1. 2 we serve the community by improving the quality of life through better health. through its...

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We serve the community by improvingthe quality of life through better health.

Through its peopleCovenant Health will be recognized

as the premier health services system in Tennessee.

Our Vision

Working together in service to God, our values are:Integrity

QualityServiceCaring

Developing PeopleUsing Resources Wisely

Our Values

Our Purpose

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Main Number (865) 541-1247

Coordinator Missy McCarter 541-1888

Coordinator Tonya McDonald 541-2572

Generalist Jason Shubert 541-1947

Senior Generalist Susan Thompson 541-1891

Director Gina Kinkaid 541-2817

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.

The Human Resources department is located in Laurel Plaza,

1901 Laurel Avenue, Suite 106, Knoxville, TN 37916.

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PATIENT CARE PHILOSOPHYEvery 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 NOT TO PARTICIPATE IN

CERTAIN ASPECTS OF CARERequests 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.

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Subject: APPEARANCE

Policy Number: HR.EE.015

Human Resources Page: 1 of 6

Generated By: Human Resources Approved By:

Samuel R. Buscetta

Executive Vice President, Human Resources

Effective Date: August 1991

Revision Date: November 2010

Scope:

This policy is applicable to employees of all wholly and jointly owned Covenant Health business affiliates except where collective bargaining agreements may exist or as specifically excluded below.

Excluded Affiliates: Methodist Medical Center (BU Employees) Interpretive Notation: This policy is intended to provide guidelines regarding

appropriate appearance standards. Individual departments or business units may establish appearance guidelines that exceed those set forth in the policy so long as they are reasonable and predicated on a bonafide business necessity. Essentially, the guidelines contained herein are minimum expectations.

Policy: The image employees portray by appearance is an important reflection of Covenant Health’s professionalism and commitment to quality. Employees will maintain a neat and professional appearance at all times. An appearance policy cannot address every potential item of clothing or accessory; therefore, managers are expected to apply good judgment in maintaining the professional and appropriate appearance of their employees.

Clothing and Fit:

All clothing, regardless of whether it is a uniform or other dress, should

be clean, fit properly, be in good repair; and, be 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. Obviously this is inclusive of messages pertaining to drugs, alcohol, tobacco use, or sexual themes. It is also inclusive of messages supporting, objecting to or otherwise pertaining to social, political, and religious causes.1

1 This provision is also inclusive of buttons worn on clothing; which may only be worn for approved, short term facility initiatives.

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Subject: APPEARANCE



Denim jeans, blue or otherwise, are not appropriate in the workplace and should not be worn.1 However, non patient care business units may allow jeans on ‘casual Fridays’. In these instances, jeans must be neat, professional in appearance, and appropriate to the work being performed. Business units may also allow blue denim skirts, dresses, and shirts again, if neat, professional in appearance, and appropriate to the work being performed. Tee shirts are not acceptable in the workplace and may not be worn at any time except in instances of approved events. Clothing articles, lanyards, etc. with vendor logos provided as gifts/promotions are not permitted.

Uniforms:

Managers will communicate the uniform requirements of their departments to all newly hired or transferring employees. 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 shirt and white pants/skirts are not acceptable.

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.

1 Jeans may be worn more routinely at Peninsula Behavioral Health where they are appropriate to the work being performed. However, they may not be worn in the hospitals by non-clinical employees in maintenance, housekeeping, food services, etc.

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Subject: APPEARANCE



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.

Scrubs are not considered appropriate wear in non-clinical areas.

Tops/Blouses:

Tops and blouses may not have revealing neckline or midriff. Tank tops are not permissible. Sweatshirts are not permissible for regular wear. Sweatshirts that reflect school or team colors and logos may be worn on casual Fridays (note: this is at the discretion of the individual business unit and generally not acceptable in patient care business units). Otherwise, sweatshirts and shirts with printed messages are not permissible. Pants:

The following pant styles are not permissible (including on casual Fridays):

warm-up or sweat pants, stirrup pants, or leggings.

Capri pants must be mid calf in length. Any style of pant above mid calf are considered shorts and are not permissible.

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 top dresses may be worn only with jackets. Shorts are not permissible.1

1 Fortress Engineering and Health & Fitness Center employees are excluded from this provision.

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Subject: APPEARANCE



Shoes:

Shoes must be appropriate to the dress and job for a given department or area. All white or all black athletic shoes may be worn if they are polished and clean. Open toed shoes are not permissible in clinical areas due to safety concerns. Flip flops or overly casual beach-type sandals are not permissible at any time. ‘Dress’ sandals may be worn in non-clinical areas at the discretion of the department or business unit. However, management maintains the prerogative and sole discretion to make a distinction between sandals and flip flops and whether or not the sandals’ style is within the spirit and intent of this policy. Undergarments: Appropriate undergarments must be worn to present a neat and professional appearance. Undergarments should not be visible. Hair:

Employees must keep their hair clean and in a fashion that does not present a safety hazard. Color, style, and length should be appropriate. Unnatural hair colors, whether a wig or dyed, are not permitted. Mustaches, sideburns, and beards must be neatly trimmed. Beards may not be worn by employees who are required, for safety reasons, to wear a respirator; i.e., they may interfere with the proper fit of the respirator.

Hats:

Hats may be worn only as a part of an approved work uniform. They are not otherwise permitted.

Jewelry:

Jewelry may be worn but should not depict an insignia offensive to the general public.1 Excessive or dangling jewelry (earrings and bracelets) may not be worn in clinical or other areas where it may present a safety hazard for patients or the employee. Earrings must be an appropriate size to maintain a professional appearance; generally not larger than the size of a quarter.

1 This does not preclude small, unobtrusive religious jewelry such as a crucifix, a Star of David, or other religious symbols; including label pins sometimes worn by Chaplains.

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Subject: APPEARANCE



Department managers have the discretion to establish a “no jewelry” policy where issues of employee and patient safety are a concern. Male employees may wear ear studs or a post while on duty. Earrings are not permitted for male employees while on duty. Ear lobe enlargements of any size are prohibited. Pierced jewelry is permitted in ears only and limited to three small earrings per ear. Other body piercings, including but not limited to, nose rings, eyebrow rings, and tongue rings may not be worn while working. Makeup and Fragrances:

Makeup and personal body fragrances, including perfume and after-shave, may be worn but employees that wear fragrances are expected to give consideration to others that may be sensitive or allergic to them. Clinical departments have the discretion to establish a “no fragrance” policy due to patient concerns. Clinical and non-clinical departments have the discretion to establish a “no fragrance” policy due to concerns regarding employees who have physician-documented fragrance allergies. Employees that smoke or use other tobacco products may not exude an odor of tobacco.

Tattoos:

Small, decorative and inoffensive tattoos are permissible. The determination of ‘small’ and ‘inoffensive’ is at the sole discretion of management.

Large, offensive -- or potentially offensive -- tattoos must be covered while the employee is on duty.

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.

Clinical departments may have a “no polish” and/or a “no artificial nail” policy due to patient/health regulations and concerns.

