2019

Hospital Division
Safety Orientation Self-Learning Packet

Pre-Orientation Employees
Host Hospital Employees
Transfer Multi-Site Employees

Revised 3.1.18
 Welcome to Kindred Hospital

Please use this Orientation Manual as an introduction to the Hospital Division and our Organization.
In this manual you will find standardized content information that must be provided to the new
employee that completes orientation in venues outside of this facilities General Hospital Orientation.

Please note: Employees beginning work prior to General Hospital Orientation and who have
completed the Pre-Orientation requirements must also be scheduled to complete the next General
Hospital Orientation. Please be sure to arrange your schedule to attend the next General Hospital
Orientation. In addition to the SLP, clinical staff must attend classroom orientation prior to
reporting to assigned care area.

Clinical Staff will complete an electronic charting training session prior to patient documentation.

All staff must begin to complete their department specific competency skills checklist.

On site safety will be conducted at the beginning of scheduled shift.

Please complete the required documents package based on your employment classification:
Pre-Orientation
Host Hospital
Transfer-Multi-Site

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 Table of Contents
Safety Orientation Manual

Infection Prevention Page 4-11

Life Safety Plan Page 11-31

Emergency Management Page 11-31

Environment of Care Page 11-31

Handling Hazardous Drugs Page 12

Workplace Violence Prevention Page 18 -19

Ergonomics/Body Mechanics/Back Safety Page 32-34

Joint Commission Hotline Page 34

Facility Code Form Provided by Educator

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 Infection Prevention and Control

The prevention and appropriate management of infection is of the utmost importance in our facility.
It is important that all staff take appropriate measures to reduce the risk of possible infections
whenever possible. Microorganisms can pass between patients and staff and have the potential to
contaminate the environment. We need to be not only aesthetically clean but must also have safe
systems of environmental control in place to reduce the potential for cross contamination. This SLP
reviews the following:

 Employee awareness of Tuberculosis and hospital’s Respiratory Protection Program

 Hepatitis, HIV/AIDS, Bloodborne Pathogens
 Discuss various isolation precautions as they relate to employee and patient safety
 Emphasize the importance of proper and diligent hand hygiene
 Provide information regarding types of personal protective equipment and use
 Emphasize the process for proper disposal of sharps and other hazardous waste
 Discuss process to follow in the event of body fluid exposure and hazardous spills
 Ensure that employees know the incident/event reporting process in the event of a work
related injury

Hand Disinfection:
 Alcohol based moisturizing hand gel is available in all patient care areas and
throughout the facility
 Gloves are never a substitute for hand hygiene. You must perform some form of
hand hygiene (either by washing or by using the alcohol gel) every time you enter
a patient care area (i.e. patient room) and remove a pair of gloves
 While hand washing mechanically removes debris, hand gels kill germs on the
hands
 The gel may cause a “pilling” effect of hand debris. If this happens, it is time to perform a hand
wash with soap and water
 Hands must be washed with soap and water after providing care to a patient with diarrhea or
when hands are physically soiled The bacterium that causes Clostridium Difficile infection
produces a toxin that irritates the lining of the intestines. If the bacteria lands on an “inhospitable
host,” such as a piece of furniture or the over bed table, after it is shed from the rectum, it forms
a protective shell around itself called a spore. The bacteria can stay alive in the spore for
prolonged periods. Alcohol gel is not effective against spores. It is the friction of washing and
the flushing action of the running water when washing that will remove any spores from your
hands that you may have inadvertently picked up when removing your gloves.
Artificial Nails:
• Artificial nails are defined as any substance applied over the natural nail that is meant to
lengthen or add thickness to the top of the natural nail.
• The staff providing direct patient care shall not wear artificial nails. This shall include,
but is not limited to:

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 – Acrylic overlay (with or without glued on tips),
– Acrylic sculptured nails,
– Shellac (gel) coated nails,
– Silk and glue wrapped nails,
– Nails glued directly onto the natural nail surface.
• Note: Direct patient care providers may include Nursing personnel, Respiratory Therapy
department, Rehab Services. Radiology, Surgery, Wound Care, Social Services and Food
and Nutrition Services.

Personal Protective Equipment (PPE)

PPE shall be utilized in accordance with OSHA and CDC Guidelines
• PPE should be worn when it is likely you will come in contact with blood or bodily fluids.
 Per OSHA’s Bloodborne Pathogens Standard, employees are required to remove
these barriers prior to leaving the work area and place them in designated areas
or containers for reprocessing or disposal.
What PPE should I wear?
 Gloves
 Gown
 Eye protection
 Mask
Gloves:
When changing tasks particularly going from a dirty task to a clean task at the patient’s bedside you
should remove your gloves, perform hand hygiene and reapply clean gloves. Some examples are: you
have bathed the patient and are preparing to change their linens; you have removed a patients wound
dressings and cleaned the wound and are now ready to reapply a clean dressing; you have completed
patient care and are preparing to document on the computer at the bedside.

Gowns:
• Wear if there is a risk of splashing or soiling by body fluids and other potentially infectious
materials (OPIM)
• Wear in Contact and Clostridium difficle Contact Precautions patient rooms
• Gowns should be put on before any other PPE
• Gowns shall be removed and thrown away prior to exiting patient room

Masks, Face & Eye Protection:

• Facial protection is worn when there’s a risk of splashing.
• Splashes can come from pouring liquids, emptying Foley Catheters, dressing changes,
etc.
• Masks, face shields, and safety glasses protect the eyes, nose and mouth.
• A surgical mask shall be worn in Droplet Precautions patient rooms.
• An N95 respirator shall be worn in Airborne Precautions patient rooms.

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Categories of Precautions:
All patient’s blood and body fluids except sweat, are considered to be potentially infected with
bloodborne pathogens or other potentially infectious materials. Establishing barriers utilizing gloves,
masks, gowns, and eyewear (personal protective equipment) against possible exposure will reduce the
risk of exposure to infections to you and to other patients. Standard precautions are to be practiced
when caring for all patients. Do not put yourself or others at risk by failing to comply.

Direct caregivers and personnel who prepare products or food for patient use are prohibited from using
artificial nails, acrylic overlay, acrylic sculpture nails, gel coated nails, silk and glue wrapped nails, or
nails glued directly onto the natural surface. Nail enhancement or nail jewelry are also prohibited. Nail
length is not to exceed ¼ inches. Nail length is measured by observing the employees hand from the
palm side. If the nail is longer than ¼ inch, they are too long.

Standard Precautions - Standard Precautions are the minimum infection prevention practices that
apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any
setting where healthcare is delivered. Standard Precautions include: 1) hand hygiene, 2) use of
personal protective equipment (e.g., gloves, gowns, masks), 3) safe injection practices, 4) safe handling
of potentially contaminated equipment or surfaces in the patient environment, and 5) respiratory
hygiene/cough etiquette.

Isolation or Transmission Based Precautions:

 Patient will be placed in Transmission Based precautions according to CDC/Hospital guidelines
 Follow all posted precautions in order to prevent the spread of infection to the staff, visitors, and
other patients
 Masks should be removed before exiting the patient room ( at doorway)

Droplet – Use droplet precautions when in contact with large droplet organisms, like meningitis,
influenza, strep throat or Pertussis (whopping cough). Large droplets do not remain suspended in the
air, but will generally travel short distances and then drop from the air. Masks must be worn when
within three feet of the patient’s face.

Contact – Use contact precautions for patients with any multi-drug resistant organism (MDRO) such as
methicillin resistant staphylococcus aureus (MRSA), vancomycin resistant enterococcus (VRE),
sympatomatic clostridium difficile associated diarrhea, and gram negative organisms such as extended
spectrum beta lactamase (ESBL) producing negative organisms/contact precautions are also used for
anyone with non-intact skin or wounds where the drainage cannot be contained. This can include
things like scabies, or simple shingles outbreaks. Patients with untreated scabies must remain on
contact precautions until cleared by the Infection Preventionist or 24 hours post treatment. Use gloves
when you enter the room. Use a mask if your mouth, eyes or nose are likely to come in contact with
body fluids. Use a gown if you will have direct contact with the patient or substantial contact with the
patient’s environment.

