EOC Documents

EC - Environment of Care

EC001P	Safety Mission
Facility Type: Acute Care Hospital	Last JCAHO Survey: Due 8/98
Safety Mission YOUR Medical Center The primary goal of YOUR Medical Center is to eliminate or control both known and potential safety and health hazards which our employee face on the job. In Order to do so, YOUR Medical Center must adhere to the following guidelines: Safety and health are a shared responsibility. Everyone from top management to Supervisors to each and every worker must take ownership of his or her own safety and that of co-workers. Maintaining a safe and healthful work environment is not just an idea B it is a top priority. It is everyone's job to spot hazards and to correct them or report them in a timely manner. Where hazards cannot be completely eliminated, they must be reduced through engineering or administrative controls or, as a final precaution, through the proper use of personal protective equipment. Every individual will be trained to perform work safely. Should an individual feel inadequately trained to perform a certain procedure, he or she will immediately discuss the problem with his or her supervisor. As a condition of employment, each employee must consistently work in a safe manner.

EC002P

Administrative Support Statement

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

ADMINISTRATION SUPPORT STATEMENT

YOUR Medical Center's policy is to do all that is reasonable to prevent injury to persons and damage to property and to protect the employees, the facility, the patients, the environment, and the public from injury, fire or other damage. In order to achieve these goals, YOUR Medical Center is instituting a comprehensive safety program. The program will be a well-planned and thoroughly organized approach to ensuring safety.

The administration urges the active cooperation and commitment of all departments and employees. In implementing the program, safety responsibilities shall become incorporated into all job descriptions, and staff will be trained in fulfilling new duties. Safety will become part of job performance evaluation, and on-going dialogue and feedback will be encouraged.

YOUR Medical Center's administration supports this program in its promotion of employee safety and health. The administration also supports the policy that everything within reason shall continue to be done throughout the facility to maintain or enhance comprehensive safety.

The safety program will include:

Safety Policies & Procedures for All Departments and Services
Incident Reporting and Investigation
Emergency Preparedness Plans
Hazardous Materials and Waste Plan
Life Safety Plan
Medical Equipment Plan
Security Management Plan
Utilities Management Plan
Patient Safety Measures
A Safety Committee
Safety Education and Training

The primary responsibility for coordinating and supervising the program shall rest with the Safety Director. He/She will regularly consult with and advise the Risk Manager and Chief Executive Officer on safety matters and is responsible for the development, implementation, and monitoring of the safety program. He/She will have the authority necessary to carry out program activities.

_____________________________________
(Chief Executive Officer's Signature)

EC003P

Safety Management Plan

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

SAFETY MANAGEMENT PLAN

Purpose:

The purpose of the Safety Management Plan at YOUR Medical Center, is to do all that is reasonable to prevent injury to persons and damage to property and to protect the employees, the facility, the patients, the environment, and the public from injury, fire or other damage.

Support Statement:

YOUR Medical Center has made a commitment to establish and support a Safety Management Plan that is based on monitoring and evaluation of organizational experience, applicable laws and regulations, and accepted practice and to develop and maintain:

A program to prevent human and economic losses from personal, physical harm and property damage.

A program to assure the security, protection, and well being of personnel and property of YOUR Medical Center by the prevention and control of physical violence, misconduct, theft, or sabotage.

A program for the supervision of all grounds and equipment, including special activity areas used by patients.

A program to ensure that emergency service areas are clearly identified and easily accessible.

A Risk Assessment Program that actively evaluates the impact on patient and public safety of the buildings, grounds, equipment, occupants, and internal physical systems.

Responsibility:

The Chief Executive Officer of YOUR Medical Center shall appoint a Safety Director who is qualified by experience and is responsible for developing, implementing and monitoring the hospital's Safety Management Plan.

Authority Statement:

YOUR Medical Center's Chief Executive Officer and Chief of Medical Staff authorize the Safety Director and/or Safety Committee Chair-person to take immediate corrective action when conditions exists that post an immediate threat to life or health or risk of damage to equipment or buildings.

Functions:

All departments shall maintain individualized safety policies and procedures. All departmental safety policies and procedures will be reviewed no less than every three years.
On-going hazard surveillance program including response to product safety recalls shall be maintained and reported through the Safety Committee.
Establish policies and procedures for reporting and investigating all incidents that involve property damage, injury or occupational illness to patients, visitors, or personnel and submit summary reports including conclusions, recommendations and actions taken to the Safety Committee.
YOUR Medical Center shall establish a Safety Committee with representation from administration, clinical services, and support services.
Promote orientation programs and continuing education on safety for all employees.
The objectives, scope, and performance of the Safety Management Plan shall be evaluated annually for its effectiveness.