Identification Badges:

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Subject: APPEARANCE



Employees are required to wear the identification badge issued by Covenant Health at all times while on duty. This is to allow patients, visitors, physicians, and other employees to readily identify them. The employee’s image must be visible at all times.1 The badge should be worn at chest level to allow for easy identification by all parties. The badge may be worn at waist level in some situations if the chest level location interferes with the work being performed. Vertical badge extenders may be used for service pins or pins/stickers that identify the employees’ clinical credentials (primarily RN, LPN, CNA, and HUC). No pins or stickers are permitted on badges except in those instances where an affiliate uses seniority stickers to identify employees that qualify for cafeteria discounts. No other pins or stickers will be allowed either on the badge itself or a badge extender.

Non-Employees:

Temporary and agency workers are expected to adhere to all provisions of this policy. Vendors, contractor employees, physicians, students or anyone else onsite working for or providing services to Covenant Health are likewise expected to adhere to all provisions of this policy.2

1 Fortress employees at Nanny’s and the Health & Fitness Center are not required to wear the standard Covenant Health badge due its potential interference with the work being performed. They are required to wear the name badge provided by Fortress, however. 2 This may exclude non-employed construction and maintenance/repair workers. However, these workers are still expected to dress and maintain an appearance that is not offensive and generally in keeping with the spirit and intent of this policy.

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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.

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.

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Most Frequently Called Numbers

FSRMC Main Line 541-1111

Benefits: Customer Service

Retirement planning 401-K - Fidelity

374-5360

1-800-343-0860

Cafeteria Menu Line 541-3166

Chaplain 541-1234 or 541-1235

Employee Assistance Program 1-866-440-6556

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, President & CAO Jenny Hanson, VP Operations/CNO Ronnie Beeler, VP/CFO Gina Kinkaid, Director HR

541-1399541-1302541-4936541-2817

TCSC 541-1678

While on campus, you only have to dial the last 5 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.

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Approved By:

Subject: TOBACCO FREE WORKPLACE

Policy Number: HR.SC.204


Lawrence KleinmanExecutive Vice President, Human Resources

Generated By: Human Resources

Effective Date: January 2011 Revision Date: October 2011

Scope:

This policy is applicable to employees of all wholly and jointly owned Covenant Health business affiliates except where collective bargaining agreements may exist or as specifically excluded below.

Excluded Affiliates: Methodist Medical Center (BU Employees)1 Parkwest Medical Center dba Peninsula Behavioral Health2

Replaces: HR.SC.201 Smoke-Free Workplace

Purpose: As the leading provider of health care services in East Tennessee, Covenant Health is committed to the promotion of good health and prevention of disease. Smoking, through both direct and indirect exposure, has been clearly identified as a major contributor to heart, lung, and other diseases. Therefore, the use of tobacco is discouraged as an unnecessary health hazard. The Tobacco Free Workplace policy is intended to further this commitment by providing a healthy environment for our patients, our employees, and visitors to our affiliates. Policy: For purposes of this policy, use of tobacco products is defined as, but not limited to smoking cigarettes, smoking cigars, smoking pipes, chewing tobacco, and ‘dipping’ snuff.

It does not include nicotine replacement therapies such as transdermal patches, nicotine lozenges or gum. However, it does include electronic cigarettes; which are not marketed as or FDA approved as a nicotine replacement therapy.

Covenant Health will comply fully with the Non Smoker Protection Act of Tennessee and any regulations related to smoking or the use of tobacco products as may be contained in accreditation and certification standards (e.g., joint commission). In addition, Covenant Health will further limit the use of tobacco products in the following manner.

1 Tobacco use is similarly banned by MMC bargaining unit work rules 2 Some discretion regarding applicability is retained by Peninsula Behavioral Health due to unique treatment and operational considerations.

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Subject:

TOBACCO FREE WORKPLACE

Policy Number:HR. SC.204


Covenant Health employees may not use tobacco products anywhere on Covenant Health premises. This includes inside personal vehicles parked in Covenant Health owned parking lots or parking garages.

Employee use of tobacco products is prohibited during the employees’ work shift; including during breaks and meal times.

Employees must not exude an odor of tobacco. This will be considered a violation of both the Tobacco Free Workplace policy and Covenant Health’s appearance standards.1

Covenant Health will assign a surcharge to health insurance rates for employees who use tobacco products.

Employees found using tobacco products on Covenant Health premises, leaving the premises without properly clocking in and out, or otherwise in violation of this policy are subject to the standard disciplinary process up to and including termination of employment.

Employees found using tobacco products in violation of the policy will be reported to the

Corporate Benefits Department. If they are found to be enrolled in the Covenant Health insurance plan and are not paying the tobacco users’ surcharge, they will be assessed the surcharge (going forward and retroactively) and subject to discipline for falsification of documents.

Covenant Health will offer smoking cessation programs and smoking cessation aids to

employees that will incorporate a combination of cessation classes, nicotine replacement therapies, and smoking cessation drugs.2

In addition to employees, this policy also applies to all other individuals on Covenant Health premises.

All contractors, vendors, volunteers, students, etc will be informed of the Tobacco Free Workplace policy prior to accepting the work or assignment. The Covenant Health sponsor of these individuals will be responsible for their compliance with the policy.

Families and patients will be informed of the Tobacco Free Workplace policy in the most appropriate manner for that line of service and care. However, it is the responsibility of all employees to educate families and patients about Covenant Health’s tobacco free environment. This information should be shared with them prior to their arrival when possible.

1 Note that the same standard is applicable to other strong fragrances such as cologne and perfume. 2 The specific combination of and funding/reimbursement for cessation support will be determined by the Executive Leadership Team (ELT).

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Subject:

TOBACCO FREE WORKPLACE

Policy Number:HR. SC.204


Visitors who do not comply with this policy will be respectfully reminded that Covenant Health affiliates are tobacco-free facilities.

Signs will be posted at every affiliate indicating its status as a tobacco free facility. Signs will comply with any/all requirements of local and state no-smoking ordinances.

All employees are responsible for adherence to the Covenant Health Tobacco Free Workplace policy and are encouraged to assist in its respectful enforcement.

If a member of management or a Security Officer observes an employee using tobacco products in violation of this policy, the individual will be directed to discontinue tobacco use. If the same employee(s) is observed repeatedly violating the policy, the employee’s manager will be informed who will then consult with Human Resources and take appropriate corrective action.

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Revised 2013

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What Is HIPAA?

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What Is HIPAA?

• The Health Insurance Portability and Accountability Act (HIPAA)

• A “Patients’ Rights” Law

• Enacted by Congress to protect patient privacy

• HIPAA protects patient information in all formats: electronic, written, and verbal

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• The HIPAA Privacy Rule gives patients the right to:– Access, inspect, copy and request

changes to medical records– Request an accounting of where

their medical records have been disclosed

– Request restrictions on disclosures of their health information

– Receive confidential communications about their health information

– File complaints regarding Covenant’s compliance with HIPAA

The Privacy Rule

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Confidentiality

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Protected Health Information

• Commonly referred to as “PHI”• According to the Department of

Health & Human Services, PHI is defined as:– individually identifiable health

information – that is transmitted or maintained in any

form or medium

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What is PHI?

