement is received. If this is not possible, the Vice President will inform the
employee in writing of the projected response date.
Step 4:
Employee
If the employee is not satisfied with the Step 3 response, the employee may request that the
Administrator or Senior Vice President consider his/her concern. A written request for such
consideration must be submitted to the Administrator or Senior Vice President within 3 working days of
the employee's receipt of a response to Step 3.
Administrator or Senior Vice President
The Administrator or Senior Vice President will review the statement and relevant information, and
provide a written response within 5 working days from receipt of the
25
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Standards of Conduct
Subject:
PROBLEM SOLVING
PROCEDURE
Policy Number: HR.SC.011
Page: 4 of 4
employee's statement. All decisions made by the Administrator or Senior Vice President
are final.
26
Complaint Filing Procedures
•
•
•
•
•
•
If the employee exhausts all means available to him/her for
resolution and the problem still persists, then the employee
can contact JCAHO and/or the Department of Health at 1-800852-2187 to report the situation. Complaints may be filed at
complaint@jcaho.org. For instructions on filing a complaint,
contact JCAHO at (800) 994-6610.
The hospital must not discipline or retaliate against any
employee who reports a quality/patient care issue to JCAHO
or an integrity issue to Integrity Compliance.
If someone perceives an issue with the quality of care a
patient is receiving, has a concern regarding safety issues, or
has an integrity concern, he/she should bring it to the attention
of his/her supervisor.
If the employee perceives that the issue is not resolved at the
facility level, then he/she should follow the chain of command
to the corporate level which is the Integrity Compliance Office.
All calls to Integrity Compliance are confidential and you may
remain anonymous if you wish.
The phone system has been modified to ensure that your call
cannot be recorded and your location cannot be identified,
EXCEPT the call centers at KBOS and PHP.
Integrity Compliance contact numbers:
Department Line: 865-374-8010
Report Line: 1-888-731-3115
On-Line: Covenant Intranet
27
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Rights and Responsibilities/Ethics
Subject:
ETHICS ISSUES,
EMPLOYEE
RESPONSIBILITY
Policy Number: RR.ET.004
Page: 1 of 1
Approved by: Administration
Generated by: VP for Nursing
12/94
Approved by: Ethics Committee
12/94
Effective date:
Approved by:
Revised date:
Approved by: 12/94
Review date: 05/00, 03/04
SCOPE: All employees of the hospital
PURPOSE:
Provide guidelines to assist employees in ethical decision making, in respect of patient rights.
PROCEDURE:
Employees of Fort Sanders Regional Medical Center who have a question or concern
regarding an ethical issue(s) should:
1)
Consult the attending physician or immediate supervisor
1)
The supervisor may then consult the attending physician and/or patient’s family.
1)
If a solution is not reached, the supervisor should notify the director of the
department regarding the issue. The director will then collaborate with the
appropriate person(s).
1) If there continues to be no resolution of the issue, the department director will
notify the administrator and/or Ethics Committee chairperson to achieve problem
resolution.
1)
As appropriate, patients and their families may be informed of how to gain access
to the Ethics Committee and ethical resolution process by contacting the hospital
operator at extension “0”.
NOTE: The Ethics Committee serves as a forum and source of ideas for resolution of ethical
conflict. It does not make patient care decisions, nor does it have enforcement power for its
recommendations.
28
These guidelines provide a mechanism to address the concerns of staff while ensuring
that a patient’s care will not be negatively affected.
ETHICS COMMITTEE
Covenant Health is committed to the care of people in a manner that ensures patient and
family dignity, privacy, and respect. Affirming the rights of the patient to participate in the
planning and decision-making processes affecting his or her treatment is facilitated
through the provision of a multidisciplinary Ethics Committee at each facility. Access to
the Ethics Committee regarding any issue is available through contacting the Chaplain at
your facility; Fort Sanders Regional Medical Center campus at 541-1235, contacting the
Administrative Supervisor or the operator.
The objective of the Ethics Committee is to provide education for its members, the staff,
and the patient/family; to be involved in the development of policy and procedure issues
concerned with ethical issues; and to be available for case reviews. Any individual, be it
staff, patient, family, or the general public, may request a review by the Ethics
Committee.
EMPLOYMENT INFORMATION
EMPLOYMENT CLASSIFICATIONS:
All employees of Covenant Health are divided into one of the following classifications of
employment:
•Initial Employment Period – The first 90 calendar days of employment are referred to as
the initial employment period. It is during this period that you will be oriented to this
facility and to your department. A complete assessment of your individual competency
to perform the duties of your position will be conducted during this period. During this
period, an eligible employee accrues CTO benefits that are available at the end of 90
days. New employees may request time off without pay in the event of death in the
immediate family.
•Full-time Employee – A full-time employee is one who is scheduled to work a minimum
of 72 hours per pay period on a regularly scheduled basis, and is eligible for full-time
benefits.
•Part-time Employee - A part-time employee is one who is scheduled to work 31-71hours
per pay period on a regularly scheduled basis. Part-time employees who work at least
32 hours per pay period are eligible for part-time benefits.
•PRN/Occasional Employee – An occasional employee is one who is employed only for
a special project or assignment, an emergency, summer employment, or non-regular
intervals. These employees are non-benefit employees. However, they are covered by
Workers’ Compensation Insurance. If an occasional job develops into a part-time or fulltime job, the effective date of the status change determines benefits accruals.
•Temporary Employee – A temporary employee is one who is employed for a special
assignment or project. Temporary employment usually does not exceed 90 days. No
benefits are given to temporary employees; however, they are covered by Worker’s
Compensation Insurance.
29
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Compensation,
Benefits and Employee Programs
Subject: Workers’ Compensation
Policy Number: HR.CB.027
Page: 1 of 3
Approved by: President & CAO, FSRMC
Generated by: Human Resources
Approved by: Director, Human Resources
Effective date: 08/91
Approved by:
Revised date: 02/04
SCOPE:
This policy applies to all Ft. Sanders Regional Medical Center, Ft. Sanders Foundation,
Thompson Cancer Survival Center, Thompson Oncology Group, and Ft. Sanders Perinatal Center
employees.
PURPOSE:
The purpose of this policy is to explain the following with regards to Workers' Compensation:
Responsibilities of the employee and manager
Medical referral procedure
Coordination of benefits
POLICY:
Employees of Covenant Health are automatically covered under the Workers' Compensation Act
in the event that they are injured on the job. In responding to employee injuries, Covenant
Health’s objectives are to:
Initiate Workers' Compensation benefits promptly to minimize the financial impact on the
injured employee.
Provide appropriate and effective medical care and to prevent re-injury.
Assist employees in returning to work promptly and safely.
Employees' Responsibilities (unless otherwise designated in a facility-specific policy):
Report injury immediately to manager or house supervisor and complete green incident
report.
If injured, report to Employee Health (or when Employee Health is closed, contact house
supervisor for triage and disposition) immediately for evaluation and treatment.
Report to Employee Health for a Return to Work release, prior to returning to duty.
Deliver Return to Work release to manager when returning to duty.
If seen in Emergency Department, report to Employee Health next business day.
Managers' Responsibilities (unless otherwise designated in a facility-specific policy):
The manager will ensure that the injured employee follows the instructions presented
above.
30
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Compensation,
Benefits and Employee Programs
Subject: Workers’ Compensation
Policy Number: HR.CB.027
Page: 2 of 3
•
The manager shall sign the incident report and forward to Employee Health (or to the
House Supervisor if after hours). Employee Health will fax completed incident report to
Cariten WORxS.
•
If there is lost time from work, the manager must ensure that the employee does not
return to work until a Return-to-Work release is obtained from Employee Health.
•
Employees must be referred back to Employee Health for any continuing problems
related to the injury.
•
The injured employee must not be held off from duty or allowed to hold himself/herself off
from duty without prior authorization from Employee Health.
•
A Personnel Action Request form (PAR) indicating leave of absence for Workers'
Compensation must be completed if the lost time exceeds seven (7) days.
•
Physical restrictions specified by Employee Health must be considered in assigning work
to the returning employee.
Medical Referrals
Section 50-6-204(4) of the Tennessee Workers' Compensation Act provides in part the
following:
"The injured employee shall accept the medical benefits afforded hereunder;
provided that the employer shall designate a group of three (3) or more reputable
physicians or surgeons not associated together in practice, if available in that
community, from which the injured employee shall have the privilege of selecting the
operating surgeon or the attending physician.“
Accordingly, when medical care is required, Employee Health will refer the injured employee
to a panel of physicians on the Covenant Health medical staff.
Covenant Health will NOT pay the medical bills of physicians unless referred by the
Employee Health Service or the Emergency Department physician. The employee has the
right to have the case manager present during exams if desired. If the employee’s
primary care physician at the employee’s request provides care, the employee shall then be
responsible for paying his/her physician for services.
All outpatient diagnostic treatment services, rehabilitation, work hardening, physical therapy,
etc. shall be rendered by a facility of the Covenant Health System and not an outside facility.
31
Fort Sanders Regional Medical Center
Fort Sanders Foundation
Fort Sanders Perinatal Center
Thompson Cancer Survival Center
Thompson Oncology Group
Human Resources/Compensation,
Benefits and Employee Programs
Subject: Workers’ Compensation
Policy Number: HR.CB.027
Page: 3 of 3
Coordination of Benefits with Workers' Compensation
When an employee is placed on a workers' compensation leave of absence (LOA), all sick
and paid time off (PTO) accruals will cease for the time period involved.
During the time period an employee is on a workers' compensation LOA, the employee will
not be allowed to receive paid sick leave or PTO.
The employee who is on a workers' compensation LOA will be able to continue their medical
insurance and other coverage by paying their usual employee premium for a period of
twelve weeks. After that date, the employee may continue coverage under COBRA
provisions, paying the higher COBRA rate. This time period may be shortened if it is known
earlier that the employee will not be returning to work.
When the employee returns to work, the manager must submit a PAR form to Human
Resources.
The employee's benefit accrual date will be adjusted by the length of time of the LOA.
32
EMPLOYEE PERFORMANCE AND BEHAVIOR
EXPECTATIONS
ATTENDANCE
When an employee fails to meet a work schedule commitment, the impact to patient
care, as well as the burden it may place on co-workers, can be quite negative. With
this in mind, all employees need to understand the potential employment
consequences of deliberate attendance violations, repeated occurrences of
unscheduled absences or tardiness and time clock violations.
DRESS, APPEARANCE AND HYGIENE:
This policy is intended to provide guidelines regarding appropriate Appearance
standards at Covenant Health. It cannot address every potential item of clothing or
accessory; therefore, Managers are expected to apply good judgment in maintaining
professional and appropriate appearance of their employees.
The image we portray through our dress and appearance is an important reflection
of our professionalism and commitment to quality. Therefore, our employees should
meet the following guidelines regardless of where they work:
Clothing and Fit
All clothing, regardless of whether it is a uniform or other dress, should be clean, fit
properly, in good repair and pressed or ironed as needed. Any article of clothing
that portrays a printed message, which could be offensive to the general public,
shall not be worn. Denim blue jeans are not appropriate in the workplace, although
departments may allow blue denim skirts, dress, and shirts if neat, professional in
appearance, and appropriate to the work being performed.
Uniforms
Managers will communicate to all newly hired or transferring employees the uniform
requirements of their departments.
Newly hired employees or transferring
employees are expected to obtain appropriate uniforms within one month after
beginning work in their new department. A department changing scrub color will
have a one-year period of transition before staff is expected to all be attired in the
new color. This also applies to employees who transfer unless the transfer is to a
department where the color is mandated.
All employees wearing uniforms should be prepared to change into clean uniforms in
the event that their uniforms become objectionably soiled during the work shift.
Employees who change into scrub uniforms at work are expected to adhere to the
organization’s appearance policy while they are in the facility, i.e., on the way to the
changing area/locker room and after changing out of their scrub uniforms.
White Uniforms for Nurses
It is always acceptable to wear white uniforms unless there is a department specific
reason not to do so. In areas where the department requires wearing uniforms,
colored street clothes may not be substituted. For example, colored or print tee
shirts and white pants/skirts are not acceptable.
33
Colored Scrubs
Colored scrubs are determined per department. The attire must be uniform scrubs, not
colored street clothes. Knit polo shirts, which match the exact scrub color, are
acceptable. Each employee must adhere to the department scrub color. Coordinating
print scrub uniform tops/lab coats of the employee’s choice may be worn with white or
unit color uniform pants.
Scrub Usage
•No change in scrub color should occur unless a department’s color is discontinued.
•A department that changes scrub color may not choose a color that is already in use
without written permission from that department manager.
•Scrub purchases should be an exact match of your department’s chosen color.
•Appropriate non-scrub or non-uniform tops will be permitted during Christmas and on
UT Game Fridays/Saturdays. Any other deviations from this policy will be specified by
Administration.
Tops/Blouses
Tops and blouses should not have a revealing neckline or midriff. Sweatshirts, tank
tops, and shirts with printed messages are not permissible.
Pants
Pants may be worn if appropriate; however, the following styles should not be worn:
overalls, warm-up or sweat pants, clamdiggers, pedal pushers, tight stirrup pants, or
leggings.
Skirts, Dresses, and Shorts
Skirts and dresses should be of appropriate length. Split skirts, city shorts, and skorts of
the appropriate length are permissible. Sundresses and tank tops may be worn only with
jackets. Hose will be worn with these at all times.
Shoes
Shoes must be appropriate to the dress and job for a given department. All white or all
black athletic shoes may be worn if they are polished and clean. Canvas or cloth shoes,
sneakers, and colored or high-top athletic shoes are not permissible. Colored
shoestrings should not be worn.
Undergarments
Appropriate undergarments (including hosiery/socks) will be worn to present a neat and
professional appearance.
34
Hair
Employees must keep their hair clean and in an orderly fashion that does not present a
safety hazard. Color, style, and length should be appropriate; mustaches, sideburns and
beards are to be neatly trimmed. For employees who are required for safety reasons to
wear a respirator, beards may not be worn since they would interfere with the proper fit
of the respirator.
Hats
Hats may be worn only as part of an approved overall work uniform.
Jewelry
Jewelry may be worn but should not depict an insignia offensive to the general public.
Excessive or dangling jewelry may be a safety hazard to the patient or employee. Male
employees may not wear earrings while on duty. Certain departments may have a “no
jewelry” policy.
Makeup and Fragrances
Make-up and personal body fragrances, including perfume and after-shave may be worn
but should not be overly strong. People who are ill may be especially sensitive to odors,
which may cause nausea or allergic reactions. Certain departments may have a “no
fragrance” policy due to patient concerns.
Fingernails
Fingernails must be kept clean, neat and trimmed to a length considered safe and
appropriate. Nail polish may be worn but the color should be viewed as appropriate and
professional. Certain departments may have a “no polish or no artificial fingernails”
policy due to patient health concerns.
Identification Badges
All employees are required to wear an identification badge at all times while on duty
enabling them to be readily identified by patients, visitors, physicians, and other
employees. The badge should generally be worn at chest level to be visible for easy
identification by all parties; however, the badge may be worn at waist level if the chest
level location interferes with the work being performed. Pins of a professional nature
may be worn on the badge as long as the pin does not cover or damage the printing,
photo, or bar code on the badge. No tape or stickers should be placed on the badge.
Workers Provided by Temporary Agencies
Temporary agency workers must adhere to all provisions of this policy.
35
Cariten Assist EAP is provided to ALL employees, regardless of your
health plan. The program is designed to provide assistance concerning
such issues as stress, anxiety, drug and alcohol abuse, family problems
and depression. Benefits include counseling services for you and your
family members.
Simply call Cariten Assist at 865-531-4500 or 800-232-8335 to make an
appointment.