EC004P	Life Safety Management Plan
Facility Type: Acute Care Hospital	Last JCAHO Survey: Due 8/98
LIFE SAFETY MANAGEMENT PLAN Purpose: The purpose of the Life Safety Management Plan of YOUR Medical Center is to adequately design and produce a functionally safe environment in and around YOUR Medical Center so as to guarantee patients the ability to receive quality care. It also creates an environment where all patients, personnel, visitors and others can be protected from fire and the products of combustion. Support Statement: YOUR Medical Center has made a commitment to establish and support a Life Safety Management Plan that is based on monitoring and evaluation of organizational experience, applicable laws and regulations, and accepted practice and to develop and maintain a program to prevent human and economic losses from personal injury. Responsibility: The Director of Environmental Services has the ultimate responsibility to implement the necessary functions of the Life Safety Management Plan while continually upgrading those areas necessary to meet the Life Safety Code of the National Fire Protection Association. The Director of Environmental Services also is responsible for using all resources to continuously improve the quality of these processes where possible to increase the safety and protection of all individuals surrounding the facilities. Functions: Establishes, supports and maintains a Life Safety Management Plan. Protects patients, personnel, visitors, and property from fire and the products of combustion. Identifies and maintains all applicable required structural features of fire protection to LSC (NFPA 101, 1991 edition) standards. Inspects, tests, and maintains fire alarm systems, including quarterly testing of all circuits and annual preventive maintenance of all components. Inspects, tests and maintains a fire alarm or fire detection system (as appropriate to the occupancy classification) that upon activation: Minimizes smoke transmission through control of designated fans and/or dampers in air-handling and smoke-management system. Transmits the fire alarm to the local fire department. Inspects, tests, and maintains all automatic fire extinguisher systems. Manages portable fire extinguishers, including guidelines for their identification, placement and use, a quarterly inspection program, and a regular maintenance program. Reviews proposed acquisitions of bedding, window draperies and other curtains, furnishings, decorations, wastebaskets, and other equipment for issues related to fire safety. Reports and investigates LSC and fire protection deficiencies, failures, and user errors that may threaten the patient care environment during fire. Requires an annual evaluation of the objectives, scope, performance, and effectiveness of the documented Life Safety Management Plan.

EC005P

Security Management Plan

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

SECURITY MANAGEMENT PLAN

Purpose:

The purpose of the Security Management Plan at YOUR Medical Center is to do all that is reasonable to prevent damage to property and to protect the employees, the facility, the patients and the public from injury or other damage.

Support Statement:

YOUR Medical Center has made a commitment to establish and support a Security Management Program that is based on monitoring and evaluation of organization experience, applicable laws and regulations, accepted practice and to develop and maintain a program to assure the security, protection, and well being of personnel and property of YOUR Medical Center by the prevention and control of physical violence, misconduct, theft, or sabotage.

Responsibility:

The Director of Environmental Services of YOUR Medical Center is responsible for developing, implementing, and monitoring the hospital's Security Management Plan.

Functions:

Establishes, supports and maintains a Security Management Plan.

Addresses security concerns regarding patients, visitors, personnel, and property.

Provides identification, as appropriate, for all patients, visitors, and staff.

Provides access control, as appropriate to sensitive areas.

Provides vehicular access to emergency service areas.

Provides traffic control for emergency service areas.

Specifies personnel, as directed by the Chief Executive Officer or designee, who is responsible for developing, implementing and monitoring the hospital's Security Management Plan.

Reports and investigates all security incidents that involve patients, visitors, personnel, or property.

Requires an annual evaluation of the objectives, scope, performance, and effectiveness of the documented Security Management Plan.

EC006P

Emergency Preparedness Management Plan

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

EMERGENCY PREPAREDNESS MANAGEMENT PLAN

Purpose:

The purpose of the Emergency Preparedness Management Plan at YOUR Medical Center is to develop emergency preparedness plans to be implemented during a disaster or other emergency, so that patient care can be continued as effectively as possible.

Support Statement:

YOUR Medical Center has made a commitment to establish and support the Emergency Preparedness Management Plan.

Responsibility:

The Safety Director is responsible for developing, implementing and monitoring the hospital's disaster preparedness plans.

Functions:

Implement plans for the following disaster based upon the space, supplies and security of the hospital.

Bomb Threat
Tornado
Earthquake
Fire
Emergencies
Chemical Spills
Hostage Situations
Power Outages
Utility Failures (Water, Heat, Natural Gas)

Establish policies for notifying proper authorities outside the hospital regarding an emergency.

Develop procedures for notification of personnel of implementation of the emergency preparedness plans.

Define responsibilities of personnel during disaster and emergency situations and assignments to reflect staffing patterns.

Develop policies for providing emergency communications during disasters and emergencies.

Policies for alternative source for essential utilities.

Policies and procedures for evacuation of the hospital if the hospital cannot continue to support adequate patient care and treatment and an alternate care site.

Integrate hospital's role with community emergency preparedness plans.

Policies for identifying available facilities for radioactive or chemical isolation and decontamination.

Develop policies/procedures for managing patients during disasters or emergencies, including the scheduling, modification, or discontinuation of services, control of patient information, and admission, transfer, and discharge of patients.