Airborne – Use airborne precautions when patients have an organism that can be carried on the air
currents and can be inhaled by or deposited on a susceptible host. Special air handling and ventilation
(Negative Flow Isolation Rooms) are required to prevent airborne transmission. Specifically identified
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rooms are used for Airborne Infection isolation. Airborne precautions are indicated to prevent and
control transmission of Tuberculosis, Chicken Pox, Disseminated Varicella Zoster (shingles), and
measles. Persons with Chicken Pox or disseminated shingles need to be in contact and airborne
precautions.

Environmental Cleaning:Why is it so Important?

• Bacteria can survive on environmental surfaces for extended periods of time (e.g. MRSA
greater than 300 days)
• Occupying a room that previously housed a patient with a MDRO is a known risk factor for
acquiring that bacteria
• One study noted that at over 40 hospitals, less than half of high touched surfaces in a patient’s
room were cleaned

How long can Bacteria/Viruses Survive on Environmental Surfaces?

Organism Survival Period
C. Difficile 35- >200 days
MRSA 14- >300 days
VRE 58- > 200 days
E.coli 40->150 days
Acinetobacter 150- >300 days
Mycobacterium Tuberculosis 120 days
Most Respiratory Tract Viruses Few days
(i.e. influenza, common cold)
Virus from the Gastrointestinal 60-90 days
Tract
Bloodborne virus (i.e. HIV, HCV) >7 days
, , ,
Kramer A., Schwebke I., & Kampf G.(2006). How long do nosocomial pathogens persist on inanimate surfaces? A
systematic review. BMC Infectious Diseases. 6:130.DOI: 10.1186/1471-2334-6-

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 Environmental Disinfection-
How, What?
• Disinfecting shared equipment between patient use
• Disinfecting patient over-bed tables; i.e. before meals, before setting up sterile field
• Disinfecting glucose monitor between patients
• Daily disinfection of high touch surfaces; i.e. bed rails, tray tables, call button, grab area of
curtain
• Terminal clean of patient room after discharge; i.e. after contact discharge- walls cleaned,
curtain changed
• Maintain contact time per manufacturer
Contact Time
• Contact time (or dwell time) is the length of time a disinfectant's label states that it
must remain wet on a surface in order to achieve efficacy.
– Other terms for Contact time:
• Kill time
• Wet time
• Dry time
• Add facility specific disinfectants and contact times

Hepatitis B Virus:
Hepatitis B is a virus that causes inflammation of the liver. It can cause liver cell damage, leading to
cirrhosis and cancer.

Modes of Transmission:
Contact with infected blood, seminal fluid, vaginal secretions, and contaminated needles including
tattoo and body piercing tools, infected mother to newborn child, sexual contact.

Prevention:
Hepatitis B vaccine, Hepatitis B immune globulin within 1-2 weeks of exposure. Wear appropriate PPE,
hand washing, safe sex. Do not share razors, toothbrushes, or needles.

Hepatitis C Virus:
Hepatitis C is another virus that causes inflammation of the liver. It can also cause liver cell damage,
leading to cirrhosis and cancer.

Mode of Transmission:
Contact with infected blood, contaminated IV needles, razors, and tattoo or body piercing tools,
infected mother to newborn child, sexual contact.

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Prevention:
No vaccine available. Wear appropriate PPE, hand hygiene, safe sex. Do not share razors,
toothbrushes, or needles.

HIV
HIV attacks the immune system and eventually causes AIDS (Acquired Immunodeficiency Syndrome).

Mode of Transmission:
Contaminated needles, infected mother to newborn child, sexual contact, body fluid contact.

Prevention: No vaccine available. Wear appropriate PPE, hand hygiene, safe sex. Do not share
needles.

Needle Stick and Blood/Body Fluid Exposure

Exposures which require follow-up include:
 Needle stick with a contaminated needle
 Cutting or scraping with a contaminated sharp instrument
 Splash to eyes, nose, mouth with blood or “other potentially infectious materials”
 Broken skin contaminated with blood or other potentially infectious materials

If an exposure occurs:
 Wash the affected skin, flush mucous membranes (eyes, nose, mouth) with water
 Know where the eyewash stations are located
 Notify your manager/director, or house supervisor immediately
 Complete an Employee Incident Report as well as the Occupational Exposure Incident Report
 Determine the source of exposure (the person to whom you were exposed) if known and the
source’s risk factors for HIV, Hepatitis B & C
 You will be offered medical evaluation by a preferred occupational provider

Tuberculosis
TB Infection: Tuberculosis is an infection, most often in the lungs, which is caused by a very small germ
called Mycobacterium Tuberculosis, so small that it can float in the air for days or weeks, traveling on
normal air currents for long distances. When a person with TB infection in the lungs coughs, sneezes,
shouts or sings, he may spread TB germs from his lungs into the air where people may then breathe
the germs into their lungs. Certain procedures done in the hospital setting; sputum induction,
bronchoscopy or suctioning of tracheal or oral secretions may cause the patient to cough, increasing
the spread of germs into the air. These procedures are considered by OSHA to be “high risk” for
transmission of TB, and should only be done in negative air flow settings, i.e., bronchoscopy suite or
negative air flow isolation room.

Signs and Symptoms of TB: Persons with infectious (“contagious, active”) TB may have signs or
symptoms of illness such as coughing (sometimes, coughing up blood or “hemoptysis”), weight loss,
poor appetite, fever, “night sweats”, shortness of breath with exertion/exercise, chest pains or fatigue

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(tiredness). Persons with latent TB will have a positive TB test but are not contagious and have no
symptoms.

Preventing TB Exposure
Exposure to TB can be avoided in several ways:
 Kindred has a written plan to control exposure to TB by recognizing, isolating and treating
patients with infectious TB
 Staff must be screened each year for TB, by TB skin testing, answering questions about signs and
symptoms of TB, and/or having a chest x-ray (only if symptomatic). Some of our facilities do not
test annually based on their TB Risk Assessment.
 Using designated isolation rooms with special ventilation and at least 6 air exchanges per hour to
house patients with known or suspected infectious TB
 Training staff to use special “respirators” to filter the air they breathe when they are caring for a
TB patient.
 Educating healthcare staff, patients, and the general public about ways to help.

Respiratory Protection Program and Tuberculosis (TB)

In order to comply with federal and state guidelines and OSHA regulations, all patients with
known or suspected tuberculosis must be placed in respiratory precautions in a monitored
negative airflow room. A NIOSH approved respirator must be worn by healthcare personnel
who enter the patient’s room. Family members in close contact of the patient may be offered
a NIOSH approved respirator, and instructed in its use before entering the room. If a NIOSH approved
mask is declined the visitor must wear a surgical mask. An N95 mask and fit testing is available upon
request.

Isolation may be discontinued when TB has been ruled out and/or when the patient has been on the
appropriate antimicrobial therapy, is showing clinical improvement and when there have been three
(3) negative AFB sputum smears. Discharge or transfer of the patient must await approval from the
assigned health department’s tuberculosis control department.

A copy of the isolation precautions policies can be located in the Kindred Hospital Infection Prevention
and Control Manual.

Fit Testing
To reduce the risk of exposure to TB in the workplace, employees who may be exposed to infectious
tuberculosis (TB) through face-to-face contact with an infected patient must participate in respiratory
protection fit testing and training prior to assignment of a NIOSH-approved air purifying respirator with
an N-, P-, or R-, rating and numerical rating of 95, 99, or 100 (e.g., N-95). Annual training, not fit
testing, is required before using a Powered Air Purifying Respirator (PAPR).

Each person must be fitted and tested before they may use an N-95 respirator. You must pass a
“respirator” fit test and use the proper brand and size mask that you were fitted and approved to wear.
Fit testing is required annually.

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A “fit-check” must be performed each time you wear a respirator. If the facial seal of the mask is tight,
when you take a brisk breath inward, the mask will collapse against your face. This “check” assures
that the respirator fits your face tightly enough to protect you from the TB germs in the air.