• PHI includes many common identifiers: – Name – Date elements – including birth,

admission, discharge, or death date– Social Security Number– Address– Telephone or fax numbers– E-mail addresses– Medical record or account numbers– Device identifiers and serial numbers – Health plan member ID numbers – Identifiable photographs – including

those of birthmarks, scars, and tattoos

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• Conversations about Patient Health• Medical Records• Arm Bracelets• Pharmacy Orders• Dietary Cards• IV and Meds Bags• Payment and Insurance Records

PHI Includes:

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• Place all medical records and other documents with PHI in a secure location when you leave the area

• Dispose of all PHI in appropriate shred bins • Escort all patients and visitors through

departmental areas• Use extreme caution sending out faxes –

use a cover sheet and verify numbers • Don’t discuss patient information openly in

public areas (halls, elevators, cafeteria, etc.)• Don’t leave sensitive computer files up on

your unattended computer screen• Never share your password with anyone!

Protecting PHI

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You Can Share PHI For Three Purposes:

1. Treatment – when talking to co-workers in the treatment area

2. Payment – when filing an insurance claim or discussing payment options

3. Operations – for purposes such as audits, customer services, quality improvements and grievance resolution

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Treatment, Payment And Operations:

• Commonly referred to as “TPO”• Information may be used and

disclosed for treatment, payment, and operations purposes without a specific authorization from the patient– However, a separate and specific

authorization IS REQUIRED for mental health and substance abuse records.

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Ask your supervisor, manager, Privacy Officer or

Integrity-Compliance

Questions?

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Minimum Necessary

• “Minimum necessary” refers to limiting the amount of information to only what is needed to accomplish a job-related task.

• Clinical staff should have access to PHI of patients for whom they provide care and to the level necessary to perform appropriate care.

• Minimum Necessary rules limit access to the computer systems, software, groups of patients, or record content required to performing the employee’s assigned duties.

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• If you, as part of Covenant’s workforce, intentionally disclose PHI, you could be held personally liable. The fines and penalties under HIPAA: – Simple Disclosure – fines up to

$50,000 and/or 1 year in prison– Disclosure under false pretenses –

fines up to $100,000 and/or 5 years in prison

– Disclosure with intent to sell or use – fines up to $250,000 and/or 10 years in prison

Fines and Penalties for Non-Compliance

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• Adjust the way we think and how we do our jobs

• Become more aware of privacy issues

• Pay close attention to training

• Ask questions

• Develop a constant consideration for our patients’ right to privacy

How Do We Remain HIPAA Compliant?

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HIPAA Review

• Only share Protected Health Information (PHI) for Treatment, Payment and Operations (TPO)

• Place items in your work area containing PHI in a secure place

• Use extreme caution sending out faxes – use a cover sheet and verify numbers

• Dispose of all PHI properly• Don’t talk about PHI outside the

treatment area• When discussing PHI – keep your voice

down• Report non-compliant actions to your

supervisor, manager, Privacy Officer, or Integrity-Compliance

• Protect your patient’s information as if it were your own!!

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Help Make A Habit of HIPAA!

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Comment Boxes

Comment boxes are located near each of

our green elevators 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 Month” cards to

recognize staff members, volunteers and

physicians who have gone above and

beyond to serve our patients. Cards area

available at the comment boxes or online at

___________________________________

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. You can contact the

department by dialing ext. 11309.

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INFECTION PREVENTION

HAND HYGIENE, WITH SOAP AND WATER OR ALCOHOL HAND

SANITIZER, IS THE SINGLE MOST EFFECTIVE WAY TO PREVENT

THE SPREAD OF INFECTION.

IT IS OUR DUTY TO PROTECT OUR PATIENTS!!!

FSRMC has Infection Control policies and an Exposure Control Plan to

prevent the transmission of bloodborne pathogens such as HIV, HBV, HCV,

and other potentially infectious agents to its staff 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.

•The following pages will cover:

–Categories of isolation

–Hepatitis B and C

–HIV

–MRSA

–C. difficile (C. diff)

–VRE

–TB

–Needlestick/Body Fluid Exposure Policy

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Type of Isolation Infections Isolated What to do for each type of isolation

CONTACT MRSAVREC. difficileMajor draining woundsMulti-drug resistant gram negative bacteria (such as Acinetobacter)

•PPE cart/cabinet stocked•Hand wash with soap/water or hand sanitizer•Glove before entry into room•Gown before entry into room•Alert other departments of patient’s isolation status•Dedicated equipment (BP cuff, stethoscope, etc) in room.

AIRBORNE Pulmonary Tuberculosis (TB)*Severe Acute Respiratory Syndrome (SARS)*Smallpox

(*Contact Infection Prevention immediately)

•Place patient in negative air pressure room •Staff must 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 a respirator•Wait one hour after patient discharge for unprotected entry into room

AIRBORNE Plus CONTACT

Chicken Pox, disseminated Shingles Measles

•Put both Contact and Airborne signs on door•Keep door closed at all times•Only staff with normal immune systems should be assigned to care for the patient•Negative air pressure room recommended if extensive draining lesions or lesions in mouth or nares(Can be transmitted through air if lesions are present in nose or mouth, or from handling contaminated linen; transmission from hands/items contaminated with drainage from lesions can occur)

DROPLET Flu, pertussis (whooping cough), Neisseria meningitidis meningitis, Mycoplasma pneumonia, Parvovirus B19, Haemophilus influenza meningitis, rubella, adenovirus, pharyngeal diphtheria, mumps, Group A strep

•Wear yellow mask to enter room•Eye protection as required•Patient should wear yellow mask, if possible, to leave room

NEUTROPENIC Patients with WBC less than 1,000Cancer patient receiving chemoOrgan transplant patient receiving immunosuppressive drugs or steroidsOther immune conditions that physicians feel need precautions

•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 must not enter the patient’s room. •All equipment that will come into contact with the patient must be disinfected 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 should wear yellow mask upon leaving the room.

Implementation Checklist

1)Stock isolation cabinet2)Place isolation sign on door3)Place isolation sticker on chart4)Make sure alcohol hand sanitizer dispenser has solution5) Place disposable stethescope in patien’ts room.

