Fountain Valley Regional Hospital Non-Employee GENERAL

Fountain Valley
Regional Hospital
Nursing: Staffing Office
Non-Nursing: Department Manager
Welcome to Fountain Valley Regional Hospital Medical Center (FVRH).
Our Mission and Vision
Our Mission: To provide world class healthcare the diverse patients of our
community in an environment of compassion, competence and quality,
where both physicians and staff are committed to those patients, as well as
each other.
Our Vision:
To maintain a comprehensive range of services that meet the needs of
the regional area we serve
To use all of our resources to deliver outstanding care and extraordinary
service to our patients while being sensitive to their cultural differences
To provide opportunities for education to our physicians and staff that
will assist in their professional growth and their ability to care for our
To distinguish ourselves both through our high quality of care delivery
and integrity with which we deliver it.
Parking Policy:
Parking is available at no charge in the Employee lot (See map).
Dress Code
All employees/students are required to wear identification badges at all times
while on duty.
All employees/students are expected to be professional in appearance.
Attire shall be modest, safe, and clean while on duty.
Employee/Student appropriate attire is defined as, but not limited to the following:
1. Artificial nails, nail extenders, silk wraps or other nail overlays, or nail jewelry
are not allowed for staff with direct patient contact or contact with patient care
supplies and equipment.
2. Fingernails must be kept neatly trimmed, ¼ inch maximum length, and clean.
3. If worn, polish will be light in color and in good repair (i.e. no chips or cracks).
4. As appropriate, hose or socks are required.
5. Closed toe shoes are required. Extreme colors, style, heel height, sandals,
beach flip-flops are not acceptable.
6. Department specific dress code may be required. Sportswear such as jeans,
denim pants of any colors, stretch pants, legging, shorts, walking shorts,
skirts, T-shirts, sweatshirts, sleeveless shirts, bare shoulder or spaghetti
strapped blouses, tank tops or sun dresses are not permitted.
7. Clothing must be modest and professional. Sheer, low cut, spandex, clinging,
bare or revealing clothing must not be worn. Proper undergarments must be
worn at all times.
8. Long hair will be pinned up or tied back.
9. For safety reasons, it is requested that if jewelry is worn, it be conservative.
Items such as earrings worn in areas other than the earlobe are considered
unprofessional and not allowed.
10. Mustache and/or beards are required to be neatly trimmed.
Smoking Policy:
FVRH is “smoke free“campus. Smoking is totally banned inside the
hospital. Smoking is only permitted outside in designated smoking areas.
Breaks and Lunches
• You are allowed a ten (10) minute paid rest period for every 4 hours that you
• You are allowed thirty (30) minutes unpaid meal period per 8 hour shift.
• 12 hour shifts are required in certain clinical areas. Please ask your department
resource for break and lunch period information.
• Rest period and meal breaks may not be combined.
Body Mechanics
¾ All staff is expected to practice safe body mechanics. Use of ARJO lift and
position assistive equipment is required. If you need equipment
orientation, please ask your staff resource.
Key Points to remember:
¾ To maintain a safe and healthy working environment Fountain Valley
Regional Medical Center attempts to prevent injury to employees who
perform lifting as a part of their job duties. Therefore, it is crucial that all
employees demonstrate safe lifting, transporting and proper back care
techniques at all times.
¾ Fountain Valley Regional Hospital and Medical Center is firmly committed
to maintaining a safe and healthful working environment. To achieve this
goal, we have implemented this comprehensive Injury & Illness Prevention
Program. This program is designed to prevent workplace accidents,
injuries, and illnesses wherever possible.
¾ Good housekeeping is an integral part of any effective Safety Program.
Keeping workplace areas neat and clean reduces the chance of accidents
and injuries. Well-organized areas also increase the ability of employees
to perform their jobs effectively. Each employee is responsible for keeping
his or her work area neat and orderly.
¾ All direct care employees shall function as a “lift team” by providing patient
handling assistance to colleagues when needed. If an urgent or emergent
need has been identified by the nurse, PT or OT may provide support to
nursing. Employees are encouraged to actively be involved in maintaining
a safe environment by reporting any unsafe conditions to the unit
¾ Be familiar with the general proper body mechanics and ergonomics
Hazardous Materials
Under the "Right to Know" requirements employees working in a healthcare
environment have a "Right to Know":
What chemical hazards exist in the facility?
What their exposure potential may be?
What precautions have been taken to protect the employee?
What "work practice controls" are in place to protect workers?
What systems are in place (engineering controls) to limit exposure?
What personal protective equipment has been provided?
The leadership within the organization is required to:
1. Establish policies and procedures for the safe use, handling and storage
of hazardous substances.
2. Orient and train staff on the potential exposure hazards and hospital
3. Provide work policies & procedures for safe work practices.
4. Provide engineering controls and personal protective equipment to protect
5. Monitor the compliance with use of the above.
6. Monitor the environment. Provide material safety data sheets.
7. Monitor accidents and incidents.
Employees are responsible to:
1. Understand and comply with hospital polices and procedures related to
hazardous material safety.
2. Use the Haz-mat spill kits when handling hazardous substances.
3. Use the Personal protective equipment provided when handling
hazardous substances.
4. Report unsafe or hazardous situations.
5. Report and document accidents, incidents, exposures and spills.
6. Understand where to find and how to read Material Safety Data Sheets
Electrical Safety
Personnel are responsible for knowing how to operate each piece of
electrical equipment before using it.
All equipment in patient care areas must be approved by the Engineering
Department of the hospital.
Check power plugs and cords before turning on equipment. Any damaged
equipment should not be used, tagged with the facility form, and sent for
If any electrical equipment “looks, smells, or sounds strange”, disconnect
the plug from power source, tag with facility form and notify engineering.
Patients are not allowed to use their own electrical appliances unless
battery operated.
