1. Fort Sanders Regional Medical Center
Welcome To
Fort Sanders Regional Medical Center
Clinical Orientation

2. Our Vision Our Values Our Purpose
We serve the community by improving
the quality of life through better health.
Through its people
Covenant Health will be recognized
as the premier health services system in Tennessee.
Our Vision
Working together in service to God, our values are:
Integrity
Quality
Service
Caring
Developing People
Using Resources Wisely
Our Values
Our Purpose

3. Human Resources Department
Laurel Plaza, Suite 106
Knoxville, Tennessee 37916
(865)
HR Director Gina Kinkaid
Sr. Generalist Susan Thompson
Generalist Jason Shubert
Coordinator Missy McCarter
Coordinator Tonya McDonald
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.

4. 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:
The Ethics Committee is available to employees as a forum and source of ideas for resolution of ethical conflict.
Employees may transfer to a position in another department, if available.
If the ethical conflict occurs when the employee is on duty, and the patient’s need for care or treatment is imminent, the staff on duty should decide who will 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.

11. 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.

12. Most Frequently Called Numbers:
FSRMC Main Line
Benefits:
Customer Service
Retirement planning
401-K - Fidelity
Cafeteria Menu Line
Chaplain or
Employee Assistance Program
Employee Health
Human Resources
Infection Control
Patient Representative
Safety
Security
Senior Leadership:
Keith Altshuler, President & CAO
Jenny Hanson, VP/CNO
Ronnie Beeler, VP/CFO
Gina Kindaid, Director HR
Julie Dougherty, Marketing Director
TCSC
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.

13. Executive Vice President, Human Resources
Subject:
TOBACCO FREE WORKPLACE
Policy Number:
HR.SC.204
Human Resources
Page:
1 of 3
Lawrence Kleinman
Executive Vice President, Human Resources
Generated By:
Effective Date: January 2011
Revision Date: October 2011
Approved By:

14. TOBACCO FREE WORKPLACE
Subject:
TOBACCO FREE WORKPLACE
Policy Number:
HR. SC.204
Human Resources
Page:
2 of 3

15. TOBACCO FREE WORKPLACE
Subject:
TOBACCO FREE WORKPLACE
Policy Number:
HR. SC.204
Human Resources
Page:
3 of 3

17. HIPAA
101
Privacy Rules

29. Lost and Found Comment Boxes
are provided for all employees, visitors or patients to provide feedback on our organization and the services we provide. The comment boxes may also be used to submit “Star of the Month” cards.
Lost and Found
All property found in the hospital including, but not limited to, personal articles, property or other valuables that are found on the premises must be turned over to the Security Department.
Star of the Month

30. INFECTION PREVENTION

31. IT IS OUR DUTY TO PROTECT OUR PATIENTS!!!
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

32. What to do for each type of isolation
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
(*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 1,000
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.
Implementation Checklist
Stock isolation cabinet
Place isolation sign on door
Place isolation sticker on chart
Make sure alcohol hand sanitizer dispenser has solution
5) Place disposable stethescope in patien’ts room.
Enter isolation status in computer
Be sure to alert other departments of patient’s status
Appropriate hand hygiene
Explain isolation to family/patient
Additional information, fact sheets, etc., available from infection

33. 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
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 precaution, get vaccinated, exposure management
HBV + individuals: protected sex, don’t donate blood or organs, don’t share personal care items
Hepatitis B vaccine is offered to eligible FSR employees at the time of employment

34. 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 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
Don’t donate blood products, body tissue, organs
Don’t share needles, razors, toothbrushes, manicure tools, or other personal items.

35. Infected needles and sharps
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.
HIV + individuals: Protected sex, don’t donate blood or organs, don’t share
personal care items

36. Methicillin-resistant Staphylococcus aureus (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 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 or House Supervisor at

37. Clostridium difficile (C. difficile) Fact Sheet
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.

38. 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 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 or the House Supervisor at

39. 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 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

40. Infection Control Safety Measures:
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
All exposure sites will be washed with soap and water. Eyes and mucous membranes exposures will be flooded with water.
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.
A tetanus booster is given per protocol, if indicated.
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)

42. Age Specific

43. 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.