Note about N-95 Respirator – The respirator must fit your face very tightly, so that the air you breathe
in is filtered through the mask. The respirator is made of special materials that do not allow the TB
germ to pass through the filter, however if it does not fit your face properly, some of the air, and the
TB germs, may pass around it, allowing germs to enter your lungs and cause TB infection.

According to OSHA regulation, annual fit testing is required when using an N-95 style respirator, and
anytime a person has at least a 10% weight gain or loss, facial disfigurement, dental/denture changes,
etc. or any other condition which may require a change in brand or size of respirator in order to achieve
a protective fit.

Using the Respirator:

The special TB respirators must be worn every time you enter the room of a patient known or suspected
to have infectious, contagious TB-this patient must be in Airborne Precautions in a private room with
special ventilation, closed door and negative pressure electronic monitor activated. The respirator
must be put on before entering the room and not removed until after exiting the room.
When putting the respirator on your face, be sure that the respirator is properly placed so that it
completely covers the nose and the chin. Most respirators have two straps – one should be placed
high at the “crown” of the head, and the other should be placed below the ears, so that it touches the
neck at the hairline. If the respirator is made with a piece of wire or a metal strip that rests on the
nose, pinch the wire starting at the bridge of the nose and move outward so that the respirator fits as
tightly as possible over the bridge of the nose.

If the respirator is in proper position, when you take a sudden deep breath the mask should collapse
against your face. Checking the position and fit of the respirator is called a “fit-check” and should be
done every time you use one of the respirators.

Kindred stocks NIOSH approved respirators. Fit testing of staff is conducted using the respirators that
are provided in several sizes. You must use the brand and size that fits your face and allows you to pass
the fit test.

Do not switch brands or sizes since they may not fit you properly and will not protect you from the
TB germ.

Storing and Replacing the Respirator:

The respirator does not have to be discarded after each use. The same respirator may be used again,
unless it has become moist, soiled or crusted, or if you are concerned that the filter material may have
been damaged. If you notice a gradual increase in the effort required to take a normal breath, the
respirator’s filter material may be full of dust, moisture or other particles (including germs), an should
be discarded and replaced.

The respirator may be stored in your locker in a paper bag to protect it from dust (a plastic bag may
trap moisture against your mask) and saved for another use. A general rule for replacement may be

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one mask every 12 hour shift; but sometimes, a mask is only worn for several minutes or hours, and
would not need to be replaced.

Other Employee Injuries:

For other work-related injuries, follow the same procedure as in bloodborne exposure. With all
employee injuries it is mandatory that you complete and return the Employee Incident Report to your
supervisor or, in the absence of your supervisor, to the house supervisor before the end of your shift.

Worker’s Compensation Report Line: (888) – 458-4506

Hazardous Drugs

All team members are informed upon hire that they may be required to work with hazardous drugs.
All personnel are informed that the procedures governing the handling of hazardous drugs in the
facility must be followed and that adherence to these procedures will be monitored. Team members
are responsible for understanding the content within the “Hazardous Drug” policy.

Hazardous Drugs are to be clearly labeled at all times during transport and use. Antineoplastic agents
are segregated in pharmacy in chemotherapy packaging. Patients receiving antineoplastic/chemo
drugs will have signage posted. During transport, the drug is placed in a sealed container to reduce
environmental contamination in the event of accidental dropping. Drug packing, transport and
preparation materials are to be disposed into appropriate waste container per facility pharmaceutical
waste management agreement. It is the team member’s responsibility to adhere to established
safety rules and use PPE as required.

Hazardous Drug Spills:

Spill kits are located in the pharmacy and pharmacy after-hours area. Team members handling the
hazardous drug are to immediately notify the supervisor and begin the spill management procedure
referring to local hazardous spill plan. An incident report is completed for staff and nonemployees
exposed to a hazardous spill.

Additional education is provided to pharmacy, nursing, respiratory, housekeeping and dietary during
the department/role specific orientation period.

Safety and Environment of Care

The goal of Kindred’s Safety, Environment of Care and Risk Management Program is to reduce the
frequency and severity of accidents, thereby providing a safer and happier environment for
employees, patients and visitor.

Kindred’s program is built around four basic elements of accident prevention:

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Employee Selection
We strive to educate all staff members in safe work habits and practices and to create an
environment where our employees can feel good about their contributions.

Safety Responsibilities
We strive to instill a sense of personal accountability for knowing safety rules, regulations, and
procedures and for adhering to them.

Motivation
We strive to motivate all employees to work smart, thereby avoiding personal injury or injuries to co-
workers, patients and customers.

The success of this program depends on the effort of every employee. Aside from assuring
compliance with local, state, and federal guidelines, adhering to our safety policies helps employees
do their job more effectively and efficiently.

The ultimate benefit comes in the form of improved service to the patients we serve. It is important
that all of us strive to do our best and to believe in what we do. In that way, we will make a
difference in the lives of people whose care is entrusted to us.

Introduction to the Safety Program

The Joint Commission and Kindred Hospital require that all hospital employees be oriented to the
Hospital’s Environment of Care/Safety Management Program. It is the intent of our Safety
Management Program to maintain a safe environment for all our employees, physicians, patients and
visitors to our facility.

The Hospital Safety Program is overseen by a multi-disciplinary EOC/Safety Committee, which is

chaired by the designated Safety Officer for the Hospital.

Environment of Care (EOC) – Safety

Functions of the Safety Committee include the development and approval of hospital wide safety
policies, reviewing and approving departmental safety policies, identifying and eliminating safety
hazards, monitoring the investigations of accidents and injuries, and overseeing the functions of the
Environment of Care as listed below. Policies and procedures relating to the functions are in a Safety
Binder located in your hospital.

Functions of the Environment of Care are:

 Utility Systems – policies and procedures relating to water, power, gas, phone, physical plant,
etc.
 Safety and Security – Policies and procedures relating to General Hospital Safety i.e., no
smoking policy, personal protective equipment (PPEs), monitoring slips and falls, needle sticks,
and sprains, employee health, infection prevention, employee safety responsibilities, etc.
Policies and procedures relating to general hospital security. ID badges locked doors, vendor
badges, security guards on nights and weekends, etc.
 Hazardous Materials and Waste – Hazardous Substance Communication Program, Policies
and procedures relating to biohazardous waste, i.e., red bags, sharps containers, SDS, waste
removal, etc.
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  Fire Safety – Policies and procedures relating to fire drills, RACE, fire extinguishers, evacuation
plan (route), etc.
 Medical Equipment – Biomed, preventative maintenance, equipment safety checks and
tagging, etc.

Utility Management
The utility Systems Management Program addresses the design and operations of the utility systems
of Kindred Hospital. The Plant Operations/Engineering Department maintains a preventive and
corrective maintenance program that regularly inspects, tests, and exercises utility systems and
related components/equipment to promote a safe, controlled, and comfortable environment of care.
Utility systems in the hospital include water, power, phone, medical gases, heating and air
conditioning, plumbing, lighting, etc. As preventive maintenance checks are performed, utility
systems and related components/equipment are assessed to ensure that optimal operational
efficiency is maintained. These monitoring checks assist in minimizing the risk of utility failures
related to equipment breakdowns/failure.

Employees are responsible for reviewing policies and procedures located in the Utilities section of the
Safety/EOC manual relating to utility safety and emergency procedures in the event of a utility failure.
All staff members are required to learn and implement various general and specific procedures to
assure safe and reliable use of the utility systems.

