EMPLOYEE ORIENTATION HANDBOOK

EMPLOYEE ORIENTATION HANDBOOK

WELCOME !!!!! We are glad you’re here! This orientation handbook was designed to help familiarize you with our facility policies. Please take time to look through this information. Again, welcome to our family!

Employee Orientation Handbook
Table of Contents WELCOME - 3 AGENDA - 7 ADMINISTRATION Purpose, Vision, Values - 11 Organizational Structures - 13 HUMAN RESOURCES Human Resource Department Contact - 17 Orientation of New Employees - 19 Harassment Policy - 20 Workplace Violence Policy - 23 Patient Care Philosophy - 28 Staff Rights - 29 Problem Solving Procedure - 30 Complaint Filing Procedures - 34 Ethics Information - 35 Employment Information - 36 Worker’s Compensation - 37 Employee Performance & Behavior Expectations - 40 Cariten Assist Employee Assistance Program - 43 Care of Equipment & Supplies - 44 Smoking Policy - 45 GENERAL INFORMATION Frequently Called Numbers Phone List - 51 Badge FAQs - 52 Parking FAQs - 53 Time Clock Instructions - 54 Comment Box - 55 Lost and Found - 55 BENEFITS Combined Time Off (CTO) for Full Time and Part Time Employees - 59 Cafeteria - 61 Employee Health Service – 61 RISK MANAGEMENT Agenda - 65 2006 National Patient Safety Goals - 66 Systems Improvement Report - 67 Potential State Reportable Events - 69 Policy Overview – Elopement and Visitor Injuries - 71 Employee Orientation Handbook

Table of Contents Continued
Employee Incident Report - 72 Behavior Report - 74 Navigating the Intranet to Review Polices - 76 SAFETY Information About Safety at Work - 81 Emergency Codes and Basic Staff Response – 83 Emergency Response Quick Reference Chart - 84 INFECTION CONTROL Isolation Implementation - 88 Hepatitis B - 89 Hepatitis C - 90 HIV - 91 Clostridium Difficile - 92 Vancomcin-Resistant Enterococcus - 93 Methicillin-Resistant Staphylococcus Aureus (MRSA) - 94 Tuberculosis - 95 Needlestick/Body Fluid Exposure Policy - 96 SECURITY Security Office Information – 99 Weapons Policy – 100 Patient Information Policy – 101 Patient Prisoners - 102 Abandoned Baby-Surrender of Infant – 103 Suicide Precautions - 110 ABUSE How to Report - 113 CHAPLAIN Chaplain Services - 117 HEALTHCARE PROFESSIONAL SUBSTANCE ABUSE Characteristics of Substance Abuse of the Healthcare Professional – 121 CLINICAL SECTION Standards of Care – 125 Age Specific Care – 127 FORMS Restraints – 133 Clinical Post Test - 137 Infection Control Test – 139 Security – Safety Tests - 141 HUMAN RESOURCES CHECKLIST FOR NEW EMPLOYEES – 143 ACKNOWLEDGEMENT OF RECEIPT OF HANDBOOK – 145

Agenda Fort Sanders Regional Medial Center 2006 New Employee Orientation
Welcome 8:00-8:15 President 8:15-8:35 HR 8:35-8:55 Risk Management 8:55-9:40 Safety 9:40-10:30 Break 10:30-10:45 Infection Control 10:45-11:30 Security 11:30-11:50 Abuse 11:50-12:15 Lunch 12:15-1:00 Patient Rights 1:00-1:15 Diversity 1:15-1:45 Chaplain 1:45-2:15 Facility Tour 2:15-3:00 Recognizing Impaired Employees 3:00-3:15 Employee Health 3:15-3:30 *These times are approximate and subject to change

ADMINISTRATION

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

THOMPSON CANCER SURVIVAL CENTER ORGANIZATION CHART
Administrative Officer Phil Johnson Chief Director of Clinical Ann Henderlight Services Chief Financial Officer Traci McCullough Josie Stanga, Manager Clinical Trials Anita Thompson, Mgr Cancer Registry Cancer Outreach Services Shelia Baucum, Manager Breast Center Karen Woten, Mgr PET Imaging Marketing Vacant Dominic Moro, Supervisor Accounting Judy Ridenour, Mgr. Business Office Sharon Mullens, Manager Foundation SVP, Organizational Effectiveness/Clinical Outcomes Sandra Marshall Medical Director Rick Grapski, MD Thompson Oncology Group Practice Mgr Rob Sanders Radiation Oncology Downtown & West Linda Linn, Mgr Patient & Family Services Genetic Counseling Clinical Dieticians Social Services Quality Mgmt Wittenbarger Deloris Multidisciplinary Cancer Care Coordination Victoria Spry Centralized Coding & Janet Love, Mgr Registration Valerie Capps, Supervisor HIM Masoud Panjehpour, Manager Laser Center THOMPSON CANCER SURVIVAL CENTER ORGANIZATION CHART COVENANT HEALTH

HUMAN RESOURCES

Human Resources Department
Laurel Plaza, Suite 106 Knoxville, Tennessee 37916 (865) Director Colleen Andrews Sr. Generalist Susan Thompson Sr. Generalist Teresa Harris Coordinator Catherine Okhuysen Associate Diane Shelton 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.

Fort Sanders Regional Medical Center
Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Compensation, Benefits & Employee Programs Subject: ORIENTATION OF NEW EMPLOYEES Policy Number: HR.CB.020 Page: 1 of 1 Approved by: President & CAO, FSRMC Generated by: Human Resources Approved by: Director, Human Resources Effective date: 08/93 Approved by: Revised date: 02/04 SCOPE: This policy applies to all Ft. Sanders Regional Medical Center, Ft. Sanders Foundation, Thompson Cancer Survival Center, Thompson Oncology Group, and Ft. Sanders Perinatal Center employees. PURPOSE: To ensure high quality care, competency, and patient and employee safety, individuals hired by Covenant Health must receive proper orientation to the facility, to their departments, to relevant policies and procedures, and to all facets of the job duties they are expected to perform. POLICY: All newly hired employees will attend a New Hire Celebration/Orientation session covering Covenant Health Purpose, Vision, Values; Integrity and Compliance; and Employee Benefits before reporting to work. In addition to this general celebration/orientation, newly hired employees will also receive orientation to their facility and department; and a complete assessment of individual competency to perform the duties of the position will be conducted by the Department Manager or designee. General follow-up sessions designed to gather employee feedback are conducted frequently during the first year of employment in an effort to improve the orientation process and increase retention. Refer to facility specific policy for more details.

Sexual harassment is also committed if:
Fort Sanders Regional Medical Center Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Standards of Conduct Subject: HARASSMENT Policy Number: HR.SC.009 Page: 1 of 3 Approved by: President & CAO, FSRMC Generated by: Human Resources Approved by: Director, Human Resources Effective date: 08/91 Approved by: Revised date: 02/04 SCOPE: This policy applies to Fort Sanders Regional Medical Center, Thompson Cancer Survival Center, Thompson Oncology Group, and Ft. Sanders Perinatal Center employees. PURPOSE: To maintain a productive work environment free from all forms of harassment, including sexual harassment. Furthermore, this policy defines harassment and provides a mechanism that is available to all employees to make complaints of harassment that will be handled in a prompt and confidential manner. POLICY: Covenant Health is committed to providing a work environment free of all forms of harassment. Accordingly, all forms of harassment are prohibited, including but not limited to, sexual harassment and harassment because of an individual’s race, color, sex (including pregnancy), national origin, ancestry, religion, marital status, age, and physical or mental disability. Covenant Health will not tolerate verbal or physical conduct by any employee, patient, physician, visitor, vendor, contractor, or any other affiliate that harasses or degrades any individual or that interferes with work performance, including the creation of an intimidating, offensive, or hostile work environment. Definitions: Harassment is any verbal, physical, or visual conduct that tends to belittle or provoke, and includes but is not limited to “jokes”, gestures, and derogatory remarks. Federal, state, and local laws prohibit sexual harassment and harassment based on a certain individual’s personal characteristics including an individual’s race, color, sex (including pregnancy), national origin, ancestry, religion, marital status, age, and physical or mental ability. Covenant Health will not tolerate any harassment. Sexual Harassment is any unwelcome sexual advance, request for sexual favors, or other verbal or physical conduct of a sexual nature, including but not limited to sexual jokes, sexual innuendoes, obscenities, and the display of sexually suggestive photographs and photographs of nude or partially nude men and women Sexual harassment is also committed if:

Reporting Requirements
Fort Sanders Regional Medical Center Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Standards of Conduct Subject: HARASSMENT Policy Number: HR.SC.009 Page: 2 of 3 Submission to the unwelcome sexual advance or request for sexual favor is made either an express or implied condition of employment; or Submission to or rejection of the unwelcome sexual advance or request for sexual favor is used as the basis for an employment decision; or The unwelcome sexual advance, request for sexual favor, or other verbal or physical conduct has the purpose or effect of interfering with the employees’ work performance or creates an intimidating, hostile, or offensive work environment. It is important to remember that an individual need not be propositioned, touched offensively, or directly subject to sexual innuendo to be sexually harassed. Any demeaning, intimidating, or hostile conduct toward an individual based on his or her sex can constitute sexual harassment. Reporting Requirements It is essential that employees immediately report all suspected instances of harassment, including sexual harassment. Any employee who feels that he/she has been or is being harassed, or who believes that another individual has been or is being harassed, must immediately report such harassment to his/her immediate supervisor or department director/manager, to Human Resources, or to any other department director/manager of his/her choosing. If a complaint of harassment is being made against the employee’s immediate supervisor, the employee should file the complaint directly with the Director of Human Resources or any department director/manager. This reporting requirement applies to harassment, which occurs off-site as well. (For example, if an employee is given a work assignment that takes him/her to a patient’s home or any other off-site location.) Employees are not required to endure insulting, degrading, intimidating, hostile, or offensive treatment on the job when their work duties take them away from Covenant Health premises. Any delay in reporting incidents of harassment inhibits Covenant Health’s commitment to prevent and, when necessary, promptly remedy such incidents. Any failure to report or delay in reporting incidents of harassment may be deemed unreasonable. Any supervisor or department director/manager who observes or is made aware of an alleged instance of harassment is required to intervene as appropriate and report the incident to the Director of Human Resources, even if no formal complaint of harassment is filed.

Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Standards of Conduct Subject: HARASSMENT Policy Number: HR.SC.009 Page: 3 of 3 Investigations Covenant Health will promptly investigate all allegations of harassment and take whatever measures are necessary to initiate investigation, promptly remedy any incidents of harassment it determines to have occurred, and prevent further incidents from occurring. The investigation will be conducted in as confidential a manner as possible; however, Covenant Health reserves the right to disclose the substance of the complaint to the extent necessary to conduct a meaningful and accurate investigation. The results of Covenant Health’s investigation will be communicated to the employee filing the complaint and to any employee accused of harassment. The Director of Human Resources will keep any documentation related to the results of the investigation. Any corrective action forms that arise out of a complaint of harassment will be placed in the disciplined employee’s personnel record. Anti-Retaliation Covenant Health will not tolerate any retaliation against an employee who makes a good faith report of harassment or cooperates with those persons investigating the allegation of harassment, regardless of the outcome of the investigation, and will take immediate corrective action against any individual who threatens or engages in such retaliation. Covenant Health will not tolerate false accusations of harassment, and employees making false claims of harassment in bad-faith intended to harass or embarrass the alleged harasser, will be subject to corrective action, up to and including termination. Corrective Action: Any individual found to have violated this harassment policy, including its anti-retaliation provisions will be subject to corrective actions, up to and including immediate termination. Any employee who has questions about this policy is encouraged to discuss the matter with his/her supervisor, department director/manager, Director of Human Resources or any member of management with whom he/she feels comfortable.

“Violence” And Specifically Prohibited Activities Defined:
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Human Resources Subject: Workplace Violence Policy Number: HR.SC.251 Page: 1 of 5 Approved by: Human Resources Director Generated by: Human Resources Approved by: President / CAO Effective date: October 2003 Approved by: Revised date: January 2004 Review date: Scope: This policy covers all employees of Fort Sanders Sevier Medical Center. Purpose: The purpose of this Covenant Health Workplace Violence Policy is to ensure a safe, nonviolent environment for all employees, patients, visitors, and clients, and to reduce the risk of violence through crisis intervention. Policy: The safety and security of employees, patients, and visitors is of vital importance to Covenant Health. Overt acts of violence, threats of physical harm and/or behaviors that are harassing, threatening, and/or considered violent will not be tolerated within Covenant Health facilities nor, by extension, at any location where business is conducted on behalf of Covenant Health. Any employee who engages in a violent act, as defined within this policy, or who makes any threat to engage in a violent act, directed toward the person or property of any employee, patient, physician, visitor, or client within a Covenant Health facility may be subject to immediate termination of employment. Possession of any item within Covenant Health facilities which may be defined as a weapon in accordance with Tennessee law, except in the instance of authorized law enforcement agents, may likewise constitute a basis for termination of employment (see Weapons Possession policy). Specific examples of weapons include firearms, explosive devices, clubbing instruments, and knives with fixed blades or blades longer than four (4) inches. “Violence” And Specifically Prohibited Activities Defined: Following are examples of violent acts and specifically prohibited activities within the context of this policy. These examples are not regarded as all-inclusive but are provided as a means to illustrate the intent of the policy. Covenant Health retains the prerogative to specify and/or define additional acts as violations of the policy. Such acts are specifically prohibited and employees engaging in such acts may be subject to disciplinary action up to and including termination of employment.