1)Enter isolation status in computer2)Be sure to alert other departments of patient’s status3)Appropriate hand hygiene4)Explain isolation to family/patientAdditional information, fact sheets, etc., available from infection prevention @ 541-1259

ISOLATION IMPLEMENTATION

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WHAT YOU SHOULD KNOW ABOUT HEPATITIS B

WHAT IS HEPATITIS B? •A virus that causes inflammation of the liver—one of your body’s most vital organs•It is found in blood and other body fluids

HOW IS IT SPREAD? (Mainly through blood)• Infected needles and sharps• Shared personal care items (razors and toothbrushes)• Unprotected sex• Membranous exposure (eyes, nose, mouth)• Bites and wounds• Perinatal transmission

HEPATITIS B CAN RESULT IN:• No symptoms• Mild illness to 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)• Can be 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 function• Blood test for virus and antibodies

HOW DO WE TREAT HEPATITIS B?• No treatment

PREVENTION - Vaccine is very effective Health care workers: Use standard precautions, get vaccinated, exposure management If you are Hepatitis C positive: Protected sex, don’t donate blood or organs, don’t share personal care items Hepatitis B vaccine is offered to eligible FSR employees at time of employment

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WHAT YOU SHOULD KNOW ABOUT HEPATITIS C

WHAT IS IT?• A virus that can cause serious liver disease• Found in blood; possibly other body fluids

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)• Blood transfusion (before 1992 only)

HOW DOES IT AFFECT YOUR HEALTH? It damages your liver• Approximately 85% develop chronic liver disease 20-30 years after initial infection• Cirrhosis (30-40%)• Cancer (2-4%)• Liver failure• Problems with your immune system

WHAT ARE THE SYMPTOMS? (Usually the 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 function • Blood test for virus and antibodies

HOW DO WE TREAT HEPATITIS C?• Avoid alcohol and non-prescription medications containing 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 Hepatitis C) Health care workers:

Use standard precaution practices if there is risk of exposureFollow hospital policy for exposure management

If you are Hepatitis C positive:Use condoms during sexDon’t donate blood products, body tissue, organsDon’t share needles, razors, toothbrushes, manicure tools, or other personal items.

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WHAT YOU SHOULD KNOW ABOUT HIVWHAT IS IT?• A virus that enters the bloodstream, invades and overwhelms the 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)• Early on - may not have symptoms for years• Later - swollen glands, minor diseases and infections• Very late - 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 drugs

PREVENTION Health care workers:

Use standard precautions, exposure management. If you are HIV positive:

Protected sex, don’t donate blood or organs, don’t share personal care items

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WHAT SHOULD YOU KNOW ABOUT METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREAU (MRSA)

What is Staphylococcus aureus?Staphylococcus aureus is a bacterium frequently found on the skin and groin and in the nose and GI system. It

can cause infection at many sites in the body. 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 antibiotics also, so MRSA can be serious or even life-threatening to your patient.

How Does Infection Occur?MRSA is usually transmitted from patient to patient by the hands of health care workers. Also, patients may

already have it on their bodies. They may become infected with their own bacteria, so MRSA already on the patient’s skin could cause a wound infection, for example.

How Do You Prevent Transmission of MRSA?Infections caused by MRSA require extra precautions in addition to Standard Precautions. Practicing good

patient care and maintaining required aseptic and sterile technique is important. Reasons for extra precautions include the potentially serious outcomes of infection, the ease by which MRSA contaminates the environment, and its ability to live for many days on the environment, objects, and fabrics. Patients with MRSA are placed in Contact Isolation.

How Do You Implement Contact Isolation?• Post the contact isolation sign on the patient’s door or door frame.

• Ensure cabinet is adequately stocked with gloves, gowns, and thermometer.• Dedicate equipment for that patient’s use only. If equipment must be used on another patient,

clean and disinfect with an appropriate cleaner/disinfectant.• Place the isolation label on the front of the chart.• Handwashing must be performed before and especially after leaving the room. Either 10-15

seconds of lathering with soap and water or alcohol hand sanitizer is okay. Be sure to clean under and around the fingernails and jewelry if worn.

• Gloves and gowns must be worn in order to enter the room. • 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.• Encourage and educate others to appropriately follow isolation precautions.• Used linen should be bagged in the patient’s room.• Place disposable stethoscope in patient room.

Family and Patient Fact Sheet for MRSA are available by calling Infection Prevention at 541-1259 or House Supervisor at 541-4948.

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WHAT YOU SHOULD KNOW ABOUT CLOSTRIDIUM DIFFICILE (C. DIFFICILE)

What is C. difficile?A spore-forming bacterium that produces toxins. It is a common cause of antibiotic-associated diarrhea (AAD).

What causes C. difficile?Antibiotics can cause diarrhea, but it is more severe if caused by C. difficile. C. difficile-associated diarrhea can

be mild and self-limited, but it can result in pseudomembranous colitis (PMC), a more severe form.

How is C. difficile transmitted?It is most often transmitted via the hands of health care personnel or unclean patient care equipment. Infection

results from ingestion of C. difficile spores. Commodes, baby baths, and electronic thermometer handles

are among the environmental sources known to transmit C. difficile.

What prevention and control measures can be taken?• Post the enteric version of the contact isolation sign on the patient’s door or door frame.• Ensure cabinet is adequately stocked with gloves, gowns, and thermometer.• Place disposable stethoscope in patient’s room.• Alcohol hand sanitizers will not kill C. difficile spores; therefore washing with soap and water is

important to physically remove the spores. • Wear gowns and gloves to enter the room.• 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). Wheelchairs, intravenous poles, and stretchers should be cleaned by vigorously wiping surfaces with an approved disinfectant/cleaner.

• The environment of the room may be highly contaminated with C. difficile spores. Thoroughly

clean and disinfect the room, especially: 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 visibly soiled areas. • Used linen should be bagged in the patient’s room.• Minimize antibiotic use in patients.

How is C. difficile infection treated?• Discontinue antibiotics if possible, or use agents less likely to cause C. difficile-associated

diarrhea .• Antibiotics effective against C. difficile may be indicated in more severe cases.

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WHAT YOU SHOULD KNOW ABOUT VANCOMYCIN-RESISTANT ENTEROCOCCUS (VRE)

What is Enterococcus?Enterococcus is a bacterium normally found in the gastrointestinal tract and female genital tract. It can cause infection of the urinary tract, abscesses and wounds, decubitus ulcers, diabetic foot ulcers, bloodstream infections, and endocarditis. If Enterococcus is resistant to the antibiotic vancomycin, it is referred to as VRE (vancomycin-resistant Enterococcus). VRE is often resistant to many of the other drugs used to treat enterococcal infection. Infections caused by VRE can be life-threatening.

How Does VRE Infection Occur?Infection often results from bacteria leaving the patient’s GI tract or GU tract, entering a site elsewhere on the body and causing an infection (i.e., wounds or a urinary catheter). VRE can also be transmitted to a patient by the contaminated hands of HCW’s (with or without gloves), contaminated patient care equipment or a contaminated environment.

How Do You Prevent Transmission of VRE?Infections caused by VRE require extra precautions in addition to Standard Precautions. Practicing good patient care and maintaining required aseptic and sterile technique is important. Reasons for extra precautions include the potentially serious outcomes of infection, the ease by which VRE contaminates the environment, and its ability to live for many days on the environment, objects, and fabrics. Patients with VRE are placed in Contact Isolation.

How Do You Implement Contact Isolation?• Post the contact isolation sign on the patient’s door or door frame.• Ensure cabinet is adequately stocked with gloves, gowns, and thermometer.• Place disposable stethoscope in patient room.• Dedicate equipment for that patient’s use only. If equipment must be used on another patient, clean and

disinfect with an appropriate cleaner/disinfectant.• Place the isolation label on the front of the chart.• Handwashing must be performed before and especially after leaving the room. Either 10-15 seconds of

lathering with soap and water or alcohol hand sanitizer is okay. Be sure to clean under and around the fingernails and jewelry if worn.