Utility Systems Failure & Basic Staff Response Plan (Example)

Failure of: What to Expect:
Computer Systems System down
Electrical Power Failure-Generators OK, Most lights out, various
Code Purple areas of hospital without
power RED outlets work
Total Electrical power failure – Code Failure of all electrical
Purple systems including hospital
emergency generator
Elevator stopped between floors Elevator alarm bell
sounding
Elevators out of service Vertical movement by
stairwells
Fire Alarm System No fire alarms or sprinklers
Medical Gases Gas alarms; No O2 or NO2
Medical Vacuum No vacuum, system failure
and alarm
Natural Gas failure or leak Odor, no flames on
burners, etc.
Nurse Call System No patient contact
Medical Equipment Equipment does not
function properly
Who to Contact:
Supervisor first
ProTouch Superuser
Supervisor First, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor, RT Dir.
Supervisor first, Plant Ops
Manager, CCO, Nursing
Supervisor, RT Dir.
Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor
Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor
Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor
Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor, RT. Dir.
Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor, RT. Dir.
Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor, RT. Dir.
Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor, RT Dir.
Supervisor first, .Biomedical Eng.
, Appropriate Dept. Mgr.
Staff Response:
Use manual/paper systems
Ensure life support systems on
emergency power. Use flashlights.
Complete all procedures asap. Use red
wall electrical outlets
Call “Code Purple”, use flashlights,
make sure that battery operated
equipment is functioning properly
Let trapped people know help is on the
way
Review fire & evacuation plans,
establish services on 1st & 2nd floors.
Move patients and equipment
Implement Fire Watch Plan. Use
runners or telephones to report fires
Hand ventilate patients, use portable
gases, transfer patients if necessary,
order extra portable gas tanks
Use portable vacuum finish cases in
progress, don’t start new cases
Open windows to ventilate, turn off gas
equipment, don’t use spark producing
equip.
Use bedside telephone, move patients,
use bells, designate a rover to check
patients
Remove from service and tag defective
equipment. Obtain alternate
equipment or initiate alternate care
process

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Sewer Stoppage Drains backing up Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor
Steam Failure No building heat, hot Supervisor first, Plant Ops
water, sterilizers Manager, Safety Officer, CCO,
Nursing Supervisor
Telephones No phone service Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supervisor
Water System Sinks & toilets don’t work Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supv, ICP
Water Non Potable Tap water unsafe to drink Supervisor first, Plant Ops
Manager, Safety Officer, CCO,
Nursing Supv., RT Dir.
Ventilation No ventilation, no heating Supervisor first, Plant Ops
or cooling Manager, Safety Officer, CCO,
Nursing Supv. RT Dir.
Do not flush toilets, do not use water,
use red bags in toilets
Conserve sterile materials & all linens,
provide extra blankets, and prepare
cold meals
Use ground start system, overhead
paging, pay phones, cellular phones
Institute Fire Watch Plan, conserve
water, turn off water in sinks, use red
bags in toilets, distribute emergency
water
Place Non-Potable water Do Not Drink
signs at all drinking fountains and wash
basins, distribute emergency water
Open windows (institute Fire Watch) or
obtain blankets if needed. Restrict use
of odorous or hazardous materials

Electrical Safety
In compliance with the electrical code and to prevent electrical hazards within the hospital premises,
especially in patient areas, we are required by law to use only approved hospital electrical plugs on all
equipment. Before any electrically powered utensil, tool, instrument or appliance not owned by the
hospital can be used on the hospital premises, it must be checked by the Engineering Department for
appropriate electrical safety features.
 Do not use equipment with defective power cords or plugs. Regularly inspect your work area
and electrical equipment for hazards such as frayed electrical cords. Make sure the electrical
cords have intact insulation
 Do not remove power plugs from wall outlets by pulling on their cords; always grasp the plug
 Do not step on or roll equipment cart wheels over power plugs or cords
 Do not touch the patient with invasive intrathoracic conductors at the same time that you are
touching another person, equipment case, or metal surface.
 Do not drape or rest, live power cords on sinks or metal surfaces of any type
 Do not place fluid, i.e. coffee, soda, juice on or near electrical equipment
 Extension cords are prohibited
 Relocatable power taps (plug strips) can only be used for computers, monitors and printers.
 In the event you or someone detects a potentially hazardous situation report the situation
immediately to your supervisor. DO NOT move equipment

Safety Management
The purpose of the Safety Management Plan is to reduce the risk of injury to patients, staff, and
visitors. The Management Plan for Hospital Safety describes the organization’s processes for the
provision of a safe environment for patients, visitors, and employees. The plan is organized and
administered by the Safety Officer through the EOC/Safety Committee on a facility-wide basis and
incorporates a quality improvement process of monitoring, reporting, and taking action to provide a
physical environment free of hazards. The plan manages staff activities and technology required to
identify, eliminate and/or reduce risk of injury and liability. The plan provides for orientation and
educational programs to encourage employee participation in maintaining a safe environment. The
program applies to all staff, volunteers, students, physicians, contractors and others who perform or
provide services at Kindred Hospital.
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Revised 3.1.18
All personnel are expected to participate in the assurance of a safe environment, familiarizing
themselves with the policies and procedures located in the Safety/EOC manual, to ensure a safe and
comfortable environment for patients, visitors, and employees.

All employee injuries must be reported immediately to your supervisor. It is in your best interest to
report such injuries for your protection. This also allows us to track and trend problem situations that
might require new procedures, re-training, etc. Such injuries include slips, falls, needle sticks,
exposure to blood and body fluids, sprains, etc.

All employees must report unsafe/unhealthy conditions to their supervisor. This allows us to make
repairs and/or revise policies and procedures to prevent injuries to patient, visitors, or staff.

Multidisciplinary teams conduct environmental tours periodically (a minimum of semiannually in

patient care areas and annually in non-patient care areas) according to facility policy.
These rounds ensure that some common safety hazards are avoided such as:
 Materials less than 18 inches from fire sprinkler head
 Blocking access to fire alarms and fire extinguishers
 Damaged or cracked flooring
 Monitoring of proper usage of Personal Protective Equipment (PPE), and check for cleanliness
of refrigerators and any expired vials, etc.
 Doors that are blocked with furniture, door stops, chocks, tie-backs, drop down, or plunger
type devices that necessitate manual unlatching or releasing actions to close the door

Event Reporting
All occurrences resulting in injury or possibility of injury to patients, visitors, or staff must be
reported. An Event Report is a factual statement about a particular incident detailing particulars as to
time, location, all persons directly involved including functional titles, and nature of the event
including a description of injuries.

The report will contain a listing of witnesses of the event. These are used in developing appropriate
measures to minimize the risk of injuries and incidents. Upon discovery of the event, an event report
must be completed in ProTouch (or on the Event Reporting Form if non-ProTouch facility). The event
report must include the following:
 The patient or employee’s name, location of incident, age, sex, admission date, admitting
diagnosis
 A clear and concise description of the incident
 Whether or not a physician was called, and if so, a brief statement of physician’s
recommendations as to medical treatment, if any
 A listing of the persons then known to be involved directly in the incident, including witnesses
 The name, signature, and title of the person completing the report along with the date and
time that the report was completed
Note: The person who discovers the incident or who has the most knowledge of the incident should
complete the event report. Only facts related to the incident should be documented on the event
report. The event report must be completed and reported promptly to the Director of Quality
Management/Risk Management.

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Revised 3.1.18
Employee Safety Responsibilities:
Training: Learn the right way to do your job. If you are not sure, ask your supervisor. Never use any
machine or perform any procedure until you have been trained in its use.

Lifting: Never lift anything too heavy or bulky to be lifted comfortable. Get
help and save your back. Practice these safe lifting techniques:
 Remove grease or water from your hands; get a good grip
 Be sure of your footing and position; and hug the object close to you
 Bend your knees and lift with the powerful muscles of your legs; not
your back
 Be sure that the wheels on beds and wheelchairs are locked
 When stocking shelves, always locate heavier, bulkier items as close to knuckle height (<28
inches) as possible. Use a ladder or step stool to reach upper shelves; never climb on racks,
boxes, or stock

Lifting and Transfers:

Follow instructions above, when lifting. Be sure to ask for assistance when necessary. If help is not
immediately available, make the patient comfortable until assistance arrives.

Wet floor signs

Place wet floor signs as appropriate. Observe wet floor signs

Falls:
When any individual falls (patient, employee or visitor), no one should help him/her to get up until a
nurse has checked for injuries.

Machinery and Equipment:

Use all safety guards provided. Unplug power cord before cleaning or adjusting any machine. Make
sure switch is off before plugging or unplugging cord. Handle electrical equipment with dry hands;
never yank cords, pull them out by the plug. Put equipment away before departing facility. If the
ground prong is missing, report it to your supervisor. Follow Lockout/Tag out procedures. You
should be familiar with and trained in the proper use of all equipment and appliances before
using/operating it.