Some examples of “violent acts” and prohibited activities are:
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Human Resources Subject: Workplace Violence Policy Number: HR.SC.251 Page: 2 of 5 Commission of, or threat to commit, any violent act prohibited by Tennessee state criminal statutes in facilities operated by or on the property of Covenant Health or at any other location where business is conducted on behalf of Covenant Health; Refusal to participate in an investigation pertaining to allegations or suspicion that a policy violation has or is likely to occur; Some examples of “violent acts” and prohibited activities are: Murder, voluntary manslaughter, aggravated rape, rape, mayhem, especially aggravated robbery, armed robbery, robbery, burglary, aggravated assault, assault, and battery; Verbal threats against an individual or personal property, verbal abuse, or any form of harassment; Intentional damage, defacement, or destruction of personal or facility property; Flagrant or impudent disregard of health and safety policies; Illegal use, possession, or sale of any weapon, as defined by Tennessee state law, in facilities or premises owned or operated under the auspices of Covenant Health, or at any location where business is conducted on behalf of Covenant Health; Refusal to consent to a search for the presence of a weapon when requested by an authorized agent of Covenant Health; and, Conviction under any criminal statute for the illegal possession of a weapon or for the commission of a violent act against the person or property of another. Facility Responsibilities: It is the responsibility of each facility’s Risk Management Department or representative to ensure compliance with the Workplace Violence policy. The actual policy administration may be assigned to the Safety Committee or an Employee Safety subcommittee. The Safety Committee or Employee Safety subcommittee will be typically comprised of at least one management level representative from Security, Worker’s Compensation, Risk Management, and Human Resources. The composition may vary by location contingent upon facility size, staffing, and organization. In those instances where a specific expertise may not be

Develop, implement, and monitor a Workplace Violence Prevention plan;
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Human Resources Subject: Workplace Violence Policy Number: HR.SC.251 Page: 3 of 5 available within the facility, a representative with the required expertise may be appointed from another facility. A primary function of the Safety Committee or Employee Safety subcommittee is to improve and promote each facility’s ability to address workplace violence. Specific responsibilities include, but are not necessarily limited to: Develop, implement, and monitor a Workplace Violence Prevention plan; Review incidents of violence at the facility, and recommend preventive measures as appropriate; Review the facility’s readiness to respond to issues or incidents associated with workplace violence; Develop an expertise regarding issues of workplace violence within the Committee and other appropriate members of management; Appoint and establish the responsibilities for a “response team” designed to respond to and assess any incidents of violence, or potential violence, which may occur (the “response team” may be defined as a responsibility of the Safety Committee or Employee Safety subcommittee); Develop and help disseminate workplace violence prevention information for facility personnel; and Establish and monitor procedural mechanisms for application of the Workplace Violence policy to employees classified as contract, temporary, and “occasional”, whether employed directly by the facility or through an agency or outside vendor. Responsibilities of Management and Supervisory Personnel: Staff members whose positions incorporate management and supervisory responsibilities will have the following obligations to support this policy: Assure that staff under their supervision receive workplace violence prevention information; Assist the Safety Committee/Employee Safety subcommittee in the implementation and maintenance of the Workplace Violence Prevention Plan;

Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Human Resources Subject: Workplace Violence Policy Number: HR.SC.251 Page: 4 of 5 Communicate all approved workplace violence prevention policies to staff under their supervision, including communication to any third party employees working within their unit/division or otherwise under their administrative auspices; and, Comply with proper reporting procedures with regard to any overt policy violations or observations of potential warning signs. Responsibility of Employees: Maintenance of a safe workplace is regarded as the responsibility of all employees. An employee who feels that he or she has been a victim of any act in violation of this policy, or who is aware of violations which may have victimized other persons, should report the circumstances immediately. In addition to reporting any overt violations of the policy, employees are likewise expected to report possible warning signs of violence they may observe (e.g., verbal abuse, aggressive behavior, loitering, and so forth). REPORTING PROCEDURE: Violations And Potential Warning Signs Should Be Reported To The Security Department. The Security Department will notify Human Resources of any confirmed incidents. An employee who has knowledge of a violation of this policy but fails to report the violation may be subject to disciplinary action. No employee will be disciplined or discharged for truthfully reporting a policy violation. Applicability to Non-Employees and Off-Site Incidents: It is not the intent of this policy to be intrusive or to infringe upon the private lives of individuals employed by or associated with Covenant Health. However, the policy may be considered applicable to certain incidents involving employees and non-employees which may occur off-site. This would generally involve issues which may originate at the facility and culminate in an off-site incident or which have a direct bearing on the individual’s ability

Limitations on Employee Benefits:
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Human Resources Subject: Workplace Violence Policy Number: HR.SC.251 Page: 5 of 5 to perform their job or is inconsistent with the mission and values of Covenant Health. Limitations on Employee Benefits: If an employee is injured as a result of instigating a violation of this policy, or while engaged as a willing participant in a policy violation, entitlement to Worker’s Compensation benefits may be denied. Employees whose employment may be terminated as a result of policy violation(s) will not be eligible for rehire. Authority To Conduct Searches: Covenant Health reserves the right to conduct searches of company-owned property, furnishings, lockers, and other similar articles which may be provided for employee use in the event of reasonable suspicion that a weapon may be present or concealed. Covenant Health also reserves the right to request to search personal property, with the employee’s approval, in the event of reasonable suspicion that a weapon may be present or concealed. An employee’s refusal to permit or cooperate in a search based on reasonable suspicion will be considered a basis for disciplinary action, up to and including termination of employment.   

PATIENT CARE PHILOSOPHY
Every patient who enters a Covenant Health facility is to be treated with courtesy, compassion, respect, and dignity. As an employee or student, you have accepted the high and special challenge of providing advanced technological care while maintaining a personal and close awareness of the individual human needs of our patients. In any activity conducted by, for, or in the organization affecting care and treatment of patients, there will be no separation, discrimination or other distinction on the basis of race, color, disability, or national origin. All cultural diversity is acknowledged and incorporated into the patient plan of care. In working with the sick and injured, it is important to remember that you are dealing with persons in exceptional circumstances. You will discover that many patients have fears and resentments that may manifest themselves as irritability, lack of cooperation and apprehension. Courtesy, kindness, and above all, sincere understanding are important steps in overcoming these problems. Always remember that what is routine for you may be a great emergency in the mind of the patient and his/her family. Your thoughtful consideration will often be remembered long after the medical services performed have been forgotten. When a patient requests to Opt Out of the Hospital Directory they are considered to become NO INFORMATION status. The patient and/or the patient’s personal representative will be advised by the registrar that as a No Information patient, all telephone calls, visitors, florists, etc., will be informed there is no listing for the patient. Only the room # and the MD’s name will appear on the front of the chart STAFF RIGHTS Requests by a staff member not to participate in any aspect of patient care where there is perceived conflict with the staff member’s cultural values or religious beliefs will be addressed in the following manner: 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.

Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Standards of Conduct Subject: STAFF RIGHTS Policy Number: HR.SC.014 Page: 1 of 1 Approved by: President & CAO, FSRMC Generated by: Human Resources Approved by: Director, Human Resources Effective date: 12/94 Approved by: Revised date: 02/04 SCOPE: This policy applies to all Ft. Sanders Regional Medical Center, Ft. Sanders Foundation, Thompson Cancer Survival Center, Thompson Oncology Group, and Ft. Sanders Perinatal Center employees. PURPOSE: To provide guidelines to address any request by a staff member not to participate in any aspect of patient care, including treatment. The guidelines ensure that a patient’s care will not be negatively affected if the request is granted. POLICY: Requests by a staff member not to participate in any aspect of patient care where there is perceived conflict with the staff member’s cultural values or religious beliefs will be addressed as indicated below. Examples of this include therapeutic abortions and “do not resuscitate.” The Ethics Committee is available to employees as a forum and source of ideas for resolution of ethical conflict. Employees may transfer to a position in another hospital service, if available. If the ethical conflict occurs when the employee is on duty and the patient’s need for care or treatment is imminent, the staff on duty should decide who will provide care to the patient. If no decision can be reached, the staff member in charge should refer the issue to the Manager, Director, House Supervisor, or Administrator On-call to render a decision to ensure that the patient receives appropriate care.

Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Standards of Conduct Subject: PROBLEM SOLVING PROCEDURE Policy Number: HR.SC.011 Page: 1 of 4 Approved by: President & CAO, FSRMC Generated by: Human Resources Approved by: Director, Human Resources Effective date: 08/91 Approved by: Revised date: 02/04 SCOPE: This policy applies to all Ft. Sanders Regional Medical Center, Ft. Sanders Foundation, Thompson Cancer Survival Center, Thompson Oncology Group, and Ft. Sanders Perinatal Center employees. POLICY: In work situations, complaints and disagreements may arise over work-related issues or incidents. Covenant Health has developed a problem-solving procedure as a method for employees to register complaints concerning their working conditions, administration of policies, or a disciplinary action an employee believes is unjust. The problem-solving procedure is available to all employees who have completed their initial employment period. Terminations are not subject to the problem-solving procedure. Terminated employees who wish to discuss the circumstances of their termination are encouraged to contact their Director of Human Resources. Covenant Health is committed to preserving positive relations between management and employees. To fulfill this commitment, Covenant Health sets the following standards: Each employee shall be guaranteed fair and honest treatment in all aspects of his or her employment. Supervisors and managers shall treat each employee with respect, shall not demonstrate personal prejudice, or grant unfair advantage to one employee over another. Each employee has the right to express his or her views concerning company policies and practices to management. Each employee is responsible, however, for expressing those views in a fair and honest manner. Every employee should be committed to making positive and constructive criticism. Each employee is responsible for following company rules of conduct, policies, and practices. Should an employee disagree with a company policy or practice, the employee is invited to express that disagreement through the Problem-Solving Procedure. An employee is expected to comply with the disputed policy or practice until the disagreement has been heard and the disagreement is addressed.

6. An employee shall present his or her own case. PROCEDURE:
Fort Sanders Regional Medical Center Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Standards of Conduct Subject: PROBLEM SOLVING PROCEDURE Policy Number: HR.SC.011 Page: 2 of 4 4. No employee shall be penalized, formally or informally, for voicing a disagreement with company policies and practices or for using the problem-solving procedure to voice such disagreement. 5. Every complaint, question, problem, or suggestion shall be considered and answered as quickly as possible. In the case of formal action by an employee, the answer and an explanation shall be given in writing. 6. An employee shall present his or her own case. PROCEDURE: An employee should generally initiate the problem-solving procedure with his or her immediate supervisor but may initiate the problem-solving procedure at later steps if the immediate supervisor is the subject of the grievance. When an employee initiates use of the problem-solving procedure, he/she should be provided with a copy of this policy. The employee or the manager may request a delay between steps if more time is needed to gather or present additional information. At any step of the problem-solving procedure, a Human Resources Department representative is available to assist either the employee or the manager with the process. Step 1: An employee has five (5) working days from the time an incident occurs to file a complaint. Employee First, an employee should discuss the issue with his or her immediate supervisor in private. To initiate the problem-solving procedure, a statement must be presented in written or typed form, dated, and signed by the employee. This statement should include an explanation of the employee's concern and what action the employee requests to satisfy the concern. If the problem or complaint is with the direct supervisor, the employee may omit Step 1 and go directly to Step 2. Department Manager Department Manager will discuss the problem with the employee and provide the employee with a written response within three (3) working days from the date he/she receives the statement. If this is not possible, the supervisor will inform the employee in writing of the projected response date. The supervisor will review the complaint based on facts, company policy, and investigative findings.

Administrator or Senior Vice President
Fort Sanders Regional Medical Center Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Standards of Conduct Subject: PROBLEM SOLVING PROCEDURE Policy Number: HR.SC.011 Page: 3 of 4 Step 2: Employee If the employee is not satisfied with the answer from the immediate supervisor or if the complaint is with the immediate supervisor, he/she may submit the statement to the Department Director. The employee's statement must be submitted within three (3) working days of the date the written response in Step 1 is received. Department Director The Department Director will discuss the problem with the employee and provide the employee with a written response within three (3) working days from the date he/she receives the statement. If this is not possible, the Department Director will inform the employee in writing of the projected response date. Step 3: If an employee is not satisfied with the Department Director's response, the employee may submit the statement to the Vice President. The statement must be submitted within three (3) working days of the date the written response in Step 2 is received. Vice President: The Vice President will review the statement and provide a written response within five (5) working days from the date the statement is received. If this is not possible, the Vice President will inform the employee in writing of the projected response date. Step 4: If the employee is not satisfied with the Step 3 response, the employee may request that the Administrator or Senior Vice President consider his/her concern. A written request for such consideration must be submitted to the Administrator or Senior Vice President within 3 working days of the employee's receipt of a response to Step 3. Administrator or Senior Vice President The Administrator or Senior Vice President will review the statement and relevant information, and provide a written response within 5 working days from receipt of the

Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Standards of Conduct Subject: PROBLEM SOLVING PROCEDURE Policy Number: HR.SC.011 Page: 4 of 4 employee's statement. All decisions made by the Administrator or Senior Vice President are final.

Complaint Filing Procedures
If the employee exhausts all means available to him/her for resolution and the problem still persists, then the employee can contact JCAHO and/or the Department of Health at to report the situation. Complaints may be filed at For instructions on filing a complaint, contact JCAHO at (800) The hospital must not discipline or retaliate against any employee who reports a quality/patient care issue to JCAHO or an integrity issue to Integrity Compliance. If someone perceives an issue with the quality of care a patient is receiving, has a concern regarding safety issues, or has an integrity concern, he/she should bring it to the attention of his/her supervisor. If the employee perceives that the issue is not resolved at the facility level, then he/she should follow the chain of command to the corporate level which is the Integrity Compliance Office. All calls to Integrity Compliance are confidential and you may remain anonymous if you wish. The phone system has been modified to ensure that your call cannot be recorded and your location cannot be identified, EXCEPT the call centers at KBOS and PHP. Integrity Compliance contact numbers: Department Line: Report Line: On-Line: Covenant Intranet

SCOPE: All employees of the hospital PURPOSE:
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Rights and Responsibilities/Ethics Subject: ETHICS ISSUES, EMPLOYEE RESPONSIBILITY Policy Number: RR.ET.004 Page: 1 of 1 Approved by: Administration 12/94 Generated by: VP for Nursing Approved by: Ethics Committee Effective date: Approved by: Revised date: Approved by: 12/94 Review date: 05/00, 03/04 SCOPE: All employees of the hospital PURPOSE: Provide guidelines to assist employees in ethical decision making, in respect of patient rights. PROCEDURE: Employees of Fort Sanders Regional Medical Center who have a question or concern regarding an ethical issue(s) should: Consult the attending physician or immediate supervisor The supervisor may then consult the attending physician and/or patient’s family. If a solution is not reached, the supervisor should notify the director of the department regarding the issue. The director will then collaborate with the appropriate person(s). If there continues to be no resolution of the issue, the department director will notify the administrator and/or Ethics Committee chairperson to achieve problem resolution. As appropriate, patients and their families may be informed of how to gain access to the Ethics Committee and ethical resolution process by contacting the hospital operator at extension “0”. NOTE: The Ethics Committee serves as a forum and source of ideas for resolution of ethical conflict. It does not make patient care decisions, nor does it have enforcement power for its recommendations.

EMPLOYMENT INFORMATION
These guidelines provide a mechanism to address the concerns of staff while ensuring that a patient’s care will not be negatively affected. ETHICS COMMITTEE Covenant Health is committed to the care of people in a manner that ensures patient and family dignity, privacy, and respect. Affirming the rights of the patient to participate in the planning and decision-making processes affecting his or her treatment is facilitated through the provision of a multidisciplinary Ethics Committee at each facility. Access to the Ethics Committee regarding any issue is available through contacting the Chaplain at your facility; Fort Sanders Regional Medical Center campus at , contacting the Administrative Supervisor or the operator. The objective of the Ethics Committee is to provide education for its members, the staff, and the patient/family; to be involved in the development of policy and procedure issues concerned with ethical issues; and to be available for case reviews. Any individual, be it staff, patient, family, or the general public, may request a review by the Ethics Committee. EMPLOYMENT INFORMATION EMPLOYMENT CLASSIFICATIONS: All employees of Covenant Health are divided into one of the following classifications of employment: Initial Employment Period – The first 90 calendar days of employment are referred to as the initial employment period. It is during this period that you will be oriented to this facility and to your department. A complete assessment of your individual competency to perform the duties of your position will be conducted during this period. During this period, an eligible employee accrues CTO benefits that are available at the end of 90 days. New employees may request time off without pay in the event of death in the immediate family. Full-time Employee – A full-time employee is one who is scheduled to work a minimum of 72 hours per pay period on a regularly scheduled basis, and is eligible for full-time benefits. Part-time Employee - A part-time employee is one who is scheduled to work 31-71hours per pay period on a regularly scheduled basis. Part-time employees who work at least 32 hours per pay period are eligible for part-time benefits. PRN/Occasional Employee – An occasional employee is one who is employed only for a special project or assignment, an emergency, summer employment, or non-regular intervals. These employees are non-benefit employees. However, they are covered by Workers’ Compensation Insurance. If an occasional job develops into a part-time or full-time job, the effective date of the status change determines benefits accruals. Temporary Employee – A temporary employee is one who is employed for a special assignment or project. Temporary employment usually does not exceed 90 days. No benefits are given to temporary employees; however, they are covered by Worker’s Compensation Insurance.