The first step to take in the event of an electrical fire or electrical shock is to
disconnect the power to the equipment.
Never handle electrical equipment while in contact with potential grounds
water faucets, sinks, or wet areas.
This fire plan is based on the acronym RACE, which is easy to remember:
R– Remove
A– Activate Alarm
C– Confine the Fire
E– Extinguish or Evacuate the area if not safe (behind smoke barriers)
For use of the fire extinguisher use the acronym PASS:
P– Pull the Pin
A– Aim
S– Squeeze
S– Sweep
Do no use elevators in the event of fire.
Keep hallways clear (place equipment only on one side of the hallway)
Do not block exits, fire alarms or prop doors open
Do not store supplies or boxes on the floor
Keep items on top shelves at least 18 inches from the ceiling.
Fires are classified according to the material that is burning. Fire
extinguishers are coded to reflect the type of fire they can put out. The
classifications are:
Class A: Ordinary combustible material, such as paper, cloth, wood and some
Class B: Liquids, oil and gases.
Class C: Electrical, such as live energized electrical equipment.
Class ABC: Extinguishes all types of fires
*It is required to know the location of the closest fire extinguisher, fire alarm
pull, and exits in your work area.
Life Safety Measures
In the event you are directed to conduct a partial or total building
evacuation know where your designated evacuation location is on the
exterior of the building. The priority of patient evacuation is as follows:
1. Any in immediate danger.
2. Ambulatory patients.
3. Semi-ambulatory patients.
4. Non-ambulatory patients.
Disaster Manuals are located in each work area for reference.
What it Means
What to do
Fire, Smoke or
Rescue those in immediate danger
Alarm the Alarm & Pull Alarm
Contain the Fire, Close Doors
Extinguish the Fire, if safe to do so
If not responding, close doors, assume the
responsibilities of those that responded, remain alert
listen for more information.
If not responding, take over the responsibilities of
the personnel that responded to the Code
Burning Smell
Assess the Patient, call for help, initiate CPR
Under 18 yrs of
Assess the Patient, call for help, initiate CPR
Infant Abduction
less than 1
month of age
Personnel go to nearest point of entry & stop all
traffic. Maintain at least one person per door, age of
missing infant will be announced
Personnel go to nearest point of entry & stop all
traffic. Maintain at least one person per door, age of
missing child will be announced
Bomb Threat
Keep caller on phone, obtain information about
bomb location, description, when it will go off, why it
was placed, listen for background noises
All personnel follow directions of the lead person in
charge until All Clear is announced
If not responding, take over the responsibilities of
the personnel that responded to the Code
All staff trained in AB508 report to location paged,
assist with de-escalation or with restraint if
Haz Mat
Spill /Release
Contain Spill
Wear personal protective equipment
Seek medical treatment if necessary
Person with
Weapon /
Patient with
I & II
Internal or
Secure yourself & others, Dial 5555 give location,
hostages, suspects & weapon
Call 5555, and state Rapid Response Team to
Room---Know the criteria for activation
Use SBAR To communicate patient’s condition
to the team
Department Directors report to Command Center,
get briefing & report unit status (census / staff on
duty), personnel without assigned duties &
If not responding, take over the responsibilities of
the personnel that responded to the Code
If not responding, take over the responsibilities of
the personnel that responded to the Code
If not responding, take over the responsibilities of
the personnel that responded to the Code
All personnel follow directions of the lead person in
charge until All Clear is announced
All personnel remain in secured area until Police
Do not enter effected location
Do Not leave the room when team arrives
Be a resource and have patients ‘ chart ready for
the team
If not responding, take over the responsibilities of
the personnel that responded to the Code
employees off duty report to personnel pool
Code AMI
Code Stroke
Code Census
Condition Help
Patients with
Patient with
possible stroke
coming to ER
ER Full, Beds
Alerts Cath Lab, EKG, HS
If not responding, take over the responsibilities of
the personnel that responded to the Code
CT Scan Alert, May initiate ROBOT
CN to coordinate
Department Directors report or call in to ED to see
what help is needed , including through put
If not responding, take over the responsibilities of
the personnel that responded to the Code
Family to
activate if it is
Patient or family calls 4357 (HELP)
Rapid Response Team Responds to the room after
operator calls it
Do Not leave the room when team arrives
Be a resource and have patients ‘ chart ready for
the team
Guidelines for Infection Control
These guidelines are intended to protect patients and healthcare
providers from potential exposure to communicable disease. The
Infection Control Manual provides extensive additional information.
¾ Standard
¾ Transmission Based
STANDARD PRECAUTIONS are designed to reduce the
transmission of blood borne pathogens.
STANDARD PRECAUTIONS apply to: Blood, all body fluids, secretions
and excretions (except sweat), regardless of whether or not they contain
visible blood. Exposure is through:
¾ Non-intact skin
¾ Mucus membranes
When Used
Some Examples
of Disease
All patients
All patients All blood, body
fluids, secretions, excretions
(except sweat) and
contaminated items.Non-intact
skin mucous membranes
Use barrier precautions as
needed to prevent contact with
blood, body fluids, excretions,
secretions, and contaminated
items. Wash hands before and
after contact or glove use. Wash
hands and change gloves
between patients. Take care to
prevent injuries when using
sharps. Dispose of properly.
Transmission Based Precautions In Addition To Standard Precautions
Private room, negative air
pressure, door closed. N95
Respirator, mask on patient
Spread by droplet nuclei particle
Chicken Pox,
during transport.
Spread by droplets
Influenza, Mumps,
Private room if possible, wear
mask, within 3 feet of patient, limit
transport, surgical mask on
patient during transport.
Spread by contact with intact
skin or surfaces
Resistant bacteria
like MRSA, VRE,
Herpes simplex,
highly contagious
skin infections ,
C. difficile
Private room, wear gloves. Avoid
contamination of hands. Wear
gown. Limit transport. Dedicate
use of patient care equipment to
a single patient.