Sharps and Needles:

Sharps and needles will only be disposed of in an approved sharp disposal container. Sharps disposal
container should be replaced when it is ¾ full. Do not recap needles.

Broken Glass:
Never pick up broken glass, etc., with bare hands. It should be brushed up with a pan and brush or
dampened paper. If in a sink, drain the sink and clean out with dampened paper. Broken glass
should be deposited in a separate receptacle, not in one, which may be emptied by hand.

Fire:

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Revised 3.1.18
Learn how to operate fire extinguishers and know their location. Know where the manual pull for the
fire alarm system is located. Learn to recognize the fire alarm and know your role when it sounds.

Hazards:
All hazards or potential hazards should be reported to your supervisor immediately. Do not attempt
to repair any faulty electrical equipment.

General Safety

Chemicals: Be sure that all chemical substances are in labeled containers, stored properly and apart
from food; follow your Hazardous Communication Training Manual

Closets and carts: All closets and carts that contain housekeeping supplies will be kept locked.

Oxygen Cylinders: Oxygen cylinders must always be properly secured so that they cannot tip over

Food Containers: Label and date all food containers

Trash: Exercise care in handling trash. Do not reach into wastebaskets to empty them

Supply Storage: Supplies should be stored neatly and must be a minimum of 18 inches from sprinkler
heads

Spills Clean Up Procedure

Slips and falls due to spills can be a major cause of injuries in our facility. In an effort to avoid these
accidents we each need to observe the following rules. Whether you “make” or just “discover” the
spill, you must ensure that it is cleaned up immediately.
 For major biohazardous spills please call a Biohazardous Code
 For minor spills (generally < 50cc) please contact Environmental Services
 Warn passers-by of the spill until the spill is removed and warning sign is in place
 For blood/body fluid spills, obtain appropriate personal protective equipment, disinfectant
solution and appropriate bio-hazardous waste bag
 Leave the floor as dry as possible
 If wet area is large, obtain additional signs
 With high traffic location and/or very slippery floor, request housekeeping to manually dry the
floor immediately (towels, fans, etc.)
 After floor is dry, remove warning sign(s). If wet floor signs are overused or used
unnecessarily they become ineffective

Workplace Violence Prevention Plan

The purpose of the Security Management Plan is to minimize the risk of personal injury or property
loss due to criminal activity or workplace violence. The Security Management Program emphasizes
controlling access to the facilities, security sensitive areas, staff and patients of Kindred Hospital. The
program addresses security issues related to staff, volunteers, medical staff, patients, visitors, and the
buildings and grounds of the hospital, and will investigate and follow-up on security incidents, such as
assaults, malicious destruction of property, and thefts. The program focuses on use of staff training
and participation. The security staff and all departmental staff are required to implement the
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Revised 3.1.18
program by following established policies and by intervening to advise non-staff persons of specific
security related requirements for them.

What is Work Place Violence?

An act of violence is the attempt (coupled with the ability) or actual use of force of violence with the
intent to either:
 Threaten
 Harass
 Commit a violent injury
 Damage/destroy property

There are 4 Types of Workplace Violence:

Type I – The aggressor has no legitimate business relationship to the workplace and usually enters the
affected workplace to commit a criminal act such as robbery
Type II – The aggressor is either the recipient or the object of a service provided by the affected
workplace or the victim, such as a current or former client, patient, passenger, criminal suspect,
inmate or prisoner
Type III – The aggressor has some employment-related involvement with the affected workplace such
as a current or former employee, supervisor, manager; a current/former spouse or significant other, a
relative, friend or some other person who has a dispute with an employee of the affected workplace
Type IV – Workplace violence committed in the workplace by someone who does not work at Kindred
Healthcare or it’s vendors, but has or is known to have a personal relationship with an employee

Security Services
 Monitor and control access to the hospital
 Provide escort services for all employees between building and parking areas, as requested
 Respond to calls that need authorized assistance in case of unmanageability or misconduct on
the premises
 Patrol hospital property to observe and deter destructive actions
 Hospital traffic crowd control

Employee Property
Protect your own property by locking your car and putting packages, etc. in the
trunk of your car. Lock up your purse while working. Do not bring large amounts
of money to work.

Identification of Patients, Visitors, and Staff

It is the policy of Kindred Hospital to properly identify all patients, visitors, and employees during
time spent on the premises and to clearly distinguish between staff and visitors and individuals who
do not have authorization to be on the premises.
 All patients will have identification wrists/ankle bands upon admission
 All employees are required to wear Kindred identification badges, at all times while on the
premises.
 All visitors are required to sign in when entering the hospital and are given identification
badges
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Revised 3.1.18
Only authorized persons will be allowed on hospital premises during non-visiting hours.
Authorized persons shall include:
 Kindred hospital employees
 Medical staff members and their assistants
 Patients, their families or significant others
 Scheduled educational meeting attendees
 Contracted vendors and representatives

Security
The patient relies on each and every employee in the hospital to help make his/her stay as pleasant
and as comfortable as possible. The patient should be content in the knowledge that strangers will
not annoy him/her and that personal property will not be damaged or stolen.

How Can You Help?

 Be curious
 Report all suspicious activity to your supervisor immediately
 Have concern for hospital and patient belongings, as well as property belonging to fellow
employees
 Report all thefts to security immediately.
 Wear your identification badge

Security is everyone’s responsibility!

Managing Abusive/Violent Situations

Any verbal threat, aggressive behavior, or assault incident must be reported to your immediate
supervisor.
 Employee reports incident to Supervisor
 Supervisor reports incident to Department Manager
 Department Manager reports incident to Safety Officer
 Safety Officer reports to Safety Committee

Information about security problems must be clearly transmitted by flagging charts, clearly noting
and identifying security risk to patient. Whenever the patient displays aggressive or hostile behavior
to staff members, it must be part of the care plan that supervisors and managers are notified and
protective measures and actions are initiated. Any act of assault and/or battery against on-duty
hospital personnel is to be reported to the Police Department within 72 hours of the incident. The
hospital will not obstruct or interfere with the reporting of assault and/or battery.

All employees will be familiar with the “Warning Signs before Violence.” Subtle clues to impending
violence include:
 “Gut feeling” – If you feel uncomfortable with or frightened by the patient, do not ignore your
feeling. Call for backup support
 Provocative behavior toward staff member-hostility, teasing, unreasonable requests
 Any angry demeanor. Watch out for the patient with a menacing facial expression or one who
is cursing or making hostile remarks, or “looking for a fight.”

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Revised 3.1.18
  Manic states. Manic may appear euphoric, grandiose, and initially friendly, often quickly
turned aggressive when faced with even minor demands
 Delirium. The level of consciousness fluctuates in delirium making such patients
unpredictable.
 Confusion and fear in the elderly. Demented or delirious elderly people often react to a busy
hospital setting with fear and may become combative

Overt Clues to Potential Violence include:

 Motor restlessness, including increased fidgeting, shifting about, rocking, or clenching and
unclenching fists. Pacing around
 Loud, angry, forceful speech. Singing or chanting may indicate a thought disorder or drug
induced psychosis
 Agitated behavior may include knocking over furniture, pounding walls
 Threats to injure or kill someone. The danger increases if the patient describes a specific
victim or plan
 Patients with known history of causing trouble
 Presence of a weapon
 Disorders associated with violence
 Drugs
 Diseases: hypoglycemia, hypoxia, meningitis, head trauma, temporal lobe epilepsy, electrolyte
imbalance, hypo/hyperthermia, anemia, dementia, etc.
 Psychiatric disorders: Mania, schizophrenia, paranoid state, etc.
 Situational frustration: mutual hostility, miscommunication with staff, etc.
 Antisocial behavior: violence not due to medical or psychiatric causes

If a patient continues to threaten or mobilize a show of force, use the overhead page using the
appropriate code.

