Download Standards of Care “C.A.R.E.S.”

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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
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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 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 NOT TO PARTICIPATE IN
CERTAIN ASPECTS OF CARE
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
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appropriate care.
Subject:
Human Resources
APPEARANCE
Policy Number:
HR.EE.015
Page:
1 of 6
Approved By:
Generated By:
Human Resources
Effective Date: August 1991
Samuel R. Buscetta
Revision Date: November 2010
Executive Vice President, Human Resources
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
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1
This provision is also inclusive of buttons worn on clothing; which may only be worn for approved, short term facility initiatives.
Subject:
Policy Number:
APPEARANCE
HR.EE.015
Page: 2 of 6
Human Resources
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.
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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.
Subject:
Policy Number:
Human Resources
Page:
APPEARANCE
HR.EE.015
3 of 6
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):
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warm-up or sweat pants,
stirrup pants, or
leggings.
Capri pants must be mid calf in length.
and are not permissible.
Any style of pant above mid calf are considered shorts
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
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1
Fortress Engineering and Health & Fitness Center employees are excluded from this provision.
Subject:
Policy Number:
Human Resources
Page:
APPEARANCE
HR.EE.015
4 of 6
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.
permitted.
They are not otherwise
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.
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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.
Subject:
Policy Number:
Human Resources
Page:
APPEARANCE
HR.EE.015
5 of 6
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.
male employees while on duty.
Earrings are not permitted for
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.
‘inoffensive’ is at the sole discretion of management.
The determination of ‘small’ and
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:
Policy Number:
Human Resources
Page:
APPEARANCE
HR.EE.015
6 of 6
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
374-5360
Retirement planning
401-K - Fidelity
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
TCSC
541-1399
541-1302
541-4936
541-2817
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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Subject:
Policy
Number:
Human Resources
Lawrence Kleinman
Executive Vice President, Human Resources
Page:
Generated
By:
TOBACCO FREE WORKPLACE
HR.SC.204
1 of 3
Human Resources
Approved By:
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.
1
Excluded Affiliates:
Methodist Medical Center (BU Employees)
2
Parkwest Medical Center dba Peninsula Behavioral Health
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.
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1
Tobacco use is similarly banned by MMC bargaining unit work rules
Some discretion regarding applicability is retained by Peninsula Behavioral Health due to unique treatment and operational
considerations.
2
TOBACCO FREE WORKPLACE
Subject:
HR. SC.204
Policy Number:
Human Resources
Page:
2 of 3
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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.
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Employee use of tobacco products is prohibited during the employees’ work shift; including
during breaks and meal times.
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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
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Covenant Health will assign a surcharge to health insurance rates for employees who use
tobacco products.
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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.
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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.
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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.
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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).
TOBACCO FREE WORKPLACE
Subject:
HR. SC.204
Policy Number:
Human Resources
Page:
3 of 3

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
What Is HIPAA?
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What Is HIPAA?
• The Health Insurance
Portability and Accountability
(HIPAA)
Act
• 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 Privacy Rule
• 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
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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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PHI Includes:
•
•
•
•
•
•
•
Conversations about Patient Health
Medical Records
Arm Bracelets
Pharmacy Orders
Dietary Cards
IV and Meds Bags
Payment and Insurance Records
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Protecting PHI
• 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!
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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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Questions?
Ask your supervisor,
manager, Privacy Officer or
Integrity-Compliance
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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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Fines and Penalties for
Non-Compliance
• 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
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How Do We Remain
HIPAA Compliant?
• 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
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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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ISOLATION IMPLEMENTATION
Type of Isolation
Infections Isolated
What to do for each type of isolation
CONTACT
MRSA
VRE
C. difficile
Major draining wounds
Multi-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
•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
(*Contact Infection Prevention
immediately)
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 1,000
Cancer patient receiving chemo
Organ transplant patient receiving
immunosuppressive drugs or
steroids
Other 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.
1)Stock isolation cabinet
2)Place isolation sign on door
3)Place isolation sticker on chart
4)Make sure alcohol hand sanitizer
dispenser has solution
5) Place disposable stethescope in
patien’ts room.
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
prevention @ 541-1259
AIRBORNE Plus
CONTACT
Implementation
Checklist
37
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
38
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 exposure
Follow hospital policy for exposure management
If you are Hepatitis C positive:
Use condoms during sex
39
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?
• 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
40
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.
41
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.
42
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.
43
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
44
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)
45
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
46
47
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.
48
49
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 3rd 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 Tags
Use 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 Operators
Call the Security Department at 541-1309 or in house #11309
Fire Emergency
Activate the nearest pull station
Remember RACE and PASS
Close ALL Doors in the hospital and clear all items from corridors
Know 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 - Rescue
A - Activate
C - Contain
E - Extinguish
P – Pull the Pin
A – Aim at the base of the fire
S – Squeeze handle
S – Sweep from side to side
50
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.
51
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
52
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
53
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
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.
54
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 3 of 10
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
55
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 4 of 10
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
56
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 5 of 10
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”
57
Fort Sanders Regional Medical Center
Emergency Operations Plan
Section 3.2 Protective Actions
CODE RED - Fire
Employee
Rev. 01/10
Fire alarm sounding, no smoke or flames sighted:
1.Off campus – evacuate building
2.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 Corridors
2.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 Evacuate
Smoke and or Flames Sighted:
1.Activate the R.A.C.E. process:
a.Rescue those in danger
b.Alarm, pull fire alarm and dial 66 - Code Red
c.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 GRAY
Severe
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 Warning
Issued when a
tornado has actually
been sighted and is
threatening the
community.
Security notifies
Administrative
Supervisor who
notifies PBX for
overhead page
Administrative
Supervisor
notifies
Administratoron-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 injuries
2.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 ORANGE
Hazmat Incident
(Nuclear, biological
radiological or
chemical)
Nursing
1.Engineering, Safety, Security, and the Emergency Department will
determine actions based on the event.
58
Fort Sanders Regional Medical Center
Emergency Operations Plan
Section 3.2 Protective Actions
01/10
Rev.
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 calm
3.Try to prolong the conversation and get as much information as
possible
4.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 Spills
Hazardous 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 SLIVER
Medical 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.
59
Fort Sanders Regional Medical Center
Emergency Operations Plan
Section 3.2 Protective Actions
Rev. 01/10
CODE YELLOW
Emergency
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 BLUE
Cardiac 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 GREEN
Security/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.
60
Security Department
•
The Security office is open 24 hours, 7 days a week. It is located on the 1 st
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
61
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
o
o
o
Keep voice volume down after 8 p.m.
Change pager to a lower volume after 8 p.m.
Close patients door at night when possible
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
o
o
o



Nursing nor EVS can do it alone
Tray pick up is to be done by everyone and not left in the room
Small trash on the floor should be picked up immediately by any employee
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
62