Safety/Risk Management/Occurrence Reporting
Report the following to your department resource:
1. Defective or damaged equipment.
2. Injuries to self, staff, visitors, patients.
3. “Sentinel Event” Any unexpected occurrence involving death or serious
physical or psychological injury.
4. “Near Miss” defined as any process variation which did not affect the
outcome, but for which a recurrence caries a serious adverse outcome.
“A close call.”
5. Hazardous Condition-Any set of circumstances which significantly
increases the likelihood of a serious adverse outcome.
Core Measures
The Joint Commission (TJC) requires accredited hospitals to collect and
submit performance data. This requirement was established to improve the
safety and quality of care and to support performance improvement in
hospitals. The Core Measure initiative allows JCAHO to review data trends
and to work with hospitals as they use the information to improve patient care.
At FVRH we have chosen as our Core Measures:
1. Acute Myocardial Infarction
2. Community Acquired Pneumonia
3. Congestive Heart Failure
4. Coronary Artery Bypass Graft
5. Surgical Site Infection Prevention
Patients with a “core measure” diagnosis have clinical pathways and
protocols. Your department resource will provide you with specific
information and criteria.
AMI : Acute Myocardial Infarction
9 ASA within 24 hours: From arrival at facility door to Aspirin
9 EKG within 10 minutes: From arrival at facility door to EKG
interpretation by MD
9 Door to Balloon within 90 minutes: From arrival at facility door to
device deployment
9 LDL Assessment: Anytime during hospitalization
9 DC Medications: Prescribe Beta-Blocker, ASA, ACEI or ARB for
LVSD, and lipid lowering agent for LDL>100.
9 Smoking Cessation: Counseling & resources if smoked cigarette within
12 months of admit
9 Patient Education: Cardiac risk factor reduction and monitored Cardiac
CAP: Community Acquire Pneumonia
9 Chest X-Ray: Pneumonia confirmed by chest x-ray interpretation
9 Blood Culture: IF ORDERED: Draw Blood Cultures prior to 1st dose of
antibiotic medication
9 Blood Culture: To be drawn within 24 hrs when pt. admitted or
transferred to ICU within 24 hrs of hospital arrival.
9 Antibiotics: Prescribe per ISDA guidelines. IV ABX converted to oral
med when tolerating Pos
9 Pneumonia Vaccination & Flu Immunization: Educate & administer
unless contraindicated
CHF: Congestive Heart Failure
9 LVEF Assessment: Before arrival, at hospital, or planned for after
9 DC Medications: Prescribe ACEI/ARB at discharge from the hospital if
LVEF is less than 40%.
9 Smoking Cessation: Counseling & resources if smoked cigarette within
12 months of admit
9 Patient Education: Discharge Instructions
♥Activity Level
♥Discharge medications
♥Weight monitoring
♥Follow-up appointmentIncluding date and time of first
♥What to do if symptoms worsen
CABG: Coronary Artery Bypass Graft
9 Pre-induction heart rate<=80
9 Peri-operative use of aspirin 48hrs pre-op to 48hrs post-op
9 Pre-operative glucose=140mg/dl
9 ACC/AHA Appropriateness Class Documented
9 Beta Blockers Used within 24 hours prior to surgery
9 Post-operative extubation in<=12 hours
9 Post-operative ICU/CCU stay of <=36 hours
9 Aspirin, Beta Blockers, Ace/ARB for LVSD, and lipid lowering agents
prescribed at discharge
SCIP: Surgical Care Improvement Program
9 Antibiotic received within 1hour of incision
9 Discontinuations of all Antibiotics within 24 hours post operatively,
unless there is documentation of infection. 48 hrs for cardiac.
9 Glucose level < 200 in cardiac patients.
9 Hair removal NO RAZORS
9 Normothermia immediately post-op
9 If on a beta blocker, given within 24hrs. Pre-op and given by the end of
POD 2.
9 VTE prevention ordered and implemented within 24hrs.
9 Urinary Catheter removal by the end of POD 2
National Patient Safety Goals 2012
NPSG 1 - Improve the accuracy of patient identification
01.01.01 - Use at least two patient identifiers (neither to be patient's room
number) - Prior to specimen collection, medication administration, transfusion
or treatment.
We utilize the patient’s name and the patient’s DOB (both of which
are located on the patient identification band). At FV, the third
Identifier is the MR # which is used for infants or if patient’s name and
DOB are the same.
Use two identifiers when administrating medications, blood
components, collecting blood and other specimens, and when
providing treatments or procedures
01.03.01 - Eliminate Transfusion errors related to patient
misidentification - before initiating blood/blood components for transfusion,
the patient is matched to the blood/blood components; match the blood or
blood component to the order, match the patient to the blood or blood
component; use a two-person bedside verification process
One of the two-person verification team must be qualified to perform
the transfusion (i.e., a Registered Nurse)
The second person on the verification team must be qualified to
participate in the process (i.e., Registered Nurse or Licensed
Vocational Nurse or MD)
Also at FV, one of the people verifying must be RN on the staff, two
registry personnel cannot verify the process.
NPSG 2 – Improve the effectiveness of communication among
02.03.01 - Report critical results of tests and diagnostic procedures on a
timely basis
The objective is to provide the responsible caregiver these results
within an established timeframe. FVRH has established a 60 minute
Report critical results of tests and diagnostic procedures in a
timely basis.
NPSG 3 - Improve the safety of using medications
3.04.01 - Label all medications, medication containers (For example:
syringes, medicine cups, basins) or other solutions on and off the
sterile field
3.05.01 - Reduce the likelihood of patient harm associated with the use
of anticoagulation therapy; use only oral unit-dose products, prefilled
syringes or premixed infusion bags; before starting warfarin assess
baseline coagulation status
Program is implemented house wide at FV.
Accomplished through patient and family education, dietary
interactions, and accurate and timely lab results.