To Approach the Violent Patient

 Never approach a dangerous patient alone
 Ask about weapons and have the patient empty pockets, wallet, or handbag.
 Do not touch the patient, approach too rapidly, or stand too close. Hostile persons require
increased personal space, and violation of this space is perceived as an attack
 Keep the door open and allow unobstructed access to the door for both yourself and the
patient. Both parties should feel they could leave the room immediately if the situation
becomes dangerous
 Do not sit behind a desk, have your arms or legs tangled up as you sit, or otherwise
compromise your ability to get away from the patient
 Do not argue with or challenge a patient’s self-esteem. Rather emphasize how much strength
it takes to remain calm and cooperative
 Call the police if the patient becomes too threatening
 Never attempt to subdue a patient alone or otherwise be a hero

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Revised 3.1.18
 Coping With an Active Shooter Situation
 Be aware of your environment and any possible dangers
 Take note of the two nearest exits in any facility you visit
 If you are in an office, stay there and secure the door
 Attempt to take the active shooter down as a last resort

How to Respond When an Active Shooter is in Your Vicinity

 Run – Have an escape route in mind, leave your belongings behind, keep hands visible
 Hide – In an area out of the shooter’s view, block entry to your hiding place/lock doors
 Fight – as a last resort only

Call 911 when it is safe to do so: Information You Should Provide to Law Enforcement or 911
Operator:
Location of the active shooter
Number of shooters
Physical description of shooters
Number and type of weapon held by shooters
Number of potential victims at the location

How to Respond When Law Enforcement Arrive

 Remain calm and follow instructions
 Put down any items in your hands
 Raise hands and spread fingers
 Keep hands visible at all times
 Avoid quick movements toward officers
 Avoid pointing, yelling or screaming
 Do not stop to ask officers for help or directions during evacuation

Hazardous Materials & Waste Management

OSHA Hazard Communication Standards have been revised to align with the United Nations’ Globally
Harmonized System of Classification and Labeling of Chemicals (GHS) and published this in the
Federal Register in March 2012. Two significant changes require: 1) use of new labeling elements and
2) standardized format for Safety Data Sheets (SDS).

Material Safety Data Sheets (MSDS), are now known as Safety Data Sheets (SDS) and are required
information provided by the manufacturer, about the product’s physical and chemical properties.

Hazard Communication Standard requires the following:

Labels for a hazardous chemical must contain:

 Name, Address and Telephone Number of the chemical manufacturer, distributor, or importer
 Product Identifier
 Signal Word
 Hazard Statement (s)
 Precautionary Statement (s)
 Pictogram (s)

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Revised 3.1.18
Product identifier: How the chemical is identified. Can be (but is not limited to) the chemical name,
code number or batch number. The same product identifier will be on both the label and in Section 1
of the SDS (Safety Data Sheet)

Signal Word: Used to indicate the relative level of severity of hazard and alert the reader to a
potential hazard on the label. There are only two signal words, “Danger” and “Warning.” Within a
specific hazard class, “Danger” is used for the more severe hazards and “Warning” is used for the less
severe hazards. There will only be one signal word on the label no matter how many hazards a
chemical may have.

Pictogram: An environmental pictogram is not mandatory but may be used to provide more
information. While the GHS uses a total of nine, OSHA has designated eight pictograms under this
standard. The environmental pictogram is not mandatory.

Hazard Statement: Describes the nature of the hazard (s) of a chemical, including, where
appropriate, the degree of hazard. All of the applicable hazard statements must appear on the label.
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Revised 3.1.18
For example: “Causes damage to kidneys through prolonged or repeated exposure when absorbed
through the skin.”

Precautionary Statement (s): Means a phrase that describes recommended measures that should be
taken to minimize or prevent adverse effects resulting from exposure to a hazardous chemical or
improper storage or handling.

Name, address, and phone number of the chemical manufacturer, distributor, or importer

Contact the Facility Plant Ops Manager to locate a copy of the SDS Manual in your facility.
Kindred SDS information can also be located on-line at:
KNECT>GLOBAL>MSDS

Legal Rights of the Employee

A copy of a Safety Data Sheet shall be made available to employees on the contents of SDS for
hazardous substances or equivalent. Information may be either written or through training programs

Employees cannot be discharged or subjected to any discrimination due to exercising their rights
afforded under the Hazardous Substances Information and Training law.

When an employer receives a new or revised SDS, such information will be provided to employees on
a timely basis, not to exceed 30 days after receipt.

Bio-Hazardous/Medical Waste
Kindred Hospital Medical Waste Management Plan was developed to describe the procedures for the
identification, safe handling, packaging, storage, transportation and disposal of biohazardous waste
generated within the confines of Kindred Hospital.

The plan was designed to ensure minimal risk of exposure or injury to patients, staff, the public and
the environment. The plan is located in the Safety/EOC Manual. Employees are required to review
this plan as part of departmental orientation.
Bio-hazardous spill is an accidental spill of hazardous/bio-hazardous material. The Bio-hazardous
Emergency Response Plan was developed to provide an effective, coordinated, and rapid response to
accidents or spills involving hazardous or bio-hazardous/infectious materials and/or waste. The plan
is designed to ensure minimal risk of injury to patients, staff, visitors, and the environment.

Initiate a bio-hazardous code in the event the following materials are spilled or released:
 Any quantity of mercury
 Any quantity of chemotherapeutic agent
 Any quantity of gasoline or fuel oils
 Any quantity of formalin or formaldehyde
 Rupture of sharps container
 Any quantity of gluteraldehyde
 Blood products, i.e. units of packed red blood cells, platelets, etc.
 Any material which poses a threat to patients, visitors, or staff

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Revised 3.1.18
The person discovering the spill should announce a Biohazardous Code and the location three times.
When a bio-hazardous code is called after hours or on weekends, the CEO/Administrator on Call must
be notified. The House Supervisor, Safety Officer, Environmental Services Manager, and the Director
of Plant Operations should respond to a bio-hazardous code.

The general procedure for a bio-hazardous code is to follow the CLEAN acronym:
C Contain the spill if possible
L Leave the area and call a Biohazardous code
E Emergency first aid/evacuate patients if needed
A Access the SDS
N Notify the House Supervisor and complete Event Report

If the spill/release poses a significant threat, the appropriate evacuation process should be followed

Emergency Management
The purpose of the Emergency Operations Plan is to provide a process and resources for the
continuation of patient care during a variety of emergencies that may disrupt operations at Kindred
Hospital. The plan includes processes designed to provide for the medical needs of patients as a
result of a hospital or community-based incident.

The emergency preparedness program is designed to assure appropriate staff response to a wide
variety of emergency situations. The primary emphasis is on short-term management of critical
patient care and business operation disruptions. The program is designed to address the emergency
response needs of all patient care and business operations of the facility. The emergency
management program applies to all staff in all patient care services operated by Kindred Hospital.

The CEO/Administrator or Incident Commander designee in the absence of the CEO, shall be
responsible for informing the Department of Health Services, via telephone, upon being notified of
the intent of the discontinuance or disruption of services by any of the events as listed below
including the threat of a walkout or a substantial number of employees or any event which causes
damage to the facility or threatens the safety or welfare of patients.

Employees are responsible for reviewing policies and procedures in the Emergency Management
binder located in strategic areas, relating to disasters, codes, and emergency procedures in the event
of an external or internal disaster.