There is NO cost for EAP visits and everything
communicated between you and your counselor is completely
confidential.
No one needs to go through difficult times alone.
36
CARE OF EQUIPMENT AND SUPPLIES
Medical equipment is one of the most important resources we use in treating
patients. It is vital that you be alert to any malfunction or disrepair of any equipment
and that you report it to your Supervisor or Manager immediately.
Do not attempt to use any equipment for which you have not been properly
trained. Always ask for assistance with unfamiliar equipment.
Supplies are expensive, and you should try to prevent waste and spoilage. If
you should find that you could not satisfactorily complete your duties because of
inadequate supplies, you should report the shortage immediately to your Supervisor
or Manager.
Cafeteria items such as trays, plates and silverware are not to be removed from
the cafeteria. If you wish to carry our food, ask for and use paper plates and plastic
utensils. If you should find cafeteria utensils outside the cafeteria, please return them
to the Food Services Department.
As part of the organization’s involvement in and commitment to the national cost
containment program, we ask your help in treating all equipment and supplies with
extreme care. Losses in these areas mean increased costs for the organization,
which result in increased costs for our patients.
37
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Leadership/Administration
Subject: SMOKING REGULATION
Policy Number: LDR.AD.018
Page 1 of 3
Approved by:
Administration 10/00
Generated by: Multidisciplinary Team (HR,
Nursing, Engineering, VP Medical Affairs)
Approved by:
MEC 09/99
Effective date:
01/90
Approved by:
Revised date:
03/04
Approved by:
Review date:
Scope:
Employees, patients, visitors and medical staff members.
Purpose:
Smoking is acknowledged to be both a fire and health hazard. As a health care provider, it is the
organization’s responsibility to join in the promotion of a more healthful lifestyle as well as provide a
safe smoke-free environment for patients, visitors, employees and the medical staff. Therefore,
FSRMC has joined other area health care providers in promoting a smoke-free environment without
exception.
For the purposes of this policy, smoke free environment means in the interior of FSRMC and all the
immediate entrances to the facility. All smoking areas will be located a sufficient distance from the
facility entrance or air intake to prevent the drafting of smoke into the building or the exposure of others
to second hand smoke.
Policy Statement:
Fort Sanders Regional Medical Center (FSRMC) has adopted the Covenant Health Statement on
Smoking by providing these written guidelines for it’s completely smoke free environment.
Procedure:
EMPLOYEES, PATIENTS, AND VISITORS
Employees, patients, visitors and medical staff members will be allowed to smoke only in designated
areas outside the facility. The designated smoking areas are described below. In most instances,
smoking huts have been provided.
Employee designated smoking area is located at the East End of the Laurel Plaza building where
bench seating has been provided. Employees should use this location from 7:00am to 7:00pm every
day.
38
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Leadership/Administration
Subject: SMOKING REGULATION
Policy Number: LDR.AD.018
Page 2 of 3
For safety and security reasons, Employee smoking is permitted from 7:00pm to 7:00am in
the designated patient smoking hut located in the Trustees Tower garage.
Employees found smoking within FSRMC or in non-designated employee smoking areas
will face disciplinary action.
Patients wishing to smoke or found smoking within the facility should be informed of the
smoking policy and then directed to their designated smoking area. The designated
patient smoking area is located in the smoking hut in the Trustees Tower garage. This
location is available 24 hours/day, every day for patient smoking.
Visitors wishing to smoke or found smoking within the facility should be informed of the
smoking policy and then directed to their designated smoking area. The designated visitor
smoking areas are located in the smoking hut in the Trustee Towers garage, as well as the
bench areas provided on Clinch Avenue. These locations are available 24 hours/day,
every day for visitor smoking.
ACUTE CARE PATIENTS
Patients will be informed of the FSRMC smoking policy at the time of admission so they
may make an informed decision regarding their stay.
FSRMC physicians will not write orders for any patients to smoke: no exceptions.
If a patient, after having been informed of the policy, continues to smoke in unsafe area,
administration shall be notified. A member of administration will consult with the physician
to allow the patient to sign out of the hospital “against medical advice”.
FSRMC will provide alternate forms of nicotine (nicotine patch) on order of the patient’s
physician at no expense to the patient. The patient’s physician will document that
alternative forms of nicotine have been suggested and discussed.
DOCUMENTATION
Documentation shall include events related to education and patient tolerance/response to
cessation interventions. Likewise, if a patient refuses to adhere to the smoking policy,
documentation shall reflect all action taken.
LONG TERM CARE PATIENTS
Settings that provide longer-term care (that is, more than 30 days) may allow patients to
smoke without a licensed independent practitioner’s written authorization. In these
39
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Leadership/Administration
Subject: SMOKING REGULATION
Policy Number: LDR.AD.018
Page 3 of 3
instances, smoking occurs in designated locations that are environmentally separate from
all patient care areas and are well ventilated. Settings that provide longer-term care for
the following patient populations are included under this provision. (See unit specific
policy):
Long-term care or intermediate care
Post-acute head trauma (social rehabilitation) patients
SAFETY PRECAUTIONS
Smoking shall be prohibited in any area where flammable liquids, gases, or oxygen are in
use or stored.
Wastebaskets shall be made of non-combustible materials and shall not be used as
ashtrays. Only facility approved ashtrays shall be used.
An air filtration device (or other method of ventilation) shall be utilized in smoking areas to
decrease second hand smoke.
When appropriate, smoking materials will be stored at the nursing station in order to
control supervision of smoking activities.
Smoking hut doors will remain closed at all times.
40
General Information
41
Most Frequently Called Numbers:
FSRMC Main Line
541-1111
Benefits:
Customer Service
Retirement planning
401-K - Fidelity
531-5469
531-5460
1-800-343-0860
Cafeteria
541-1177
Chaplain
541-1235
Employee Assistance Program
531-4500
Employee Health
541-1374
Human Resources
541-1247
Infection Control
541-1259
Patient Representative
541-1611
Safety
541-1213
Security
541-1309
Senior Leadership:
Keith Altshuler
Ruth Crawley
Beverly Graham
David McReynolds
Colleen Andrews
Julie Dougherty
541-1399
541-4997
541-2616
541-4936
541-1247
541-1542
TCSC
541-1678
While on campus, you only have to dial the last 4 digits of the # for all 541-####.
HR cannot transfer personal calls except on an emergency basis.
If you use the main hospital number as your work number, be sure to indicate your
department. The hospital operator may not have this information.
42
Badge FAQ’s
1.
I do not want my last name on my badge. May I have it taken off?
Full names are required for most areas within the hospital. The only exceptions are the ER and Registration
and Women’s Services.
However, if you feel you are being harassed or receiving unwanted attention from a patient because they know
your last name, please talk with your manager. Those situations can be reviewed with your manager and HR
administration on a case by case basis.
2.When I swipe my badge at the time clock it does not display my name. It displays:
“X-PUN”. What do I do?
“X-PUN” simply means that your badge number was not assigned a “home” time clock. You need to inform
your timekeeper to verify that it did register your clocking in and out. If it is, please have your timekeeper
contact payroll to be assigned a home time clock. It may take a few moments longer for your time to show in
Timekeeper, but your timekeeper should be able to view your clocking in and out.
If it is not registering with your timekeeper, please come to HR and request that a new badge made.
3.My badge only beeps when I try to clock in and out? What does this mean?
Please come to HR to see if you need a replacement badge. If the bar code on the back is rubbed off in any
way, it will not work. There is not a charge for replacement badges if the badge is not working.
4.I have a SmartBadge, but it has stopped letting me in the secured areas. What do I
do?
First please contact Security to see if your smart badge number is showing in their system. If it is, then bring it
to HR and we will provide a new one at no charge. If it isn’t working, Security will input the number and it should
work properly.
5.I have lost my badge? Can I get a new one?
Yes, however, there is a $10 charge for a replacement badge. This can be paid for by cash, check or by payroll
deduction.
6.What if my badge is broken?
Please come to HR to request a replacement badge. Please bring the broken badge with you. There is not a
charge for a badge that is broken.
7.I have forgotten to clock in or clock out. What do I do?
Inform your manager and your timekeeper. Most departments require you to sign in your time if you have
failed to clock in or out.
If you have further questions, please contact your Manager or Human Resources.
43
Parking FAQ’s
1.What are my parking options?
Day Shift:
There is a charge for parking. You may either participate in Payroll deduct parking and receive a hang tag
that is valid for the entire calendar year or you may purchase a parking pass from Central Parking on a
Month to Month basis during the first 5 days of the respective month.
Night Shift: [7P-7a]
There is no charge for night shift Parking, but you still need to register with HR and
receive a Night Shift Hang tag.
2.Why is there a charge for parking?
Parking lots are managed by Central Parking. We have arranged for discounted rates for employees.
3.What is the charge for parking in the surface lots?
The rate is $8.50 whether you purchase it directly from Central Parking or participate in the Payroll deduct
parking program. You save money on tax dollars if you participate in the payroll deduction and also have
the convenience of not having to purchase a hang tag every month
4.May I purchase a Payroll Deduct Hang-Tag Anytime?
No, you must either enroll in Payroll deduct parking during your first 30 days of employment or status
change. If you do not do it during this time, you will be required to wait until Annual Enrollment for Parking?
This is because Payroll Deduct parking is a pre-taxed based benefit. This guideline is set forth by the IRS.
5.I would like to cancel my Payroll deduct parking. May I do this anytime?
No. You may only cancel Payroll deduct parking during Annual Enrollment for parking or if your employment
status changes. This would include going from FT to PT or changing from day shift to night shift.
6.I have lost my annual hang tag. May I receive another one?
Yes, however, there is a $10 charge. We must either have a check or cash. We CANNOT do payroll
Deduction This money is given directly to Central Parking.
7.I have multiple vehicles. May I switch the hang-tag between them?
Yes, you are paying for a parking space and it doesn’t matter which vehicle you use as long as you have a
parking hang tag. However, you must get a new hang tag yearly.
8.I want to park in the parking garage. How can I do this?
There is a long waiting list to be able to park in the Garages. You may however, contact, Sheila Payne, in
Facility Services at x4907 to add your name to the list.
9.Where do I park as a student?
Students who are going to be here during the day should purchase a hang tag from the Central
Parking attendant across 19th Street from the emergency room. Students who will be here at night
may park free, however you should put a note in your car stating you are a student at Regional. All
Students are allowed to park in the employee parking lots.
44
Time Clock Instructions
Information Services
Personnel Services Division
Function Keys on Time Clock
Activity
F1
Education
F2
Call Back (On Call Worked)
F3
Charge
F4
Shift Leader (Charge Leader)
F5
Total Hours Worked (Does not include PTO,
Sick, Fam Wellness, or other benefit time)
F6
Float to alternate company for your facility (If
at TCSC, this will float you to TOG)
F7
View Last Punch (Check day/time of last
punch)
F8
Orientation
F12
Clear Activity (way to clear self out of any of
the above activities)
#
Float time to another cost center
(Automatically float the company in which
you are standing – i.e. TCSC, FSR)
To use function keys F1-F5, F7, F8, and F12:
1.Push Function key on the left of the time clock (see above table). The screen will say
“Education or Charge, etc”.
2.Wait until the screen says “Enter Badge” and then swipe your badge.
To float time to another Cost Center (this will automatically float you to the facility in which
you are standing):
1.Push the # key on the bottom right of the time clock. The screen will say “Department”.
2.Type in the cost center number (ex: 6145 for surgery) and tap enter. The screen will say
the name of the cost center (ex: Surgery).
3.Wait until the screen says “Enter Badge” and swipe your badge.
****If you need to float back to your home department during your shift, follow steps 1-3
above.
NOTES:
If you make a mistake in doing any of the above prior to swiping your badge, you can tap
the “Clear” key at the bottom of the clock and back out to the date/time screen.
When you leave for the day, JUST SWIPE YOUR BADGE. Do not tap the function keys
again.
45
Comment boxes
are provided for all employees,
visitors, or patients to provide
feedback on our organization
and the services we provide.
The comment boxes may also
be used to submit “Star of the
Star of the
Month
Month” cards
Lost and Found
All property found in the
hospital including but not
limited to; personal articles,
property or other valuables that
are found on the premises
must be turned over to the
Security Department.
46
BENEFITS
47
48
Available
Available
Available
Available
Available
Available
Vision
Long Term Disability
Short Term Disability
Group Life Insurance
Aetna Long Term Care
Optional Life Insurance
Covenant Health is providing this benefits summary for informational purposes only. For a complete description of benefits, exclusions and limitations, see the appropriate plan document.
Additional benefits include but are not limited to: childcare discounts and referral service; health & fitness center discounts on initiation fees; tuition reimbursement; credit union
membership; flexible spending accounts for medical and dependent care.
401(k)
Available
Dental
Retirement Plan
Available
80 Hours
CTO Sell Back
Vested for Sell Back after 2nd
anniversary
Medical
Vested for payouts after 2nd anniversary
Option to convert vested CTO hours into cash once a year during annual Benefits enrollment.
Minimum conversion – 24 hours. Maximum conversion – 80 hours. Must maintain minimum
balance of 40 hours in account.
PHP-Cariten: POS & 2 HMO plans. Employee/employer paid.
Effective 1st of month coincident with or following 2 months of continuous employment.
Various plans available. 100% employee paid.
Effective 1st of month coincident with or following 2 months of continuous employment.
100% employee paid.
Effective 1st of month coincident with or following 2 months of continuous employment.
60% of Base Monthly Salary up to $5,000 per month. 100% employer paid.
Effective 1st of month coincident with or following 2 months of continuous employment.
Two options (30-day or 45-day) for coverage. 100% employee paid.
Effective 1st of month coincident with or following 2 months of continuous employment.
One x base salary; Maximum coverage $750,000 – 100% employer paid.
Effective 1st of month coincident with or following 2 months of continuous employment.
Individual policies available for employee, spouse and family members. Guarantee issue on
employee if enrolled during first 30 days of eligibility. 100% employee paid.
Employee, spouse and dependent life insurance. 100% employee paid. Overall maximum benefit
on employee is the lesser of 5x annual earnings or $500,000. Maximum benefit for spouse is the
lesser of 100% of employee amount of life insurance or $250,000. Maximum benefit for
dependent is the lesser of 100% of employee amount of life insurance or $10,000. Guarantee
issue $100,000 on employee, $25,000 on spouse and $10,000 on dependent if elected within first
30 days of hire.
Effective 1st of month coincident with or following 2 months of continuous employment.
Dollar for dollar match up to 6% -- match amount may vary by facility
Eligible to participate after 90 days of employment.
Accrual begins with the first day of employment. Available for use after 90 days of
employment.
(23 days) Annual Maximum -- 230 hours (28.75 days) Maximum Accumulation
(28 days) Annual Maximum -- 336 hours (42 days) Maximum Accumulation
(30.5 days) Annual Maximum -- 488 hours (61 days) Maximum Accumulation
(33 days) Annual Maximum -- 594 hours (74.25 days) Maximum Accumulation
(33 days) Annual Maximum -- 660 hours (82.5 days) Maximum Accumulation
184 Hours
224 Hours
244 Hours
264 Hours
264 Hours
7.08 Hrs/PP
8.62 Hrs/PP
9.38 Hrs/PP
10.15 Hrs/PP
10.15 Hrs/PP
CTO (Combined Time Off)
Applies only to employees hired
on or after July 1, 2005 and may
be used for holidays, vacations
and personal or family illness.