NPSG 7 - Reduce the risk of health care –associated infections
07.01.01 - Comply with the current CDC hand Hygiene guidelines. At FV
we follow CDC guidelines, there are set goals for improving the compliance
with the hand hygiene guidelines. Audits are done monthly. Staff teaching is
done during orientation and annual reorientation at minimum
Good hand hygiene: Not visibly soiled, waterless hand rubs. Visibly
soiled, soap & water.
C. Diff requires soap and water hand hygiene.
No artificial nails will be worn by anyone providing direct patient care.
NPSG 7 - Reduce the risk of health care –associated infections
07.03.01 - Implementation of guidelines to prevent multi-drug resistant
organisms; see Guidelines for Infection Control
07.04.01 - Implement evidence based practices to prevent of central line
associated bloodstream infections
Implement evidenced-based medicine (EBM) practices to prevent
central line-associated bloodstream infections. Central line Bundle is
implemented at FV
07.05.01 - Prevention of surgical site infections - Implement evidencedbased medicine (EBM) practices for preventing surgical site infection – refer
to SCIPS protocol
07.06.01- Implement evidence based practices to prevent indwelling
catheter-associated urinary tract infections (CAUTI)
Implement evidenced-based medicine (EBM) practices, CAUTI bundle
is implemented at FV
NPSG 15 - The hospital identifies safety risk inherent in its patient
15.01.01 - Identification of patients that are likely to harm themselves,
suicide risk.
We provide one-on-one supervision and referral to these individuals as
UNIVERSAL PROTOCOL - Eliminate wrong site, wrong patient, and
wrong procedure/ surgery.
UP 01.01.01 - Conduct a pre procedure verification process
Pre-op verification process / checklist, availability of appropriate
documents. Consent is completed & signed, risk/ benefits/ alternatives
are explained, H&P and Pre op VS are done, and all
documents/special equipment/implants are available.
UP 01.02.01 - Mark the procedure site
Marking the surgical site, which involves the patient.
Required for all cases, “YES” is marked with a permanent marker in an
area that will be visible after draping.
UP 01.03.01 - A time-out is performed before the procedure
Conduct a “time-out” immediately before starting the procedure
FVRH NPSG Requirement
Implementation of applicable NPSG’s and associated requirements by
competent and practitioners sites
Staff is informed about NPSG’s during general orientation and ongoing
Nursing orientation and department specific orientation also includes
info about NPSG’s
All department directors quiz staff on rounds about NPSG’s
Staff is reeducated on NPSGs during safety fair and on going
Sentinel Event
Any serious occurrence or unanticipated event that causes serious physical
or psychological injury, death, or the risk thereof is termed a sentinel event.
An occurrence that may be a sentinel event should be reported to your
manager/director immediately as well as to the Administrative Supervisor.
When notified, the Risk Manager and Administration will take further action
which may include performing a root cause analysis, mandatory reporting to
the State of California, and a corrective plan of action.
XVII. Patient Rights
A copy of these rights and responsibilities is given to all patients and posted
in the facility. This information is also included in patient handbook that
patient receives at admission. These rights include:
Access to Care
Hospital Charges
Advance Directives
Hospital Rules and Regulations
Complaints & Conflict Resolution
Pain Management
Personal Safety
Dying/Grieving Process
Privacy and confidentiality
Ethical Issues
Refusal or Acceptance of Treatment
Experimental Drugs/Devices/Clinical
Respect and Dignity Trials
Transfer and Continuity of Care
Patient responsibilities:
Provide accurate, complete information
Follow treatment plan; comply with instructions
Accept responsibility if treatment refused
Financial obligations
Follow hospital rules; be considerate of others
Patients have the right to register complaints without fear of retribution, to have
their complaints investigated and resolved, and be provided with timely follow
up. Furthermore, a patient complaint will not compromise continued care or
access to care in the future.
Additionally, patients and employees alike have the right to report concerns they
may have about safety or quality of care provided in the hospital and may report
these concerns to the Joint Commission. The hospital will take no disciplinary
action if an employee or patient reports safety or quality of care concerns to the
Joint Commission
See the Administration Manual for the complete policy and procedure titled:
Patient Rights and Responsibility
XVIII. Patient Satisfaction/Customer Service
It is the goal of FVRH that every patient and customer is completely
satisfied with the care and services provided. Our customers include
patients, visitors, employees, and medical staff. It is our policy to follow
up on patient concerns. If you should hear a patient or family member
voice a concern while at FVRH, please notify your department resource
immediately so the appropriate action can be take. Our approach to
customer service is as follows:
Acknowledge our Customers
Make eye contact
Stop what you are doing so your customer knows he/she is important
Introduce Yourself
Offer greeting
State your name
State your department
Explain how you will be serving them
Explain how long before the treatment, procedure, test, process starts.
Explain how long the activity will last.
If applicable, explain the post-activity report process.
Explain the treatment, procedure, test or process.
Explain who is involved providing their care/service.
If a clinical procedure, explain if the test will cause pain or discomfort,
or if post procedure instructions are necessary.
Solicit and/or offer to answer any questions, concerns.
Service Recovery (ACT)
Correcting and recovering when we have failed in service
A: Acknowledge and/or apologize
C: Correct the problem(s) ASAP
T: Thank the customer for raising the issue.
Population Specific Issues
Healthcare providers are required to relate to their patients in age/populationappropriate ways. This is based on criteria identified for each unit and position
Forensic Services
Non-employee personnel and/or contract staff receive orientation to the
facility as appropriate to their role.
XVIII. End of Life Issues
All disciplines must comply with procedures to ensure respectful, responsive
care of the dying patient.
Organ/Tissue Donation
All deaths are reportable for possible donation to “ONE LEGACY” .See
hospital policy for specifics.