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Revised 3.1.18
Example Table of Emergency Conditions and the response plan

Problem and Description Initial Response Secondary Response Follow Up

Announcement
Bomb Threat Notification of a bomb, Obtain as much Call 911, notify police Conduct search with
by outside caller information as possible. and fire dept. Activate appropriate personnel
Notify Administrator, evacuation plan if and bomb squad. Do
CCO, Safety Officer ordered by police/fire not touch if found. Fill
immediately dept. out threat form
Cardiac Arrest Cardiac/Respiratory Dial ___ give location x Start CPR, perform until Complete Event Report
Arrest 3 Code Team arrives
External Mass Casualty Earthquake, flood, riots, All depts. Activate Prepare to discharge Coordinate activities
Disaster etc. Disaster Plan, activate non-critical patients as with command center,
recall roster necessary for bed space take any necessary
Check supplies, call in actions
off duty personnel
Fire Fire, smoke or smell Rescue, alarm, contain Use extinguisher to put Evacuate if necessary,
something burning extinguish –RACE out fire. Verify type ambulatory, then non-
ambulatory
Fire/Evacuation Remaining in area may Notify all in area to Report to designated Report evacuation
be hazardous to life, evacuate, ambulatory assembly area and status to fire dept.
health, safety then bedridden pts. account for all who control center, identify
Take records if possible were in previous area any unaccounted
personnel
Hazardous Material Incidental – small spill Trained user cleans up Appropriately dispose Complete report of the
Spill – Minor (no presenting no hazard to with appropriate equip. of materials, notify incident
announcement) trained & decontamination supervisor and others
employee/envir. material as necessary
Hazardous Material spill Emergency – Any spill Isolate area. Notify EVS, Seek/Coordinate Complete report of
– Major which presents a Safety Officer, & CCO medical treatment of incident, call Fire Dept.
hazard to victims if necessary. Treat any
people/environment injuries
Violent Any person causing a Dial ___, announce Assist response team Complete report of
Person/Restraint physical threat to staff Code ___ and location x with necessary actions, incident, treat any
or others 3, Clear immediate area if patient, notify MD injuries
Utility Failure Power failure Announce Code ____ Ensure life support If complete power
and location x 3 systems on emergency failure, hand ventilate
power. Use flashlights, patients, activate
complete all disaster plan if
procedures asap, use necessary
red wall sockets

Types of Emergency Codes

 Cardiac or Respiratory Arrest
 Fire or Explosion
 Security Emergency/Combative Person
 External/Internal Disaster
 Ventilator Failure/Power Failure
 Biohazardous/Hazardous Spill
 Bomb Threat

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Revised 3.1.18
External Disaster:
On Duty Personnel:
 Immediate action will be taken according to each department’s role in the plan. During a
disaster situation, you may be called upon to perform duties other than those of your regular
job
 Department Managers report to Command Center

Off Duty Personnel:

 Each department has a call back roster, which will be instituted if needed
 If you are at home and your surrounding area is safe, remain there until notified by phone of
the need to return to the hospital

All arriving personnel must report to labor pool to sign in, except for Department Managers who will
report to the Command Center

Power Failure:
The Power Failure Response Plan is designed to provide a mechanism whereby hospital staff can
assist respiratory therapists in providing ventilation to patients in the event of ventilator failure
generally due to a power failure. Most Kindred hospitals have ventilators with emergency battery
back-up. However, Kindred provides a contingency plan should ventilators fail/malfunction. When
the hospital loses power, the hospital’s emergency generator will start automatically within 10
seconds and provide power to any ventilator plugged into a red outlet. In such a situation a Power
Failure Code is called and initiated. This procedure alerts the staff to the fact that the hospital is
operating on emergency generator. If, for some reason, the back-up system fails to start up, the
ventilators in use switch to emergency back-up battery. If emergency back-up battery fails the
ventilators must be disconnected from the patient and manual bagging, with a resuscitation bag must
take place. Extra personnel may be needed to ventilate the patient during the time of total power
failure. Non-clinical staff may be asked to help the nurses and therapists on the floors as needed.
Upon receiving notice of a power outage, the receptionist or Nursing Supervisor should immediately
obtain as much information as possible about the type of disaster, and then notify the
CEO/Administrator or the Administrator on call. When notified that a utility failure has occurred, the
operator will announce over the PA system as follows: Power Failure Code x 3.

All personnel report to assigned patient care areas.

 All hospital personnel are expected to respond to a Power Failure Code
 All new employees will be instructed on Power Failure Code procedures. All staff will receive
instruction on manual ventilation of patients during General Hospital Orientation and annually
thereafter.
 The CCO or designee is responsible for overseeing manual ventilation at the bedside and re-
establishing ventilation per ventilator equipment
 If total power failure occurs during evening or night hours, the Nursing Supervisor or designee
will call 911 and request assistance, and notify the Administrator on Call.
 Equipment: Resuscitation (Ambu) bags are available in each patient room

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Revised 3.1.18
Hospital employees will respond to assigned areas. The staff members are to report to the Senior
Team Leader or the Respiratory Therapist to receive directions. The Nursing Supervisor or
Respiratory Therapist will dismiss staff members to their own department when assistance is no
longer required.

Fire Safety
It is our commitment at Kindred Hospital to provide a fire-free environment of care. In order to
minimize possible fire hazard conditions or damage to this facility, or personnel injury, all staff have
the responsibility of adhering to the following fire prevention principles:

R Rescue anyone in immediate danger. If you discover a fire in a patient’s room, remove
patients to a safe area

A Activate alarm. Locate the nearest fire alarm pull box and pull handle down. Pick up the
nearest phone, dial paging system and announce Fire Code with location x 3

C Confine the fire by closing doors

E Extinguish the fire. Return to the location of the fire with proper type of extinguisher and if
there is no danger to your safety or life, attempt to extinguish the fire. Evacuate if necessary.

Using a fire extinguisher requires four steps:

P Pull the pin

A Aim at the base of the fire
S Squeeze the handle trigger
S Sweep from side to side

Try to keep in mind that the greatest danger in most fires is when people panic. Remember that our
patients will look to you for protection. Do not alarm people by making excited motions and never
shout, “fire.” Help prevent fires by making a habit of watching for fire hazards. Remember that we
are a non-smoking facility.
Interim Life Safety Measures or ILSM are policies and procedures that are put into effect in the
hospital whenever there is a compromise of Life Safety (fire), such as construction, loss of water
which will cause failure of fire sprinklers, etc.

Fire Safety Staff Knowledge:

 Plan now. Be ready to do the right thing at the right time
 Review your departmental fire plan, which is located in the Safety Manual
 Know what your role is in a fire
 Know where the fire alarm pull station is located in your work area
 Know where the fire extinguisher is located in your area
 Know where the fire evacuation route is posted in your area, and note different ways out in
case fire blocks the normal exit

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Medical Equipment Management Plan
The Biomedical Engineering Department at Kindred Hospital or the Biomedical Equipment Vendor is
responsible for inspecting, testing and maintaining medical equipment in the hospital. There are
three categories of medical equipment; therapeutic, such as infusion pump, etc., analytical, such as
centrifuge, etc., and diagnostic, such as bedside monitors. Any equipment that does not fall under
these three categories is not considered medical equipment.

Every piece of equipment has to be inspected prior to use, regardless if it is rented, loaned, or non-
hospital owned. Once the department has approved the equipment it will be released with a sticker
stating the date inspected and the due date for the next inspection. In a case of equipment failure,
please tag the unit with a red “out of use” or “defective” sticker, and notify the biomedical
engineering department.

Safe Medical Device Act of 1990

The law that requires us to report any incident of equipment failure that causes death or serious
injury or illness to patients.

Radiation Safety
What Should You Know About Radiation in Your Facility?
 Radiation is a form of energy that may be in the form of particles or electromagnetic waves
 Recognize where these materials are stored and used
 Know what to do when you work in a room that contains radioactive materials
 Understand general restrictions for working in these rooms
 Control your exposure to radioactive materials should problems occur
 Sources of radiation will vary from facility to facility depending upon the location of the
radiology equipment (stationery or mobile)
 Use caution if you are working in a surgical area where the C-arm may be used

Hazards and Control

Four Basic Radiation Safety Techniques to Control Exposures
 Time: Limit your time around the exposure area to the least amount of time specific to the
test that is being done
 Distance: Maximize your distance from the area to at least 6 feet
 Shielding: Lead is the most commonly used shield material. Low density materials like wood
or drywall are not as effective
 Contamination Control: Use secondary containment and absorbent pads to prevent spread of
contamination and Don’t forget PPE

Good radiation safety practice involves keeping radiation doses As Low As Reasonably Achievable
(ALARA)

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Safety Issues Associated With Exposure
- Radiation badges are required for those likely to be exposed to
an excess of 500
mrem/yr