Date of Hire
5th Anniversary
10th Anniversary
15th Anniversary
20th Anniversary
EXPLANATION
BENEFIT
FULL-TIME EMPLOYEE BENEFITS SUMMARY (EFFECTIVE 7-1-05)
Available
Available
Available
Available
Vision
Group Life Insurance
Aetna Long Term Care
Optional Life Insurance
401(k)
Available
Dental
Retirement Plan
Available
80 Hours
CTO Sell Back
Vested for sell back after 2nd
anniversary
Medical
Vested for payouts after 2nd anniversary.
Option to convert vested CTO hours into cash once a year during annual Benefits enrollment.
Minimum conversion – 24 hours. Maximum conversion – 80 hours. Must maintain minimum
balance of 40 hours in account.
PHP-Cariten: POS & 2 HMO plans. Employee/employer paid.
Effective 1st of month coincident with or following 2 months of continuous employment.
Various plans available. 100% employee paid. Effective 1st of month coincident with or
following 2 months of continuous employment.
100% employee paid. Effective 1st of month coincident with or following 2 months of
continuous employment.
$10,000 - 100% employer paid.
Effective 1st of month coincident with or following 2 months of continuous employment.
Individual policies available for employee, spouse and family members. Guarantee issue on
employee if enrolled during first 30 days of eligibility. 100% employee paid.
Employee, spouse and dependent life insurance. 100% employee paid. Overall maximum
benefit on employee is the lesser of 5x annual earnings or $500,000. Maximum benefit for
spouse is the lesser of 100% of employee amount of life insurance or $250,000. Maximum
benefit for dependent is the lesser of 100% of employee amount of life insurance or $10,000.
Guarantee issue $100,000 on employee, $25,000 on spouse and $10,000 on dependent if
elected within first 30 days of hire.
Effective 1st of month coincident with or following 2 months of continuous employment.
Dollar for dollar match up to 6% -- match amount may vary by facility
Eligible to participate after 90 days of employment.
Accrual begins with the first day of employment. Available for use after 90 days of
employment.
Maximum accrual is 120 Hours (15 days)
Maximum accrual is 128 Hours (16 days)
Maximum accrual is 136 Hours (17 days)
Maximum accrual is 144 Hours (18 days)
CTO (Combined Time Off)
Applies only to employees hired
on or after July 1, 2005 and may
be used for holidays, vacations
and personal or family illness.
Hire Date = Hrs worked x .04
5th Anniv. = Hrs worked x .05
10th Anniv = Hrs worked x .06
15th Anniv = Hrs worked x .07
EXPLANATION
BENEFIT
PART-TIME EMPLOYEE BENEFITS SUMMARY (EFFECTIVE 7-1-05)
Covenant Health is providing this benefits summary for informational purposes only. For a complete description of benefits, exclusions and limitations, see the appropriate plan document.
Additional benefits include but are not limited to: childcare discounts and referral service; health & fitness center discounts on initiation fees; tuition reimbursement;
credit union membership; flexible spending accounts for medical and dependent care.
49
Additional Benefit Information
CAFETERIA
To receive a discount in the cafeteria during appropriate hours, you must wear
your identification badge.
EMPLOYEE HEALTH SERVICE
We provide an Employee Health service to promote and safeguard the health of
our employees.
Employee Health is responsible for pre-placement health exams and minor
treatment of illness and injury occurring in the workplace.
When the occupational illness or injury is beyond the scope of what the Employee
Health office can treat, the employee will be referred to another physician. In the
case of a work-related injury, the employee would be referred to a physician on
the Workers’ Compensation PPO panel.
The services of Employee Health are available to employees free of charge in the
treatment of work-related illnesses and injuries. You should not consider this
service as a substitute for your private physician.
50
RISK MANAGMENT
51
Fort Sanders Regional Medical Center Orientation
2006
Risk Management
1.
Joint Commission’s National Patient Safety Goals for
2006
2.
Systems Improvement Report (SIR)
3.
State Reporting
4.
Documentation/Miscellaneous
5.
Policy Overview
6.
Worker’s Compensation
7.
Intranet
8.
Behavior Form
9.
Q&A
52
2005 National Patient Safety Goals
Goal: Improve the accuracy of patient identification
***Always use 2 patient identifiers – Name and DOB***
Goal: Improve the effectiveness of communication among
caregivers
1.
2.
3.
4.
TORB/VORB
Dangerous Abbreviations
Timeliness of reporting of critical values
“Hand-off” communication
Goal: Improve the safety of using medications
1.
2.
3.
4.
Concentrated electrolytes
High alert medications
Label Medications
Look-alike/sound-alike medications
Goal: Reduce the risk of health care-associated infections
1. CDC Guidelines for Handwashing
2. Sentinel events r/t infection
Goal: Accurately and completely reconcile medications across the
continuum of care
1. Home medications
2. Transfer form/Medication Reconciliation
3. Communication to next provider
Goal: Reduce the risk of patient harm resulting from falls
1. Falls Risk Assessment
2. Signage/Armband
3. Pt/Family Education
53
Patient Status
Inpatient
ED
Outpatient
Resident
Visitor
Other_______
Facility/ Entity _________________
SYSTEMS IMPROVEMENT REPORT
Confidential and Privileged document- not to be copied or released outside of Risk Management
For Healthcare Quality Improvement Committee Use
GENERAL INFORMATION
NOTIFICATION
Age: ____ Gender: Male Female Admitting Diagnosis __________________
Occurrence Date: __________ Time: _______ Department: ________________
Room: ___________ Location of Occurrence: ____________________________
Unit Reporting Occurrence: ____________________________________________
Reported by: ____________________________ Date: ____________________
Date SIR Completed: __________________________
Physician Yes No
Date_____________ Time______________
Dr. ___________________________________
Shift Supervisor Yes No
Name _________________________________
Family/ Personal Representative Yes No
Name _________________________________
INJURY/EVENT (CHECK ALL THAT APPLY)
None
Abrasion
Anoxia
Aspiration
Bleeding- Minor
Bleeding- Hemorrhage
Blister
Burn- Superficial
Burn- Deep
Cardioresp. ArrestUnexpected
Change in mental
status Circulatory
Impairment
Concussion
Contusion
Damaged/ Lost teeth
Decubitis/ skin
breakdown Dermatitis/rash/h
ives
Deterioration on condition
Dislocation _____________
Extravasation- IV site
Fracture _______________
Hematoma
Infection
line
incisional/surgical
sepsis
other
Laceration
Loss of consciousness
Neurological deficit
Pain
Paralysis
Perforation
Phlebitis
Pneumothorax
PATIENT CONDITION
Poisoning
Puncture
Respiratory distress
Restraint Injury
Sexual assault
Skin tear
Soreness/pain
Sprain/strain
Stillborn/ fetal death
Subdural hematoma
Swelling/edema
Unexpected death
Unknown
Unplanned return to
surgery
Wound disruption
Other_______________
___________________
Vital Signs
BP_____ P_____ R_____ T_____ O2 Sat ______
Alert/Oriented
ConfusedSed
atedAgitatedU
nresponsiveIn
capable of
following
instructionsNo
ncompliantNon
ambulatoryDiz
zyImpaired
GaitUnknown
Other______
___________
Pre-Event
Post –Event
TREATMENT/ INTERVENTIONREQUIRED
DESCRIPTION OF OCCURRENCE
(Be brief, state facts only, name persons involved and witnesses)
None
MD Examined Date:___________ Time: ________
X-ray of _____________Results ________________
Labs _______________________________________
Results _______________________________________
Other diagnostics _____________________________
Results _______________________________________
Surgery ____________________________________
Sutures ____________________________________
Other _______________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________
EVENT CATEGORY
Please mark applicable
category and proceed to
indicated section.
rComplaint by Pt/Visitor
rEquipment/ Device
Related
rFall/ Found on Floor
Obstetrical
rPatient Action Related
Patient Care
Personal Belongings
Select
A-G
(A)
(B)
(C)
(D)
(E)
(F)
(G)
A. COMPLAINT
Abduction
rAbout another patient
rAlleged abuse
rDelay
rFire
rPatient Rights
rPhysician related
rQuality of Care
rStaff related
rThreatened legal action
Other _____________
B. EQUIPMENT/ DEVICE RELATED
Breakage
Contact with equipment
Injured by moving equipment
Disconnected/ dislodged
Malfunction/ failure
Improper use
Not available
rOther__________________
Name/ Type of
Equipment________________
__________Manufacturer____
______________________ID/
Model #__________________
Contact Engineering
immediately and secure
equipment with facility
specific equipment
malfunction tag.
54
CONFIDENTIAL - DO NOT DUPLICATE
DO NOT place in or refer to in medical record
Complete within 24 hours
C. FALLS
rAmbulation related
rAssisted to floor/ controlled descent
rDuring recreational activity
rFainted/ dizzy
rFound on floor
rFrom bed/ stretcher
rFrom commode
rFrom bedside commode
rFrom chair
rFrom wheelchair
rReported/ not witnessed
rShower/ tub
rStairs
rTable/ stretcher related
rTransfer related
rTo/ from bathroom
rWhile changing positions
rWhile standing
rEquipment related
Other ________________
D. OBSTETRICAL
Related Information Prior to Fall
rFalls prevention program implemented
rFalls risk assessment done
rRisk identified
rLeft unattended
rNon-compliant with instructions
rPrevious falls this admit
rReceived sedating/ mind altering drugs w/i 2hrs
preceding fall,
list___________________________
rRestraints ordered
Not applied Applied incorrectly
Pt/ Family removed
Environment
r# bed rails up ______
rBed position, High Low
rShoes/slippers
rSlick/ wet surface
rSnow/ ice
rUneven surface/ obstacle
Wheels not locked
rApgar < 6 at 5 min
rDelivery outside OB
rFetal death
rForceps injury/ complications
r4th degree laceration
rInfant abduction
rMeconium aspiration
rMonitoring issue
rMaternal complication
rNeonatal/ infant injury
rRetained placenta
rReturn to delivery room/ OR
rShoulder dystocia
rTransfer to level III nursery- unexpected
rUnrecognized CPD
rUterine rupture
rPrecipitous/ unattended
Other _________________
F. PATIENT CARE INDICATORS
Anesthesia complication
Body injury during surgery
Cancellation after induction
Chart/documentation variance
Communication
Consent absent
Consent incomplete
Consent inaccurate
Counts incorrect
instrument sponge
needle
other
Diet- wrong diet served
Diet- NPO patient served
Death in OR
Duplicate procedure
Foreign body retained\
Inadequate patient prep
Narcotic discrepancy
Identification
Wrong patient
Wrong site
Wrong tx/procedure performed
E. PATIENT ACTION
AMA
rAlleged assault
rCombative
rElopement (except ED)
rFamily dispute
rIllegal substance
rInappropriate language
rInappropriate behavior
rIntoxication
rNon-compliant
rRefuses treatment
rSelf-extubation
rSelf-inflicted injury
rSmoking in hospital
rSuicide
rSuicide attempt
rThreatening others
rWeapon possession
Other _________________
G. PERSONAL BELONGINGS
Wrong tx/procedure ordered
Infection risks due to
technique
sterilization/packaging
prep
other ___________________
IV site problem
IV infiltration
Monitoring issue
Needle/sharp stick
Omitted treatment/procedure
Positioning related
Results reporting error
Results reporting delay
Return to OR
Specimen related
missing/lost
incorrect preparation
mislabeled
incorrect processing/handling
Transfer/moving of patient
Transfusion
reaction
wrong type transfused
wrong patient received
other ____________________
Treatment delay/cancellation
anesthesia services
chart incomplete
diagnostic info not avail
equipment issue
instrumentation used
latex allergy
staffing issue
physician availability
other __________________
Unexpected injury
Unplanned removal/repair organ/part
Other
_______________________________
_______________________________
rMissing Damage Vandalism
rAuto/vehicle
Clothing
rDentures
rEquipment
rGlasses/contacts
rHearing aid
rHome meds
rJewelry
rMoney/credit cards
rWallet/billfold/purse
rOther ____________________________
Items documented in record
r Yes
No
N/A
Search initiated
r Yes
No
N/A
rReported to security
Reported to law enforcement
DEPARTMENT MANAGER/ SUPERVISOR REVIEW AND FOLLOW-UP**
To be completed by supervisor after reporter has completed both sides of form. May attach additional sheets if needed.
Assessment of Injury
rNo apparent injury
rNursing Intervention/ self correction
rPhysician intervention/ no treatment
rPhysician intervention/ treatment
rPotential for delayed surgery
rDelay in discharge
Death
rUnknown
rTransfer to higher level of care
Other ____________________
Assessment of Process
rP&P followed
rP&P not followed
rCommunication failure
rEducation needed
rPersonnel related
Other
_____________________________
_____________________________
_____________________________
_____________________________
Performance Improvement Action/
Remarks__________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_______________________________________________________
Supervisor Signature/Title/Date (PLEASE SEND SIR TO RISK MANAGER WITHIN 72 RS)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
FOR RISK MANAGEMENT USE ONLY
rA. Circumstances/ events exist that have capacity to cause error. (Concern identified)
rB. Event occurred but did not reach the patient. (Near miss)
rC. Event occurred that reached the patient but did not cause harm.
rD. Event occurred that reached the patient, required monitoring to confirm that it resulted in no
harm and/or required intervention to preclude harm.
rE. Event occurred that may have contributed to or resulted in temporary harm to patient and
required intervention.
rF. Event occurred that may have contributed to or resulted in temporary harm to the patient and
require initial or prolonged hospitalization.
rG. Event occurred that may have contributed to or resulted in permanent patient harm.
rH. Event occurred that required intervention necessary to sustain life.
I. Event occurred that may have contributed to or resulted in patient’s death.
Follow-up/ Referral
None
rAction plan requested from department manager
rCompliance Review
rInvestigation
rQuality/ Clinical Effectiveness
rRCA
rReferral _________________________________________________________
rSMDA Reporting
State reportable
Other ___________________________________________________________
Risk Manager _________________
Date _________________Follow-up
____________________________________________________________________
CONFIDENTIAL - DO NOT DUPLICATE
55
The following are some instances of potential state reportable events. This
list is not all inclusive and does not include exclusions. It is the
responsibility of the Risk Management Team to determine, along with
Administration, whether an event is state reportable or not. Please do not
hesitate to call Risk Management with any questions.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Medication Errors, Categories E-I
Aspiration in a non-intubated patient related to conscious/moderate sedation
Intravascular catheter related events including necrosis or infection requiring
repair, or intravascular catheter related pneumothorax
Volume overload leading to pulmonary edema
Blood Transfusion reactions such as wrong blood type and/or delivery of
blood to the wrong patient
Perioperatrive/procedural related complications that occur within 48 hours of
the operation or procedure such as central or peripheral neurological deficits
or motor weakness.
Burns of a 2nd or 3rd degree
Falls resulting in radiographically proven fractures or subdural/epidural
hematoma, subarachnoid hemorrhage, etc… or any fall that requires
sutures/staples for repair
Procedure related incidents, including readmissions and within 30 days of
the original procedure:
A: procedure related injury requiring repair or removal of an
organ
B: Hemorrhage
C: Displacement, migration or breakage of an implant, device, graft or drain
D: Post-op wound infection following clean or clean/contaminated case
E: Any unexpected return to OR related to the primary procedure
F: Hysterectomy in a pregnant woman
G: Ruptured Uterus
H: Circumcision requiring repair
I: Incorrect procedure or incorrect treatment that is invasive
J: Wrong patient/wrong site surgical procedure
K: Retained foreign body
L: Loss of limb or impairment of limb at discharge or at least 2 weeks after
occurrence
M: Criminal acts
N: Suicide or attempted suicide
O: Elopement from the facility
P: Infant abduction or infant discharged to the wrong family
Q: Adult abduction
R: Rape
S: Patient altercation
T: Patient abuse or misappropriation of funds
U: Restrain related incidents
56
V: Poisoning occurring within the facility
Risk Management
New Hire Orientation
2005
1) Systems Improvement Report (SIR)
Formerly known as incident reports
Purpose: to be able to analyze an occurrence to prevent reoccurrence
A.