Cultural Diversity
FVRH recognizes the diverse cultural make-up of our local population,
and seeks to accommodate each patient's cultural needs
HIPAA/Patient Confidentiality
All patients are entitled to have their protected medical information
remain private. To accomplish this:
Health information is shared on a need-to-know basis according to
hospital policy. All paperwork containing patient information will be placed
in the designated bins for proper disposal. IV bags have a perforated
label that must be removed prior to disposal.
Patient information is not shared with anyone who is not directly involved
in the care of the patient. This includes family members not authorized by
the patient to receive that information, other staff, and visitors. Please do
not hesitate to question anyone attempting to access patient information,
reading the patient's paper chart, or attempting to access an electronic
record. Report anyone who is attempting to gain information to your
department resource immediately.
Family members and visitors are not authorized to be in the nurses'
No photographs may be taken in the hospital unless associated with
medical/surgical related documentation (a signed Consent for
Photography must be obtained).
Employees, Contracted Staff, or Volunteers may not use cellular
telephones to text or otherwise relay protected health information or the
personal identification of patients to anyone whether they are involved
with the patient’s care or not.
Some patients may choose not to release their name on the general
census. These patients are referred to as “no information”. The charts are
labeled “No Info”, and “No Info” is placed on the census board instead of
their name. The designation “occupied” also delineates patients for which
no information is provided outside of direct care providers. At no time
should information be shared with visitors or over the phone for either of
these patient categories.
XXII. Moderate Sedation
FVRH provides specific policies for the monitoring of patients receiving
moderate sedation by the professional registered nurse and medical staff
during diagnostic and therapeutic procedures. Policies are available on
the nursing unit and clinical department.
XXIII. Pain Management
All patients are entitled to pain management. Please let your department
resource know immediately if your patient's pain is not well controlled. A
variety of 0-10 pain scales are used based on the patient's age and cognitive
status. Non-pharmaceutical pain management measures such as distraction,
music, and relaxation techniques are used in addition to ordered
medications. Reassessment of pain after intervention is required and must
be documented.
XXIV. Restraints
FVRH promotes the minimal use of restraints. Restraint may be the most
appropriate means of preventing patient injury. Restraints are only applied
after all other alternatives have been attempted and found unsuccessful.
Protocols for restraints are not used: each patient is individually assessed for
the need for restraints. When restraints are applied, hospital policy and the
manufacturer’s directions must be followed. Non-Violent / Non-Behavioral
restraints must be renewed every 24 hours by the MD. Written orders for
Violent / Behavioral restraints are limited to 4 hours for adults 18 or older; 2
hours for children 9-17; or 1 hour for children under age 9. The restrained
patient must be assessed, monitored and reassessed as per hospital policy.
Documentation of restraints is to be done on the Restraint Flow Sheet. Refer
to the Administration Manual for the Restraint and Seclusion policy.
XXV. Fall Prevention
FVRH has a fall prevention program to promote patient safety. Patients are
assessed using the Morse Fall Risk Scale on admission for the adult
population and the Graf – PIF Scale for the pediatric population. Yellow
nonskid socks, yellow “Fall Risk” wristbands are placed on patients
identified as “At Risk”. A magnetic “SAFE” sign is placed on the doorframe
of the patient’s room and yellow “Fall Prevention” stickers are placed on
the patient’s chart and kardex. The Fall Prevention Policy details the Morse
Fall Risk Scale and the Graf – PIF for assessment and requirements for
XXVI. Abuse
All healthcare workers are mandated reporters of domestic violence,
child abuse , elder and dependent abuse. See hospital policy for
specific criteria.
XXVII. Recognition of Impairment
Impaired and disruptive behavior of a licensed independent practitioner can
impact the safety and care of patients, endanger the physical safety of
hospital employees and may create a working environment that is hostile and
unproductive. FVRH has program to identify and manage physician
impairment. Please report symptoms of both impairment and disruption to
your department supervisor.
XXVIII. Team Dynamics
The medical, nursing, and ancillary professional staff of FVRH function
collaboratively as part of a multi- disciplinary team united in a purpose to
achieve positive patient outcomes.
XXIX. Chain of Command
Each unit/department has a charge nurse or supervisor who is responsible for
the function of the unit during their shift. The Administrative person on call
and nursing supervisor is available at all times including nights and
weekends. Unit managers have 24-hour responsibility for the unit. Unit
directors answer to the Chief Nursing Officer. Issues related to medical staff
are reported to the charge nurse or department supervisor for follow-up
through the chain of command.
XXX. Central Supply Items
Chargeable central supply items have a sticker attached. Remove the
sticker and place on the patient's central supply card.
XXXI. Verbal/Telephone Order Read Back
Verbal and telephone orders will be written on the “Physician’s Orders”
form. Orders will be read back to the physician and noted as such on the
physician orders form by placing a check- mark in the box next to “Verbal
Order Read Back.” It is the policy of the facility to discourage verbal orders
unless it is under an emergency situation or the physician is surgically
scrubbed in and unable to write orders. A nurse may not accept verbal
orders for chemotherapy.
XXXII. Medication Administration
All licensed staff are required to follow the "Five Rights" of medication
Two identifiers are used prior to administering medication: patient name, DOB
Only approved abbreviations may be used. Refer to hospital policy.
How are staff’ notified of medications shortages or outages?
The Pharmacy Department sends a notice to all affected areas each time a
shortage or outage occurs. The notice provides instructions as to alternative
medications available. Lists of shortages are available on the Pharmacy
How are investigational medications managed?
The hospital’s Protocol Review Committee approves all investigational
medications for use in the facility. A copy of the investigational protocol
governing the medication is placed in the patient’s medical record. Staff’ is
oriented to any requirements regarding the medication.
How do you assure that medications are appropriately stored?
We have developed specific policies to assure that medications are
appropriately stored. These policies require that:
Internal and external medications are stored in separate locations.