Responsibilities of the employee and manager
Fort Sanders Regional Medical Center Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Compensation, Benefits and Employee Programs Subject: Workers’ Compensation Policy Number: HR.CB.027 Page: 1 of 3 Approved by: President & CAO, FSRMC Generated by: Human Resources Approved by: Director, Human Resources Effective date: 08/91 Approved by: Revised date: 02/04 SCOPE: This policy applies to all Ft. Sanders Regional Medical Center, Ft. Sanders Foundation, Thompson Cancer Survival Center, Thompson Oncology Group, and Ft. Sanders Perinatal Center employees. PURPOSE: The purpose of this policy is to explain the following with regards to Workers' Compensation: Responsibilities of the employee and manager Medical referral procedure Coordination of benefits POLICY: Employees of Covenant Health are automatically covered under the Workers' Compensation Act in the event that they are injured on the job. In responding to employee injuries, Covenant Health’s objectives are to: Initiate Workers' Compensation benefits promptly to minimize the financial impact on the injured employee. Provide appropriate and effective medical care and to prevent re-injury. Assist employees in returning to work promptly and safely. Employees' Responsibilities (unless otherwise designated in a facility-specific policy): Report injury immediately to manager or house supervisor and complete green incident report. If injured, report to Employee Health (or when Employee Health is closed, contact house supervisor for triage and disposition) immediately for evaluation and treatment. Report to Employee Health for a Return to Work release, prior to returning to duty. Deliver Return to Work release to manager when returning to duty. If seen in Emergency Department, report to Employee Health next business day. Managers' Responsibilities (unless otherwise designated in a facility-specific policy): The manager will ensure that the injured employee follows the instructions presented above.

to a panel of physicians on the Covenant Health medical staff.
Fort Sanders Regional Medical Center Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Compensation, Benefits and Employee Programs Subject: Workers’ Compensation Policy Number: HR.CB.027 Page: 2 of 3 The manager shall sign the incident report and forward to Employee Health (or to the House Supervisor if after hours). Employee Health will fax completed incident report to Cariten WORxS. If there is lost time from work, the manager must ensure that the employee does not return to work until a Return-to-Work release is obtained from Employee Health. Employees must be referred back to Employee Health for any continuing problems related to the injury. The injured employee must not be held off from duty or allowed to hold himself/herself off from duty without prior authorization from Employee Health. A Personnel Action Request form (PAR) indicating leave of absence for Workers' Compensation must be completed if the lost time exceeds seven (7) days. Physical restrictions specified by Employee Health must be considered in assigning work to the returning employee. Medical Referrals Section (4) of the Tennessee Workers' Compensation Act provides in part the following: "The injured employee shall accept the medical benefits afforded hereunder; provided that the employer shall designate a group of three (3) or more reputable physicians or surgeons not associated together in practice, if available in that community, from which the injured employee shall have the privilege of selecting the operating surgeon or the attending physician.“ Accordingly, when medical care is required, Employee Health will refer the injured employee to a panel of physicians on the Covenant Health medical staff. Covenant Health will NOT pay the medical bills of physicians unless referred by the Employee Health Service or the Emergency Department physician. The employee has the right to have the case manager present during exams if desired. If the employee’s primary care physician at the employee’s request provides care, the employee shall then be responsible for paying his/her physician for services. All outpatient diagnostic treatment services, rehabilitation, work hardening, physical therapy, etc. shall be rendered by a facility of the Covenant Health System and not an outside facility.

Coordination of Benefits with Workers' Compensation
Fort Sanders Regional Medical Center Fort Sanders Foundation Fort Sanders Perinatal Center Thompson Cancer Survival Center Thompson Oncology Group Human Resources/Compensation, Benefits and Employee Programs Subject: Workers’ Compensation Policy Number: HR.CB.027 Page: 3 of 3 Coordination of Benefits with Workers' Compensation When an employee is placed on a workers' compensation leave of absence (LOA), all sick and paid time off (PTO) accruals will cease for the time period involved. During the time period an employee is on a workers' compensation LOA, the employee will not be allowed to receive paid sick leave or PTO. The employee who is on a workers' compensation LOA will be able to continue their medical insurance and other coverage by paying their usual employee premium for a period of twelve weeks. After that date, the employee may continue coverage under COBRA provisions, paying the higher COBRA rate. This time period may be shortened if it is known earlier that the employee will not be returning to work. When the employee returns to work, the manager must submit a PAR form to Human Resources. The employee's benefit accrual date will be adjusted by the length of time of the LOA.

EMPLOYEE PERFORMANCE AND BEHAVIOR EXPECTATIONS
ATTENDANCE When an employee fails to meet a work schedule commitment, the impact to patient care, as well as the burden it may place on co-workers, can be quite negative. With this in mind, all employees need to understand the potential employment consequences of deliberate attendance violations, repeated occurrences of unscheduled absences or tardiness and time clock violations. DRESS, APPEARANCE AND HYGIENE: This policy is intended to provide guidelines regarding appropriate Appearance standards at Covenant Health. It cannot address every potential item of clothing or accessory; therefore, Managers are expected to apply good judgment in maintaining professional and appropriate appearance of their employees. The image we portray through our dress and appearance is an important reflection of our professionalism and commitment to quality. Therefore, our employees should meet the following guidelines regardless of where they work: Clothing and Fit All clothing, regardless of whether it is a uniform or other dress, should be clean, fit properly, in good repair and pressed or ironed as needed. Any article of clothing that portrays a printed message, which could be offensive to the general public, shall not be worn. Denim blue jeans are not appropriate in the workplace, although departments may allow blue denim skirts, dress, and shirts if neat, professional in appearance, and appropriate to the work being performed. Uniforms Managers will communicate to all newly hired or transferring employees the uniform requirements of their departments. Newly hired employees or transferring employees are expected to obtain appropriate uniforms within one month after beginning work in their new department. A department changing scrub color will have a one-year period of transition before staff is expected to all be attired in the new color. This also applies to employees who transfer unless the transfer is to a department where the color is mandated. All employees wearing uniforms should be prepared to change into clean uniforms in the event that their uniforms become objectionably soiled during the work shift. Employees who change into scrub uniforms at work are expected to adhere to the organization’s appearance policy while they are in the facility, i.e., on the way to the changing area/locker room and after changing out of their scrub uniforms. White Uniforms for Nurses It is always acceptable to wear white uniforms unless there is a department specific reason not to do so. In areas where the department requires wearing uniforms, colored street clothes may not be substituted. For example, colored or print tee shirts and white pants/skirts are not acceptable.

Skirts, Dresses, and Shorts
Colored Scrubs Colored scrubs are determined per department. The attire must be uniform scrubs, not colored street clothes. Knit polo shirts, which match the exact scrub color, are acceptable. Each employee must adhere to the department scrub color. Coordinating print scrub uniform tops/lab coats of the employee’s choice may be worn with white or unit color uniform pants. Scrub Usage No change in scrub color should occur unless a department’s color is discontinued. A department that changes scrub color may not choose a color that is already in use without written permission from that department manager. Scrub purchases should be an exact match of your department’s chosen color. Appropriate non-scrub or non-uniform tops will be permitted during Christmas and on UT Game Fridays/Saturdays. Any other deviations from this policy will be specified by Administration. Tops/Blouses Tops and blouses should not have a revealing neckline or midriff. Sweatshirts, tank tops, and shirts with printed messages are not permissible. Pants Pants may be worn if appropriate; however, the following styles should not be worn: overalls, warm-up or sweat pants, clamdiggers, pedal pushers, tight stirrup pants, or leggings. Skirts, Dresses, and Shorts Skirts and dresses should be of appropriate length. Split skirts, city shorts, and skorts of the appropriate length are permissible. Sundresses and tank tops may be worn only with jackets. Hose will be worn with these at all times. Shoes Shoes must be appropriate to the dress and job for a given department. All white or all black athletic shoes may be worn if they are polished and clean. Canvas or cloth shoes, sneakers, and colored or high-top athletic shoes are not permissible. Colored shoestrings should not be worn. Undergarments Appropriate undergarments (including hosiery/socks) will be worn to present a neat and professional appearance.

Identification Badges
Hair Employees must keep their hair clean and in an orderly fashion that does not present a safety hazard. Color, style, and length should be appropriate; mustaches, sideburns and beards are to be neatly trimmed. For employees who are required for safety reasons to wear a respirator, beards may not be worn since they would interfere with the proper fit of the respirator. Hats Hats may be worn only as part of an approved overall work uniform. Jewelry Jewelry may be worn but should not depict an insignia offensive to the general public. Excessive or dangling jewelry may be a safety hazard to the patient or employee. Male employees may not wear earrings while on duty. Certain departments may have a “no jewelry” policy. Makeup and Fragrances Make-up and personal body fragrances, including perfume and after-shave may be worn but should not be overly strong. People who are ill may be especially sensitive to odors, which may cause nausea or allergic reactions. Certain departments may have a “no fragrance” policy due to patient concerns. Fingernails Fingernails must be kept clean, neat and trimmed to a length considered safe and appropriate. Nail polish may be worn but the color should be viewed as appropriate and professional. Certain departments may have a “no polish or no artificial fingernails” policy due to patient health concerns. Identification Badges All employees are required to wear an identification badge at all times while on duty enabling them to be readily identified by patients, visitors, physicians, and other employees. The badge should generally be worn at chest level to be visible for easy identification by all parties; however, the badge may be worn at waist level if the chest level location interferes with the work being performed. Pins of a professional nature may be worn on the badge as long as the pin does not cover or damage the printing, photo, or bar code on the badge. No tape or stickers should be placed on the badge. Workers Provided by Temporary Agencies Temporary agency workers must adhere to all provisions of this policy.

Cariten Assist EAP is provided to ALL employees, regardless of your health plan. The program is designed to provide assistance concerning such issues as stress, anxiety, drug and alcohol abuse, family problems and depression. Benefits include counseling services for you and your family members. Simply call Cariten Assist at or to make an appointment. There is NO cost for EAP visits and everything communicated between you and your counselor is completely confidential. No one needs to go through difficult times alone.

CARE OF EQUIPMENT AND SUPPLIES
Medical equipment is one of the most important resources we use in treating patients. It is vital that you be alert to any malfunction or disrepair of any equipment and that you report it to your Supervisor or Manager immediately. Do not attempt to use any equipment for which you have not been properly trained. Always ask for assistance with unfamiliar equipment. Supplies are expensive, and you should try to prevent waste and spoilage. If you should find that you could not satisfactorily complete your duties because of inadequate supplies, you should report the shortage immediately to your Supervisor or Manager. Cafeteria items such as trays, plates and silverware are not to be removed from the cafeteria. If you wish to carry our food, ask for and use paper plates and plastic utensils. If you should find cafeteria utensils outside the cafeteria, please return them to the Food Services Department. As part of the organization’s involvement in and commitment to the national cost containment program, we ask your help in treating all equipment and supplies with extreme care. Losses in these areas mean increased costs for the organization, which result in increased costs for our patients.

Name of Category/Sub-Category:
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Leadership/Administration Subject: SMOKING REGULATION Policy Number: LDR.AD.018 Page 1 of 3 Approved by: Administration 10/00 Generated by: Multidisciplinary Team (HR, Nursing, Engineering, VP Medical Affairs) MEC 09/99 Effective date: 01/90 Revised date: 03/04 Review date: Scope: Employees, patients, visitors and medical staff members. Purpose: Smoking is acknowledged to be both a fire and health hazard. As a health care provider, it is the organization’s responsibility to join in the promotion of a more healthful lifestyle as well as provide a safe smoke-free environment for patients, visitors, employees and the medical staff. Therefore, FSRMC has joined other area health care providers in promoting a smoke-free environment without exception. For the purposes of this policy, smoke free environment means in the interior of FSRMC and all the immediate entrances to the facility. All smoking areas will be located a sufficient distance from the facility entrance or air intake to prevent the drafting of smoke into the building or the exposure of others to second hand smoke. Policy Statement: Fort Sanders Regional Medical Center (FSRMC) has adopted the Covenant Health Statement on Smoking by providing these written guidelines for it’s completely smoke free environment. Procedure: EMPLOYEES, PATIENTS, AND VISITORS Employees, patients, visitors and medical staff members will be allowed to smoke only in designated areas outside the facility. The designated smoking areas are described below. In most instances, smoking huts have been provided. Employee designated smoking area is located at the East End of the Laurel Plaza building where bench seating has been provided. Employees should use this location from 7:00am to 7:00pm every day.

Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Leadership/Administration Subject: SMOKING REGULATION Policy Number: LDR.AD.018 Page 2 of 3 For safety and security reasons, Employee smoking is permitted from 7:00pm to 7:00am in the designated patient smoking hut located in the Trustees Tower garage. Employees found smoking within FSRMC or in non-designated employee smoking areas will face disciplinary action. Patients wishing to smoke or found smoking within the facility should be informed of the smoking policy and then directed to their designated smoking area. The designated patient smoking area is located in the smoking hut in the Trustees Tower garage. This location is available 24 hours/day, every day for patient smoking. Visitors wishing to smoke or found smoking within the facility should be informed of the smoking policy and then directed to their designated smoking area. The designated visitor smoking areas are located in the smoking hut in the Trustee Towers garage, as well as the bench areas provided on Clinch Avenue. These locations are available 24 hours/day, every day for visitor smoking. ACUTE CARE PATIENTS Patients will be informed of the FSRMC smoking policy at the time of admission so they may make an informed decision regarding their stay. FSRMC physicians will not write orders for any patients to smoke: no exceptions. If a patient, after having been informed of the policy, continues to smoke in unsafe area, administration shall be notified. A member of administration will consult with the physician to allow the patient to sign out of the hospital “against medical advice”. FSRMC will provide alternate forms of nicotine (nicotine patch) on order of the patient’s physician at no expense to the patient. The patient’s physician will document that alternative forms of nicotine have been suggested and discussed. DOCUMENTATION Documentation shall include events related to education and patient tolerance/response to cessation interventions. Likewise, if a patient refuses to adhere to the smoking policy, documentation shall reflect all action taken. LONG TERM CARE PATIENTS Settings that provide longer-term care (that is, more than 30 days) may allow patients to smoke without a licensed independent practitioner’s written authorization. In these

Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Leadership/Administration Subject: SMOKING REGULATION Policy Number: LDR.AD.018 Page 3 of 3 instances, smoking occurs in designated locations that are environmentally separate from all patient care areas and are well ventilated. Settings that provide longer-term care for the following patient populations are included under this provision. (See unit specific policy): Long-term care or intermediate care Post-acute head trauma (social rehabilitation) patients SAFETY PRECAUTIONS Smoking shall be prohibited in any area where flammable liquids, gases, or oxygen are in use or stored. Wastebaskets shall be made of non-combustible materials and shall not be used as ashtrays. Only facility approved ashtrays shall be used. An air filtration device (or other method of ventilation) shall be utilized in smoking areas to decrease second hand smoke. When appropriate, smoking materials will be stored at the nursing station in order to control supervision of smoking activities. Smoking hut doors will remain closed at all times.

General Information

Most Frequently Called Numbers:
FSRMC Main Line Benefits: Customer Service Retirement planning 401-K - Fidelity Cafeteria Chaplain Employee Assistance Program Employee Health Human Resources Infection Control Patient Representative Safety Security Senior Leadership: Keith Altshuler Ruth Crawley Beverly Graham David McReynolds Colleen Andrews Julie Dougherty TCSC While on campus, you only have to dial the last 4 digits of the # for all 541-####. HR cannot transfer personal calls except on an emergency basis. If you use the main hospital number as your work number, be sure to indicate your department. The hospital operator may not have this information.