B.
C.
D.
E.
F.
G.
H.
Do chart the event
Do give all the facts on the SIR, include all witnesses and their
involvement
Do give the patient’s status at the time of the report
Do use the SIR for all falls, including visitor and patient
Do not chart that the SIR was completed
Do not copy the SIR or place the SIR in the medical record
Do not give ANYONE a copy of the SIR
Do not use the SIR for employee injuries, there is a separate form for
employee injuries
2) Charting
A.
B.
C.
D.
E.
Remember, if it isn’t charted, it wasn’t done
Always chart specifics such as who, what, when, where
Document date and time on ALL orders and entries
Correcting errors: Line through and initial
WRITE LEGIBLY
3) Things to Know
A.
B.
C.
Know where manuals are kept
Be familiar with policies/procedures/guidelines and where manuals are
kept and how to access the intranet
Know the chain of command
57
NAME OF BUSINESS UNIT
Fort Sanders Regional Medical Center
Subject: Visitor Accident / Injury
Policy Number: EC.SF.019
Name of Category / Sub-category
Environment of Care / Safety
Page 1 of 1
Approved by:
Administration 04/73 01/81 10/04
Generated by:
Risk Management
Approved by:
Effective date:
04/73
Approved by:
Revised date:
01/81 10/04
Approved by:
Review date:
02/01 02/04
Scope: All employees
Purpose:
Provide guidelines for response to an emergency involving a visitor to the hospital
Policy Statement:
When a visitor is injured as a result of an accident on the premises of Fort Sanders
Regional Medical Center, emergency first aid will be provided either at the site of the
accident, or in the Emergency Department. If the visitor requests medical treatment,
the admission process through the emergency department will be handled per the
normal triage protocol and procedure.
Procedure:
1. Give immediate assistance. If the visitor desires medical treatment, direct him/her
to the Emergency Department, providing appropriate transportation as necessary.
In an emergency situation, the Emergency Department must be called for
assistance.
2. The injured visitor will be registered in the Emergency Department and given
medical care promptly as per normal routine. The Emergency Department
Registration Desk or Team Leader will notify the Risk Manager during regular
working hours (or the nursing supervisor if after regular working hours) that the
visitor is being treated in the Emergency Department.
3. The Risk Manager (Nursing Supervisor after hours) will proceed to investigate the
accident immediately.
4. Complete (or have a witness to the accident complete) a Systems Improvement
Report including the cause of the accident, names of all witnesses, weather
conditions if pertinent, and other relevant information.
58
5. The completed report will be forwarded to Risk Management.
EMPLOYEE INCIDENT REPORT
Please circle your location:
Covenant Health (Parent Corp)
Covenant Staffing Services
Fort Sanders Perinatal Center
Fortress Corp.
Parkwest Medical
Resources Mgmt Group
Thompson Oncology Group
To Be Completed by Employee:
Covenant Homecare
Fort Loudoun Medical
Fort Sanders Regional
Methodist Medical Cntr.
Peninsula Behavioral Health
Thompson Cancer Survival Center
Thompson Oncology Group -West
Covenant Medical Mgmt
Fort Sanders Foundation
Fort Sanders Sevier
MMC Foundation
PHP Companies, Inc.
Date of Injury: ____________________________________________________________________ime of Injury:___________________________A.M. P.M.
Employee Name: ___________________________________________________________________________________ Male ________ Female________
Home Address: ________________________________________City: ___________________________________State: __________ Zip: _____________
Home Phone #: ______________________________________________Marital Status: ____Married ___ Single ____ Divorced ____ Widowed _________
Soc. Sec.#________________________________________ Date of Birth: ______________________________ Date of Hire:________________________
Department: _____________________________________ Cost Center #: ________________________ Department Telephone #:____________________
Job Title: ____________________________________________________ Supervisors’ Name: ________________________________________________
Shift: ________ Work schedule: _____________________ Time Employee Began Work on Date Of Injury: __________________-____________________
Date Reported: ____________________Date Employer Notified of Injury: ______________________ Last Day Worked: _____________________________
Injured Body Part Description: _____________________________________________________________________________________________________
Location of Incident: _____________________________________________________________________________________________________________
How Injury Occurred: ____________________________________________________________________________________________________________
Was there a hazard noted? (If so, describe): _________________________________________________________________________________________
Name(s) of witnesses: ___________________________________________________________________________________________________________
Needle Stick-Sharps, Bloody Body Fluids & Exposures (Only)
Needle Stick Device:
Safety Device:
Yes
Manufacturer:
No
List Safety Devices used:
Supervisor/Analysis and Counseling Report Evaluation
(Completed by Dept. Manager or House Supervisor)
Describe any break in technique or procedure:
Suggestions for preventing any future accidents:
Actions taken to implement suggestions (including employee counseling):
Was employee in violation of any established Policy & Procedures:
The employee has read and understands that it is a crime to knowingly provide false, incomplete or misleading information to
any party regarding a workers’ compensation transaction for the purpose of committing fraud. Penalties include imprisonment,
fines and denial of insurance benefits.
________________________________________________
____________________________________
Employee Signature
Date
_______________________________________________
____________________________________
CH80850039 (12/04)
Supervisor Signature
Date
59
Please send employee and completed report to Employee Health.
REFERENCE SHEET FOR COMPLETING
GREEN INCIDENT REPORT
EMPLOYEES
§ When a work-related injury occurs you must immediately complete a green incident
report.
§ Sign and date the green incident report at the bottom.
§ Immediately notify your supervisor/manager of the incident and ensure that they
have reviewed the incident report.
§ Once you have met with your manager, you are to report to Employee Health
immediately. If Employee Health is closed you must contact the House Supervisor for
triage. YOU MUST BRING YOUR COMPLETED GREEN INCIDENT REPORT WITH YOU.
SUPERVISORS
§Review the completed green incident report.
§Ensure that all the spaces are completed---please provide cost center # if the
employee has not done so.
§Complete the Supervisor Analysis/Counseling section of the form. DO NOT JUST
LEAVE THIS AREA BLANK.
§Sign and date the green incident report at the bottom.
§Ensure that the employee reports to Employee Health when Employee Health is open
(Monday-Friday from 7-4) or contacts the House Supervisor for triage when Employee
Health is closed.
§After the evaluation, expect the employee to bring a copy of his/her Return to Work
note, which will indicate the employee’s status.
DO NOT SEND INCIDENT REPORTS TO EMPLOYEE
HEALTH VIA INNEROFFICE MAIL. THE EMPLOYEE
MUST BE SEEN BY EMPLOYEE HEALTH OR TRIAGED
BY THE HOUSE SUPERVISOR.
60
RM 15
BEHAVIOR REPORT (BR)
The purpose of the BR form is to document specific and significantly inappropriate behavior by staff
or by physician and is not a replacement for collegial discussion or appropriate dialogue between staff
and immediate supervisor. The basis of this document is to support the values of Covenant Health.
Values of Covenant Health:
Integrity  Quality  Serving the Customer  Caring for and Developing Our People  Using the Community’s Resources Wisely
Acceptable Behaviors of Regional and Parkwest (partial list):
 Tell the truth
 Acknowledge mistakes and convey apologies
 Consider impact of your decisions on others
 Discuss matters with appropriate person (no triangulation)
 Create an environment in which employees and physicians feel safe in reporting inappropriate actions
 Treat people like you want to be treated
 Provide praise when deserved and discipline when warranted
 Build a trusting environment by listening with an open mind; valuing different opinions; asking questions for understanding;
and allowing others to speak freely
 Treat all people with respect
PLEASE COMPLETE THE FOLLOWING:
Event Location
Event Date
Name of submitter
Event Time
Patient Name (Last, First, MI) only if patient involved
Room No.
Medical Record No.
Account No.
SUBMITTER’S DESCRIPTION OF INAPPROPRIATE BEHAVIOR EVENT (objective, factual account to include precipitating
circumstances and any action taken to remedy situation)
ANALYSIS/RESOLUTION
Submit to Senior Nurse Executive if re: staff

Submit to Medical Staff Office if re: physician
This form does not replace Incident Report for patient injury
jls/forms\br898.doc
61
WHAT TO DO IF AN EMPLOYEE SUSTAINS
A WORK-RELATED INJURY
•
•
•
•
•
•
Instruct employee to notify manager or shift leader
ASAP.
Employee completes all sections of the top portion of
Green Incident report.
Manager or shift leader will complete the supervisor
section.
Ensure incident report is completed in its entirety and is
signed and dated-- do not leave any spaces blank
Immediately contact Employee Health at 541-1374.
When Employee Health is closed (open M-F 7-4),
contact House Supervisor for triage.
If the House Supervisor sends an employee to the ED
for an evaluation, he/she MUST follow-up with
Employee Health the next business day.
IMPORTANT POINTS TO REMEMBER
•Employees may not call themselves off of work.
•If seen by Employee Health, they will have a return to work note to give
to their manager.
•Whenever an employee is given restrictions, he/she will have follow-up
appointment(s) in Employee Health until released to full duty and/or
seen by a specialist.
•Once an employee has seen a specialist, he/she needs to contact
WORxS to discuss any problems (670-3000).
•If an employee completes a green incident report, he/she must contact
Employee Health for an evaluation. It is imperative we evaluate all
strains/sprains and anyone who was initially evaluated in the ED.
•Sedgwick (our WC company) is the only one who determines
62
compensability.
63
64
SAFETY
65
INFORMATION ABOUT
SAFETY AT WORK
PHONE NUMBERS
Fort Sanders Regional Medical Center 541-1213 pager #: 417-3401
The Safety Department is here for you! We want you to work safely and
feel safe at work. This is one of many safety training sessions you will be
a part of during your employment with Fort Sanders Health System. This
session will touch on a few areas of safety that are important for the new
employee.
CODE RED: The Hospitals Fire Policy.
When an employee discovers a fire, they should remember R-A-C-E!
R
Rescue people from immediate danger
...WHILE....
A
Alert the staff by calling “CODE RED” loudly. Any
employee who hears someone shout “CODE RED”
should pull the closest pull station and report to the
fire scene.
C
Contain the fire by closing all doors and windows.
E
Extinguish the fire when possible.
Remember, even if it is a drill, the fire alarm is ALWAYS pulled.
…to remember how to use a fire extinguisher think of P-A-S-S…
P
A
S
S
Pull the pin.
Aim at the base of the fire and to the left or right.
Squeeze the handle.
Sweep from side-to-side.
Every employee is involved when a fire alarm sounds. When hearing fire
alarm follow RACE:
• Check all rooms to determine the fire location and close the door as
you exit.
• Begin fire emergency procedures when a fire is discovered.
• Determine all clear status if no fire exists
66
Dial “66” at Regional if…
•the alarm system has been activated and a fire exists. Tell the operator the exact
location of the fire.
•when fire responders determine the reason for the alarm and/or that no fire exists.
•the fire alarm system is out of order.
HAZARDS!!!!!
Categories of hazards within a hospital setting include:
1.Electrical
2. Chemical
3.Infectious
4. Radiation
5.Unsafe behavior by humans
6. Chemotherapy drug exposure
Any information needed about a hazardous material in the work place can
be gotten from the Material Safety Data Sheet (MSDS) which can be
found in the orange MSDS manual in your department. The MSDS
contains information about health risks, disposal information and
decontamination procedures. Pull your department’s MSDS manual and
familiarize yourself with the MSDS for your area.
Employees can protect themselves from body fluid and chemical exposure
by wearing the proper personal protective equipment and working in a wellventilated area. Examples of protective equipment include: gloves, eye
shields, hearing protection, splash shields, gowns, tyvek suits, protective
clothing.
CONSTRUCTION!!!
Interim Life Safety measures are used in construction areas to protect
employees, patients, and visitors from smoke and fire. Safety officials
regularly conduct fire drills, daily inspections of the construction areas, and
isolate the area by barriers. Heed warnings to stay out of construction
area. These warnings are for your protection!!
DEFECTIVE EQUIPMENT!!!
Defective equipment that is hazardous to the user or patient must be
tagged and labeled “OUT OF SERVICE.” Speak with your Manager or
Supervisor for instruction.
DISASTER/EMERGENCY SITUATIONS!!!
During a disaster situation (code purple, black, yellow, pink, gray, and
white), reference the policies in the RED Safety Manual and refer all questions or
information to the Control Center: Telephone extensions: #2000 or #2001.
67
EMERGENCY CODES AND BASIC STAFF RESPONSE
CODE
Description
Code Black
Bomb Threat
Notification of a bomb on
campus, usually by an
outside caller or
suspicious package or
letter
A person requiring
immediate medical
attention
Secondary
Response
Follow-Up
Notify PBX Operator via Code
Telephone “66” of a “Code Black”
situation. Obtain as much info as
possible.
Search all areas for a
suspicious object.
DO NOT TOUCH
ANYTHING
Report all information
to the Control Center
2000 and 2001.
Notify PBX via Code Telephone “66”.
Designated team responds to area
following PBX announcement.
If needed, team
requests additional
assistance.
Review done by Code
Blue Team and others.
Notification of Severe
Weather in our area
Lower beds, close drapes, remove articles
from window ledge, cover patients with
extra blankets, close doors and windows
Assess damage.
Assure that patients
and staff are safe and
unharmed
Code Green
Patient or Staff
in Danger
An patient or employee is
in danger
Code Pink
Infant Abduction
Abduction of an infant.
(For Pediatric Abduction
other than Code Pink
notify Security.)
Only after verbal
intervention fails
does team apply
physical intervention
techniques
Refer to departmental
procedures.
Code Purple
Hostage
Situation
Code Red
Fire
An individual is being
held against their will by
an armed perpetrator
Notify PBX via Code Telephone “66”.
Designated team responds to area
following PBX announcement.
Deescalate violent behavior using verbal
intervention
Assess whether infant has been removed
from premises. Notify immediate
supervisor. Notify PBX via Code
Telephone “66”. When Code Pink is
announced, search for the abductor.
Clear the area and establish perimeter to
prevent unauthorized entry.
Communicate all
building damage to
Plant Engineering
and/or the Control
Center.
Evaluate the response,
Complete Incident
Report and route to
Risk Management.
Fire and/or smoke present
R.A.C.E.
Rescue those in immediate danger
Activate the alarm: Pull manual
alarm/Call “Code Red” aloud.
Contain the fire (close doors)
Extinguish the fire (if safe to do so)
To Extinguish fire follow P-A-S-S
Code White
NBC/Hazmat
Potential terrorism event
in the community or mass
casualty hazardous
materials incident possibly
involving contaminated
patients.
Notification of a disaster
either in the community or
internal to the facility.
Administrative Supervisor to verify
information. Activate “Code White”
plan. Erect decontamination tents; decon
team to meet at ambulance bay. Security
to secure perimeter and lock down
facility. Close 19th Street.
Have PBX announce “Code Yellow”
overhead. Report to department for
further instruction. Activate Control
Center.
Remove persons from the hazard. Review
appropriate spill plan in Safety Manual.
Call Environmental. Serv. for mercury
spill. All other spills are cleaned up by
trained users of the material.
When called by security, all personnel in
area need to move out of the immediate
area. Preferably stand behind security
officer.
Code Blue
Medical
Emergency
Code Gray
Severe Weather
Code Yellow
Disaster
Hazardous
Materials Spill
(Internal)
Code Clear
(Security Code
Only)
Chemical, radiation, or
infectious material spill
presenting hazard to
people and the
environment.