Medications requiring refrigeration are stored in refrigerators. The
temperature is monitored each day to assure that proper temperature is
• Medications are protected from light as required.
• Medications are made available in the most “ready to
use” form as possible.
• Medications are provided in unit dose form whenever
• Pharmacy staff makes routine inspections of medication
storage areas to assure compliance with policy.
o “Look-alike” and “sound alike” medications are
stored with special precautions
o Outdated medications are returned to
Pharmacy for appropriate disposal
How do you keep medications secured?
We have developed specific policies to assure that medications are appropriately
secured. These policies require that:
Medication rooms and carts are locked.
Only authorized licensed staff are permitted access to medication storage
Emergency medication carts and tackle boxes are checked regularly. Tags
are controlled only by Pharmacy staff
No medications are kept on top of medication carts or in patient rooms.
Staff is not allowed access into the main Pharmacy
How do you keep controlled substances secure and reconciled?
We have developed specific policies to assure that controlled substances are
appropriately controlled. These policies require that:
All controlled substances are stored in Pyxis.
Only licensed authorized staff will have access to controlled substances
Discrepancies of controlled substances are reconciled each shift. If a
discrepancy is noted, the Charge Nurse must be notified immediately.
Any wastage of controlled substances is witnessed by two licensed personnel
What steps do you take to protect patients from risks of errors in care
when dealing with high -risk medications?
We have taken steps to manage high-risk medications such as:
Specific policies have been developed to manage high-risk medications such
as insulin, heparin, and chemotherapy.
Special warning labels and precautionary statements are placed on high -risk
medications and look alike sound alike medications. These are also identified
on the Pyxis machine.
Special precautions have been taken to reduce the risk of administration
errors such as requiring two licensed nurses to verify identified high risk
How do you spot a potential adverse drug reaction?
The following strategies have been developed to spot potential
adverse drug reactions
• Pay particular attention to the first time a patient receives a
• Monitor for allergic reactions such as fever, rash,
• Monitor for hypersensitivity to a drug such as changes in
vital signs, acute or severe manifestations of side effects.
• Look for drug intolerance – a lowered threshold to the
normal pharmacological effect of the drug.
• Look for idiosyncratic reactions – an uncommon response by
a patient to a drug given at normal doses.
Chart notation should be made.
What do you do if you suspect an adverse drug reaction or a medication
Staff should take the following actions when there is a suspected adverse
drug reaction or medication error:
Support the patient. Assess the patient for untoward effects. Notify the
patient’s Physician for orders and treatment.
Notify the charge nurse and/or clinical Manager and Pharmacy
Charge nurse will complete eSRM a “Suspected Adverse Drug Reaction
Report” form and forward it to Pharmacy. If a medication error occurred,
complete an Occurrence Report or Medication Error Report form.
Document the pertinent facts in the patient’s medical record.
Is there any concentrated Potassium or hypertonic saline stored in the
various patient care areas?
No…concentrated Potassium and hypertonic saline are stored under the control
of Pharmacy. They are not stored in patient care areas.
How do you assure that you administer medications to a patient safely and
We have developed specific policies to guide staff in administering medication.
Key steps to safely administering medication include:
Wash your hands.
Correctly identify the patient using two patient identifiers.
Using the patient’s armband and the medication
administration record
Verify that you have the correct medication / dose / route
against both the drug label and the medication order.
Check the expiration date on the drug to make sure it is still
good. Do not use if the drug has expired.
As appropriate, visualize the medication for stability (i.e.,
color, clarity, presence of particulate matter). Does not use if
the medication appears compromise.
Check the patient’s medical record to make sure there are
no contra-indications to giving the medication.
Verify that you are giving the medication at the proper time.
Advise the patient of the purpose of the medication, and, as
appropriate, of any potential adverse reactions or side
If you have any questions or concerns regarding the
medication, discuss them in advance with the Physician or
call the Pharmacist for assistance.
Remember Five Rights: Right Drug,
Right Dosage, Right Route, Right Time
& Right Patient
6th Right- Right Documentation
How do you process a new medication order?
Our policy requires that Pharmacy review all new medication orders before staff
may give the first dose. That means that staff cannot take the medication from
Pyxis until Pharmacy has reviewed the order. There are some exceptions:
The Physician is in control of the medication process such as in Surgery, ED,
invasive procedures, etc.
There is a clinical emergency and there is no time for Pharmacy to review the
order (i.e. Code Blue, impending cardiovascular or respiratory failure, etc)
Can Nursing admix IV’s outside of Pharmacy?
Only under emergency conditions. Otherwise, all IV admixtures are done in
Pharmacy. If Nursing must admix a medication, special training and precautions
are taken.
XXXIII. Documentation
Initial Assessment
A complete assessment by a registered nurse shall be conducted on every
patient as follows:
• Critical Care: An initial physical assessment shall be done within 15
minutes of the patient's arrival to the unit.
• Emergency Room: -Per ED triage policy
• Medical/Surgical/Telemetry--Within eight hours of admission
• The Admission Data Base will be completed within 24 hour.
Each nursing unit individualizes documentation. Please check with your
resource that will show you the forms to use for your assignment.
In patient assessment, nursing flow sheets, outcome notes, interdisciplinary
plan of care, patient and family education form, and belonging list are some of
the forms that get initiated as part of initial assessment. Ask your resource on
the floor to share these forms with you.
Patients are reassessed every shift or more frequently as their condition
Nursing flow sheet—initiated upon patient admission and every shift there
Interdisciplinary Plan of Care—
• Initiated by the RN after completion of the admission assessment. All
entries on the Interdisciplinary Plan of Care will be initialed on the page
where documentation occurs and signature recorded at the end of the
document. The Interdisciplinary Plan of Care is individualized and based
upon actual or potential problems, anticipated length of stay, assessed
needs, policies, patient care standards, cultural issues, available
resources and will be consistent with other therapies and/or disciplines.