Badge FAQ’s 1. I do not want my last name on my badge. May I have it taken off? Full names are required for most areas within the hospital. The only exceptions are the ER and Registration and Women’s Services. However, if you feel you are being harassed or receiving unwanted attention from a patient because they know your last name, please talk with your manager. Those situations can be reviewed with your manager and HR administration on a case by case basis. When I swipe my badge at the time clock it does not display my name. It displays: “X-PUN”. What do I do? “X-PUN” simply means that your badge number was not assigned a “home” time clock. You need to inform your timekeeper to verify that it did register your clocking in and out. If it is, please have your timekeeper contact payroll to be assigned a home time clock. It may take a few moments longer for your time to show in Timekeeper, but your timekeeper should be able to view your clocking in and out. If it is not registering with your timekeeper, please come to HR and request that a new badge made. My badge only beeps when I try to clock in and out? What does this mean? Please come to HR to see if you need a replacement badge. If the bar code on the back is rubbed off in any way, it will not work. There is not a charge for replacement badges if the badge is not working. I have a SmartBadge, but it has stopped letting me in the secured areas. What do I do? First please contact Security to see if your smart badge number is showing in their system. If it is, then bring it to HR and we will provide a new one at no charge. If it isn’t working, Security will input the number and it should work properly. I have lost my badge? Can I get a new one? Yes, however, there is a $10 charge for a replacement badge. This can be paid for by cash, check or by payroll deduction. What if my badge is broken? Please come to HR to request a replacement badge. Please bring the broken badge with you. There is not a charge for a badge that is broken. I have forgotten to clock in or clock out. What do I do? Inform your manager and your timekeeper. Most departments require you to sign in your time if you have failed to clock in or out. If you have further questions, please contact your Manager or Human Resources.

Parking FAQ’s What are my parking options?
Day Shift: There is a charge for parking. You may either participate in Payroll deduct parking and receive a hang tag that is valid for the entire calendar year or you may purchase a parking pass from Central Parking on a Month to Month basis during the first 5 days of the respective month. Night Shift: [7P-7a] There is no charge for night shift Parking, but you still need to register with HR and receive a Night Shift Hang tag. Why is there a charge for parking? Parking lots are managed by Central Parking. We have arranged for discounted rates for employees. What is the charge for parking in the surface lots? The rate is $8.50 whether you purchase it directly from Central Parking or participate in the Payroll deduct parking program. You save money on tax dollars if you participate in the payroll deduction and also have the convenience of not having to purchase a hang tag every month May I purchase a Payroll Deduct Hang-Tag Anytime? No, you must either enroll in Payroll deduct parking during your first 30 days of employment or status change. If you do not do it during this time, you will be required to wait until Annual Enrollment for Parking? This is because Payroll Deduct parking is a pre-taxed based benefit. This guideline is set forth by the IRS. I would like to cancel my Payroll deduct parking. May I do this anytime? No. You may only cancel Payroll deduct parking during Annual Enrollment for parking or if your employment status changes. This would include going from FT to PT or changing from day shift to night shift. I have lost my annual hang tag. May I receive another one? Yes, however, there is a $10 charge. We must either have a check or cash. We CANNOT do payroll Deduction This money is given directly to Central Parking. I have multiple vehicles. May I switch the hang-tag between them? Yes, you are paying for a parking space and it doesn’t matter which vehicle you use as long as you have a parking hang tag. However, you must get a new hang tag yearly. I want to park in the parking garage. How can I do this? There is a long waiting list to be able to park in the Garages. You may however, contact, Sheila Payne, in Facility Services at x4907 to add your name to the list. Where do I park as a student? Students who are going to be here during the day should purchase a hang tag from the Central Parking attendant across 19th Street from the emergency room. Students who will be here at night may park free, however you should put a note in your car stating you are a student at Regional. All Students are allowed to park in the employee parking lots.

Time Clock Instructions
Information Services Personnel Services Division Time Clock Instructions Function Keys on Time Clock Activity F1 Education F2 Call Back (On Call Worked) F3 Charge F4 Shift Leader (Charge Leader) F5 Total Hours Worked (Does not include PTO, Sick, Fam Wellness, or other benefit time) F6 Float to alternate company for your facility (If at TCSC, this will float you to TOG) F7 View Last Punch (Check day/time of last punch) F8 Orientation F12 Clear Activity (way to clear self out of any of the above activities) # Float time to another cost center (Automatically float the company in which you are standing – i.e. TCSC, FSR) To use function keys F1-F5, F7, F8, and F12: Push Function key on the left of the time clock (see above table). The screen will say “Education or Charge, etc”. Wait until the screen says “Enter Badge” and then swipe your badge. To float time to another Cost Center (this will automatically float you to the facility in which you are standing): Push the # key on the bottom right of the time clock. The screen will say “Department”. Type in the cost center number (ex: 6145 for surgery) and tap enter. The screen will say the name of the cost center (ex: Surgery). Wait until the screen says “Enter Badge” and swipe your badge. ****If you need to float back to your home department during your shift, follow steps 1-3 above. NOTES: If you make a mistake in doing any of the above prior to swiping your badge, you can tap the “Clear” key at the bottom of the clock and back out to the date/time screen. When you leave for the day, JUST SWIPE YOUR BADGE. Do not tap the function keys again.

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

BENEFITS

Additional Benefit Information
CAFETERIA To receive a discount in the cafeteria during appropriate hours, you must wear your identification badge. EMPLOYEE HEALTH SERVICE We provide an Employee Health service to promote and safeguard the health of our employees. Employee Health is responsible for pre-placement health exams and minor treatment of illness and injury occurring in the workplace. When the occupational illness or injury is beyond the scope of what the Employee Health office can treat, the employee will be referred to another physician. In the case of a work-related injury, the employee would be referred to a physician on the Workers’ Compensation PPO panel. The services of Employee Health are available to employees free of charge in the treatment of work-related illnesses and injuries. You should not consider this service as a substitute for your private physician.

RISK MANAGMENT

Fort Sanders Regional Medical Center Orientation 2006 Risk Management
Joint Commission’s National Patient Safety Goals for 2006 Systems Improvement Report (SIR) State Reporting Documentation/Miscellaneous Policy Overview Worker’s Compensation Intranet Behavior Form Q&A

2005 National Patient Safety Goals
Goal: Improve the accuracy of patient identification ***Always use 2 patient identifiers – Name and DOB*** Goal: Improve the effectiveness of communication among caregivers 1. TORB/VORB 2. Dangerous Abbreviations 3. Timeliness of reporting of critical values 4. “Hand-off” communication Goal: Improve the safety of using medications 1. Concentrated electrolytes 2. High alert medications 3. Label Medications 4. Look-alike/sound-alike medications Goal: Reduce the risk of health care-associated infections 1. CDC Guidelines for Handwashing 2. Sentinel events r/t infection Goal: Accurately and completely reconcile medications across the continuum of care 1. Home medications 2. Transfer form/Medication Reconciliation 3. Communication to next provider Goal: Reduce the risk of patient harm resulting from falls 1. Falls Risk Assessment 2. Signage/Armband 3. Pt/Family Education

Patient Status SYSTEMS IMPROVEMENT REPORT
 Inpatient  ED  Outpatient  Resident  Visitor  Other_______ Facility/ Entity _________________ SYSTEMS IMPROVEMENT REPORT Confidential and Privileged document- not to be copied or released outside of Risk Management For Healthcare Quality Improvement Committee Use GENERAL INFORMATION NOTIFICATION Age: ____ Gender:  Male  Female Admitting Diagnosis __________________ Occurrence Date: __________ Time: _______ Department: ________________ Room: ___________ Location of Occurrence: ____________________________ Unit Reporting Occurrence: ____________________________________________ Reported by: ____________________________ Date: ____________________ Date SIR Completed: __________________________ Physician  Yes  No Date_____________ Time______________ Dr. ___________________________________ Shift Supervisor  Yes  No Name _________________________________ Family/ Personal Representative  Yes  No INJURY/EVENT (CHECK ALL THAT APPLY) PATIENT CONDITION None Abrasion Anoxia Aspiration Bleeding- Minor Bleeding- Hemorrhage Blister Burn- Superficial Burn- Deep Cardioresp. Arrest- Unexpected Change in mental statusCirculatory Impairment Concussion Contusion Damaged/ Lost teeth Decubitis/ skin breakdownDermatitis/rash/hives Deterioration on condition Dislocation _____________ Extravasation- IV site Fracture _______________ Hematoma Infection line incisional/surgical sepsis other Laceration Loss of consciousness Neurological deficit Pain Paralysis Perforation Phlebitis Pneumothorax Poisoning Puncture Respiratory distress Restraint Injury Sexual assault Skin tear Soreness/pain Sprain/strain Stillborn/ fetal death Subdural hematoma Swelling/edema Unexpected death Unknown Unplanned return to surgery Wound disruption Other__________________________________ Vital Signs BP_____ P_____ R_____ T_____ O2 Sat ______ Alert/OrientedConfusedSedatedAgitatedUnresponsiveIncapable of following instructionsNon-compliantNon-ambulatoryDizzyImpaired GaitUnknownOther_________________ Pre-Event  Post –Event TREATMENT/ INTERVENTIONREQUIRED DESCRIPTION OF OCCURRENCE (Be brief, state facts only, name persons involved and witnesses)  None  MD Examined Date:___________ Time: ________  X-ray of _____________Results ________________  Labs _______________________________________ Results _______________________________________  Other diagnostics _____________________________  Surgery ____________________________________  Sutures ____________________________________ Other _______________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ EVENT CATEGORY A. COMPLAINT B. EQUIPMENT/ DEVICE RELATED Please mark applicable category and proceed to indicated section. Complaint by Pt/Visitor Equipment/ Device Related Fall/ Found on Floor  Obstetrical Patient Action Related  Patient Care  Personal Belongings Select A-G (A) (B) (C) (D) (E) (F) (G)  Abduction About another patient Alleged abuse Delay Fire Patient Rights Physician related Quality of Care Staff related Threatened legal action  Other _____________  Breakage  Contact with equipment  Injured by moving equipment  Disconnected/ dislodged  Malfunction/ failure  Improper use  Not available Other__________________ Name/ Type of Equipment__________________________Manufacturer__________________________ID/Model #__________________ Contact Engineering immediately and secure equipment with facility specific equipment malfunction tag. CONFIDENTIAL - DO NOT DUPLICATE DO NOT place in or refer to in medical record Complete within 24 hours

CONFIDENTIAL - DO NOT DUPLICATE
C. FALLS D. OBSTETRICAL E. PATIENT ACTION Ambulation related Assisted to floor/ controlled descent During recreational activity Fainted/ dizzy Found on floor From bed/ stretcher From commode From bedside commode From chair From wheelchair Reported/ not witnessed Shower/ tub Stairs Table/ stretcher related Transfer related To/ from bathroom While changing positions While standing Equipment related Other ________________ Related Information Prior to Fall Falls prevention program implemented Falls risk assessment done Risk identified Left unattended Non-compliant with instructions Previous falls this admit Received sedating/ mind altering drugs w/i 2hrs preceding fall, list___________________________ Restraints ordered  Not applied Applied incorrectly  Pt/ Family removed Environment # bed rails up ______ Bed position,  High  Low Shoes/slippers Slick/ wet surface Snow/ ice Uneven surface/ obstacle  Wheels not locked Apgar < 6 at 5 min Delivery outside OB Fetal death Forceps injury/ complications 4th degree laceration Infant abduction Meconium aspiration Monitoring issue Maternal complication Neonatal/ infant injury Retained placenta Return to delivery room/ OR Shoulder dystocia Transfer to level III nursery- unexpected Unrecognized CPD Uterine rupture Precipitous/ unattended  Other _________________  AMA Alleged assault Combative Elopement (except ED) Family dispute Illegal substance Inappropriate language Inappropriate behavior Intoxication Non-compliant Refuses treatment Self-extubation Self-inflicted injury Smoking in hospital Suicide Suicide attempt Threatening others Weapon possession  Other _________________ F. PATIENT CARE INDICATORS G. PERSONAL BELONGINGS Anesthesia complication Body injury during surgery Cancellation after induction Chart/documentation variance Communication Consent absent Consent incomplete Consent inaccurate Counts incorrect instrument sponge needle other Diet- wrong diet served Diet- NPO patient served Death in OR Duplicate procedure Foreign body retained\ Inadequate patient prep Narcotic discrepancy Identification Wrong patient Wrong site Wrong tx/procedure performed Wrong tx/procedure ordered Infection risks due to technique sterilization/packaging prep other ___________________ IV site problem IV infiltration Monitoring issue Needle/sharp stick Omitted treatment/procedure Positioning related Results reporting error Results reporting delay Return to OR Specimen related missing/lost incorrect preparation mislabeled incorrect processing/handling Transfer/moving of patient Transfusion reaction wrong type transfused wrong patient received other ____________________ Treatment delay/cancellation anesthesia services chart incomplete diagnostic info not avail equipment issue instrumentation used latex allergy staffing issue physician availability other __________________ Unexpected injury Unplanned removal/repair organ/part Other ______________________________________________________________ Missing  Damage  Vandalism Auto/vehicle  Clothing Dentures Equipment Glasses/contacts Hearing aid Home meds Jewelry Money/credit cards Wallet/billfold/purse Other ____________________________ Items documented in record Yes  No  N/A Search initiated Reported to security  Reported to law enforcement DEPARTMENT MANAGER/ SUPERVISOR REVIEW AND FOLLOW-UP** To be completed by supervisor after reporter has completed both sides of form. May attach additional sheets if needed. Assessment of Injury No apparent injury Nursing Intervention/ self correction Physician intervention/ no treatment Physician intervention/ treatment Potential for delayed surgery Delay in discharge  Death Unknown Transfer to higher level of care  Other ____________________ Assessment of Process P&P followed P&P not followed Communication failure Education needed Personnel related  Other ____________________________________________________________________________________________________________________ Performance Improvement Action/ Remarks____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Supervisor Signature/Title/Date (PLEASE SEND SIR TO RISK MANAGER WITHIN 72 RS) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ FOR RISK MANAGEMENT USE ONLY A. Circumstances/ events exist that have capacity to cause error. (Concern identified) B. Event occurred but did not reach the patient. (Near miss) C. Event occurred that reached the patient but did not cause harm. D. Event occurred that reached the patient, required monitoring to confirm that it resulted in no harm and/or required intervention to preclude harm. E. Event occurred that may have contributed to or resulted in temporary harm to patient and required intervention. F. Event occurred that may have contributed to or resulted in temporary harm to the patient and require initial or prolonged hospitalization. G. Event occurred that may have contributed to or resulted in permanent patient harm. H. Event occurred that required intervention necessary to sustain life.  I. Event occurred that may have contributed to or resulted in patient’s death. Follow-up/ Referral  None Action plan requested from department manager Compliance Review Investigation Quality/ Clinical Effectiveness RCA Referral _________________________________________________________ SMDA Reporting  State reportable Other ___________________________________________________________ Risk Manager _________________ Date _________________Follow-up ____________________________________________________________________ CONFIDENTIAL - DO NOT DUPLICATE DO NOT place in or refer to in medical record Complete within 24 hours