• Gown and gloves must be worn in order to enter the room. • 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.• Encourage and educate others to appropriately follow isolation precautions.• Used linen should be bagged in the patient’s room.

Family and Patient Fact Sheet for VRE If the patient or family requests information about VRE, contact Infection Control at 541-1259 or the

House Supervisor at 541-4948.

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WHAT YOU SHOULD KNOW ABOUT TUBERCULOSIS (TB)

WHAT IS IT?An infection that occurs mostly in the lungs, although other body sites (such as the larynx and bones) can also be infected.

HOW IS IT SPREAD?The germs are spread in the air when an infected person coughs or sneezes.

WHAT ARE THE RISK FACTORS FOR TB?• HIV infection/AIDS • IV drug abusers • Foreign-born• Elderly • Homeless • Institutionalized persons (eg, in nursing homes, prisons) • Heavy smokers • Alcoholics

WHAT ARE THE SIGNS/SYMPTOMS? (May vary from person to person)• Fevers, cough, weight loss, and night sweats• May have a positive TB skin test• May have an abnormal chest x-ray• Symptoms may depend on the body part that is infected

HOW DO WE TEST FOR TB?• TB skin test, which is “read” within 48-72 hours after placement• Chest X-Ray• Sputum specimen for smear and culture

HOW DO WE TREAT TB?• Airborne isolation. • A respirator, not a paper mask, must be worn by HCWs entering the patient’s room. The room door

must be kept shut and the pressure monitor turned on.• Anti-tuberculosis drugs

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NEEDLESTICK/BODY FLUID EXPOSURE POLICY

Policy Statement

All work-related percutaneous (needlestick, laceration, bite) or permucosal (ocular, mucous membrane) exposure to blood

or body fluids must be reported to Employee Health. CDC guidelines will be followed for assessment and treatment.

Objective

To prevent transmission of hepatitis B (HBV), hepatitis C (HCV), and HIV to 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. Incidents (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, HCV, 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 sharps container. When full, the container is closed off and placed in the appropriate location for disposal. Contaminated needles are not to be recapped unless there is no safe alternative. A one-handed scoop technique must be used by the employee.

(see EOHS, Blood/Body Fluid Exposures Policy and FSRMC Exposure Control Plan – Policy # EC.SF.006)

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10 Ways to Protect Yourself and Your Co-Workers From Bloodborne Pathogens

Reference: OSHA Standard 1910.1030

1. Use Universal Precautions

2. Wash your hands

3. Do not remove, recap, bend, or break needles

4. Do not eat or drink in contaminated areas

5. Wear your PPE

6. Clean and disinfect contaminated work surfaces

7. Dispose of regulated waste properly in an approved sharps container

8. Take the hepatitis B vaccination series

9. Report exposure incidents to your

supervisor

10. Know the Biohazard symbol

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AGE SPECIFIC CARE

When caring for patients it is important to take into consideration their age and developmental stage. There are 5 stages of life:

#1 Infancy (newborn to 1 year)

During this stage, patient safety is important. Make sure side rails are up on cribs, small objects cannot be swallowed, limit visitors and increase security. Approach infants in a calm, caring manner.

#2 Pediatrics (1 year to 12 years of age)

For patients during this developmental stage, provide a safe environment and use age appropriate equipment such as potty chairs. Involve the child in their care and allow them to make choices when appropriate. Use praise, reward and positive attitude.

#3 Adolescence (12years to 18 years of age)

It is important to involve patients of this age in their care, speak directly to them, and allow time for questions. Allow for their privacy during personal hygiene and give them choices to ensure self confidence. Also, it is important to provide the patient and parents with information regarding health care issues related to their age (sex, contraception, substance abuse, nutrition, etc.)

#4 Adulthood (19 years to 64 years of age)

It is important to involve these patients in their care, treatment, diagnosis, and procedures. Family support and visitors are necessary to their improvement. Allow them to verbalize fears, anxiety, and concerns related to their care.

#5 Geriatrics (65 years and older)

It is crucial to maintain a safe environment for these patients (side rails up, fall prevention, mobility needs, and communication.) Prior to performing any treatments of procedures, explain fully to the patient and allow time for questions. Provide for sensory losses such as visual impairment and hearing loss. Involve family in patients care and decision making.

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SAFETY DEPARTMENT

Fort Sanders Regional Medical Center’s Safety Department phone number is 541-1213.The Safety Department is here for YOU! We want you to work safely and feel safe while

you are at work. The Safety Department is located on the 3 rd floor of Laurel Plaza.

To Report a Safety Issue:Notify your Supervisor Immediately!Or, notify the Safety Department (if immediate assistance is needed call the PBX Operators to contact Safety Representative)

Safety Manual (Red Book) Contains polices regarding: Spills, Decorations, Hazard Communication & Respiratory

Protection Program Smoke Compartment diagrams Know where this book is located in your Department!

Emergency Operations Manual (Yellow Book)Contains Emergency Operating Procedures (Notifications/Responsibilities)Contains Hazard Vulnerability Analysis (Know what are top threats are and know your responsibilities are during a Code Yellow)Know where this book is located in your Department!

Material Safety Data Sheet (MSDS) Manual (Orange or Labeled Book)Your Right to Know what chemicals you work around.A MSDS will give you information on how to clean up a spill, what Personal Protective Equipment to wear and how to dispose of the waste.Know where this book is located in your Department!

Danger Out Of Order TagsUse on any piece of equipment that is broken, damaged or malfunctioning.Fill out the Form Completely and Attach to the equipment.This includes but not limited to patient – non-patient equipment,

furniture, computers etc……

• Activation of any Emergency Dial “66” - this is the Emergency Line to the OperatorsCall the Security Department at 541-1309 or in house #11309

• Fire EmergencyActivate the nearest pull stationRemember RACE and PASSClose ALL Doors in the hospital and clear all items from corridorsKnow where the next smoke compartment is if evacuation is necessary (located in Safety Manual)Respond to the affected area if available with yourself, wheelchair or fire extinguisher

R - RescueA - ActivateC - ContainE - Extinguish

P – Pull the PinA – Aim at the base of the fireS – Squeeze handle S – Sweep from side to side

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Safe Haven Law

• Hospitals and clinics are designated under TN state Law as a location where a new mom, desperate to hide an unwanted baby, can bring her newborn instead of abandoning the infant in an unsafe place where it may die.• As a Safe Haven, all employees are required to perform any act necessary to protect the physical health and/or safety of the child.

Surrendered Newborn

• If a baby is surrendered anywhere on the hospital property, ANY hospital employee will accept the newborn infant presented to them assuring the mother that this is a Safe Haven.

Students and Instructors: Promptly contact the unit manager or shift leader for assistance.

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Falls Safety Program

Identify those at “high risk” for falls using the Heinrich II assessment tool.