Security is about to spray
“Pepper Spray”
Initial Response
Administration and
Marketing/Public
Relations to establish
follow-up plan.
Report all pertinent
information to
Security and Police
in charge of response.
Protect people from
smoke & fire. Secure
the area to prevent
fire responders,
visitors, and
physicians from
walking into a
hazardous situation.
Do emergency call in
when directed to do
so by Control Center.
Assess bed
availability.
Provide CISD for all
affected staff.
Call in additional
staff as needed
Communicate with the
Control Center for
needs, resources and
information.
Person cleaning up the
spill will complete a
“Chemical Spill
Report” and send to
Safety Deptartment
Evaluate the response,
Complete Incident
Report and route to
Risk Management.
Notify the Safety
Officer;
Seek/Coordinate
medical treatment of
any exposed persons..
Account for all persons
in the area.
Safety Officer to
complete report of the
incident and send to
appropriate agencies.
68
EMERGENCY RESPONSE QUICK REFERENCE CHART
SYTEMS FAILURE AND BASIC STAFF RESPONSE
Failure of:
What to Expect
Who to Contact:
Responsibility of User:
Computer Systems
System Down
Help Desk at 374-4900
Use backup manual / paper systems
Electrical Power Failure,
Emergency Generators
Work
Failure of Electrical
Systems. Many lights
are out. Only RED plug
outlets work.
Plant Engineering 1244
Ensure that life support systems are on
emergency power (red outlets) Ventilate
patients by hand as necessary. Complete
cases in progress ASAP. Use flashlights
Total Electrical Power
Failure No emergency
power
Failure of all emergency
systems, loss of
computers, coolers,
HVAC & Fire Alarm
Systems.
All vertical movements
will have to be by
stairwells
Notify PBX via the Code
Telephone “66”, Plant
Engineering at 1244, and
Administrative Supervisor.
Activate Code Yellow
Plant Engineering at 1244
and Security at 1309
Elevator stopped between
floors
Elevator alarm
sounding
Notify Plant Engineering at
1244 and Security at 1309
Fire Alarm System
No fire alarms and/or
sprinklers.
Plant Engineering at 1244
Medical Gases
Gas alarms, no oxygen,
medical air, or nitrous
oxide.
Plant Engineering at 1244,
Respiratory Therapy at
1137
Medical Vacuum
No Vacuum, vacuum
systems fail and in
alarm
Plant Engineering at 1244
Natural Gas, Failure or
leak
Odor no flames on
burners, etc.
Plant Engineering at 1244
and Safety Department at
1213
Utilize flashlights, hand ventilate patients,
manually regulate IV’s don’t start new cases.
Assess critical equipment issues, request
additional staff as needed from Control
Center at 2000/2001.
Review fire and evacuation plans. If
necessary, assess patient needs, if outage
will be lengthy, activate Code Yellow and
move all non-ambulatory patients to lower
floors.
Keep verbal contact with personnel still in
elevator and let them know help is on the
way.
Institute Fire Watch, minimize fire hazards,
use code telephone, 2-way radios, and
runners to report a fire.
Hand ventilate patients, transfer patients, if
necessary, use portable tanks for oxygen and
other gases, call Respiratory for additional
portable cylinders
Call Central Supply for portable vacuum,
obtain portable vacuum from crash cart,
complete cases in progress, don’t start new
cases
Open Windows to ventilate, turn off gas
equipment, don’t use any spark producing
devices, electrical switches, etc.
Nurse Call System
No patient contact
Bio-Med at 4906
Patient Care,
Equipment/Systems
including Diagnostic
Imaging
Equipment / system
does not function
properly
Bio-Med at 4906
Sewer Stoppage
Drains backing up
Plant Engineering at 1244
Do not flush toilets, do not use water. See
Water outage for further information.
Steam Failure
No building heat, hot
water steam sterilizers
inoperative, limited
cooking
No phone service
Plant Engineering at 1244
Water
Sinks and toilets
inoperative
Water Non-Potable
Tap Water unsafe to
drink
Ventilation
(Heating/Cooling)
No ventilation; no
heating or cooking
Plant Engineering at 1244,
Administrative Supervisor,
Safety Department at 1213,
and Infection Control at
1259
Plant Engineering at 1244,
Administrative Supervisor,
Safety Department at 1213,
and Infection Control at
1259
Plant Engineering at 1244
Conserve sterile materials and all linens,
provide extra blankets, and prepare cold
meals. Use chemical sterilization were
possible.
Use red emergency telephones if operable;
overhead paging, cell phones as appropriate,
use runners as needed
Institute Fire Watch, conserve water, use
bottled water for drinking. Be sure to turn off
water in sinks, use RED bags in toilets. Use
alternative hand washing methods such as
alcohol, foam and wipes
Place “Non Potable Water-Do Not Drink”
signs at all drinking fountains and wash
basins. See Water outage for further
information.
Elevators Out of Service
Telephones
Help Desk at 374-4900
Use bedside patient telephone if available,
move patients if necessary; use bells, assign
a runner to check patients periodically.
Tag defective equipment with out of service
tag. Fill tag out completely.
Use fans for cooling, or obtain blankets if
needed, restrict/discontinue use of
odorous/hazardous materials.
69
INFECTION CONTROL
70
INFECTION CONTROL
FSRMC has an Infection Control / Exposure Control Plan to prevent the
transmission of blood borne pathogens such as: HIV, HBV, HCV, and other
potentially infectious agents by:
–Reducing reasonably anticipated exposure to blood and other
potentially infectious materials
–Establishing engineering and work practice controls
–Providing appropriate employee training and follow-up, and monitoring
of work practices
HANDWASHING IS THE SINGLE-MOST EFFECTIVE WAY TO
PREVENT THE SPREAD OF DISEASE / INFECTION.
IT IS OUR DUTY TO PROTECT THE PATIENTS!!!
The following pages will provide detailed information on disease-specific
pathogens.
–Hepatitis B & C
–HIV
–C Diff
–VRE
–MRSA
–TB
–Exposure Policy
–Protective Equipment
–Standard Precautions
71
ISOLATION IMPLEMENTATION
Type of Isolation
MAXIMUM
CONTACT
AFB (Acid-fast
bacilli)
AIRBORNE /
CONTACT
Infections Isolated
What to do for each type of isolation
MRSA, VRE, C. diff, major draining
wounds, multi-drug resistant gram
negative bacteria
PPE cart/cabinet stocked
Hand wash with soap/water or hand sanitizer
Glove before entry into room
Gown if potential contact with contaminated surfaces
Alert other departments of patient’s isolation status
Dedicated equipment (BP cuff, stethoscope, thermometer, etc)
Pulmonary Tuberculosis (TB)
*(Severe Acute Respiratory
Syndrome (SARS) –requires
negative air room)
*(Smallpox –requires negative air
room)
*Contact Inf Control/Health Dept
Place patient in negative air pressure room
Employee fitted for the particulate respirator
Wear respirator to enter room
Keep door closed at all times (even when the patient is
temporarily out of the room)
Negative Air Pressure turned on
Patient wears a yellow mask (if possible) to leave room
Visitors instructed to wear the particulate respirator
One hour after patient discharge for unprotected entry into
room
Chicken Pox, disseminated
Shingles, Measles
Keep door closed at all times
Only immune-competent staff should be assigned to care for
the patient
Negative air pressure room recommended if extensive draining
lesions and in mouth or nares
Can be airborne transmitted if lesions are in nares and mouth or
from handling contaminated linen
Contact transmission from hands/items contaminated with
drainage from lesions
DROPLET
Flu, Pertussis (whooping cough),
Neisseria meningitidis,
Mycoplasma pneumonia,
Parvovirus B19, Haemophilus
Influenza meningitidis, Rubella,
Adenovirus, pharyngeal Diphtheria,
mumps, Group A strep
PROTECTIVE
Patients with WBC less than 1,000
Cancer patient receiving chemo
Organ transplant patient receiving
immunosuppressive steroids
Other immune conditions that
physicians feel need protective
isolation
All persons must wash their hands before entering the room.
No fresh fruits or plants in the room (no decorative leafy
garnish on the food tray)
Employees with respiratory infections, fevers, draining wounds,
herpetic lesions, or other potentially communicable conditions
may not enter the patient’s room.
All equipment that will come into contact with the patient must
be disinfected with alcohol prior to and after use.
Remove all soiled linen ASAP; do not keep hamper in the room
Do not remove ice pitcher from the room. Carry the ice to the
room in a closed paper or plastic bag.
Restrict visitors to immediate family; Restrict persons with
known infection.
Patient wears yellow mask upon leaving the room.
1)Stock isolation cart/cabinet
2)Place isolation sign on door
3)Place isolation sticker on chart
4)Make sure alcohol hand sanitizer
dispenser has solution
1)Enter isolation status in computer
2)Be sure to alert other departments of patient’s status
3)Appropriate hand hygiene
4)Explain isolation to family/patient
Additional information, fact sheets, etc available from infection
control @ 541-1259
Implementation
Checklist
Wear yellow mask to enter room
Eye protection as required
Patient wears yellow mask, if possible, to leave room
72
WHAT YOU SHOULD KNOW ABOUT HEPATITIS B
WHAT IS HEPATITIS B?
•Virus that causes inflammation of the liver—one of your body’s most vital organs
•Found in blood
HOW IS IT SPREAD? Mainly through blood
•Infected needles and sharps
•Shared personal care items
•Unprotected sex
•Membranous exposure (eyes, nose, mouth)
•Bites and wounds
•Perinatal transmission
HEPATITIS B CAN RESULT IN:
•No symptoms
•Mild illness
•Acute (severe) illness
•Chronic infection
•Liver damage, such as cirrhosis
•Liver Cancer
•Death due to liver failure
WHAT ARE THE SYMPTOMS? May appear 1-9 months later
•Asymptomatic
•Flu-like (vomiting, nausea, diarrhea, sore muscles and joints, mild fever,
headaches)
•Fatigue
•Stomach pain
•Loss of appetite/weight
•Jaundice
•Dark urine
HOW DO WE TEST FOR HEPATITIS B?
•Physical exam to check if liver is swollen
•Blood test for liver profile
•Blood test for virus and antibodies
HOW DO WE TREAT HEPATITIS B?
•No treatment
PREVENTION Vaccine is very effective
•Health care workers: Use standard precaution, get vaccinated, exposure management
•HBV + individuals: Protected sex, don’t donate blood or organs, don’t share personal care
items
•Hepatitis B vaccine is offered to the eligible employee at the time of employment
73
WHAT YOU SHOULD KNOW ABOUT HEPATITIS C
WHAT IS IT?
•A virus that can cause serious liver disease
•Found in blood
HOW IS IT SPREAD? Mainly through infected blood
•Infected needles (IV drug, body piercing, and tattoo needles)
•Shared personal care items (razors and toothbrushes)
•Unprotected sex (less common cause)
•Blood transfusion before 1992
HOW DOES IT AFFECT YOUR HEALTH? Damages your liver
•Approximately 85% develop chronic disease found 20-30 years after initial infection
•Cirrhosis (30-40%)
•Cancer (2-4%)
•Liver failure
•Problems with your immune system
WHAT ARE THE SYMPTOMS? Usually acute infection is without symptoms
•Flu-like (fatigue, nausea, vomiting, diarrhea, sore muscles and joints, mild fever,
headaches)
•Loss of appetite
•Weight loss
•Right upper abdomen tenderness
•Jaundice
•Abdominal swelling
•Itching
•Dark urine
HOW DO WE TEST FOR HEPATITITS C?
•Physical exam to check if your liver is swollen
•Blood test for liver profile
•Blood test for virus and antibodies
HOW DO WE TREAT HEPATITIS C?
•Avoid alcohol and non-prescriptive medications like acetaminophen
•Eat a well-balanced diet
•Get adequate rest
•Exercise
•Take medication as prescribed by your doctor
PREVENTION STEPS No vaccine or medication can prevent the spread of Hepatitis C
Health care workers:
Use standard precaution practices if there is risk of exposure
Follow hospital policy for exposure management
If you are Hepatitis C positive:
Use condoms during sex
74
Don’t donate blood products, body tissue, organs
Don’t share needles, razors, toothbrushes, manicure tools, or other personal items
WHAT YOU SHOULD KNOW ABOUT HIV
WHAT IS IT?
Virus that enters bloodstream, invades immune system, overwhelms immune system
Causes AIDS (acquired immunodeficiency syndrome)
HOW IS IT SPREAD?
Infected needles and sharps
Shared personal care items
Unprotected sex
Membranous exposure (eyes, nose, mouth)
Broken skin exposure
Perinatal transmission
HOW DOES IT AFFECT YOUR HEALTH? Stages of the disease
May not show symptoms for years
Swollen glands, lesser diseases
Inability to fight off life-threatening diseases
WHAT ARE THE SYMPTOMS?
Weakness
Fever
Sore throat
Nausea
Diarrhea
White coating on tongue
Weight loss
Swollen lymph glands
HOW DO WE TEST FOR HIV?
Antibody test
Western Blot
HOW DO WE TREAT HIV? No vaccine or cure
Anti-retroviral
Protease inhibitor
PREVENTION
Health care workers: Use standard precautions, exposure management
HIV + individuals: Protected sex, don’t donate blood or organs, don’t share
personal care items
75
Clostridium difficile (C. difficile) Fact Sheet
What is C. difficile?
Anaerobic gram-positive spore-forming bacteria producing toxins that cause disease.
What causes C. difficile?
Diarrhea may occur as a result of antibiotic use but is most severe if caused by C. difficile. Types of diarrheaassociated C. difficile are a) Nonspecific diarrhea which is self-limited, and relatively mild b) CDAD is an
infectious diarrhea which is almost always acquired by patients who have taken antibiotics recently
(usually within 2 months). The mechanism by which antibiotics induce C. difficile disease is not well
understood and c) Pseudomembranous colitis (PMC) is a more severe form of CDAD characterized by
the presence of pseudomembranes that are yellow, white, or gray neutrophilic mucosal plaques in the
colon.
How is C. difficile transmitted?
The organism is most often transmitted via the hands of health care personnel who have had contact with
contaminated feces or contaminated environmental surfaces. Infection results from ingestion of C.
difficile spores, which survive the acid environment of the stomach, convert to the vegetative forms in the
colon, and produce toxins that result in the clinical symptoms. Commodes, baby baths, and electronic
thermometer handles are among the environmental sites implicated in the transmission of C. difficile.
What prevention and control measures can be taken?
•
•
•
•
•
•
•
•
Contact Isolation precautions. Isolation cart outside patient’s room.
Alcohol hand sanitizers will kill vegetative forms but not C. difficile spores; therefore washing with soap
and water is important to physically remove the kill-resistant spores.
Wear gloves before entering the room. Gowns should be worn to prevent contamination to your clothes.
Dedicate equipment for that patient’s use only.
Adequate disinfection of medical devices is important (especially items likely to be contaminated with
feces such as thermometers). Non-critical care items such as blood pressure cuffs and stethoscopes
should be bagged in clear plastic and sent to Sterile Processing for gas sterilization. Reusable critical
care equipment should be disinfected and steam or gas sterilized based on the manufacturer’s
recommendation. Wheelchairs, intravenous poles, and stretchers that are contaminated by infected
patient should be cleaned by vigorously wiping surfaces with an approved disinfectant/cleaner. Reusable
bedpans should be cleaned daily with disinfectant and terminally in the cart washer.
The environment of the room may be highly contaminated with C. difficile spores depending on the
severity of the diarrhea. Thoroughly clean and disinfect the isolation room. A sporicidal agent is
preferred. Areas for attention include toilets, reusable bedpans, furniture, floors (in the bathrooms,
patients’ rooms, and soiled utility room), sinks, bedrails, and telephones. Mops and water are changed
for each isolation room. Special cleaning attention should be given to areas around the toilet. Walls
should be spot cleaned for all visible soiled areas.