The following are some instances of potential state reportable events
The following are some instances of potential state reportable events. This list is not all inclusive and does not include exclusions. It is the responsibility of the Risk Management Team to determine, along with Administration, whether an event is state reportable or not. Please do not hesitate to call Risk Management with any questions. Medication Errors, Categories E-I Aspiration in a non-intubated patient related to conscious/moderate sedation Intravascular catheter related events including necrosis or infection requiring repair, or intravascular catheter related pneumothorax Volume overload leading to pulmonary edema Blood Transfusion reactions such as wrong blood type and/or delivery of blood to the wrong patient Perioperatrive/procedural related complications that occur within 48 hours of the operation or procedure such as central or peripheral neurological deficits or motor weakness. Burns of a 2nd or 3rd degree Falls resulting in radiographically proven fractures or subdural/epidural hematoma, subarachnoid hemorrhage, etc… or any fall that requires sutures/staples for repair Procedure related incidents, including readmissions and within 30 days of the original procedure: A: procedure related injury requiring repair or removal of an organ B: Hemorrhage C: Displacement, migration or breakage of an implant, device, graft or drain D: Post-op wound infection following clean or clean/contaminated case E: Any unexpected return to OR related to the primary procedure F: Hysterectomy in a pregnant woman G: Ruptured Uterus H: Circumcision requiring repair I: Incorrect procedure or incorrect treatment that is invasive J: Wrong patient/wrong site surgical procedure K: Retained foreign body L: Loss of limb or impairment of limb at discharge or at least 2 weeks after occurrence M: Criminal acts N: Suicide or attempted suicide O: Elopement from the facility P: Infant abduction or infant discharged to the wrong family Q: Adult abduction R: Rape S: Patient altercation T: Patient abuse or misappropriation of funds U: Restrain related incidents V: Poisoning occurring within the facility

A. Remember, if it isn’t charted, it wasn’t done
Risk Management New Hire Orientation ) Systems Improvement Report (SIR) Formerly known as incident reports Purpose: to be able to analyze an occurrence to prevent reoccurrence Do chart the event Do give all the facts on the SIR, include all witnesses and their involvement Do give the patient’s status at the time of the report Do use the SIR for all falls, including visitor and patient Do not chart that the SIR was completed Do not copy the SIR or place the SIR in the medical record Do not give ANYONE a copy of the SIR Do not use the SIR for employee injuries, there is a separate form for employee injuries 2) Charting A Remember, if it isn’t charted, it wasn’t done B Always chart specifics such as who, what, when, where C Document date and time on ALL orders and entries D Correcting errors: Line through and initial E WRITE LEGIBLY 3) Things to Know A Know where manuals are kept Be familiar with policies/procedures/guidelines and where manuals are kept and how to access the intranet C Know the chain of command

Subject: Visitor Accident / Injury
NAME OF BUSINESS UNIT Subject: Visitor Accident / Injury Fort Sanders Regional Medical Center Policy Number: EC.SF.019 Name of Category / Sub-category Environment of Care / Safety Page 1 of 1 Approved by: Administration 04/73 01/81 10/04 Generated by: Risk Management Effective date: 04/73 Revised date: 01/81 10/04 Review date: 02/01 02/04 Scope: All employees Purpose: Provide guidelines for response to an emergency involving a visitor to the hospital Policy Statement: When a visitor is injured as a result of an accident on the premises of Fort Sanders Regional Medical Center, emergency first aid will be provided either at the site of the accident, or in the Emergency Department. If the visitor requests medical treatment, the admission process through the emergency department will be handled per the normal triage protocol and procedure. Procedure: Give immediate assistance. If the visitor desires medical treatment, direct him/her to the Emergency Department, providing appropriate transportation as necessary. In an emergency situation, the Emergency Department must be called for assistance. The injured visitor will be registered in the Emergency Department and given medical care promptly as per normal routine. The Emergency Department Registration Desk or Team Leader will notify the Risk Manager during regular working hours (or the nursing supervisor if after regular working hours) that the visitor is being treated in the Emergency Department. The Risk Manager (Nursing Supervisor after hours) will proceed to investigate the accident immediately. Complete (or have a witness to the accident complete) a Systems Improvement Report including the cause of the accident, names of all witnesses, weather conditions if pertinent, and other relevant information. The completed report will be forwarded to Risk Management.

EMPLOYEE INCIDENT REPORT
Please circle your location: Covenant Health (Parent Corp) Covenant Homecare Covenant Medical Mgmt Covenant Staffing Services Fort Loudoun Medical Fort Sanders Foundation Fort Sanders Perinatal Center Fort Sanders Regional Fort Sanders Sevier Fortress Corp Methodist Medical Cntr. MMC Foundation Parkwest Medical Peninsula Behavioral Health PHP Companies, Inc. Resources Mgmt Group Thompson Cancer Survival Center Thompson Oncology Group Thompson Oncology Group -West EMPLOYEE INCIDENT REPORT To Be Completed by Employee: Date of Injury: ____________________________________________________________________ime of Injury:___________________________A.M. P.M. Employee Name: ___________________________________________________________________________________ Male ________ Female________ Home Address: ________________________________________City: ___________________________________State: __________ Zip: _____________ Home Phone #: ______________________________________________Marital Status: ____Married ___ Single ____ Divorced ____ Widowed _________ Soc. Sec.#________________________________________ Date of Birth: ______________________________ Date of Hire:________________________ Department: _____________________________________ Cost Center #: ________________________ Department Telephone #:____________________ Job Title: ____________________________________________________ Supervisors’ Name: ________________________________________________ Shift: ________ Work schedule: _____________________ Time Employee Began Work on Date Of Injury: __________________-____________________ Date Reported: ____________________Date Employer Notified of Injury: ______________________ Last Day Worked: _____________________________ Injured Body Part Description: _____________________________________________________________________________________________________ Location of Incident: _____________________________________________________________________________________________________________ How Injury Occurred: ____________________________________________________________________________________________________________ Was there a hazard noted? (If so, describe): _________________________________________________________________________________________ Name(s) of witnesses: ___________________________________________________________________________________________________________ Needle Stick-Sharps, Bloody Body Fluids & Exposures (Only) Needle Stick Device: Manufacturer: Safety Device: Yes No List Safety Devices used: Supervisor/Analysis and Counseling Report Evaluation (Completed by Dept. Manager or House Supervisor) Describe any break in technique or procedure: Suggestions for preventing any future accidents: Actions taken to implement suggestions (including employee counseling): Was employee in violation of any established Policy & Procedures: The employee has read and understands that it is a crime to knowingly provide false, incomplete or misleading information to any party regarding a workers’ compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. ________________________________________________ ____________________________________ Employee Signature Date _______________________________________________ ____________________________________ CH (12/04) Supervisor Signature Date Please send employee and completed report to Employee Health.

REFERENCE SHEET FOR COMPLETING GREEN INCIDENT REPORT
EMPLOYEES When a work-related injury occurs you must immediately complete a green incident report. Sign and date the green incident report at the bottom. Immediately notify your supervisor/manager of the incident and ensure that they have reviewed the incident report. Once you have met with your manager, you are to report to Employee Health immediately. If Employee Health is closed you must contact the House Supervisor for triage. YOU MUST BRING YOUR COMPLETED GREEN INCIDENT REPORT WITH YOU. SUPERVISORS Review the completed green incident report. Ensure that all the spaces are completed---please provide cost center # if the employee has not done so. Complete the Supervisor Analysis/Counseling section of the form. DO NOT JUST LEAVE THIS AREA BLANK. Sign and date the green incident report at the bottom. Ensure that the employee reports to Employee Health when Employee Health is open (Monday-Friday from 7-4) or contacts the House Supervisor for triage when Employee Health is closed. After the evaluation, expect the employee to bring a copy of his/her Return to Work note, which will indicate the employee’s status. DO NOT SEND INCIDENT REPORTS TO EMPLOYEE HEALTH VIA INNEROFFICE MAIL. THE EMPLOYEE MUST BE SEEN BY EMPLOYEE HEALTH OR TRIAGED BY THE HOUSE SUPERVISOR.

WHAT TO DO IF AN EMPLOYEE SUSTAINS A WORK-RELATED INJURY
Instruct employee to notify manager or shift leader ASAP. Employee completes all sections of the top portion of Green Incident report. Manager or shift leader will complete the supervisor section. Ensure incident report is completed in its entirety and is signed and dated-- do not leave any spaces blank Immediately contact Employee Health at When Employee Health is closed (open M-F 7-4), contact House Supervisor for triage. If the House Supervisor sends an employee to the ED for an evaluation, he/she MUST follow-up with Employee Health the next business day. IMPORTANT POINTS TO REMEMBER Employees may not call themselves off of work. If seen by Employee Health, they will have a return to work note to give to their manager. Whenever an employee is given restrictions, he/she will have follow-up appointment(s) in Employee Health until released to full duty and/or seen by a specialist. Once an employee has seen a specialist, he/she needs to contact WORxS to discuss any problems ( ). If an employee completes a green incident report, he/she must contact Employee Health for an evaluation. It is imperative we evaluate all strains/sprains and anyone who was initially evaluated in the ED. Sedgwick (our WC company) is the only one who determines compensability.

SAFETY

CODE RED: The Hospitals Fire Policy.
INFORMATION ABOUT SAFETY AT WORK PHONE NUMBERS Fort Sanders Regional Medical Center pager #: The Safety Department is here for you! We want you to work safely and feel safe at work. This is one of many safety training sessions you will be a part of during your employment with Fort Sanders Health System. This session will touch on a few areas of safety that are important for the new employee. CODE RED: The Hospitals Fire Policy. When an employee discovers a fire, they should remember R-A-C-E! R Rescue people from immediate danger ...WHILE.... A Alert the staff by calling “CODE RED” loudly. Any employee who hears someone shout “CODE RED” should pull the closest pull station and report to the fire scene. C Contain the fire by closing all doors and windows. E Extinguish the fire when possible. Remember, even if it is a drill, the fire alarm is ALWAYS pulled. …to remember how to use a fire extinguisher think of P-A-S-S… P Pull the pin. A Aim at the base of the fire and to the left or right. S Squeeze the handle. S Sweep from side-to-side. Every employee is involved when a fire alarm sounds. When hearing fire alarm follow RACE: Check all rooms to determine the fire location and close the door as you exit. Begin fire emergency procedures when a fire is discovered. Determine all clear status if no fire exists

DISASTER/EMERGENCY SITUATIONS!!!
Dial “66” at Regional if… the alarm system has been activated and a fire exists. Tell the operator the exact location of the fire. when fire responders determine the reason for the alarm and/or that no fire exists. the fire alarm system is out of order. HAZARDS!!!!! Categories of hazards within a hospital setting include: 1.Electrical Chemical Infectious Radiation 5.Unsafe behavior by humans Chemotherapy drug exposure Any information needed about a hazardous material in the work place can be gotten from the Material Safety Data Sheet (MSDS) which can be found in the orange MSDS manual in your department. The MSDS contains information about health risks, disposal information and decontamination procedures. Pull your department’s MSDS manual and familiarize yourself with the MSDS for your area. Employees can protect themselves from body fluid and chemical exposure by wearing the proper personal protective equipment and working in a well- ventilated area. Examples of protective equipment include: gloves, eye shields, hearing protection, splash shields, gowns, tyvek suits, protective clothing. CONSTRUCTION!!! Interim Life Safety measures are used in construction areas to protect employees, patients, and visitors from smoke and fire. Safety officials regularly conduct fire drills, daily inspections of the construction areas, and isolate the area by barriers. Heed warnings to stay out of construction area. These warnings are for your protection!! DEFECTIVE EQUIPMENT!!! Defective equipment that is hazardous to the user or patient must be tagged and labeled “OUT OF SERVICE.” Speak with your Manager or Supervisor for instruction. DISASTER/EMERGENCY SITUATIONS!!! During a disaster situation (code purple, black, yellow, pink, gray, and white), reference the policies in the RED Safety Manual and refer all questions or information to the Control Center: Telephone extensions: #2000 or #2001.

INFECTION CONTROL

IT IS OUR DUTY TO PROTECT THE PATIENTS!!!
INFECTION CONTROL FSRMC has an Infection Control / Exposure Control Plan to prevent the transmission of blood borne pathogens such as: HIV, HBV, HCV, and other potentially infectious agents by: Reducing reasonably anticipated exposure to blood and other potentially infectious materials Establishing engineering and work practice controls Providing appropriate employee training and follow-up, and monitoring of work practices HANDWASHING IS THE SINGLE-MOST EFFECTIVE WAY TO PREVENT THE SPREAD OF DISEASE / INFECTION. IT IS OUR DUTY TO PROTECT THE PATIENTS!!! The following pages will provide detailed information on disease-specific pathogens. Hepatitis B & C HIV C Diff VRE MRSA TB Exposure Policy Protective Equipment Standard Precautions

What to do for each type of isolation AFB (Acid-fast bacilli)
ISOLATION IMPLEMENTATION Type of Isolation Infections Isolated What to do for each type of isolation MAXIMUM CONTACT MRSA, VRE, C. diff, major draining wounds, multi-drug resistant gram negative bacteria PPE cart/cabinet stocked Hand wash with soap/water or hand sanitizer Glove before entry into room Gown if potential contact with contaminated surfaces Alert other departments of patient’s isolation status Dedicated equipment (BP cuff, stethoscope, thermometer, etc) AFB (Acid-fast bacilli) Pulmonary Tuberculosis (TB) *(Severe Acute Respiratory Syndrome (SARS) –requires negative air room) *(Smallpox –requires negative air room) *Contact Inf Control/Health Dept Place patient in negative air pressure room Employee fitted for the particulate respirator Wear respirator to enter room Keep door closed at all times (even when the patient is temporarily out of the room) Negative Air Pressure turned on Patient wears a yellow mask (if possible) to leave room Visitors instructed to wear the particulate respirator One hour after patient discharge for unprotected entry into room AIRBORNE / CONTACT Chicken Pox, disseminated Shingles, Measles Keep door closed at all times Only immune-competent staff should be assigned to care for the patient Negative air pressure room recommended if extensive draining lesions and in mouth or nares Can be airborne transmitted if lesions are in nares and mouth or from handling contaminated linen Contact transmission from hands/items contaminated with drainage from lesions DROPLET Flu, Pertussis (whooping cough), Neisseria meningitidis, Mycoplasma pneumonia, Parvovirus B19, Haemophilus Influenza meningitidis, Rubella, Adenovirus, pharyngeal Diphtheria, mumps, Group A strep Wear yellow mask to enter room Eye protection as required Patient wears yellow mask, if possible, to leave room PROTECTIVE Patients with WBC less than 1,000 Cancer patient receiving chemo Organ transplant patient receiving immunosuppressive steroids Other immune conditions that physicians feel need protective isolation All persons must wash their hands before entering the room. No fresh fruits or plants in the room (no decorative leafy garnish on the food tray) Employees with respiratory infections, fevers, draining wounds, herpetic lesions, or other potentially communicable conditions may not enter the patient’s room. All equipment that will come into contact with the patient must be disinfected with alcohol prior to and after use. Remove all soiled linen ASAP; do not keep hamper in the room Do not remove ice pitcher from the room. Carry the ice to the room in a closed paper or plastic bag. Restrict visitors to immediate family; Restrict persons with known infection. Patient wears yellow mask upon leaving the room. Implementation Checklist Stock isolation cart/cabinet Place isolation sign on door Place isolation sticker on chart Make sure alcohol hand sanitizer dispenser has solution 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

WHAT YOU SHOULD KNOW ABOUT HEPATITIS B
WHAT IS HEPATITIS B? Virus that causes inflammation of the liver—one of your body’s most vital organs Found in blood HOW IS IT SPREAD? Mainly through blood Infected needles and sharps Shared personal care items Unprotected sex Membranous exposure (eyes, nose, mouth) Bites and wounds Perinatal transmission HEPATITIS B CAN RESULT IN: No symptoms Mild illness Acute (severe) illness Chronic infection Liver damage, such as cirrhosis Liver Cancer Death due to liver failure WHAT ARE THE SYMPTOMS? May appear 1-9 months later Asymptomatic Flu-like (vomiting, nausea, diarrhea, sore muscles and joints, mild fever, headaches) Fatigue Stomach pain Loss of appetite/weight Jaundice Dark urine HOW DO WE TEST FOR HEPATITIS B? Physical exam to check if liver is swollen Blood test for liver profile Blood test for virus and antibodies HOW DO WE TREAT HEPATITIS B? No treatment PREVENTION Vaccine is very effective Health care workers: Use standard precaution, get vaccinated, exposure management HBV + individuals: Protected sex, don’t donate blood or organs, don’t share personal care items Hepatitis B vaccine is offered to the eligible employee at the time of employment