• The Interdisciplinary Plan of Care will be reviewed every shift and updated
as patient progress indicates.
Outcome Notes—
• Enter problem number from Plan of Care that is being addressed, enter
date, record time of documentation, enter discipline completing the entry
from the Key at bottom of page, enter assessment/data/observation
information in the "assessment" column, and enter interventions
completed in appropriate column.
Patient and Family education—
• The RN admitting the patient is responsible for coordinating the education
assessment, formulation of the plan, referral to other disciplines and
completing the initial "Core Education."
• Educational needs and barriers to leaning will be assessed upon entry into
the clinical setting.
• Educational interventions and response are documented on the
Patient/Family Education Record by all disciplines throughout the
XXXIV. Performance Improvement
FVRH is committed to continuously improving performance and patient care
The medical staff, employees and contracted services participate in
identifying opportunities to improve, data collection, multidisciplinary
teams and implement actions to sustain improvements.
The methodology selected by FVRH to analyze and improve
care/services and processes/outcomes is called the PDSA
P- Plan the Improvement
D- Do the Improvement
S- Study the results
A- Act to hold the gains
How to Report an Event
To report an event, contact your immediate charge nurse/supervisor.
They will facilitate completion of an occurrence report.
All Tenet Hospitals utilize an on-line incident reporting system that
employees access through eTenet. As a contract employee you don’t
have access to this system
This report is limited to factual statements that document the occurrence,
any interventions taken and shall not admit to or attempt to assign blame,
liability or causation
What is a Reportable Event?
¾ This occurrence isn’t consistent with the routine operation of the hospital
or routine care of a patient/s. Even the potential for accident, injury,
illness or property damage is considered a reportable event.
¾ An unintended event or act of omission or commission that departs from
or fails to achieve what was intended is considered reportable.
¾ Errors may or may not result in negative consequences. This includes a
system &/or an individual error of judgment or inaction. These are
REMEMBER: Any Hospital Staff, who witnesses, discovers or has
direct involvement/knowledge of a reportable event, shall complete an
occurrence report before the end of their shift.
Examples of Reportable Events include (but are not limited to):
Patient falls
Property (loss of or damage to)
Adverse drug events - medication errors Equipment failure or malfunction
Adverse drug reaction (allergic reaction) All stages of Hospital acquired pressure
Stage III and above decubitus ulcers
Why Report Potential/Actual Occurrences?
Supports a culture of shared accountability for identification of events that
may impact hospital & patient safety
Integrates risk reduction strategies into the hospital’s performance
improvement, peer review, credentialing & liability prevention activities
Supports compliance with requirements of federal/state law and standards of
accrediting organizations
Establishes process to ensure documentation and investigation is conducted
appropriate to the type/level of severity of reportable events
“How to Complete a POA Form”
What is a Present on Admission (POA) Form?
Beginning October 01, 2008, the federal government and 3rd party payers will
no longer pay for certain hospital acquired conditions (HAC). Because of this new
ruling, we’re highlighting certain conditions as especially important to assess
upon your patient’s admission to the hospital. Documentation is an extremely
important part of this process!
Hospital – Acquired Conditions selected for 2008
Stage III & IV Pressure ulcers
Catheter-associated urinary tract
infections (UTI)
Retained foreign object
Mediastinitis after CABG (Coronary
Artery Bypass Graft surgery)
Air embolism
Blood incompatibility
Manifestations of poor glycemic control
Surgical site infections following certain ele
(Diabetic Ketoacidosis, Nonketotic
Hyperosmolar Coma, Hypoglycemic Coma
o Orthopedic procedures involving
Secondary Diabetes with
repair/replacement/fusion of join
Ketoacidosis, Secondary Diabetes
shoulder, elbow, neck
with Hyperosmolarity
& spine
Bariatric surgery for obesity
(Laparoscopic Gastric Bypass,
Gastroenterostomy, Laparoscopic
Gastric Restrictive Surgery)
Deep Vein Thrombosis (DVT)/Pulmonary Blood Incompatibility
Embolism (PE) following total
hip/knee replacement
How is it determined that conditions are “Present on Admission”?
If they meet any of the following criteria:
• Present at the time the order for patient admission occurs
• Conditions originate in the ED, observation, or outpatient surgery
• Conditions that were clearly present but not diagnosed until after the admission
took place are considered present on admission
If a submitted claim contains one of these conditions acquired during the hospital stay, that
claim’s processed as if the diagnosis was NOT present on admission. This may result in
a DROP in severity tier & decreased reimbursement.
How to complete a POA form
(2 main sections completed by the nurse & physician)
NURSE: FV policy requires two nurses to complete POA form. This is considered “Four
eye check”. One of the nurse must be FV staff nurse. Two registry staff cannot perform the
assessment or documentation together.
Skin Assessment (If you’re unable/unsure how to assess, stage & document your
findings, please check with your supervisor)
• Note all stages of pressure ulcers on the form
• At FV, we also require that all patients that meet the “High Risk” criteria will also have
pictures taken regardless of skin breakdown or intact skin.
• Two Nurses will also take picture of Cocyx/sacral area and both heels of intact or
impaired if patient meets high risk criteria.
• High Risk Criteria for obtaining photographs in this policy is defined as - Any
transfers from: acute hospitals; long term acute facilities; Skilled Nursing facilities or
boarding care; any patient with Braden score of 12 or under; patient that is diagnosed
as malnourished/anorexic ; and patient with impaired mobility.
• Nurses will take the picture(s) to include scale and patient identifier, and will mount
picture(s) on the Photographic Wound Documentation form (FVH-8740-04(12-07). This
form will be signed by the same two nurses to ensure assessment for POA indicators
and photographs were taken by two nurses together. This process will be the
considered 4 eye check.