Used linen should be bagged in the patient’s room.
Minimizing or preventing anitmicrobial use in patients such as restricting Clindamycin use and controlled
use of extended-spectrum cephalosporins.
How is C. difficile disease treated?
The first line of treatment is to discontinue the causative antimicrobials or select agents such as metronidazole,
vancomycin, aminoglycosides, or possibly fluroquinolones, which are less likely to cause CDAD.
76
Vancomycin-Resistant Enterococcus (VRE)
What is Enterococcus?
Enterococcus is gram-positive bacteria normally found in the gastrointestinal tract and female genital tract. It
can cause infection of the following: urinary tract, abscesses and wounds, decubitus ulcers, diabetic foot
ulcers, bloodstream infections, and endocarditis. Vancomycin is a drug that is frequently used to treat many
types of infections. If Enterococcus is resistant to vancomycin it is referred to as VRE (vancomycin-resistant
Enterococcus). Frequently, VRE is also resistant to many of the other drugs used to treat Enterococcal
infection. Therefore, infections caused by VRE can be life threatening.
How Does VRE Infection Occur?
Infection often results from the patient’s endogenous carriage (residing on or in the patient’s body). The
bacteria leave the area of colonization such as the GI tract or GU tract, enters a site, multiplies and causes an
infection (i.e., wounds or migration along a catheter).
VRE can also be transmitted from the contaminated hands of HCW’s (with or without gloves) or contaminated
items or contaminated environment to a patient.
How Do You Prevent Transmission of VRE?
Infections caused by VRE require enhanced precautions beyond Standard Precautions in order to prevent
transmission to a distant site on the colonized patient or transmission to another patient. Practicing good
patient care and maintaining required aseptic and sterile technique is important. Reasons for enhanced
precautions include the potentially serious outcomes of infection, the ease by which VRE contaminates the
environment and its ability to live for days on the environment, objects, and fabrics. Therefore these patients
are placed in Contact Isolation.
How Do You Implement Contact Isolation?
After you are alerted to the patient’s VRE status you will do the following:
•Obtain and place a contact isolation cart outside the patient’s door. The cart will be stocked with gloves,
gowns, disinfectant, and thermometer.
•Dedicate devices such as blood pressure cuffs and stethoscopes to prevent transmitting Enterococcus to
yourself and others. If reasons necessitate the use of such devices on another patient, you must clean and
disinfect the device with an appropriate cleaner/disinfectant such wiping with 70% isopropyl alcohol or other
FDA registered product.
•Post the contact isolation sign on the patient’s door or door frame so that it is noticeable to people who will be
entering the room.
•Place the contact isolation label on the front of the chart so that those who look at the chart can easily see it.
•Handwashing must be performed before and especially after leaving the room. 10-15 seconds of lathering
with soap and water. 15-20 seconds of rubbing with the alcohol hand sanitizer. Be sure to also focus under
and around the fingernails and jewelry if worn.
•Gloves must be worn in order to enter the room. Gowns must be worn if you anticipate contact with the
patient or the environment.
•Alert other departments if the patient is to be transferred for diagnostic testing (i.e., surgery and radiology) or
if transferred to a different unit.
•Whenever possible, communicate the VRE isolation to the physician, other clinicians, dietary and
housekeeping. Encourage and educate others to appropriately follow isolation precautions.
Family and Patient Fact Sheet for VRE
If the family requests information about VRE or if you determine that such information would be of benefit
to the family, contact Infection Control at 541-1259 or the House Supervisor at 541-4948.
77
Methicillin-resistant Staphylococcus aureus (MRSA)
What is Staphylococcus aureus?
Staphylococcus aureus is Gram-positive bacteria frequently found on the skin, nares, groin, and GI system. It
may cause infection in the sputum, blood, surgical wounds, burn wounds, decubitus ulcers, perineum,
rectum, tracheostomy, or grastrostomy sites. Methicillin is a drug frequently used to treat S. aureus. If S.
aureus becomes resistant to Methicillin it is called Methicillin-resistant Staphylococcus aureus (MRSA).
MRSA strains are frequently resistant to other classes of drugs, therefore MRSA is serious or may even
be life threatening to your patient.
How Does Infection Occur?
MRSA is usually transmitted from patient to patient via hand carriage of Health Care Workers in the hospital
setting. Also, patients may be colonized (carries it somewhere on their body). Colonized patients may
become infected with their own bacteria, such as MRSA on the patient’s skin migrating into a Foley
catheter.
How Do You Prevent Transmission of MRSA?
Infections caused by MRSA require enhanced precautions along with Standard Precautions to prevent
transmission to a distant site on the colonized patient or transmission to another patient. Practicing good
patient care and maintaining aseptic and sterile technique is important. Reasons for enhanced
precautions include the potentially serious outcomes of infection, the ease by which MRSA contaminates
the environment and its ability to live for days on the environment, objects, and fabrics. Therefore these
patients are placed in Contact Isolation.
How Do You Implement Contact Isolation?
After you are alerted to the patient’s MRSA status you will do the following:
•
Contact isolation for MRSA positive patients is required if the culture site is draining, secreting, excreting,
etc., and is determined to be at high risk of transmission. If the culture site has a low risk of transmission
because it is not draining, secreting, excreting, etc., then standard precautions will be applied (No
isolation sign required on door; does require isolation sticker on the chart to alert others to MRSA).
•
If requirements for contact isolation are met:
•
place a contact isolation cart outside the patient’s door. The cart will be stocked with gloves,
gowns disinfectant, and thermometer.
•
Dedicate devices i.e. blood pressure cuffs and stethoscopes to prevent transmitting S. aureus to
you and others. If reasons necessitate the use of such devices on another patient, you must
clean and disinfect the device with an appropriate cleaner/disinfectant such wiping with 70%
isopropyl alcohol or other FDA registered product.
•
Post the contact isolation sign on the patient’s door.
•
Place the contact isolation label on the front of the chart.
•
Handwashing must be performed before and especially after leaving the room. 10-15 seconds of
lathering with soap and water or 15-20 seconds of rubbing with the alcohol hand sanitizer. Be
sure to also focus under and around the fingernails and jewelry if worn.
•
Gloves must be worn in order to enter the room. Gowns must be worn if you anticipate contact
with the patient or the environment (including activities such as holding clipboard in the room,
dispensing meds to the patient, etc.).
•
Alert other departments of the patient’s MRSA history if the patient is to be transferred for testing (i.e.,
surgery and radiology) or if transferred to a another unit so that they can take precautions.
•
Communicate MRSA status to physicians, other clinicians, dietary and housekeeping. Encourage and
educate others to appropriately follow isolation precautions.
Family and Patient Fact Sheet for MRSA are available by calling Infection Control at 541-1259 or House
Supervisor at 541-4948.
78
WHAT YOU SHOULD KNOW ABOUT TUBERCULOSIS (TB)
WHAT IS IT?
Airborne infection that occurs in the body sites of greatest ventilation, usually the middle or lower lung zones
or the anterior portion of an upper lobe. An infection, caused by a bacteria, that starts in the lungs and can
spread to other body organs.
HOW IS IT SPREAD?
The germs are spread in the air from person to person by coughing or sneezing or singing.
RISK FACTORS?
•
•
•
•
•
•
•
•
HIV-infection/AIDS
IV drug abusers
Foreign-born minorities (esp from Africa, Asia, Latin America)
Elderly
Low-income populations, including homeless
Institutionalized persons (eg, in nursing homes, prisons)
Heavy smokers
Alcoholics
WHAT ARE THE SYMPTOMS? May vary from person to person
•
•
•
•
Sudden high fevers, sore throat, and cough
Tired feeling with body aches, night sweats, and low-grade fevers for months
Symptoms may depend on the body part that is infected
It has been estimated that >90% of persons with clinically apparent disease are those who have harbored TB
infection for at least 1 year or more and that remaining 10% have immediate progression of recently acquired
infection (CDC, 1990b)
HOW DO WE TEST FOR TB?
TB Skin Test which is “read” within 48-72 hours after placement
Chest X-Ray
Sputum specimen for AFB
HOW DO WE TREAT TB?
AFB Isolation--respiratory isolation.
Antituberculosis drugs
Report all cases of TB to local health department.
79
NEEDLESTICK/BODY FLUID EXPOSURE POLICY
Policy Statement
Any work-related percutaneous (needlestick, laceration, bite) or permucosal (ocular, mucous membrane) exposure to
blood or body fluids will be reported to Employee Health. CDC guidelines will be followed for assessment and
treatment.
Objective
To control transmission of hepatitis B (HBV), hepatitis C (HCV), and HIV among health care workers.
Procedure
1.
All exposure sites will be washed with soap and water. Eyes and mucous membranes exposures will be
flooded with water.
2.
Accidents (including needlesticks, eye/nose/mouth exposure, and intact skin exposure if amount of body
substance or if duration of exposure is considered to be significant) must be reported immediately to the
employee's supervisor or the house supervisor and an Incident Report completed. The employee will then go
to Employee Health with the report. If the injury occurs during a time in which Employee Health is closed, the
employee will contact the House Supervisor for evaluation and follow-up by Employee Health.
3.
A tetanus booster is given per protocol, if indicated.
4.
Subsequent management of the employee depends on the serological status of the source patient and the
vaccination and/or serological status of the employee
Infection Control Safety Measures:
•
Personal Protective Equipment includes gowns, gloves, masks, eye protection, and face shields.
The procedure to be performed dictates the type(s) of equipment needed. Disposable gloves must
be changed between patients, when visibly soiled, or when their ability to function as a barrier has
been compromised.
•
Standard Precautions:
An approach to infection control that regards all bodily secretions,
excretions, drainage and warm moist body areas as having a microbial population such that
transmission to others could occur.
•
Universal Precautions: An approach to infection control. According to the concept of Universal
Precautions, all human blood and certain human body fluids are treated as if known to be infections
for HIV, HBV, and other blood borne pathogens.
•
Clean-up of blood spills or other potentially infectious materials includes: using gloves, remove the
visible material, then clean the area with detergent followed by an EPA-approved hospital
disinfectant.
•
Contaminated needles are to be placed in an appropriate receptacle such as a sharp’s container.
When full, the container is placed in a red bag for proper disposal and incineration. Contaminated
needles are not to be recapped unless there is no safe alternative present. At such times the onehanded scoop technique may be used by the employee.
(see EOHS, Blood/Body Fluid Exposures Policy and FSRMC Exposure Control Plan – Policy # EC.SF.006)
80
SECURITY
81
•
•
•
•
The Security office is open 24
hours, 7 days a week. It is
located on the 1st floor next to
the Emergency Room.
Phone extension for the
Security Office is 1309. If you
forget the extension, call “0” for
the operator.
If you have a cell phone it is a
good idea to program the
Security Office phone number
in it – 541-1309.
The officers are here to ensure
staff and patient safety. You
may request an officer
–
–
–
–
To escort you to your
car
To assist with prisoners
Whenever weapons are
noted
For a “no-information”
situation
82
Weapons Policy
No employee will be allowed in any
Covenant Health facility when in
possession of a personal weapon,
including but not limited to firearms,
any knife with a blade of four inches
or more or with a fixed blade, or a
club. The use, possession, sale, or
purchase of personal weapons by
any employee at any time on
company premises, by any
employee during his/her work
hours, or by any employee on
company business anywhere, is
strictly prohibited. Only those
employees who are issued or
Authorized weapons by Covenant
Health to perform their specific job
functions (i.e., Security Officers) are
excluded from this
policy.
83
What Is a No
Information
Patient?
POLICY:
Refer to HIPAA policy C13 – Use and Disclosure for Hospital Directory. When NO
INFORMATION status is requested patient will be listed “No Publicity / No
information” in
hospital computer system.
PROCEDURE:
1.During the registration process, a discussion will be held with the patient and/or
the patient’s personal representative regarding whether the patient desires his/her
name and room number to be included in the hospital directory.
2.When a patient requests to Opt Out of the Hospital Directory they are considered
to become NO INFORMATION status. The registrar will document on the
Opportunity to Agree or Object form as appropriate and answer any questions the
patient may have.
3.The patient and/or the patient’s personal representative will be advised by the
registrar that as a No Information patient, all telephone calls, visitors, florists, etc.,
will be informed there is no listing for the patient. This will apply to ALL inquiries, as
hospital personnel cannot screen for certain telephone calls or visitors.
4.After explanation of the status, if patient still wishes NO INFORMATION, the
registrar will complete the following steps on the miscellaneous page in the
admission process: 1) select “yes” from the table option in the Opt Out field 2)
enter the date the decision was made to Opt Out 3) select “! No Information” in the
publicity field. Proper entries will automatically place an exclamation point (!) by the
patient’s name on the name inquiry screen on StarClin.
5.The patient and/or the patient’s personal representative will be asked to sign the
Opportunity to Agree or Object form. The original form will be placed in the patient’s
medical record chart and a copy scanned into the Optical System.
6.Computer systems utilized at the Information Desk(s) restrict Courtesy
Ambassadors from viewing patients listed as NO INFORMATION.
7.Nursing Unit – Place only the room number and the doctor’s name on outside of
chart, omitting patient’s name. At no time will the patient’s name or ID numbers be
changed to accommodate the no information status of the patient.
84
Procedure to Follow When a Prisoner is
Admitted to the Hospital….
Procedure:
1.
Nursing staff shall notify the Security Department when a prisoner is admitted
as a patient to their floor, and when discharged.
2.
Nursing staff and Security Officers should introduce themselves to the police
officer in charge of the patient. Introductions should be made each time a shift
change occurs for either the police officer or the affected nursing staff.
3.
Security officers will pass on information as necessary to the police officer and
log the information relative to the prisoner in the Security Department.
4.
The Security Department will give the officer a copy of the “Law Enforcement
Orientation” packet and ask the officer to read the material provided, answer
specific questions about the material, and sign the “Law Enforcement
Orientation Form”. Once completed, the police officer should have the Security
Department notified so a Security Officer can pick up the signed form. The
forms will be kept on file in the Security Department.
5.
Any patient that is a prisoner must be constantly monitored by a police officer,
without exception. The Security Department may relieve the on-site officer for
up to two, fifteen-minute breaks per 8 hour shift as the workload allows. If the
Security Department is not available, or for any additional breaks or breaks
longer than fifteen minutes, the responsible law enforcement agency will need
to provide relief.
6.
Under no circumstances, should anyone other than a hospital Security Officer
or another law enforcement agent relieve the on-site police officer.
85
Abandoned Babies:
•
FSRMC will offer protective shelter, medical care and treatment in a
hospital setting to unwanted, unharmed infants aged seventy-two (72)
hours or younger.
•
An “unharmed condition” can be interpreted as meaning the infant was
not harmed through abuse or neglect after being born.
•
If medical assessment reveals injury or abuse to the infant or if the
assessment determines that the infant is greater than 72 hours old, this
policy will not be utilized and the appropriate authorities/agencies will be
notified.
PROCEDURE:
•
Any hospital employee will accept a newborn infant presented for
surrender and assure person surrendering newborn that this is a safe
haven.
•
Immediately notify the House Supervisor/designee.
•
House SV will then obtain an Abandoned Baby-Surrender of Infant
Packet. Each packet is coded with a number that corresponds with and
ID band for the infant. This identifying number will be used to track
infant during hospitalization. Corresponding number appears on selfaddressed, stamped envelope provided for return of questionnaire.
(Completed packets will be given to the facility Risk Manager for
sequestering information necessary to maintain confidentiality.