Utilize the Falls Safety Bundle including:• Yellow arm band• Yellow star on door frame• Continuous bathroom observation• Scheduling toileting• Bed Alarm• Gait Belt with ambulation• Helmet and mat if patient is on an anticoagulant

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SUBJECT: Photographs, Videotapes, Films, Digital Images, and Any Other Means of Recording That Captures Images in Covenant Health Facilities POLICY NUMBER: C49 PAGE 1 OF 8

GENERATED BY: Integrity-Compliance Office

APPROVED BY: ELT

ISSUED: 2/23/06

REVISED: 1/21/11 REVIEWED: 2/17/11

REFERENCE:

Scope All Covenant Health operations. Purpose To establish parameters for the taking and use of photographs, videotapes, films, digital images, or any other means of recording that captures the images of patients, visitors, staff, volunteers, and physicians, as well as equipment and physical locations within Covenant Health facilities. Definition “Photograph, photography, or photographing” as used in this policy means any recording (or the making of any recording) that captures images of patients, visitors, staff, volunteers, or physicians, as well as equipment and physical locations within Covenant Health facilities, and includes still photography, video taping, filming, and digital imaging. Policy A Covenant Health facility or organization may take, and permit the taking of, photographs for use in furtherance of educational, treatment, research, scientific, public relations and charitable goals in accordance with the procedures set forth in this policy. As a general rule, the Covenant Health facility or organization must obtain the consent of the subject of the photograph (or his/her personal representative) before taking and using any photograph. In some cases, the subject of the photograph must consent to such photography in writing and must provide written authorization for uses and disclosures of the photograph(s). Except as provided in this policy or by other Covenant Health policies, taking and use of photographs is not permitted in Covenant Health facilities or organizations. Procedure 1. Public Areas. No photography shall be permitted in public areas of Covenant Health facilities or organizations, including registration areas, waiting areas, entrances/exits, hallways, or restrooms, except for the facility’s or the organization’s security purposes, approved marketing purposes, or as approved by the chief officer of the facility/organization after any necessary consultation with risk management. 2. Equipment and Physical Locations. Photographing equipment or physical locations within Covenant Health facilities and organizations is prohibited except for security

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approved by the chief officer of the facility/organization after any necessary consultation with risk management. 3. Staff, Volunteers, and Physicians. Photographing Covenant Health facility staff, volunteers, and physicians by anyone other than Covenant Health, a Covenant Health facility/organization, or their agents, employees, and contractors is prohibited except as expressly authorized by the person being photographed. If a Covenant Health facility/organization employee, staff member, volunteer, or physician is to be photographed for purposes of public relations, publicity, advertising, or promotion of Covenant Health or any of its related organizations, such person(s) shall sign a consent form substantially in the form of Attachment A. Such consent shall be maintained for six (6) years after the expiration of the public relations, publicity, advertising, or promotional campaign in which such photograph was used. 4. Patients. Federal and state law protects patient health information, including photographs identifying a patient. Photographs therefore must be treated as protected health information in accordance with the Covenant Health HIPAA policies and procedures. Patient consent generally should be obtained before taking a photograph. Photographing patients in Covenant Health facilities or organizations is prohibited except as described below:

a. In Private Non-Treatment Settings by Friends or Family Members. A patient may be photographed by the patient’s family members or friends in nonpublic areas of the Covenant Health facility or organization if the patient or his/her personal representative verbally consents to such action and the patient is not currently undergoing treatment at the time the patient’s photograph is taken. This exception permits, for example, a family member or friend to take a newborn’s photograph in a hospital nursery if the infant’s mother or father consents to such action. It also permits a patient’s family members or friends to take the patient’s photograph in the patient’s room as long as the patient consents to such action and is not receiving treatment at the time the photograph is taken. This exception is qualified by the following:

i. Covenant Health staff or the treating physician may intervene at any time

to prohibit the patient’s photograph from being taken if such action is or could be intrusive, invasive, bothersome, or disrespectful to the patient or if such action interferes or could interfere with patient care.

ii. Photography of surgical procedures, invasive procedures, operations,

and rendering of medical care to a patient is not allowed. iii. Photography is allowed of a minor or incompetent patient only with

consent of the minor’s parent or legal representative. iv. Photography is not allowed in an intensive care unit or any other unit in

which such photography could interfere with patient care. v. Photographs shall not be taken of other patients or their visitors. vi. Facility staff, volunteers, and physicians shall not be photographed

without their express consent. vii. Before a photograph is taken for legal reasons, permission must be

obtained from the treating physician (with the treating physician’s consent documented in the patient’s medical record) and the House Supervisor, who may wish to consult with Risk Management.

Policy No. C49 Title: Photographs, Videotapes, Films, Digital Images, and Any Other Means of Recording That Captures Images in Covenant Health Facilities Date Approved: 2/23/06 (issued) Page 2 of 10

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b. Newborn Portraits. A newborn’s photograph may be taken in accordance with Policy C.47, “Uses and Disclosures of PHI Pertaining to Newborns.”

c. For Treatment or Health Care Operations Purposes. A patient’s photograph

may be taken by a Covenant Health facility or organization for treatment purposes or for purposes of “health care operations.” See Policy C.11, “Úses and Disclosures for Health Care Operations.” For example, objective recording of trauma, decubitus ulcers, and similar conditions may be necessary to provide proper treatment to the patient and for facility training purposes. The patient or his/her personal representative must sign a consent form substantially in the form of Attachment B. A nurse must be in attendance at all times while photographs are being taken to assist the patient as needed. The photograph must be used only for purposes of treating the patient or for purposes of health care operations and must be maintained in the patient’s medical record, except as otherwise provided in Section 6 of this policy.

d. For Purposes Unrelated to Treatment or Health Care Operations. A patient’s

photograph may be taken for purposes unrelated to treatment or health care operations if (i) the Covenant Health facility or the treating physician initiates the request, (ii) the patient or his/her personal representative consents to such action in the form of the written consent attached to this policy as Attachment C, and (iii) the patient or his/her personal representative authorizes use and disclosure of such photographs in the form of written authorization attached to Policy C.8, “Authorization to Release Protected Health Information.” The signed consent and authorization shall be included in the patient’s medical record. This exception permits, for example, photographs to be taken of a particular condition for research purposes or for marketing and publicity purposes (refer to HIPAA Policy C.30, “Uses & Disclosures for Advertising and Marketing”). A nurse must be in attendance at all times while photographs are being taken to assist the patient as needed, and the photographs must be used and disclosed only for the purposes described in the authorization.

e. For Mandatory Reporting of Abuse or Neglect and Investigations of the

Same. A patient’s photograph may be taken by a Covenant Health facility or organization if necessary to supplement the written report of actual or suspected abuse or neglect for which there is a mandatory reporting requirement (e.g., child abuse or neglect; abuse or neglect of vulnerable adults). See Policies C.23 “Disclosures Required by Law,” C.24 “Disclosures for Public Health Purposes,” C.27 “Disclosures About Adult Victims of Abuse, Neglect, or Domestic Violence,” and the Covenant Health Mandatory Reporting Manual. The patient or his/her personal representative must consent to the taking of such photographs, with such consent documented in the patient’s medical record. Authorization to disclose the photograph to the governmental agency responsible for receiving reports of actual or suspected abuse or neglect is not required because reporting is mandatory. A nurse must be in attendance at all times while photographs are being taken to assist the patient as needed, and the photographs must be used only for purposes of reporting patient abuse or neglect. The photograph must be used only for purposes of reporting abuse or neglect and must be maintained in the patient’s medical record, except as otherwise provided in Section 6 of this policy. Photographs taken of a patient by the Tennessee Department of Children’s Services or the Department of Adult Protective Services while investigating actual or suspected cases of abuse or neglect do not require the Covenant Health facility or organization to obtain consent from the patient or his or her legally authorized representative. Tenn. Code Ann. §§ 37-1-406(f), 37-1-609, and 71-6-118(j)(1) (2006).