WHAT YOU SHOULD KNOW ABOUT HEPATITIS C
WHAT IS IT? A virus that can cause serious liver disease Found in blood HOW IS IT SPREAD? Mainly through infected blood Infected needles (IV drug, body piercing, and tattoo needles) Shared personal care items (razors and toothbrushes) Unprotected sex (less common cause) Blood transfusion before 1992 HOW DOES IT AFFECT YOUR HEALTH? Damages your liver Approximately 85% develop chronic disease found years after initial infection Cirrhosis (30-40%) Cancer (2-4%) Liver failure Problems with your immune system WHAT ARE THE SYMPTOMS? Usually acute infection is without symptoms Flu-like (fatigue, nausea, vomiting, diarrhea, sore muscles and joints, mild fever, headaches) Loss of appetite Weight loss Right upper abdomen tenderness Jaundice Abdominal swelling Itching Dark urine HOW DO WE TEST FOR HEPATITITS C? Physical exam to check if your liver is swollen Blood test for liver profile Blood test for virus and antibodies HOW DO WE TREAT HEPATITIS C? Avoid alcohol and non-prescriptive medications like acetaminophen Eat a well-balanced diet Get adequate rest Exercise Take medication as prescribed by your doctor PREVENTION STEPS No vaccine or medication can prevent the spread of Hepatitis C Health care workers: Use standard precaution practices if there is risk of exposure Follow hospital policy for exposure management If you are Hepatitis C positive: Use condoms during sex Don’t donate blood products, body tissue, organs Don’t share needles, razors, toothbrushes, manicure tools, or other personal items

WHAT YOU SHOULD KNOW ABOUT HIV
WHAT IS IT? Virus that enters bloodstream, invades immune system, overwhelms immune system Causes AIDS (acquired immunodeficiency syndrome) HOW IS IT SPREAD? Infected needles and sharps Shared personal care items Unprotected sex Membranous exposure (eyes, nose, mouth) Broken skin exposure Perinatal transmission HOW DOES IT AFFECT YOUR HEALTH? Stages of the disease May not show symptoms for years Swollen glands, lesser diseases Inability to fight off life-threatening diseases WHAT ARE THE SYMPTOMS? Weakness Fever Sore throat Nausea Diarrhea White coating on tongue Weight loss Swollen lymph glands HOW DO WE TEST FOR HIV? Antibody test Western Blot HOW DO WE TREAT HIV? No vaccine or cure Anti-retroviral Protease inhibitor PREVENTION Health care workers: Use standard precautions, exposure management HIV + individuals: Protected sex, don’t donate blood or organs, don’t share personal care items

Clostridium difficile (C. difficile) Fact Sheet
What is C. difficile? Anaerobic gram-positive spore-forming bacteria producing toxins that cause disease. What causes C. difficile? Diarrhea may occur as a result of antibiotic use but is most severe if caused by C. difficile. Types of diarrhea-associated C. difficile are a) Nonspecific diarrhea which is self-limited, and relatively mild b) CDAD is an infectious diarrhea which is almost always acquired by patients who have taken antibiotics recently (usually within 2 months). The mechanism by which antibiotics induce C. difficile disease is not well understood and c) Pseudomembranous colitis (PMC) is a more severe form of CDAD characterized by the presence of pseudomembranes that are yellow, white, or gray neutrophilic mucosal plaques in the colon. How is C. difficile transmitted? The organism is most often transmitted via the hands of health care personnel who have had contact with contaminated feces or contaminated environmental surfaces. Infection results from ingestion of C. difficile spores, which survive the acid environment of the stomach, convert to the vegetative forms in the colon, and produce toxins that result in the clinical symptoms. Commodes, baby baths, and electronic thermometer handles are among the environmental sites implicated in the transmission of C. difficile. What prevention and control measures can be taken? Contact Isolation precautions. Isolation cart outside patient’s room. Alcohol hand sanitizers will kill vegetative forms but not C. difficile spores; therefore washing with soap and water is important to physically remove the kill-resistant spores. Wear gloves before entering the room. Gowns should be worn to prevent contamination to your clothes. Dedicate equipment for that patient’s use only. Adequate disinfection of medical devices is important (especially items likely to be contaminated with feces such as thermometers). Non-critical care items such as blood pressure cuffs and stethoscopes should be bagged in clear plastic and sent to Sterile Processing for gas sterilization. Reusable critical care equipment should be disinfected and steam or gas sterilized based on the manufacturer’s recommendation. Wheelchairs, intravenous poles, and stretchers that are contaminated by infected patient should be cleaned by vigorously wiping surfaces with an approved disinfectant/cleaner. Reusable bedpans should be cleaned daily with disinfectant and terminally in the cart washer. The environment of the room may be highly contaminated with C. difficile spores depending on the severity of the diarrhea. Thoroughly clean and disinfect the isolation room. A sporicidal agent is preferred. Areas for attention include toilets, reusable bedpans, furniture, floors (in the bathrooms, patients’ rooms, and soiled utility room), sinks, bedrails, and telephones. Mops and water are changed for each isolation room. Special cleaning attention should be given to areas around the toilet. Walls should be spot cleaned for all visible soiled areas. Used linen should be bagged in the patient’s room. Minimizing or preventing anitmicrobial use in patients such as restricting Clindamycin use and controlled use of extended-spectrum cephalosporins. How is C. difficile disease treated? The first line of treatment is to discontinue the causative antimicrobials or select agents such as metronidazole, vancomycin, aminoglycosides, or possibly fluroquinolones, which are less likely to cause CDAD.

Vancomycin-Resistant Enterococcus (VRE)
What is Enterococcus? Enterococcus is gram-positive bacteria normally found in the gastrointestinal tract and female genital tract. It can cause infection of the following: urinary tract, abscesses and wounds, decubitus ulcers, diabetic foot ulcers, bloodstream infections, and endocarditis. Vancomycin is a drug that is frequently used to treat many types of infections. If Enterococcus is resistant to vancomycin it is referred to as VRE (vancomycin-resistant Enterococcus). Frequently, VRE is also resistant to many of the other drugs used to treat Enterococcal infection. Therefore, infections caused by VRE can be life threatening. How Does VRE Infection Occur? Infection often results from the patient’s endogenous carriage (residing on or in the patient’s body). The bacteria leave the area of colonization such as the GI tract or GU tract, enters a site, multiplies and causes an infection (i.e., wounds or migration along a catheter). VRE can also be transmitted from the contaminated hands of HCW’s (with or without gloves) or contaminated items or contaminated environment to a patient. How Do You Prevent Transmission of VRE? Infections caused by VRE require enhanced precautions beyond Standard Precautions in order to prevent transmission to a distant site on the colonized patient or transmission to another patient. Practicing good patient care and maintaining required aseptic and sterile technique is important. Reasons for enhanced precautions include the potentially serious outcomes of infection, the ease by which VRE contaminates the environment and its ability to live for days on the environment, objects, and fabrics. Therefore these patients are placed in Contact Isolation. How Do You Implement Contact Isolation? After you are alerted to the patient’s VRE status you will do the following: Obtain and place a contact isolation cart outside the patient’s door. The cart will be stocked with gloves, gowns, disinfectant, and thermometer. Dedicate devices such as blood pressure cuffs and stethoscopes to prevent transmitting Enterococcus to yourself and others. If reasons necessitate the use of such devices on another patient, you must clean and disinfect the device with an appropriate cleaner/disinfectant such wiping with 70% isopropyl alcohol or other FDA registered product. Post the contact isolation sign on the patient’s door or door frame so that it is noticeable to people who will be entering the room. Place the contact isolation label on the front of the chart so that those who look at the chart can easily see it. Handwashing must be performed before and especially after leaving the room seconds of lathering with soap and water seconds of rubbing with the alcohol hand sanitizer. Be sure to also focus under and around the fingernails and jewelry if worn. Gloves must be worn in order to enter the room. Gowns must be worn if you anticipate contact with the patient or the environment. Alert other departments if the patient is to be transferred for diagnostic testing (i.e., surgery and radiology) or if transferred to a different unit. Whenever possible, communicate the VRE isolation to the physician, other clinicians, dietary and housekeeping. Encourage and educate others to appropriately follow isolation precautions. Family and Patient Fact Sheet for VRE If the family requests information about VRE or if you determine that such information would be of benefit to the family, contact Infection Control at or the House Supervisor at

Methicillin-resistant Staphylococcus aureus (MRSA)
What is Staphylococcus aureus? Staphylococcus aureus is Gram-positive bacteria frequently found on the skin, nares, groin, and GI system. It may cause infection in the sputum, blood, surgical wounds, burn wounds, decubitus ulcers, perineum, rectum, tracheostomy, or grastrostomy sites. Methicillin is a drug frequently used to treat S. aureus. If S. aureus becomes resistant to Methicillin it is called Methicillin-resistant Staphylococcus aureus (MRSA). MRSA strains are frequently resistant to other classes of drugs, therefore MRSA is serious or may even be life threatening to your patient. How Does Infection Occur? MRSA is usually transmitted from patient to patient via hand carriage of Health Care Workers in the hospital setting. Also, patients may be colonized (carries it somewhere on their body). Colonized patients may become infected with their own bacteria, such as MRSA on the patient’s skin migrating into a Foley catheter. How Do You Prevent Transmission of MRSA? Infections caused by MRSA require enhanced precautions along with Standard Precautions to prevent transmission to a distant site on the colonized patient or transmission to another patient. Practicing good patient care and maintaining aseptic and sterile technique is important. Reasons for enhanced precautions include the potentially serious outcomes of infection, the ease by which MRSA contaminates the environment and its ability to live for days on the environment, objects, and fabrics. Therefore these patients are placed in Contact Isolation. How Do You Implement Contact Isolation? After you are alerted to the patient’s MRSA status you will do the following: Contact isolation for MRSA positive patients is required if the culture site is draining, secreting, excreting, etc., and is determined to be at high risk of transmission. If the culture site has a low risk of transmission because it is not draining, secreting, excreting, etc., then standard precautions will be applied (No isolation sign required on door; does require isolation sticker on the chart to alert others to MRSA). If requirements for contact isolation are met: place a contact isolation cart outside the patient’s door. The cart will be stocked with gloves, gowns disinfectant, and thermometer. Dedicate devices i.e. blood pressure cuffs and stethoscopes to prevent transmitting S. aureus to you and others. If reasons necessitate the use of such devices on another patient, you must clean and disinfect the device with an appropriate cleaner/disinfectant such wiping with 70% isopropyl alcohol or other FDA registered product. Post the contact isolation sign on the patient’s door. Place the contact isolation label on the front of the chart. Handwashing must be performed before and especially after leaving the room seconds of lathering with soap and water or seconds of rubbing with the alcohol hand sanitizer. Be sure to also focus under and around the fingernails and jewelry if worn. Gloves must be worn in order to enter the room. Gowns must be worn if you anticipate contact with the patient or the environment (including activities such as holding clipboard in the room, dispensing meds to the patient, etc.). Alert other departments of the patient’s MRSA history if the patient is to be transferred for testing (i.e., surgery and radiology) or if transferred to a another unit so that they can take precautions. Communicate MRSA status to physicians, other clinicians, dietary and housekeeping. Encourage and educate others to appropriately follow isolation precautions. Family and Patient Fact Sheet for MRSA are available by calling Infection Control at or House Supervisor at

WHAT YOU SHOULD KNOW ABOUT TUBERCULOSIS (TB)
WHAT IS IT? Airborne infection that occurs in the body sites of greatest ventilation, usually the middle or lower lung zones or the anterior portion of an upper lobe. An infection, caused by a bacteria, that starts in the lungs and can spread to other body organs. HOW IS IT SPREAD? The germs are spread in the air from person to person by coughing or sneezing or singing. RISK FACTORS? HIV-infection/AIDS IV drug abusers Foreign-born minorities (esp from Africa, Asia, Latin America) Elderly Low-income populations, including homeless Institutionalized persons (eg, in nursing homes, prisons) Heavy smokers Alcoholics WHAT ARE THE SYMPTOMS? May vary from person to person Sudden high fevers, sore throat, and cough Tired feeling with body aches, night sweats, and low-grade fevers for months Symptoms may depend on the body part that is infected It has been estimated that >90% of persons with clinically apparent disease are those who have harbored TB infection for at least 1 year or more and that remaining 10% have immediate progression of recently acquired infection (CDC, 1990b) HOW DO WE TEST FOR TB? TB Skin Test which is “read” within hours after placement Chest X-Ray Sputum specimen for AFB HOW DO WE TREAT TB? AFB Isolation--respiratory isolation. Antituberculosis drugs Report all cases of TB to local health department.

Infection Control Safety Measures:
NEEDLESTICK/BODY FLUID EXPOSURE POLICY Policy Statement Any work-related percutaneous (needlestick, laceration, bite) or permucosal (ocular, mucous membrane) exposure to blood or body fluids will be reported to Employee Health. CDC guidelines will be followed for assessment and treatment. Objective To control transmission of hepatitis B (HBV), hepatitis C (HCV), and HIV among health care workers. Procedure All exposure sites will be washed with soap and water. Eyes and mucous membranes exposures will be flooded with water. Accidents (including needlesticks, eye/nose/mouth exposure, and intact skin exposure if amount of body substance or if duration of exposure is considered to be significant) must be reported immediately to the employee's supervisor or the house supervisor and an Incident Report completed. The employee will then go to Employee Health with the report. If the injury occurs during a time in which Employee Health is closed, the employee will contact the House Supervisor for evaluation and follow-up by Employee Health. 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, and other blood borne pathogens. Clean-up of blood spills or other potentially infectious materials includes: using gloves, remove the visible material, then clean the area with detergent followed by an EPA-approved hospital disinfectant. Contaminated needles are to be placed in an appropriate receptacle such as a sharp’s container. When full, the container is placed in a red bag for proper disposal and incineration. Contaminated needles are not to be recapped unless there is no safe alternative present. At such times the one-handed scoop technique may be used by the employee. (see EOHS, Blood/Body Fluid Exposures Policy and FSRMC Exposure Control Plan – Policy # EC.SF.006)

SECURITY

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

Weapons Policy No employee will be allowed in any
Covenant Health facility when in possession of a personal weapon, including but not limited to firearms, any knife with a blade of four inches or more or with a fixed blade, or a club. The use, possession, sale, or purchase of personal weapons by any employee at any time on company premises, by any employee during his/her work hours, or by any employee on company business anywhere, is strictly prohibited. Only those employees who are issued or Authorized weapons by Covenant Health to perform their specific job functions (i.e., Security Officers) are excluded from this policy.