• If skin integrity is impaired, nurse will document the wound location on the form and will
obtain Physician orders to initiate wound care consult. Pbar number for the consult will
also be documented on the space provided on this form. The charge nurse or nurse
helping you take pictures will help you put the order in the PBAR for wound care consult
• This form will be placed under the Physician progress note section.
• “High Risk Criteria for Pressure Ulcer Prevention Protocols to included
patients: 75 years of age or greater, Peripheral vascular disease, Myocardial
infarction, Stroke, Multiple trauma, Musculoskeletal disorders, GI bleed, Spinal
cord injury, Neurological and/or chronic medical conditions (e.g., Guillain Barre’,
multiple sclerosis), Unstable and/or chronic medical conditions (e.g., diabetes,
renal disease, cancer, COPD, CHF, dementia), History of previous pressure
ulcer, Obesity, and Anasarca. If patient meets this criterion pressure ulcer
prevention protocols must be initiated, even if there is no skin breakdown.
• This process will be validated by POA audits and visual checks during multidisciplinary
• Note any area of surgical site infection – surrounding skin, wound site, drainage
• Use 1 line per breakdown area
Genitourinary Assessment
• Document if a catheter is present on admission.
• If so, indicate date of insertion and locale of insertion. (In the field, nursing home, ED,
home, etc)
Central Line
• Document if a catheter is present; state the type of device & date of insertion
• Document the date if patient had one of the following surgeries with the last 6
months: CABG; Orthopedic; Bariatric Surgery
Once you complete the admission assessment:
• If none of the previously noted indicators are present, check all appropriate boxes
labeled “Indicator NOT present”
• If no indicators are identified, the process stops here. Make sure the form is complete,
properly dated/timed, and signed.
Place signed & completed form in the “Progress Note” section of the medical record.
“Flag” the form for physician attention.
Wound Care Policy & Procedure
Wound Care and Skin Care Guidelines, Management & Documentation- PCSW-4.0
POA information is as above
Updated, photograph each wound upon discovery and weekly on
Wednesday, at the time of transfer, and at the time of discharge..
Photographs should also be obtained if the condition of the wound
Charge Nurse is responsible for checking the camera and delete pictures
that are no longer needed every day. Compliance officer will audit the
process during Environment of Care (EOC) rounds.
Document skin assessment on admission and every shift on Patient Care
Flow Sheet (TRC1024). Four eye check process will be followed at the
bedside shift report to perform skin assessment for all patients. Two
nurses performing the visual check will initial on the skin assessment
section on the nursing flow sheet (TRC 1024).
Document reassessment of each wound weekly (every Wednesday) and
upon transfer or discharge of patient. Reassessment of the wound should
also be documented if the condition of the wound deteriorates.
Document on the Pressure Ulcer Prevention Protocol form, and update it
every shift and as needed. Place the form under Wound Care Tab.
Document asterisk (*) interventions on the Treatment Administration
Record (TAR) every shift, if initiated.
Patients with existing wounds or with a Braden Scale score of 18 or less,
get R.D. Nutritional Assessment for wound care initiated by entering the
consult request in the PBAR system.
Patients with existing wounds or with a Braden Scale score of 18 or less,
get PT functional screen initiated, if patient has impaired mobility. Enter
the request using the PBAR system.
Ensure that visual cues are in place (door frame magnet, census board
magnet, and chart stickers). Follow the auditory cues to observe the turn
schedule (Addendum E).
Use “Help Us Protect Your Skin” brochure for education (Addendum F).
Nursing must notify central supply of the patient transfer using PBAR for
bed management
The Primary Care Nurse is responsible for entering an eSRM for any & all
skin breakdown & for any advancement in pressure ulcers.
The Primary Care Nurse is responsible for notifying the patient’s
physician for any skin breakdown, any advanced stages, infection, and/or
a Braden Scale score of 12 and below to obtain a Wound Care Consult.
The Wound Care Nurse will make recommendations only, does not follow
the wound care management of the patient. It is the nurses ultimate
responsibility to manage the wound care with the collaboration of Wound
Care Team, Nutrition, Physical Therapy, & Physician
The Primary Care Nurse is responsible to Notify Wound Care Nurse for
any new onset of skin breakdown and/or advanced wound changes.
When in doubt just do it
The Primary Care Nurse is responsible for initiating a Dietitian consult for
any patient with existing wounds or with a Braden Scale score of 18 or
The Primary Care Nurse is responsible for initiating a Physical Therapy
Functional Screen for any patient with impaired mobility on the Braden
The Primary Care Nurse is responsible for initiating the Pressure Ulcer
Prevention Protocol for patients with a Braden Score of 18 or less and/or
patients with existing skin breakdown. Ensure Audio & Visual cues are in
The Primary Care Nurse, along with the Charge Nurse can determine
need for a support surface bed. Complete & fax the Support Surface
Rental Requisition form as appropriate. A Physician’s order is required.
Any delays, notify RNC/Director as soon as possible.
Wound Care Documentation
Photograph each wound upon discovery and weekly on Wednesdays, if the
wound condition changes , and upon discharge or transfer of the patient
Document new & existing skin breakdown/wounds on Wound Assessment &
Progress Record. Reassessment is weekly (Wednesdays) and with any
changes, and upon discharge and transfer.
Only use one form per wound.
Document skin assessment every shift on Patient Care Flow sheet under the
Document Braden Risk Assessment score on admission and every shift on
Patient Care Flow sheet.
During bedside shift report, all RNs are to assess patient’s skin and both
nurses are to document their initials on the Patient Care Flow Sheet under the
SKIN/MUCOUS MEMBRANES section. This applies to all patients.
For complete information review the Policy: Wound Care and Skin Care
Guidelines, Management & Documentation- PCS-W-4.0
Thank you for completing this self study module
Please refer any questions/clarifications you might have to your resource. Complete the
certificate on the first page and return it to the designated person
Do not hesitate to call education department if you need additional information on any of
the topics covered in this packet.