f. Law Enforcement. A patient’s photograph may be taken by law enforcement for purposes of documenting evidence of a crime if such photography does not interfere with patient care, the patient or his/her personal representative consents to law enforcement taking such a photograph, with such consent documented in the patient’s medica record, and either (i) the disclosure to law enforcement complies with HIPAA Policy C.26, “Disclosures for Law


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Enforcement, including Criminal Subpoenas”; or (ii) the patient or his/her personal representative authorizes disclosure of such photographs to law enforcement in the form of written authorization attached to Policy C.8, “Authorization to Release Protected Health Information.” A nurse must be in attendance at all times while photographs are being taken to assist the patient as needed. Covenant Health facility or organization staff and volunteers shall not take photographs of patients on behalf of law enforcement.

5. Former Patients or Non-Patients Participating in “Non-Covered Entity” Covenant Health Services or Programs. Former patients who are voluntarily participating in marketing initiatives such as testimonials, interviews, etc., must sign the consent form associated with HIPAA Policy C.30, “Uses & Disclosures for Advertising and Marketing.” In addition, if a visual image is to be captured, the former patient must sign the consent form attached to this policy as Attachment D. Non-patient individual participants of programs or services which are not classified as covered entities under HIPAA guidelines (e.g, a student in Covenant Health’s nursing education program, a member of Fort Sanders Health and Fitness Center) who are participating in marketing initiatives must sign only the consent form attached to this policy as Attachment D.

6. Photos at Covenant Health-Sponsored Special Events. Individuals (employees, physicians, volunteers, patients, or members of the public) who participate in special events where capturing visual images would be an expected aspect of the event (e.g., groundbreakings, holiday celebrations, public health fairs, etc.) do not have to sign consent forms for photographs. Staff coordinating the event should make every effort to inform participants that photographs or visual images of the event are being taken, and where reasonably possible, give people the opportunity to opt out of participating in photos if they so choose. 7. Storage, Transfer and Retention. Photographs must be clearly identified with the subject’s name and/or identification number (e.g., medical record number; employee badge number), and date. If it is not possible or practicable to maintain photographs with a patient’s medical record, the photographs must be stored securely to protect confidentiality, and a note or record must be maintained in the medical record indicating the availability and location of the photographs. The form attached to this policy as Attachment E may be used for such purpose. Photographs shall be retained in accordance with the Covenant Health Document Retention Schedule, with photographs that are part of the patient’s medical record being maintained in accordance with the retention requirements for medical records.

a. Images not installed in a camera (photographs, film, video tapes, DVDs, etc.) must be labeled with the identifier “PHI” if the images include PHI. Stored “hard copy” images containing PHI should be kept in a locked or secured area.

b. Digital images which include PHI should be labeled “PHI” through file naming

conventions or metadata tags. Digital images should not be stored in a camera’s built-in memory, but should be saved to a dedicated and labeled memory card which is labeled and stored in a secured area, or to an encrypted laptop or appropriate network storage.

c. Images which are no longer being used will be deleted (if electronic) or disposed of in

a secure manner through shredding of paper photographs or full destruction of tapes, DVDs, etc.

Any images containing PHI that are e-mailed outside Covenant Health must be sent using [SECURE] in the subject line and if otherwise transmitted over the internet, be encrypted and password protected using a utility approved by the Covenant Health


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a. Information Security Office and supported by the IT department. Images e-mailed by Covneant Health marketing representatives to media outlets for public distribution require the subject’s consent (included on Attachments C and D) for unsecured transmission if the media outlet(s) request unencrypted messaging.

b. Access to images containing PHI must be logged or tracked for disclosure reporting if

access is for a reason other than outlined in the patient’s consent form. 8. Use of Personal Photographic Devices by Covenant Health Employees. Employees may not use their personal multi-function communications devices, such as camera phones or “smart phones,” to take individual pictures of patients, former patients, or individual non-patient participants in Covenant Health programs, even if the photo is being taken for work-related purposes. Photos/images/videos of these individuals must be taken with a standard camera, either film-based or digital. If digital, the image must be stored on a memory card or other dedicated device that is used exclusively for images related to Treatment/Payment/Operations, or approved marketing purposes, and which can be removed from the camera, identified clearly, and stored securely.

Personal Communications dervices may be used to take photos of employees, physicians, volunteers and/or special events, if approved for work-related purposes and with consent from the individual subjects, or (for group photos) as outlined in Item 6. Such photos may only be taken/used for a specific work-related purpose and must be deleted from the personal device once transferred to another format for the approved purpose (e.g., using a camera phone to take a group photo at a Covenant Health-sponsored hike, and sending the image to the Covenant Health marketing department for to promote the walking program). Related Policies Covenant Health Policy C2 “Personal Representatives and Authority to Exercise Privacy Rights”


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Fort Sanders Regional Medical Center Fort Sanders Regional Medical Center Emergency Operations PlanEmergency Operations PlanSection 3.2 Protective ActionsSection 3.2 Protective Actions Rev. 01/10Rev. 01/10

CODE RED - Fire Employee Fire alarm sounding, no smoke or flames sighted:1.Off campus – evacuate building2.Hospital – Close all doors in the area, prepare to evacuate patients, visitors and staff to safe area.Code Red announced overhead, no smoke or flames sighted:1.Hospital – Close all fire doors, if available respond to affected area with a fire extinguisher or wheelchair. Clear all items from Corridors2.Hospital – Staff not responding to affected area; prepare to evacuate patients, visitors and staff to safe area.Smell something burning, no smoke:1.Activate fire alarm; Shout “Code Red”2.Dial 66 – Code Red and give exact location.3.Close all doors, including patient rooms. 4.Prepare to EvacuateSmoke and or Flames Sighted:1.Activate the R.A.C.E. process:

a.Rescue those in dangerb.Alarm, pull fire alarm and dial 66 - Code Redc.Confine the fire by closing all doors behind you as you leave the area.d.Evacuate as needed and/or attempt to extinguish the fire, if possible.

2.Extinguish Fire (if safe to do so) follow P-A-S-S.3.DO NOT use elevators.Department Evacuation Plan – Determined and called by the person in the first line of authority.Medical gas shut-off - Respiratory Therapy will be responsible for turning off the zone valves for that location when indicated

CODE GRAYSevere Thunderstorm Warning

Security notifies Administrative Supervisor who notifies PBX for overhead page

1.Staff must ensure medical equipment is plugged into the red outlets for generator power.2.Staff must ensure flashlights are accessible and ready.