•
House SV will accompany parent/person to ER for infant triage and
medical screening exam. If the person refused, a numbered bracelet
will be placed on the infant’s arm and leg.
•
House SV will notify the Administrator on Call.
•
Emergency Department Procedures are outlined in Administrative Policy
# 5.033.
86
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Patient Care Services/Maternal Child
Subject: ABANDONED BABY
SURRENDER OF INFANT
Policy Number: PC.MC.001
Page: 1 of 7
Approved by: Administration
Generated by: Organizational Effectiveness
& Clinical
Outcomes
11/01
Approved by: System Quality Improvement
& Professional Relations Committee 11/01
Effective date:
11/01
Approved by:
Revised date:
Approved by:
Review date:
02/04
Scope: All employees
Purpose:
This policy sets general guidelines for Covenant-affiliated hospitals and birthing centers to
follow in order to comply with the Abandoned Baby Act and to meet other obligations of
licensed health care facilities.
Policy:
Covenant Health will offer protective shelter, medical care and treatment in a hospital setting
to unwanted, unharmed infants aged seventy-two (72) hours or younger.
An “unharmed condition” can be interpreted as meaning the infant was not harmed through
abuse or neglect after being born.
If medical assessment reveals injury or abuse to the infant or if the assessment determines
that the infant is greater than 72 hours old, the Abandoned Baby-Surrender of Infant policy will
not be utilized and the appropriate authorities/agencies will be notified. If the newborn infant is
less than 72 hours old, the acute care facility will notify the nearest office of the Department of
Health Children’s Services. If the newborn infant’s age is determined within medical certainty
to be greater than 72 hours at the time of surrender acceptance or if negligence/abuse is
assessed by a physician, local law enforcement will be notified.
Procedure:
1.
2.
3.
4.
Any hospital employee will accept a newborn infant presented for surrender and assure
the person surrendering the newborn that this is a safe haven.
Upon acceptance of the newborn infant, the hospital employee will immediately notify the
House Supervisor/designee.
The House Supervisor/designee, upon being notified, will obtain an Abandoned BabySurrender of Infant Packet.
The Abandoned Baby-Surrender of Infant Packet is a large red envelope that contains
information that parent/person can return and a list of resources available. Each packet
is coded with a number that corresponds with an ID band for infant. This identifying
number will be used to track infant during hospitalization. Corresponding number
87
appears on self-addressed, stamped envelope provided for return of questionnaire.
Packets are available in the following departments:
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Patient Care Services/Maternal Child
•
•
•
•
Subject: ABANDONED BABY
SURRENDER OF INFANT
Policy Number: PC.MC.001
Page: 2 of 7
Emergency Department
House Supervisor/Designee
Labor & Delivery
Other locations as designated by affiliates
When a packet is used, the department in which the packet is used will obtain
replacement from the Nursing Supervisor’s office.
5.
6.
7.
Completed packets/records will be given to the facility risk manager for sequestering of
information necessary to maintain confidentiality.
The House Supervisor/designee will request that the mother/person accompany him/her
to the Emergency Department. If the mother/person refuses to accompany the House
Supervisor to the Emergency Department, a numbered bracelet obtained from the
Abandoned Baby-Surrender of Infant Packet will be placed on the infant’s arm and leg.
An identical numbered bracelet will be offered to the mother/person and the questionnaire
along with a self-addressed envelope will be provided. The mother/person will be
encouraged to complete the questionnaire and return it to the facility.
The House Supervisor/designee ensures that the infant is transported to the Emergency
Department for triage and a medical screening exam.
The House Supervisor/designee will notify the Administrator on Call.
Emergency Department:
1. Triages infant and assures identification bracelet is in place.
2. Emergency Department physician will provide initial medical screening exam to
determine:
a. Physical condition of infant and any medical treatment necessary to stabilize the
infant.
b. Within a reasonable degree of medical certainty the infant is less than 72 hours old.
3. Emergency Department nurse will:
a. Receive infant.
b. Inquire about the medical history of the mother or newborn and seek the identity of
the mother, infant or the father of the infant.
c. Inform the mother that she is NOT required to respond, but that such
information will facilitate the adoption of the child.
d. Inform the mother that any information obtained concerning the identity of the
mother, infant or other parent shall be kept confidential and may only be disclosed
to the Department of Children’s Services.
e. Assure 2 ID bands on the infant and offer to give the mother the
corresponding mother’s band.
88
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Patient Care Services/Maternal Child
h.
i.
4.
Subject:
ABANDONED BABY
SURRENDER OF INFANT
Policy Number: PC.MC.001
Page: 3 of 7
f. Give the mother the Abandoned Baby-Surrender of Infant Packet.
g. Assist the ED physician with an initial assessment.
Notify Department of Children’s Services after surrendering party leaves
premises. The ED nurse will inform the DCS caseworker of the infant identification
number assigned to the infant. For security, the DCS caseworker will be asked the
infant ID number whenever inquiries are made to or from the hospital.
Notify the House Supervisor/designee of infant disposition and uses same
process as admission and assessment of a baby born outside the hospital.
Emergency Department physician will:
a. Assess the Neonate and follow guideline on the physician order sheet in the
Abandoned Baby-Surrender of Infant Packet.
b.Relay assessment findings to the assigned neonatologist, pediatrician, or
family practitioner on call or designee.
Registration Services:
1.Admits infant with name: Abandoned Baby. Number assigned to bracelet will
be entered in the diagnosis field.
2.Admits infant as a non-publicity patient.
Nursing Unit:
1.Document the numbers from the ID band on the Newborn Identification Sheet.
2.Admits infant to unit and provides appropriate care and treatment.
3.Infant is confidential patient.
4.Initiates referral to Care Maps/Case Management Department.
5.When discharge order is written, completes Discharge Assessment and
Instructions and discharges infant into custody of properly identified
representative of Department of Children’s Services.
6.Notifies Medical Records of correct name of infant, if available.
Case Management/Social Services:
Contacts Department of Children’s Services and coordinates discharge planning.
References:
Senate Bill No. 774
89
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Patient Care Services/Maternal Child
Subject:
ABANDONED BABY
SURRENDER OF INFANT
Policy Number: PC.MC.001
Page: 4 of 7
Fort Sanders Regional Medical Center
Abandoned Baby - Surrender of Infant Order Guidelines
1.
Infant will be triaged in the Emergency Department prior to the determination of
appropriate disposition.
2.
Triage vital signs will include temperature, HR, RR, O2 saturation, weight, and color.
3.
Nursery RN will be called (541-1138) to support activities performed in the Emergency
Department.
4.
If the infant is distressed, the East Tennessee Children's Hospital transport team should
be called (541-8155) to respond to the Fort Sanders Regional Medical Center
Emergency Department.
5.
The Emergency Physician will relate infant assessment findings to the Neonatologist on
call.
The infant may be admitted to the newborn nursery by transport isolette, if stable.
6.
7.
Nursery RN will contact Neonatologist of infant admission. Notify the Department of
Children's Services of infant admission (within 24 hours).








Vital signs hourly x 4, then every 2 hours x 4, then every 4 hours.
Labs
Stat CBC, BMP
Serum Welcogen
Type and Screen, Direct Coombs, and Rh
Urine drug screen
VDRL
HIV (rapid evaluation)
Check patency of both nares using suction catheter
- Note volume and color of aspirate
Peripheral blood glucose
Hourly until first feeding, then before feedings x 4. Call if PBG < 40mg%.
Feeding - Similac with iron per newborn orders.
Medications
Erythromycin eye prophylaxis
AquaMephyton 1mg IM
Hepatitis B Vaccine 0.5cc IM
HBIG 0.5cc I
Umbilical cord - Defer triple dying until seen by neonatologist.
Bathe when stable.
90
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Patient Care Services/Maternal Child
Subject: ABANDONED BABY
SURRENDER OF INFANT
Policy Number: PC.MC.001
Page: 5 of 7
To Whom It May Concern:
Your choice to surrender your infant has been a brave and difficult decision. In
compliance with the Tennessee Safe Haven Bill, the Covenant facility will
contact the Department of Children's Services and relinquish custody of your
infant to them. Any inquiry regarding your infant should be done through the
Department of Children's Services (see enclosed list).
We request that you complete the attached questionnaire regarding your
medical history and return it in the self-addressed stamped envelope provided.
Providing this information is strictly voluntary, however, it will assist in providing
care for your infant.
You are urged to seek medical attention if you feel you need to do so.
Included in this packet is information regarding agencies and resources that
may be able to assist you through this difficult time.
April 2004
91
Name of Business Unit
Fort Sanders Regional Medical Center
Name of Category/Sub-Category:
Patient Care Services/Maternal Child
Subject: ABANDONED BABY
SURRENDER OF INFANT
Policy Number: PC.MC.001
Page: 7 of 7
The following is a list of resources and agencies that may be of assistance to
you:
Department of Human Services: (931) 484-2573
Alcohol and Drug Information and Referral: (800) 889-9789
Battered Women: (931) 484-4642, 456-0747, (800) 641-3434
Social Worker:
EMERGENCY
Child & Family Crisis Center: 637-8000
Child & Family Runaway Shelter: 523-2689
Florence Crittenton Agency: 602-2021
Knox Area Rescue Ministries: 291-4024
Salvation Army: 525-9401
Serenity Shelter: 971-4673
Volunteers of America: 525-7136
DOMESTIC VIOLENCE
Child & Family, Inc.
Family Crisis Center + (24-hr. crisis line): 637-8000
Managing Emotions Nonviolently: 524-7483
The Conley Center, East: 546-7483; West: 691-3332
Knox Area Rescue Ministries
Serenity Shelter: 971-4673
Knox County Sheriff's Department
Major Crimes Unit (covers domestic violence): 215-3590
Knoxville Police Department
Domestic Violence Unit: 521-1200
The Salvation Army
Women and Children's Program: 522-4673
SEXUAL ABUSE
Child and Family, Inc.
Project Against Sexual Abuse of Appalachian Children (PASAAC): 524-7483
Helen Ross McNabb Center: 523-8695
Sexual Assault Crisis Center: 558-9040
Crisis Line: 522-7273
92
SUICIDE PRECAUTIONS
•
FSRMC is obligated to exercise reasonable care in rendering services
to all patients, and this includes the protection of suicidal or severely
depressed patients from self-destructive acts.
•
Suicide Precautions is a set of rules which may be placed into effect by
an RN concerned with the clinical care of a patient or by the patient’s
attending physician or medical consultants. When ordered, the rules
will be followed by all departments involved in the clinical care or other
services rendered to a potentially suicidal patient.
•
Suicide Precautions will remain in effect until the patient is declared
“non-suicidal” by the psychiatrist or attending physician and a written
order to discontinue suicide precautions is given.
•
The following shall be considered potentially suicidal:
•
–
Any patient admitted for an apparent suicide attempt
–
Any patient making a suicide attempt while hospitalized
–
Any patient voicing threats of suicide
–
Any patient who, in the joint professional judgment of the primary nurse and
appropriate nursing supervisor is considered suicidal
–
Any patient who, in the judgment of the attending physician, consulting
physician or psychiatrist, is suicidal
Department-specific procedures have been outlined in the
Administrative Policy Manual, reference policy # 5.100.
–
Nursing Department
–
Security Services
–
Environmental Services
–
Dietary
–
Facility Services
93
ABUSE
94
ABUSE: Adult & Child
DEFINITIONS:
•
Abuse or neglect means the infliction of physical pain, injury or mental anguish, or
the deprivation of services by a caretaker which are necessary to maintain the health
or welfare of a dependent adult.
•
(See Tennessee Code 71-6-102.)
Child abuse, brutality or neglect means any wound, injury, disability, or physical or
mental condition which is of such a nature as to reasonably indicate that it has
caused an adverse effect upon the physical or mental health and welfare of a child.
•
Signs of abuse may include:
The type of the injury
Story that does not match injury
Unusual behavior
•
All known or suspected abuse cases MUST be reported to the Case Manager.
•
If the abuse of a child is suspected, it must also be reported to the Dept. of
Children’s Services and to the to the Child Abuse Hotline at 594-6767 or
1-877-54ABUSE.
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ABUSE
“The five letter word no one wants to think about”
Identifying Victims of Abuse
•
Forms of Abuse:
– Neglect: a form of physical abuse involving depriving the person of needed
medical services or treatment; failure to provide food, clothing, hygiene, and
other basic needs.
– Emotional: humiliation, harassment, ridicule, and threats of being punished;
includes being deprived of needs such as food, clothing, care, a home, or a
place to sleep.
– MUNCHAUSEN BY PROXY (MSP) is a label for a pattern of behavior in which
caretakers deliberately exaggerate and/or fabricate and/or induce physical
and/or psychological-behavioral-mental health problems in others.
This pattern of behavior constitutes a separate kind of maltreatment
(abuse/neglect) that manifests as physical abuse, sexual abuse, emotional
abuse, neglect, or a combination. The primary purpose of this behavior is to
gain some form of internal gratification, such as attention, for the perpetrator.
– Emotional: humiliation, harassment, ridicule, and threats of being punished;
includes being deprived of needs such as food, clothing, care, a home, or a
place to sleep.
– Material: misusing a person’s personal property or finances for personal gain
– Physical: grabbing, hitting, slapping, pushing, kicking, pinching, hair pulling, or
beating; includes corporal punishment – punishment inflicted on the body.
•
Steps to be taken by patient care providers if abuse is suspected:
–
–
–
–
–
–
•
RECOGNIZE IT
Document, Document, Document
Report to the primary nurse / Case Manager
Take pictures
Offer information such as pamphlets, brochures, and/or phone numbers
for resources or agencies that can provide them assistance
If the patient is a child, report to the department of Children’s Services
and to the Child Abuse Hotline at 594-6767 or 1-877-54ABUSE
Steps to be taken by non-patient care providers if abuse is suspected:
1. Report to manager or shift leader immediately
2. Report to the Child Abuse Hotline at 594-6767 or 1-877-54ABUSE
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CHAPLAIN
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CHAPLAIN SERVICES: 541-1235
The Chaplains are here for
YOU,
our patients,
and
their loved ones.
•
The Chapel and Chaplain’s office are located on the main lobby just
inside the Clinch Avenue entrance.
•
The Chaplains are here to serve our patients, their loved ones, and our
employees. If you have questions or would like to speak with a
Chaplain, feel free to drop by their office or call them on the phone.
You will reach voice mail if they are not in at that time. Voice mail
messages are updated regularly to provide the caller with the best
method to contact them quickly. After hours please call the house
supervisor for the chaplain on call.
•
YOU are our most important asset…the Chaplains would like to stress
the importance of employees taking care of themselves as well as their
patients. You are welcome to visit the chapel at any time to enjoy a
quiet moment in a peaceful setting.
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Health Care Professional
Substance Abuse
99
Characteristics of Substance Abuse of the Healthcare Professional
Patient safety and staff well-being are primary priorities at Fort Sanders Regional
Medical Center. Please read the following information:
Characteristics of the Impaired
•
•
•
•
•
•
•
•
•
•
•
•
Belligerence
Mood swings
Inappropriate behavior at work
Frequent days off for implausible reasons (Days before and after scheduled off
days)
Non-compliance with standard policies & procedures
Deteriorating job performance
Sloppy, illegible charting
Errors in charting
Alcohol on breath
Forgetfulness
Poor judgment & concentration, jeopardizing patient safety
Lying
Signs of Diversion
•
•
•
•
•
•
•
•
Volunteers to be Med Nurse
Medicates other nurses’ patients
Uses the maximum PRN dosage
Patients complain about ineffective pain meds or deny receiving charted doses
Frequent wastage or spilling of narcotics
Problem on unit with drugs disappearing
Seals have been tampered with
Meds signed out of narcotic cabinet but not charted in patient record
Healthcare and Substance Abuse Statistics
•
•
•
•
Healthcare professionals are more likely to abuse prescription drugs and less likely
to use alcohol than the general population
Estimates of incidence range from 6 to 16 percent for healthcare professionals; 10
to 12 percent for doctors
Incidence is higher for anesthesia providers (20% or 1 in 5)
Notify your supervisor or Employee Assistance Program @ 531-4500 with any
questions or concerns you might have.