What Is a No Information Patient?
POLICY: Refer to HIPAA policy C13 – Use and Disclosure for Hospital Directory. When NO INFORMATION status is requested patient will be listed “No Publicity / No information” in hospital computer system. PROCEDURE: During the registration process, a discussion will be held with the patient and/or the patient’s personal representative regarding whether the patient desires his/her name and room number to be included in the hospital directory. When a patient requests to Opt Out of the Hospital Directory they are considered to become NO INFORMATION status. The registrar will document on the Opportunity to Agree or Object form as appropriate and answer any questions the patient may have. The patient and/or the patient’s personal representative will be advised by the registrar that as a No Information patient, all telephone calls, visitors, florists, etc., will be informed there is no listing for the patient. This will apply to ALL inquiries, as hospital personnel cannot screen for certain telephone calls or visitors. After explanation of the status, if patient still wishes NO INFORMATION, the registrar will complete the following steps on the miscellaneous page in the admission process: 1) select “yes” from the table option in the Opt Out field 2) enter the date the decision was made to Opt Out 3) select “! No Information” in the publicity field. Proper entries will automatically place an exclamation point (!) by the patient’s name on the name inquiry screen on StarClin. The patient and/or the patient’s personal representative will be asked to sign the Opportunity to Agree or Object form. The original form will be placed in the patient’s medical record chart and a copy scanned into the Optical System. Computer systems utilized at the Information Desk(s) restrict Courtesy Ambassadors from viewing patients listed as NO INFORMATION. Nursing Unit – Place only the room number and the doctor’s name on outside of chart, omitting patient’s name. At no time will the patient’s name or ID numbers be changed to accommodate the no information status of the patient.

Procedure to Follow When a Prisoner is Admitted to the Hospital….
Nursing staff shall notify the Security Department when a prisoner is admitted as a patient to their floor, and when discharged. Nursing staff and Security Officers should introduce themselves to the police officer in charge of the patient. Introductions should be made each time a shift change occurs for either the police officer or the affected nursing staff. Security officers will pass on information as necessary to the police officer and log the information relative to the prisoner in the Security Department. The Security Department will give the officer a copy of the “Law Enforcement Orientation” packet and ask the officer to read the material provided, answer specific questions about the material, and sign the “Law Enforcement Orientation Form”. Once completed, the police officer should have the Security Department notified so a Security Officer can pick up the signed form. The forms will be kept on file in the Security Department. Any patient that is a prisoner must be constantly monitored by a police officer, without exception. The Security Department may relieve the on-site officer for up to two, fifteen-minute breaks per 8 hour shift as the workload allows. If the Security Department is not available, or for any additional breaks or breaks longer than fifteen minutes, the responsible law enforcement agency will need to provide relief. Under no circumstances, should anyone other than a hospital Security Officer or another law enforcement agent relieve the on-site police officer.

Abandoned Babies: FSRMC will offer protective shelter, medical care and treatment in a hospital setting to unwanted, unharmed infants aged seventy-two (72) hours or younger. An “unharmed condition” can be interpreted as meaning the infant was not harmed through abuse or neglect after being born. If medical assessment reveals injury or abuse to the infant or if the assessment determines that the infant is greater than 72 hours old, this policy will not be utilized and the appropriate authorities/agencies will be notified. PROCEDURE: Any hospital employee will accept a newborn infant presented for surrender and assure person surrendering newborn that this is a safe haven. Immediately notify the House Supervisor/designee. House SV will then obtain an Abandoned Baby-Surrender of Infant Packet. Each packet is coded with a number that corresponds with and ID band for the infant. This identifying number will be used to track infant during hospitalization. Corresponding number appears on self-addressed, stamped envelope provided for return of questionnaire. (Completed packets will be given to the facility Risk Manager for sequestering information necessary to maintain confidentiality. House SV will accompany parent/person to ER for infant triage and medical screening exam. If the person refused, a numbered bracelet will be placed on the infant’s arm and leg. House SV will notify the Administrator on Call. Emergency Department Procedures are outlined in Administrative Policy #

licensed health care facilities. Policy:
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Patient Care Services/Maternal Child Subject: ABANDONED BABY SURRENDER OF INFANT Policy Number: PC.MC.001 Page: 1 of 7 Approved by: Administration 11/01 Generated by: Organizational Effectiveness & Clinical Outcomes Approved by: System Quality Improvement & Professional Relations Committee 11/01 Effective date: Approved by: Revised date: Review date: 02/04 Scope: All employees Purpose: This policy sets general guidelines for Covenant-affiliated hospitals and birthing centers to follow in order to comply with the Abandoned Baby Act and to meet other obligations of licensed health care facilities. Policy: Covenant Health will offer protective shelter, medical care and treatment in a hospital setting to unwanted, unharmed infants aged seventy-two (72) hours or younger. An “unharmed condition” can be interpreted as meaning the infant was not harmed through abuse or neglect after being born. If medical assessment reveals injury or abuse to the infant or if the assessment determines that the infant is greater than 72 hours old, the Abandoned Baby-Surrender of Infant policy will not be utilized and the appropriate authorities/agencies will be notified. If the newborn infant is less than 72 hours old, the acute care facility will notify the nearest office of the Department of Health Children’s Services. If the newborn infant’s age is determined within medical certainty to be greater than 72 hours at the time of surrender acceptance or if negligence/abuse is assessed by a physician, local law enforcement will be notified. Procedure: Any hospital employee will accept a newborn infant presented for surrender and assure the person surrendering the newborn that this is a safe haven. Upon acceptance of the newborn infant, the hospital employee will immediately notify the House Supervisor/designee. The House Supervisor/designee, upon being notified, will obtain an Abandoned Baby-Surrender of Infant Packet. The Abandoned Baby-Surrender of Infant Packet is a large red envelope that contains information that parent/person can return and a list of resources available. Each packet is coded with a number that corresponds with an ID band for infant. This identifying number will be used to track infant during hospitalization. Corresponding number appears on self-addressed, stamped envelope provided for return of questionnaire. Packets are available in the following departments:

House Supervisor/Designee Labor & Delivery
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Patient Care Services/Maternal Child Subject: ABANDONED BABY SURRENDER OF INFANT Policy Number: PC.MC.001 Page: 2 of 7 Emergency Department House Supervisor/Designee Labor & Delivery Other locations as designated by affiliates When a packet is used, the department in which the packet is used will obtain replacement from the Nursing Supervisor’s office. Completed packets/records will be given to the facility risk manager for sequestering of information necessary to maintain confidentiality. The House Supervisor/designee will request that the mother/person accompany him/her to the Emergency Department. If the mother/person refuses to accompany the House Supervisor to the Emergency Department, a numbered bracelet obtained from the Abandoned Baby-Surrender of Infant Packet will be placed on the infant’s arm and leg. An identical numbered bracelet will be offered to the mother/person and the questionnaire along with a self-addressed envelope will be provided. The mother/person will be encouraged to complete the questionnaire and return it to the facility. The House Supervisor/designee ensures that the infant is transported to the Emergency Department for triage and a medical screening exam. The House Supervisor/designee will notify the Administrator on Call. Emergency Department: Triages infant and assures identification bracelet is in place. Emergency Department physician will provide initial medical screening exam to determine: a. Physical condition of infant and any medical treatment necessary to stabilize the infant. b. Within a reasonable degree of medical certainty the infant is less than 72 hours old. Emergency Department nurse will: a. Receive infant. b. Inquire about the medical history of the mother or newborn and seek the identity of the mother, infant or the father of the infant. c. Inform the mother that she is NOT required to respond, but that such information will facilitate the adoption of the child. d. Inform the mother that any information obtained concerning the identity of the mother, infant or other parent shall be kept confidential and may only be disclosed to the Department of Children’s Services. e. Assure 2 ID bands on the infant and offer to give the mother the corresponding mother’s band.

f. Give the mother the Abandoned Baby-Surrender of Infant Packet.
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Patient Care Services/Maternal Child Subject: ABANDONED BABY SURRENDER OF INFANT Policy Number: PC.MC.001 Page: 3 of 7 f. Give the mother the Abandoned Baby-Surrender of Infant Packet. g. Assist the ED physician with an initial assessment. Notify Department of Children’s Services after surrendering party leaves premises. The ED nurse will inform the DCS caseworker of the infant identification number assigned to the infant. For security, the DCS caseworker will be asked the infant ID number whenever inquiries are made to or from the hospital. Notify the House Supervisor/designee of infant disposition and uses same process as admission and assessment of a baby born outside the hospital. Emergency Department physician will: Assess the Neonate and follow guideline on the physician order sheet in the Abandoned Baby-Surrender of Infant Packet. Relay assessment findings to the assigned neonatologist, pediatrician, or family practitioner on call or designee. Registration Services: Admits infant with name: Abandoned Baby. Number assigned to bracelet will be entered in the diagnosis field. Admits infant as a non-publicity patient. Nursing Unit: Document the numbers from the ID band on the Newborn Identification Sheet. Admits infant to unit and provides appropriate care and treatment. Infant is confidential patient. Initiates referral to Care Maps/Case Management Department. When discharge order is written, completes Discharge Assessment and Instructions and discharges infant into custody of properly identified representative of Department of Children’s Services. Notifies Medical Records of correct name of infant, if available. Case Management/Social Services: Contacts Department of Children’s Services and coordinates discharge planning. References: Senate Bill No. 774

Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Patient Care Services/Maternal Child Subject: ABANDONED BABY SURRENDER OF INFANT Policy Number: PC.MC.001 Page: 4 of 7 Fort Sanders Regional Medical Center Abandoned Baby - Surrender of Infant Order Guidelines Infant will be triaged in the Emergency Department prior to the determination of appropriate disposition. 2. Triage vital signs will include temperature, HR, RR, O2 saturation, weight, and color. 3. Nursery RN will be called ( ) to support activities performed in the Emergency Department. 4. If the infant is distressed, the East Tennessee Children's Hospital transport team should be called ( ) to respond to the Fort Sanders Regional Medical Center Emergency Department. 5. The Emergency Physician will relate infant assessment findings to the Neonatologist on call. 6. The infant may be admitted to the newborn nursery by transport isolette, if stable. 7. Nursery RN will contact Neonatologist of infant admission. Notify the Department of Children's Services of infant admission (within 24 hours).  Vital signs hourly x 4, then every 2 hours x 4, then every 4 hours.  Labs Stat CBC, BMP Serum Welcogen Type and Screen, Direct Coombs, and Rh Urine drug screen VDRL HIV (rapid evaluation)  Check patency of both nares using suction catheter - Note volume and color of aspirate  Peripheral blood glucose Hourly until first feeding, then before feedings x 4. Call if PBG < 40mg%.  Feeding - Similac with iron per newborn orders.  Medications Erythromycin eye prophylaxis AquaMephyton 1mg IM Hepatitis B Vaccine 0.5cc IM HBIG 0.5cc I  Umbilical cord - Defer triple dying until seen by neonatologist.  Bathe when stable.

You are urged to seek medical attention if you feel you need to do so.
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Patient Care Services/Maternal Child Subject: ABANDONED BABY SURRENDER OF INFANT Policy Number: PC.MC.001 Page: 5 of 7 To Whom It May Concern: Your choice to surrender your infant has been a brave and difficult decision. In compliance with the Tennessee Safe Haven Bill, the Covenant facility will contact the Department of Children's Services and relinquish custody of your infant to them. Any inquiry regarding your infant should be done through the Department of Children's Services (see enclosed list). We request that you complete the attached questionnaire regarding your medical history and return it in the self-addressed stamped envelope provided. Providing this information is strictly voluntary, however, it will assist in providing care for your infant. You are urged to seek medical attention if you feel you need to do so. Included in this packet is information regarding agencies and resources that may be able to assist you through this difficult time. April 2004

Department of Human Services: (931) 484-2573
Name of Business Unit Fort Sanders Regional Medical Center Name of Category/Sub-Category: Patient Care Services/Maternal Child Subject: ABANDONED BABY SURRENDER OF INFANT Policy Number: PC.MC.001 Page: 7 of 7 The following is a list of resources and agencies that may be of assistance to you: Department of Human Services: (931) Alcohol and Drug Information and Referral: (800) Battered Women: (931) , , (800) Social Worker: EMERGENCY Child & Family Crisis Center: Child & Family Runaway Shelter: Florence Crittenton Agency: Knox Area Rescue Ministries: Salvation Army: Serenity Shelter: Volunteers of America: DOMESTIC VIOLENCE Child & Family, Inc. Family Crisis Center + (24-hr. crisis line): Managing Emotions Nonviolently: The Conley Center, East: ; West: Knox Area Rescue Ministries Knox County Sheriff's Department Major Crimes Unit (covers domestic violence): Knoxville Police Department Domestic Violence Unit: The Salvation Army Women and Children's Program: SEXUAL ABUSE Child and Family, Inc. Project Against Sexual Abuse of Appalachian Children (PASAAC): Helen Ross McNabb Center: Sexual Assault Crisis Center: Crisis Line:

SUICIDE PRECAUTIONS FSRMC is obligated to exercise reasonable care in rendering services to all patients, and this includes the protection of suicidal or severely depressed patients from self-destructive acts. Suicide Precautions is a set of rules which may be placed into effect by an RN concerned with the clinical care of a patient or by the patient’s attending physician or medical consultants. When ordered, the rules will be followed by all departments involved in the clinical care or other services rendered to a potentially suicidal patient. Suicide Precautions will remain in effect until the patient is declared “non-suicidal” by the psychiatrist or attending physician and a written order to discontinue suicide precautions is given. The following shall be considered potentially suicidal: Any patient admitted for an apparent suicide attempt Any patient making a suicide attempt while hospitalized Any patient voicing threats of suicide Any patient who, in the joint professional judgment of the primary nurse and appropriate nursing supervisor is considered suicidal Any patient who, in the judgment of the attending physician, consulting physician or psychiatrist, is suicidal Department-specific procedures have been outlined in the Administrative Policy Manual, reference policy # Nursing Department Security Services Environmental Services Dietary Facility Services

Report it... It's the law! ABUSE: Adult & Child DEFINITIONS:
Abuse or neglect means the infliction of physical pain, injury or mental anguish, or the deprivation of services by a caretaker which are necessary to maintain the health or welfare of a dependent adult (See Tennessee Code ) Child abuse, brutality or neglect means any wound, injury, disability, or physical or mental condition which is of such a nature as to reasonably indicate that it has caused an adverse effect upon the physical or mental health and welfare of a child. Signs of abuse may include: The type of the injury Story that does not match injury Unusual behavior All known or suspected abuse cases MUST be reported to the Case Manager. If the abuse of a child is suspected, it must also be reported to the Dept. of Children’s Services and to the to the Child Abuse Hotline at or ABUSE. Report it... It's the law!

ABUSE “The five letter word no one wants to think about”
Identifying Victims of Abuse Forms of Abuse: Neglect: a form of physical abuse involving depriving the person of needed medical services or treatment; failure to provide food, clothing, hygiene, and other basic needs. Emotional: humiliation, harassment, ridicule, and threats of being punished; includes being deprived of needs such as food, clothing, care, a home, or a place to sleep. MUNCHAUSEN BY PROXY (MSP) is a label for a pattern of behavior in which caretakers deliberately exaggerate and/or fabricate and/or induce physical and/or psychological-behavioral-mental health problems in others. This pattern of behavior constitutes a separate kind of maltreatment (abuse/neglect) that manifests as physical abuse, sexual abuse, emotional abuse, neglect, or a combination. The primary purpose of this behavior is to gain some form of internal gratification, such as attention, for the perpetrator. Material: misusing a person’s personal property or finances for personal gain Physical: grabbing, hitting, slapping, pushing, kicking, pinching, hair pulling, or beating; includes corporal punishment – punishment inflicted on the body. Steps to be taken by patient care providers if abuse is suspected: RECOGNIZE IT Document, Document, Document Report to the primary nurse / Case Manager Take pictures Offer information such as pamphlets, brochures, and/or phone numbers for resources or agencies that can provide them assistance If the patient is a child, report to the department of Children’s Services and to the Child Abuse Hotline at or ABUSE Steps to be taken by non-patient care providers if abuse is suspected: Report to manager or shift leader immediately Report to the Child Abuse Hotline at or ABUSE

CHAPLAIN

The Chaplains are here for
CHAPLAIN SERVICES: The Chaplains are here for YOU, our patients, and their loved ones. The Chapel and Chaplain’s office are located on the main lobby just inside the Clinch Avenue entrance. The Chaplains are here to serve our patients, their loved ones, and our employees. If you have questions or would like to speak with a Chaplain, feel free to drop by their office or call them on the phone. You will reach voice mail if they are not in at that time. Voice mail messages are updated regularly to provide the caller with the best method to contact them quickly. After hours please call the house supervisor for the chaplain on call. YOU are our most important asset…the Chaplains would like to stress the importance of employees taking care of themselves as well as their patients. You are welcome to visit the chapel at any time to enjoy a quiet moment in a peaceful setting.