44. SAFETY & EMERGENCY MANAGEMENT

45. SAFETY DEPARTMENT
Fort Sanders Regional Medical Center Safety Department phone number is
The Safety Department is here for YOU! We want you to work safely and feel safe at work
so that you may go home to your families. 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)
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.
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
Security Department is 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

46. Safe Haven Law Surrendered Newborn
Hospitals and clinics are designated under TN state Law 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.

47. 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

53. Fort Sanders Regional Medical Center Emergency Operations Plan
Section 3.2 Protective Actions Rev. 01/10
CODE RED - Fire
Employee
Fire alarm sounding, no smoke or flames sighted:
Off campus – evacuate building
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:
Hospital – Close all fire doors, if available respond to affected area with a fire extinguisher or wheelchair. Clear all items from Corridors
Hospital – Staff not responding to affected area; prepare to evacuate patients, visitors and staff to safe area.
Smell something burning, no smoke:
Activate fire alarm; Shout “Code Red”
Dial 66 – Code Red and give exact location.
Close all doors, including patient rooms.
Prepare to Evacuate
Smoke and or Flames Sighted:
Activate the R.A.C.E. process
Rescue those in danger
Alarm, pull fire alarm and dial 66 - Code Red
Confine the fire by closing all doors behind you as you leave the area.
Evacuate as needed and/or attempt to extinguish the fire, if possible.
Extinguish Fire (if safe to do so) follow P-A-S-S
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
Staff must ensure medical equipment is plugged into the red outlets for generator power.
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.
Administrative Supervisor notifies Administrator-on-call that Code Gray is in effect.
Close all interior doors (including fire doors).
Ensure all staff members and patients are moved to the interior hallways and have a pillow and blanket.
Follow specific Department Plan for removal to safe areas, if applicable.
Everyone will remain in his/her tornado warning shelter until the warning has expired and/or the threat has passed.
PBX will announce “Code Gray All Clear”.
After the tornado/winds have passed:
Staff members assess for staff, patient and visitor injuries
Engineering will assess for structural damage and report to administrator-on-call.
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
Engineering, Safety, Security, and the Emergency Department will determine actions based on the event.

54. Emergency Operations Plan
Fort Sanders Regional Medical Center
Emergency Operations Plan
Section 3.2 Protective Actions Rev. 01/10
CODE PURPLE Hostage Situation
Employee
Department Affected:
If possible, evacuate your area to place of safety without endangering the life of anyone present.
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.
Close the doors to the affected area to block off additional entrance by those who are not aware of the hostage situation.
Assign someone to stay outside the affected area to warn others from entering until relieved by security or police.
Advise security personnel of any and all information.
Meet with law enforcement agency and administrative personnel to relay all information about the hostage situation.
CODE BLACK Bomb Threat by telephone.
If you receive telephone bomb threat…
Do not hang up.
Remain calm
Try to prolong the conversation and get as much information as possible
Note what you hear.
Background noises (music, voices)
Caller’s accent, sex, age, unusual words or phrases.
Does the caller know the medial center?
How is the bomb location described?
Does the caller use a person’s name?
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.
Notify your supervisor immediately and stand by for further instructions.
CODE BLACK Suspicious Item or Bomb
Employee, Security
Leave it untouched and secure area until security arrives.
Call ext. 66 and report a suspicious item.
If directed, evacuate your area.
Chemical Spills
Hazardous Materials
Employee, Safety Officer, Environmental Services
Minor Spill
Isolate the immediate area. Notify immediate Supervisor, obtain MSDS/Spill Kit, Fill out Spill Report and Notify Safety Officer and Environmental Services.
DO NOT touch, smell, or taste the spilled material.
Major Spills (in addition to the above)
Be prepared to evacuate staff and patients from the building following evacuation plan for your department.
Chemical Spills Hazardous Drugs
Restrict access to area until spill is cleaned.
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
One staff member should respond to elevator lobby & stairwells in their area to look for suspicious persons.
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
ED receives notification of a medical helicopter arriving at our facility.
Administrative Supervisor and Receiving Dept. are notified.
PNRC brings all patients and visitors inside off of the balcony. Facility Services shuts down air handlers.
Security escorts Receiving Dept. staff to Penthouse.

55. 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.

56. The Security office is open 24 hours, 7 days a week
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 If you forget the extension, call “0” for the operator.
If you have a cell phone it is a good idea to program the Security Office phone number in it –
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