100
Only clinical staff need
to complete the
following section.
101
Standards of Care
“C.A.R.E.S.”
Comfort
All patients treated by the nursing staff of FSRMC can
expect comfort to be optimized through effective
utilization of appropriate comfort measures (Standard I)..
heAling All patients treated by the nursing staff can expect
healing to be promoted through maintenance of
effective hydration and nutrition, appropriate medication
administration and the recognition, acceptance and
support of his/her psychosocial and spiritual needs
(Standard II)..
Respect
All patients can expect to receive respect for his/her
rights as a patient and individualized nursing care
based on research findings, ethical principles and
continuous quality improvement, according to his/her
unique health care needs (Standard III)..
Education
Safety
All patients can expect to receive education specific to
his/her continuing health care needs (Standard IV)..
All patients can expect care to be delivered in a safe
environment free of nosocomial infections and
injurious insults (Standard V)..
AGE SPECIFIC CARE:
Individualized care based on patient needs and abilities generated by aging.
Some examples are:
GERIATRIC
Decreased eyesight
Hearing loss
Diminished immune system
Nutritional challenges
Poly-pharmacy
Safety impaired
Skin breakdown
Diminished information processing
Needs referrals to community resources
ADULT
Stress Management – with care of parents, children,
jobs, and now in the hospital these patients can be
highly stressed.
Lifestyle changes – educate for wellness.
Needs referrals to community resources.
TEENS
Needs high level of privacy.
Concerned with how their physical appearance can be
affected by hospital tests and procedures.
Feels immortal.
Teach away from peers.
103
Pre-schoolers & School-age patients:
Use short quick explanations.
Demonstrate procedures on a teddy bear or doll.
Use games or toys to explain unfamiliar objects.
Allow the child to have some control.
Toddlers
Use play as a means of explanations.
Give one direction at a time.
Allow choices when possible.
Use distraction for unpleasant procedures.
Identify motor skills when determining food choices.
INFANTS
Keep parents in infant’s line of vision
within safety limits.
Give infant a familiar object.
Cuddle and hug the patient frequently.
Provide protective environment.
Remove equipment when used.
Remember, A patient’s age may determine
how they need to receive information, but ALL age groups
need education on how to maintain a healthy life-style.
104
Screen Print of AgeAppropriate
Care Section :
105
Safety Screen for
all patients:
Hendrich II Fall Risk
Tool for predicting the
likelihood and risk of
fall for hospitalized
patients. Add up the
numeric values for all
elements of the tool. If
the score is =>5
consider the patient
level II or high risk.
Match risk factors with
interventions to prevent
falls.
106
REQUIRED FORMS TO BE
TURNED IN UPON
COMPLETION OF THIS
ORIENTATION SESSION:
Clinical Employees:
•Handbook Receipt
•Confidentiality Statement
•Infection Control Post-Test
•Safety/Security Post-Test
•Post-Clinical Test
•Computer skills check list is to be turned into the nurse manager
when orientation to computerized documentation/order entry has
been completed.
107
Key Points:
1. The use of restraint should be the final choice for protecting a patient.
Alternative interventions should be evaluated prior to restraint use.
2. Alternative interventions may include but are not limited to:
2.1) review of administration, discontinuation, or alteration of
current medications
2.2) supervised activity as allowed
2.3) increased monitoring and supervision of the patient by staff
2.4) family or sitters staying with the patient
2.5) diversionary activities
2.6) modification of the patient’s environment
3. Frequent assessment of the patient’s psychosocial and physical status
and careful thorough explanation of environment, procedures, and
events should be implemented on admission and continue until
discharge. This measure may help to prevent the need for restraint.
4. If restraints are deemed necessary, soft restraints are to be used unless
the need for heavier restraint is indicated.
5. Restraint for infants and children:
5.1) Hospital policy requires that parents stay with infants and
children under age twelve (12). Restraints should not be used
unless the parent is unable or unwilling to assist with
preventing the child from injuring himself/herself.
5.2) If restraints are indicated for an infant or child, the same
procedures apply. Restraint should be the least restrictive that
will control the child and should be removed as soon as
possible.
6. Consider a constant attendant in addition to the restraint if patient is
actively non-compliant, i.e., removing the restraint device.
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A Physical Restraint is any manual
method or physical or mechanical device,
material, or equipment attached or adjacent
to the patient’s body that he or she cannot
easily remove that restricts freedom of
movement or normal access to one’s body.
Seclusion refers to the involuntary confinement of a person alone in a room where the
person is physically prevented from leaving.
Voluntary Restraint – instituted following consent from a cognitively intact patient.
Example: an elderly patient who has just taken a sleeping pill and has agreed to have a
halter type device applied for the evening as a reminder not to get out of bed without
pressing the call button to ask for assistance.
A “drug used as a restraint” is a medication used to control
behavior or to restrict the patient’s freedom of movement and
is not a standard treatment for the patient’s medical or
psychiatric condition.
Routine treatment restraint – utilized to assist in a specific treatment or
diagnostic procedure such as IV infusions, diagnostic x-rays,
catheterizations,etc. Routine treatment restraint is not utilized primarily to
involuntarily immobilize a patient. Treatment restraints may include
immobilization used during surgery and during non-cognitive states.
Forensic and corrective restrictions for security, e.g.,
handcuffs, applied by a police guard, are not defined as
restraint.
Postural/safety supports – utilized to assist the patient in achieving or
maintaining proper body position, alignment and balance or compensating
for a specific defect. These may be used to prevent non-cognitive patient109
from falling out of bed or chair.
1.
Assessed need for restraint.
2.
The outcome of alternative interventions tried before restraint.
3.
Patient/family education.
4.
Performance of q2h safety checks (CSM checks, skin checks, side rails up,
bed in low position, call light within reach) and actions taken to ensure that
the patient has opportunity for the activities of daily living (toilet needs,
nourishment, position changes).
5.
Reassessment of the continued need for restraints q2h.
6.
Restraints may be discontinued (expired order/pt no longer needs),
reinstated (patient has a reoccurrence of the same issues that led to the
restraint being applied) or renewed (new order written) or simply “off” (as in
trial temporary period).
7.
New physician order every 24 hours.
110
CLINICAL
POST-TEST
Name ____________________
Badge #___________________
Date _________ Page 1 of 1
1.
Define the acronym: C.A.R.E.S
2.
The restraint policy states: Patients in restraints must be checked every ________.
3.
A ____________ _______________ is any manual method or physical or
mechanical device, material, or equipment attached or adjacent to the patient’s
body that he or she cannot easily remove that restricts freedom of movement or
normal access to one’s body.
4.
Select the correct age group who most needs education on a healthy life-style.
a.
Geriatric
c. Teen
b.
Adult
d. All of the above
5.
Individualized care based on patient needs and abilities generated by aging is
referred to as:
a.
The Aging Process
c. The Nursing Process
b.
Age Specific Care
d. Geriatric Nursing
6.
List the four types of abuse.
1.
________________________
2.
________________________
3.________________________
4. ________________________
7.
What are the two steps YOU take if violent abuse is suspected?
1.
______________________________________________________________
2.
______________________________________________________________
8.
The single most important tool a nurse can use to prove good nursing care is:
a.
Good hand washing technique
c. Physician orders
b.
Nursing care plan
d. Clinical documentation
9.
Complete the following list to show all the necessary steps for implementing an
Isolation set-up:
1.
Stock cart/cabinet
5. ____________________
2.
Place sign on door
6. Alert other departments
3.
________________________
7. appropriate hand hygiene
4.
Ensure alcohol hand cleaner is available 8. _____________________
10.
List the steps you would follow if you are exposed to HIV.
111
INFECTION CONTROL ORIENTATION POST-TEST
Name _______________________ Badge #: __________________ Date ___________
Circle the correct answer.
Page 1 of 2
Bloodborne Pathogen Standard/Isolation
1. According to the Exposure Control Plan, the choice and use of Personal Protective
Barriers is based primarily on specific patient diagnosis and not procedure or
expected risk.
a. True
b. False
2. In any procedure where “splash” is a risk, eye protection is always required along with
a mask.
a. True
b. False
3. Gloves –
a. Must be changed when contamination has occurred.
b. Can be used patient to patient if not visibly soiled.
c. Should be worn in the hall since surfaces may be contaminated.
d. Should always be worn when cleaning up a blood spill.
e. A and C
f.
A and D
g. All of the above
4. When Employee Health Services is closed, the Nursing House Supervisor is always
notified following a blood exposure incident (needlestick, etc.)
a. True
b. False
5. Hepatitis B immunization is offered to eligible employees at the time of employment.
a. True
b. False
6. All “used” or dirty linen is considered potentially contaminated/infectious.
a. True
b. False
7. Needles can only be recapped by using a recapping device or a one-handed
technique.
a. True
b. False
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INFECTION CONTROL ORIENTATION POST-TEST
Name _________________________________________
Page 2 of 2
8.
Full needle disposal boxes are placed inside red lined infectious waste containers for
proper disposal and incineration.
a. True
b. False
9.
Which of the following is the correct procedure for cleaning up a blood spill?
a. Notify environmental services immediately and secure the area
b. Absorb the spill, spray Clorox solution on the area, bag all waste and dispose
of it in the infectious waste container.
c. Put on gloves, absorb the spill, clean area with a detergent, disinfect the area
with either a Clorox solution or hospital grade germicide, and dispose of all
waste in a buff colored bag as infectious
10. Isolation for known or suspected TB requires which of the following?
a. Negative pressure room, personal respirator (PR)
b. Positive pressure room, isolation mask
c. Any private patient room, as long as orange barrier masks are worn
11. TB skin test must be read 48-72 hours after placement.
a. True
b. False
12. In employee follow-up after exposure to blood or body fluid, it is not necessary to
report to Employee Health Services as long as an Employee Accident Report Form
is completed.
a. True
b. False
13. Standard Precautions and Universal Precautions apply to all patients and includes
the use of personal protective barriers, when contact with blood, any body fluids,
non-intact skin and mucous membranes is anticipated.
a. True
b. False
14. Contact Isolation includes the wearing of gloves upon entering the patient room.
a. True
b. False
113
SECURITY / SAFETY ORIENTATION POST-TEST
Name _________________________ Badge # ___________________
________________
Date
Grade ________ Graded by ___________________________________ Page 1 of 2
Please answer the following questions. You may refer to your Orientation Handbook for
assistance. A score of 100% is required before you may provide patient care.
SECURITY
1.
What is a “no information” or “closed chart” patient?
2.
How will you know if a patient is a “no information” or “closed chart” patient?
3.
What does “CODE CLEAR” mean?
4.
Weapons are allowed outside of facility (on facility grounds). True or False
5.
What should you do if a patient prisoner arrives?
6.
Security personnel may be called to escort you to your car. True or False
SAFETY
1.
What doe R.A.C.E. mean?
2.
What should you do when you hear a fire alarm?
3.
How do you alert others in the hospital that there is a fire?
4.
What can you do to protect yourself from body fluids and hazardous chemicals?
5.
What should you do if you discover that the equipment you are using is
defective and hazar4dous to a patient or user?
6.
You do not have to report accidents that do not result in injury. True or False
114
SECURITY / SAFETY ORIENTATION POST-TEST
Name _________________________________________
Page 2 of 2
SAFETY continued:
7.
What should you do if there is an accident?
Match the letter of the code with the correct response below:
A.
Code Black
B.
Code Purple
C.
Code Pink
D.
Code Blue
E.
Code Green
F.
Code Red
G.
Hazardous Material Spill
H.
Code Yellow
I.
Code White
8.
_____ Complete duties and report to immediate supervisor for release to personnel
staging area.
9.
_____ Isolate the spill area (evacuate). Call nuclear medicine for spill clean-up.
J. Evacuation
10. _____ Check for suspicious package and report to security. Immediately notify
staff and PBX when bomb treat is received.
11. _____ Clear the area to avoid others from becoming a hostage.
12. _____ Notify all in area of need to evacuate. Evacuate ambulatory, wheelchair,
then bedridden. Take records if safety permits. Notify PBX to activate internal
evacuation alert.
13. _____ Assess whether infant has been removed from premises. Notify immediate
supervisor. When code is announced, search for abductor.
14. _____ Potentially violent person exhibits anger or uncontrolled behavior toward
staff.
15. _____ RACE
16. _____ Remove persons from hazard. Trained user cleans up spill. If you can do it
safely, assist contaminated victims in decontamination process.
17. _____ Designated team responds to area following PBX announcement.
115
Fort Sanders Regional Medical Center
Fort Sanders Perinatal Center
Thompson Cancer Survival Center and Thompson Oncology Group
HUMAN RESOURCES CHECKLIST FOR NEW EMPLOYEES
Employee Name (Print) ___________________________ Date of Hire________________
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Location/Hours of Business for HR Office, Forms, Contact Numbers
Harassment Policy
Workplace Violence Policy
Patient Care Philosophy
Staff Rights Policy
Problem Solving Procedure
Ethics Committee
Employment Information
Worker’s Compensation
Employee Performance & Behavior Expectations
Cariten Assist Employee Assistance Program
Care of Equipment & Supplies
Smoking Policy
Identification Badge (Must wear at all times above the waist)
Employee Parking
Benefits
Risk Management
Safety
Infection Control
Security
Abandoned Baby
Patient Abuse
Diversity
Facility Tour
Characteristics of Substance Abuse of the Healthcare Professional
Acknowledgement Card and Receipt for Handbook
__________________________________________________________________________
Employee Signature
Date
___________________________________________________________________________
Human Resources Representative
Date
116
ACKNOWLEDGEMENT CARD AND RECEIPT FOR HANDBOOK
This Employee Orientation Handbook is not intended to be a contract nor is
it intended to create any contractual rights on behalf of any employee of Fort
Sanders Regional Medical Center, Fort Sanders Perinatal Center, Fort
Sanders Foundation, Thompson Cancer Survival Center, or Thompson
Oncology Group, or of any other Covenant Health entity. None of the
statements, policies, procedures, rules, regulations, or other provisions
contained in this Employee Orientation Handbook constitutes a guarantee of
any other rights or benefits, or a contract of employment, express or implied.
Each employee of Fort Sanders Regional Medical Center, Fort Sanders
Perinatal Center, Fort Sanders Foundation, Thompson Cancer Survival
Center, or Thompson Oncology Group or of any other Covenant Health
entity is an at-will employee under Tennessee law and is subject to
termination at any time without cause and without notice. Fort Sanders
Regional Medical Center, Fort Sanders Perinatal Center, Fort Sanders
Foundation, Thompson Cancer Survival Center, Thompson Oncology
Group, and Covenant Health reserve the right to modify or eliminate any or
all terms of this Employee handbook at any time with or without notice. This
Employee Orientation Handbook supersedes all previous Orientation
Handbooks.
I have read and understand the above statement and agree to read the
employee orientation handbook which I hereby acknowledge having
received.
I also understand that Covenant Health is committed to providing a safe
working environment for the employees and the patients we serve.
Accordingly, I consent to undergo a drug and/or alcohol test if asked by a
manager who has reasonable cuase. I understand that refusal of such test
will constitute grounds for termination.
_________________________________________
Employee Signature
_________________________________________
Date
117