Health Care Professional Substance Abuse

Characteristics of Substance Abuse of the Healthcare Professional
Patient safety and staff well-being are primary priorities at Fort Sanders Regional Medical Center. Please read the following information: Characteristics of the Impaired Belligerence Mood swings Inappropriate behavior at work Frequent days off for implausible reasons (Days before and after scheduled off days) Non-compliance with standard policies & procedures Deteriorating job performance Sloppy, illegible charting Errors in charting Alcohol on breath Forgetfulness Poor judgment & concentration, jeopardizing patient safety Lying Signs of Diversion Volunteers to be Med Nurse Medicates other nurses’ patients Uses the maximum PRN dosage Patients complain about ineffective pain meds or deny receiving charted doses Frequent wastage or spilling of narcotics Problem on unit with drugs disappearing Seals have been tampered with Meds signed out of narcotic cabinet but not charted in patient record Healthcare and Substance Abuse Statistics Healthcare professionals are more likely to abuse prescription drugs and less likely to use alcohol than the general population Estimates of incidence range from 6 to 16 percent for healthcare professionals; 10 to 12 percent for doctors Incidence is higher for anesthesia providers (20% or 1 in 5) Notify your supervisor or Employee Assistance with any questions or concerns you might have.

Only clinical staff need to complete the following section.

Standards of Care “C.A.R.E.S.”
Comfort All patients treated by the nursing staff of FSRMC can expect comfort to be optimized through effective utilization of appropriate comfort measures (Standard I).. heAling All patients treated by the nursing staff can expect healing to be promoted through maintenance of effective hydration and nutrition, appropriate medication administration and the recognition, acceptance and support of his/her psychosocial and spiritual needs (Standard II).. Respect All patients can expect to receive respect for his/her rights as a patient and individualized nursing care based on research findings, ethical principles and continuous quality improvement, according to his/her unique health care needs (Standard III).. Education All patients can expect to receive education specific to his/her continuing health care needs (Standard IV).. Safety All patients can expect care to be delivered in a safe environment free of nosocomial infections and injurious insults (Standard V)..

AGE SPECIFIC CARE: Individualized care based on patient needs and abilities generated by aging.
Some examples are: GERIATRIC Decreased eyesight Hearing loss Diminished immune system Nutritional challenges Poly-pharmacy Safety impaired Skin breakdown Diminished information processing Needs referrals to community resources ADULT Stress Management – with care of parents, children, jobs, and now in the hospital these patients can be highly stressed. Lifestyle changes – educate for wellness. Needs referrals to community resources. TEENS Needs high level of privacy. Concerned with how their physical appearance can be affected by hospital tests and procedures. Feels immortal. Teach away from peers.

Pre-schoolers & School-age patients: Use short quick explanations
Pre-schoolers & School-age patients: Use short quick explanations. Demonstrate procedures on a teddy bear or doll. Use games or toys to explain unfamiliar objects. Allow the child to have some control. Toddlers Use play as a means of explanations. Give one direction at a time. Allow choices when possible. Use distraction for unpleasant procedures. Identify motor skills when determining food choices. INFANTS Keep parents in infant’s line of vision within safety limits. Give infant a familiar object. Cuddle and hug the patient frequently. Provide protective environment. Remove equipment when used. ! Remember, A patient’s age may determine how they need to receive information, but ALL age groups need education on how to maintain a healthy life-style.

Screen Print of Age-Appropriate
Care Section :

Safety Screen for all patients:
Hendrich II Fall Risk Tool for predicting the likelihood and risk of fall for hospitalized patients. Add up the numeric values for all elements of the tool. If the score is =>5 consider the patient level II or high risk. Match risk factors with interventions to prevent falls.

REQUIRED FORMS TO BE TURNED IN UPON COMPLETION OF THIS ORIENTATION SESSION:
Clinical Employees: Handbook Receipt Confidentiality Statement Infection Control Post-Test Safety/Security Post-Test Post-Clinical Test Computer skills check list is to be turned into the nurse manager when orientation to computerized documentation/order entry has been completed.

Restraints Key Points:
1. The use of restraint should be the final choice for protecting a patient. Alternative interventions should be evaluated prior to restraint use. 2. Alternative interventions may include but are not limited to: 2.1) review of administration, discontinuation, or alteration of current medications 2.2) supervised activity as allowed 2.3) increased monitoring and supervision of the patient by staff 2.4) family or sitters staying with the patient 2.5) diversionary activities 2.6) modification of the patient’s environment 3. Frequent assessment of the patient’s psychosocial and physical status and careful thorough explanation of environment, procedures, and events should be implemented on admission and continue until discharge. This measure may help to prevent the need for restraint. 4. If restraints are deemed necessary, soft restraints are to be used unless the need for heavier restraint is indicated. 5. Restraint for infants and children: 5.1) Hospital policy requires that parents stay with infants and children under age twelve (12). Restraints should not be used unless the parent is unable or unwilling to assist with preventing the child from injuring himself/herself. 5.2) If restraints are indicated for an infant or child, the same procedures apply. Restraint should be the least restrictive that will control the child and should be removed as soon as possible. 6. Consider a constant attendant in addition to the restraint if patient is actively non-compliant, i.e., removing the restraint device.

A Physical Restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body. Types of Restraints Seclusion refers to the involuntary confinement of a person alone in a room where the person is physically prevented from leaving. Voluntary Restraint – instituted following consent from a cognitively intact patient. Example: an elderly patient who has just taken a sleeping pill and has agreed to have a halter type device applied for the evening as a reminder not to get out of bed without pressing the call button to ask for assistance. A “drug used as a restraint” is a medication used to control behavior or to restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition. Routine treatment restraint – utilized to assist in a specific treatment or diagnostic procedure such as IV infusions, diagnostic x-rays, catheterizations,etc. Routine treatment restraint is not utilized primarily to involuntarily immobilize a patient. Treatment restraints may include immobilization used during surgery and during non-cognitive states. Forensic and corrective restrictions for security, e.g., handcuffs, applied by a police guard, are not defined as restraint. Postural/safety supports – utilized to assist the patient in achieving or maintaining proper body position, alignment and balance or compensating for a specific defect. These may be used to prevent non-cognitive patient from falling out of bed or chair.

Restraint Documentation
Assessed need for restraint. The outcome of alternative interventions tried before restraint. Patient/family education. Performance of q2h safety checks (CSM checks, skin checks, side rails up, bed in low position, call light within reach) and actions taken to ensure that the patient has opportunity for the activities of daily living (toilet needs, nourishment, position changes). Reassessment of the continued need for restraints q2h. Restraints may be discontinued (expired order/pt no longer needs), reinstated (patient has a reoccurrence of the same issues that led to the restraint being applied) or renewed (new order written) or simply “off” (as in trial temporary period). New physician order every 24 hours.

CLINICAL POST-TEST Name ____________________
Badge #___________________ Date _________ Page 1 of 1 Define the acronym: C.A.R.E.S The restraint policy states: Patients in restraints must be checked every ________. A ____________ _______________ is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body. Select the correct age group who most needs education on a healthy life-style. Geriatric c. Teen Adult d. All of the above Individualized care based on patient needs and abilities generated by aging is referred to as: The Aging Process c. The Nursing Process Age Specific Care d. Geriatric Nursing List the four types of abuse. ________________________ ________________________ ________________________ 4. ________________________ What are the two steps YOU take if violent abuse is suspected? ______________________________________________________________ The single most important tool a nurse can use to prove good nursing care is: Good hand washing technique c. Physician orders Nursing care plan d. Clinical documentation Complete the following list to show all the necessary steps for implementing an Isolation set-up: Stock cart/cabinet ____________________ Place sign on door Alert other departments ________________________ 7. appropriate hand hygiene Ensure alcohol hand cleaner is available 8. _____________________ List the steps you would follow if you are exposed to HIV.

INFECTION CONTROL ORIENTATION POST-TEST
Name _______________________ Badge #: __________________ Date ___________ Circle the correct answer. Bloodborne Pathogen Standard/Isolation According to the Exposure Control Plan, the choice and use of Personal Protective Barriers is based primarily on specific patient diagnosis and not procedure or expected risk. True False In any procedure where “splash” is a risk, eye protection is always required along with a mask. Gloves – Must be changed when contamination has occurred. Can be used patient to patient if not visibly soiled. Should be worn in the hall since surfaces may be contaminated. Should always be worn when cleaning up a blood spill. A and C A and D All of the above When Employee Health Services is closed, the Nursing House Supervisor is always notified following a blood exposure incident (needlestick, etc.) Hepatitis B immunization is offered to eligible employees at the time of employment. All “used” or dirty linen is considered potentially contaminated/infectious. Needles can only be recapped by using a recapping device or a one-handed technique. Page 1 of 2

INFECTION CONTROL ORIENTATION POST-TEST
Name _________________________________________ Full needle disposal boxes are placed inside red lined infectious waste containers for proper disposal and incineration. True False Which of the following is the correct procedure for cleaning up a blood spill? Notify environmental services immediately and secure the area Absorb the spill, spray Clorox solution on the area, bag all waste and dispose of it in the infectious waste container. Put on gloves, absorb the spill, clean area with a detergent, disinfect the area with either a Clorox solution or hospital grade germicide, and dispose of all waste in a buff colored bag as infectious Isolation for known or suspected TB requires which of the following? Negative pressure room, personal respirator (PR) Positive pressure room, isolation mask Any private patient room, as long as orange barrier masks are worn TB skin test must be read hours after placement. In employee follow-up after exposure to blood or body fluid, it is not necessary to report to Employee Health Services as long as an Employee Accident Report Form is completed. 13. Standard Precautions and Universal Precautions apply to all patients and includes the use of personal protective barriers, when contact with blood, any body fluids, non-intact skin and mucous membranes is anticipated. 14. Contact Isolation includes the wearing of gloves upon entering the patient room. Page 2 of 2

SECURITY / SAFETY ORIENTATION POST-TEST
Name _________________________ Badge # ___________________ Date ________________ Grade ________ Graded by ___________________________________ Page 1 of 2 Please answer the following questions. You may refer to your Orientation Handbook for assistance. A score of 100% is required before you may provide patient care. SECURITY What is a “no information” or “closed chart” patient? How will you know if a patient is a “no information” or “closed chart” patient? What does “CODE CLEAR” mean? Weapons are allowed outside of facility (on facility grounds). True or False What should you do if a patient prisoner arrives? Security personnel may be called to escort you to your car. True or False SAFETY What doe R.A.C.E. mean? What should you do when you hear a fire alarm? How do you alert others in the hospital that there is a fire? What can you do to protect yourself from body fluids and hazardous chemicals? What should you do if you discover that the equipment you are using is defective and hazar4dous to a patient or user? You do not have to report accidents that do not result in injury. True or False

SECURITY / SAFETY ORIENTATION POST-TEST
Name _________________________________________ Page 2 of 2 SAFETY continued: What should you do if there is an accident? Match the letter of the code with the correct response below: A. Code Black B Code Purple C. Code Pink D. Code Blue E Code Green F. Code Red G. Hazardous Material Spill H. Code Yellow I Code White J. Evacuation _____ Complete duties and report to immediate supervisor for release to personnel staging area. _____ Isolate the spill area (evacuate). Call nuclear medicine for spill clean-up. _____ Check for suspicious package and report to security. Immediately notify staff and PBX when bomb treat is received. _____ Clear the area to avoid others from becoming a hostage. _____ Notify all in area of need to evacuate. Evacuate ambulatory, wheelchair, then bedridden. Take records if safety permits. Notify PBX to activate internal evacuation alert. _____ Assess whether infant has been removed from premises. Notify immediate supervisor. When code is announced, search for abductor. _____ Potentially violent person exhibits anger or uncontrolled behavior toward staff. _____ RACE _____ Remove persons from hazard. Trained user cleans up spill. If you can do it safely, assist contaminated victims in decontamination process. _____ Designated team responds to area following PBX announcement.

Fort Sanders Regional Medical Center Fort Sanders Perinatal Center
Thompson Cancer Survival Center and Thompson Oncology Group HUMAN RESOURCES CHECKLIST FOR NEW EMPLOYEES Employee Name (Print) ___________________________ Date of Hire________________ _____ Location/Hours of Business for HR Office, Forms, Contact Numbers _____ Harassment Policy _____ Workplace Violence Policy _____ Patient Care Philosophy _____ Staff Rights Policy _____ Problem Solving Procedure _____ Ethics Committee _____ Employment Information _____ Worker’s Compensation _____ Employee Performance & Behavior Expectations _____ Cariten Assist Employee Assistance Program _____ Care of Equipment & Supplies _____ Smoking Policy _____ Identification Badge (Must wear at all times above the waist) _____ Employee Parking _____ Benefits _____ Risk Management _____ Safety _____ Infection Control _____ Security _____ Abandoned Baby _____ Patient Abuse _____ Diversity _____ Facility Tour _____ Characteristics of Substance Abuse of the Healthcare Professional _____ Acknowledgement Card and Receipt for Handbook __________________________________________________________________________ Employee Signature Date ___________________________________________________________________________ Human Resources Representative Date

ACKNOWLEDGEMENT CARD AND RECEIPT FOR HANDBOOK
This Employee Orientation Handbook is not intended to be a contract nor is it intended to create any contractual rights on behalf of any employee of Fort Sanders Regional Medical Center, Fort Sanders Perinatal Center, Fort Sanders Foundation, Thompson Cancer Survival Center, or Thompson Oncology Group, or of any other Covenant Health entity. None of the statements, policies, procedures, rules, regulations, or other provisions contained in this Employee Orientation Handbook constitutes a guarantee of any other rights or benefits, or a contract of employment, express or implied. Each employee of Fort Sanders Regional Medical Center, Fort Sanders Perinatal Center, Fort Sanders Foundation, Thompson Cancer Survival Center, or Thompson Oncology Group or of any other Covenant Health entity is an at-will employee under Tennessee law and is subject to termination at any time without cause and without notice. Fort Sanders Regional Medical Center, Fort Sanders Perinatal Center, Fort Sanders Foundation, Thompson Cancer Survival Center, Thompson Oncology Group, and Covenant Health reserve the right to modify or eliminate any or all terms of this Employee handbook at any time with or without notice. This Employee Orientation Handbook supersedes all previous Orientation Handbooks. I have read and understand the above statement and agree to read the employee orientation handbook which I hereby acknowledge having received. I also understand that Covenant Health is committed to providing a safe working environment for the employees and the patients we serve. Accordingly, I consent to undergo a drug and/or alcohol test if asked by a manager who has reasonable cuase. I understand that refusal of such test will constitute grounds for termination. _________________________________________ Employee Signature Date

EMPLOYEE ORIENTATION HANDBOOK

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