Radiation risk limits

- Whole body: 5,000 mrem/yr
- Eyes: 15,000 mrem/yr
- Skin: 50,000 mrem/yr
- Extremities: 50,000 mrem/yr

An “rem” is a unit of ionizing radiation dose. You receive about 300 mrem/yr from natural sources
(earth, radon, cosmic rays, etc.) over the years scientific organizations have developed the
occupational dose limit to be 5,000 mrem/yr
What is Your Exposure?
Natural Sources
- Radon gas: 198 mrem/yr
- Cosmic radiation: 28 mrem/yr
- Food, water, air: 29 mrem/yr

Human Made Sources

- Chest X-ray: 5 mrem per x-ray
- Dental x-ray: 1 mrem per x-ray
- Consumer products: 11 mrem/yr

Did you know? Regularly smoking cigarettes adds about 1300 mrem/yr to one’s exposure

Radiation Precautions
X-ray equipment, including radiographic x-ray and fluoroscopy, only produces radiation when
energized. Only state licensed operators are permitted to operate x-ray equipment. Keep out of the
room while the patient is being exposed. If staying out of the room is not possible without
compromising patient care, you should:
- Keep all parts of your body out of the primary beam
- Wear a lead apron or stand behind a lead barrier

Reporting Problems
If you encounter a liquid or solid spill in an area posted as “Radioactive Materials”:
 close the door and notify your supervisor
 Do not handle, move, or remove bags or containers labeled “radioactive material.”

Contact Radiation Safety to report any emergency situations or unsafe work conditions:

In conclusion: Remember
 Protect both yourself and your patient

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  Control contamination by using absorbent pads and personal protective equipment to cover
any body parts that could have unnecessary exposure; this helps prevent the spread of
radiation from one person to another

For additional radiation safety information; access the following website:

Epa.gov/radiation
Contact Radiation Safety in your state to report any emergency situations or unsafe work conditions

Ergonomics, Back Safety, and Body Mechanics

Ergonomics has been defined as the “science of fitting the job to the worker.”
OSHA (Occupational Safety and Health Administration) regulations provide
guidelines for workplace safety.

Depending on the type of work that you do, your job may involve movements or
activities that cause you discomfort, pain or even an injury.

Kindred provides a Saf-Lift Program to educate direct caregivers on safe lifting

procedures. The Saf-Lift policy provides a framework and defines responsibility to create and
maintain an environment that supports and addresses a patient safe handling program. By
addressing patient safe handling, employee training of appropriate and safe patient positioning and
transfer techniques is addressed to ensure patient and employee well-being.

The primary goal of Kindred's Saf-Lift program is to reduce both the risk and occurrence of workplace
injuries. According to the bureau of statistics, more than 1 million workers suffer back injuries
annually. The use of proper body mechanics can significantly reduce your risk of injury at work.

The back is the foundation of the entire body. It holds the body up. The back operates at a 10- to- 1
ratio with the waist as the pivot point. When you bend at the waist, the actual amount of weight is
magnified 10 times on the lower back.

The actual amount of weight includes the weight of the upper body, which accounts for about two
thirds of your total body weight. Ways to lift an object and reduce risk include:

1. Get as close as possible to the load when lifting

2. Stager your feet for better balance
3. Squat down, bending your knees
4. Keep your stomach muscles tight. Maintain the natural S curve of the back
5. Stand up slowly, keeping your back straight
6. Do not twist your upper body while carrying the load. Turn with your feet or legs
7. Set the load down slowly, bending your knees and keeping your back straight

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Other Safety tips:
1. Use mechanical assist devices
2. Get help if the load is too heavy or awkward. Never
attempt to lift a load beyond your capabilities
3. Reduce the amount of weight lifted if possible
4. Use handles and lifting straps
5. The higher the frequency of lifts, the lower the amount of
weight that should be lifted
6. Keep the heaviest end of the load closest to the body to support the weight of the
object
7. Maintain proper body mechanics at all times
8. Keep your eyes open for spills, cords and other hazards
9. Avoid reaching overhead. Get a step stool
10. Change tasks regularly to avoid prolonged postures and repetitive motion.

Employees:
 Keep safe, report risks, modify workspace to reduce risk and immediately report early signs or
symptoms of musculoskeletal problems. Early correction can reduce the severity of injury.
 Participate in ergonomic training and education provided at orientation, as well as annual
review
 Notify your Supervisor or Employee Health Nurse if you have a question or concern

Supervisors:
 Identify conditions of potential risk and make timely recommendations to reduce or eliminate
risk
 Respond to employee reports of risk or injury

EOC/Safety Committee:
 Oversees the Ergonomics Program to assist employees in attaining a risk free workplace
 Designate responsibility for reporting and responding to reports of risk or injury
 Assess hazards and recommend steps to minimize or eliminate hazards
 Insure ergonomic education is available to all staff

Basic Rules for Safe Lifting:

 Size up the load: If you think it may be too heavy or awkward, get help. Remember to use
mechanical lifting aids whenever possible.
 Make sure the path is clear by removing all obstacles
 Keep your legs apart while lifting and lowering for better base of support and balance
 Effectively use your leg muscles by bending at your hips and knees when lifting and lowering a
load
 Keep your back upright as much as possible, maintaining the natural curves of your spine by
keeping your abdominal muscles engaged
 Keep the load close to your body and avoid twisting.

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Basic Tips for the Workplace:

 Follow tips for safe lifting

 Use proper footwear and keep your eyes open for spills, cords and other hazards
 Set up your work station to avoid excessive twisting, reaching, and awkward postures
 Avoid reaching overhead, get a step stool
 Avoid stooping over with your back to reach low objects, bend at your knees or sit on a low
stool
 Maintain good posture with an upright head and neck and a neutral spine position
 Change tasks regularly to avoid prolonged postures and repetitive motion. Take rest breaks

Basic Safety Tips for Patient Care

Transfers:
 Use mechanical devices whenever possible; power lift, transfer belts, draw sheets, etc.
 Use as many helpers as needed to safely move the patient
 Keep transfer surface level by raising or lowering bed height
 Lock bed, wheelchair, gurney, or commodes with wheels
 Make sure path and floor are clear of hazards
 Instruct/educate the patient before repositioning or relocating
 Move in two phases; 1st to the edge of the bed, then to the alternate surface
 Use safe lifting tips
 If the patient is falling, lower them gently to the floor by bending your knees while protecting
the patient’s head

Re-Positioning a Patient in Bed:

 Use as many helpers as needed to safely move the patient
 Enlist the patient’s assistance as able, and instruct them in the process
 Raise the bed to waist level to avoid stooping
 Bend knees, pushing on count of three
 Use draw sheets for ease of motion
 Make sure the bed is locked and use all safe lifting tips
 Lift and glide to move the patient up in bed

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 The Joint Commission Hotline Information

The Joint Commission uses information from a variety of sources to improve the quality and safety of
healthcare organizations it accredits and certifies. One of these sources is complaints from patients,
their families, government agencies, and the public, as well as from an organization’s own staff.

If you have a complaint about a healthcare organization that the Joint Commission accredits or
certifies, The Joint Commission’s Office of Quality and Patient Safety is interested in the details of
your complaint. Although The Joint Commission cannot serve as complaint mediators, they use the
information you provide to identify possible non-compliance with accreditation or certification
standards. For direct resolution of your complaint, you may want to bring your issue to the attention
of the organization’s leadership.

When a complaint is received by The Joint Commission:

The Joint Commission evaluates the complaint information in terms of its relevance to compliance
with a hospital’s accreditation or certification standards. The Joint Commission focuses on safety and
quality of care. Matters of billing, insurance, payment disputes, personnel issues, or labor relations
are not within The Joint Commission’s scope.

To Report a Complaint:
If you wish, you can remain anonymous. However, providing a name and a mailing or e-mail address
allows The Joint Commission to contact you for additional information or clarification, if needed.
Should you decide to disclose your name and address, The Joint Commission will keep this
information confidential.

Report your complaint to:

TJC Hotline # 800-994-6610 or e-mail complaint@jointcommission.org

FAX: Office of Quality Monitoring 630-792-5636

Mail: Office of Quality and Patient Safety

The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181

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