CODE GRAY Tornado WarningIssued when a tornado has actually been sighted and is threatening the community.

Security notifies Administrative Supervisor who notifies PBX for overhead pageAdministrative Supervisor notifies Administrator-on-call that Code Gray is in effect.

1.Close all interior doors (including fire doors).2.Ensure all staff members and patients are moved to the interior hallways and have a pillow and blanket.3.Follow specific Department Plan for removal to safe areas, if applicable. 4.Everyone will remain in his/her tornado warning shelter until the warning has expired and/or the threat has passed.5.PBX will announce “Code Gray All Clear”.After the tornado/winds have passed:1.Staff members assess for staff, patient and visitor injuries2.Engineering will assess for structural damage and report to administrator-on-call.3.Depending upon the extent of damage, number of injuries and expectations from community influx the Emergency Operation Plan may be implemented.

CODE ORANGEHazmat Incident (Nuclear, biological radiological or chemical)

Nursing 1.Engineering, Safety, Security, and the Emergency Department will determine actions based on the event.

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Fort Sanders Regional Medical Center Fort Sanders Regional Medical Center Emergency Operations PlanEmergency Operations PlanSection 3.2 Protective ActionsSection 3.2 Protective Actions

Rev. 01/10Rev. 01/10 CODE PURPLE Hostage Situation

Employee Department Affected:1.If possible, evacuate your area to place of safety without endangering the life of anyone present.2.Notify the PBX ext. 66. PBX will immediately transfer the call to Security. An overhead announcement will be made only at the direction of the Administrative Supervisor.3.Close the doors to the affected area to block off additional entrance by those who are not aware of the hostage situation.4.Assign someone to stay outside the affected area to warn others from entering until relieved by security or police.5.Advise security personnel of any and all information.6.Meet with law enforcement agency and administrative personnel to relay all information about the hostage situation.

CODE BLACK Bomb Threat by telephone.

Employee If you receive telephone bomb threat…1.Do not hang up.2.Remain calm3.Try to prolong the conversation and get as much information as possible4.Note what you hear:

a.Background noises (music, voices)b.Caller’s accent, sex, age, unusual words or phrases.c.Does the caller know the medial center?d.How is the bomb location described?e.Does the caller use a person’s name?

5.Dial 66 and report a bomb threat - PBX will immediately transfer the call to Security. Identify yourself – give your name, phone number, and department. Security will immediately notify the Administrative Supervisor who will begin notifications. 6.Notify your supervisor immediately and stand by for further instructions.

CODE BLACK Suspicious Item or Bomb

Employee, Security

1.Leave the item untouched and secure the area until security arrives.2.Call ext. 66 and report a suspicious item. 3.If directed, evacuate your area.

Chemical SpillsHazardous Materials

Employee, Safety Officer, Environmental Services

1.Minor Spill:a.Isolate the immediate area. Notify immediate Supervisor, obtain MSDS/Spill Kit, Fill out Spill Report and Notify Safety Officer and Environmental Services.b.DO NOT touch, smell, or taste the spilled material.

2.Major Spills (in addition to the above):a.Be prepared to evacuate staff and patients from the building following evacuation plan for your department.

Chemical Spills Hazardous Drugs

Employee, Safety Officer, Environmental Services

1.Restrict access to area until spill is cleaned.2.Refer to the Acid/Base Spill Policy (SM-43), Guteraldehyde Spill Policy (SM-45), Mercury Spill Policy (SM-46) or Safe Handling of Cytotoxic Drugs

CODE PINK Infant abduction

Employees 1.One staff member should respond to elevator lobby & stairwells in their area to look for suspicious persons.2.If suspicious person(s) is observed IMMEDIATELY contact Security. For more information refer to Section 3.13 Emergency Codes

CODE SLIVERMedical Helicopter

Facility Services, Administrative Supervisor, PNRC, Receiving Dept., ED, Security

1.ED receives notification of a medical helicopter arriving at our facility.2.Administrative Supervisor and Receiving Dept. are notified.3.PNRC brings all patients and visitors inside off of the balcony.4.Facility Services shuts down air handlers.5.Security escorts Receiving Dept. staff to Penthouse.

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Fort Sanders Regional Medical Center Fort Sanders Regional Medical Center Emergency Operations PlanEmergency Operations PlanSection 3.2 Protective ActionsSection 3.2 Protective Actions

Rev. 01/10Rev. 01/10 CODE YELLOWEmergency Operations Plan

Notification of a disaster/ emergency in the community, or internal to the facility.

Refer to the Emergency Operations Plan for specific duties.

CODE BLUECardiac Arrest

Employee •Managed through Nursing not Safety•The plan addresses proper notification and response procedures as well as who is to respond.•It is important, especially for non-clinical staff, to know that if you need help for someone you can call a Code Blue.

CODE GREENSecurity/Disruptive Behavior

Security

Nursing Department Managers

Emergency Department Staff

Engineering Staff

Other staff as available

•If you are in danger or a patient is in danger call Code Green by either calling Security or 66•If you see a situation that may escalate it is ok to go ahead and call Security to see if they can assist in diffusing the situation.

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Security Department

• 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 11309. If you forget the extension, call “0” for the operator.

• If you have a cell phone it is a good idea to program in the Security Office phone number –

• 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

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The mission of Fort Sanders Regional Medical Center is to serve our community by improving the quality of life through better health. In order to better accomplish this mission, all employees of the hospital that interact with patients and families must abide by the practices established below in order to provide outstanding service to the community we serve.

STANDARDS AND EXPECTATIONS

I am committed to provide Excellent service within my organization.

AIDET: Acknowledgement, Introduction, Duration, Explanation, Thank you. Commit to a Quiet Environment

o Keep voice volume down after 8 p.m. o Change pager to a lower volume after 8 p.m. o Close patients door at night when possible o Manage patient’s perceptions and set expectations when discussing quiet at night

Implement the “No Pass Zone” o Do not pass by when a call light is going off o Respond quickly to patient/visitor requests for assistance

Cleanliness is the Responsibility of All Employees. o Nursing nor EVS can do it alone o Tray pick up is to be done by everyone and not left in the room o Small trash on the floor should be picked up immediately by any employee o Dirty linen will be placed in the proper container and not left on the floor in the

patient room or shower Hourly Rounding: All nursing staff will conduct hourly rounding as established to

assess for Pain, Potty, Position, and Possessions. Bedside Shift Report: Nurses will conduct their shift report at the patient bedside and

include the patient and family as appropriate in establishing the plan of care for the shift. Use of key words by nurses while delivering medications

o Every time a new medication is given, explain the medication’s purpose and side effects in a way the patient can understand

o Utilize Micromedex CareNotes to produce electronic printed instructions Pain Management

o Write the pain goal for the day on the white board o Write the time the next dose can be given on the white board

Use of White Board o Fill out the white board completely and update each shift

As an employee of Fort Sanders Regional Medical Center, I will abide by these standards and expectations.

_______________________________________

Employee Name (Please Print)

_______________________________________________ Employee Signature / Date

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