Emergency preparedness plans shall be evaluated annually for their effectiveness.

Promote orientation programs and continuing education on emergency preparedness plans for all personnel.

Implement emergency preparedness plans semi-annually, in response to an emergency or planned drill.

EC007P

Medical Equipment Management Plan

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

MEDICAL EQUIPMENT MANAGEMENT PLAN

Purpose:

The purpose of the Medical Equipment Management Plan of YOUR Medical Center is to establish an Medical Equipment Management Plan to manage the risk posed by electrical devices and to record and document all findings thus creating a safe environment for patients, employees, and visitors and providing high quality patient care.

Support Statement:

YOUR Medical Center has made a commitment to establish and support a Medical Equipment Management Plan that is based on monitoring and evaluation of organizational experience, applicable laws and regulations, and accepted practice and to develop and maintain a program to assure the well being of personnel, patients, and visitors.

Responsibility:

The Director of Support Services of YOUR Medical Center is responsible for developing, implementing and monitoring the hospital's Medical Equipment Management Plan.

Functions:

Establish, support and maintain a Medical Equipment Management Plan.

Select and acquire medical equipment.

Establishing written criteria to identify, evaluate, and inventory medical equipment to be included in the Medical Equipment Management Plan. This criteria addresses:

Equipment function (diagnosis, treatment and monitoring).
Physical risks associated with equipment during usage.
Equipment incident history.
Equipment maintenance requirements.

Assesses and minimizes the clinical and physical risks associated with medical equipment through inspection, testing, and maintenance of equipment and education of users and maintainers of medical equipment.

Monitors and acts on as appropriate medical equipment hazard notices and recalls.

Monitors and reports incidents in which a medical device may have caused or contributed to the death, serious injury, or serious illness of a patient or another

individual, as required by the Safe Medical devices Act of 1990.

Reports and investigates Medical Equipment Plan problems, failures, and user errors that have or may have an adverse effect on patient safety and/or the quality of care.

Requires an annual evaluation of the objectives, scope, performance, and effectiveness of the documented Medical Equipment Management Plan.

EC008P

Utility Systems Management Plan

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

UTILITY SYSTEMS MANAGEMENT PLAN

Purpose:

The purpose of the Utility Systems Management Plan at YOUR Medical Center is to help minimize the risk of utility failure, to lessen the effects of utility failures and provide a safe environment for the provision of high quality patient care.

Support Statement:

YOUR Medical Center has made a commitment to establish and support a Utility Systems Management Program that is based on monitoring and evaluation of organizational experience, applicable laws and regulations, and accepted practice and to develop and maintain a Utility Systems Management Plan.

Responsibility:

The Director of Environmental Services of YOUR Medical Center is responsible for developing, implementing and monitoring the hospital's Utility Systems Management Plan.

Functions:

Establishes, supports and maintains a Utility Systems Management Plan.
Establishes written criteria to identify, evaluate, and inventory critical operating components of utility systems to be included in the Utility Systems Management Plan. This criteria addresses:

Life support systems.
Infection Control Systems
Environmental Support Systems
Communication Systems

Assesses and minimizes the special risks and ensuring the operational reliability associated with utility systems through inspection, testing, and maintenance of critical operating components and the education of users and maintainers of utility systems.

Develops and maintains current utility system, including labeling of controls for partial or complete emergency shut down of each utility system.

Identifies the distribution of each utility system, including labeling of controls for a partial or complete emergency shutdown of each utility system.

Reports and investigates Utility Systems Management Plan problems, failures or user errors that are or may be a threat to the patient care environment.

Requires an annual evaluation of the objectives scope, performance, and effectiveness of the documented Utility Systems Management Plan.

EC009P

Hazardous Materials and Wastes Management Plan

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

HAZARDOUS MATERIALS AND WASTES MANAGEMENT PLAN

Purpose:

The purpose of the Hazardous Materials and Wastes Management Plan of YOUR Medical Center is to identify, evaluate, and control safety and health hazards, and provide for emergency response for employees, patients, and the public.

Support Statement:

YOUR Medical Center has made a commitment to establish and support a Hazardous Materials and Wastes Management Plan that is based on monitoring and evaluation of organizational experience, applicable laws and regulations, and accepted practice and to develop and maintain a program to prevent human and economic losses from personal injury.

Responsibility:

The Director of Environmental Services is responsible for developing, implementing and monitoring the hospital=s Hazardous Materials and Wastes Management Plan.

Functions:

Establishes, supports and maintains a Hazardous Materials and Waste Management Plan.

Selects, handles, stores, uses, and disposes of hazardous materials from receipt through use and hazardous wastes from generation to final disposal.

Establishes written criteria in accordance with applicable laws and regulations, to identify, evaluate and inventory hazardous materials and wastes used or generated by each department.

Manages chemical wastes, chemotherapeutic wastes, radioactive wastes, and regulated medical or infectious wastes, including sharps.

Educates and monitors personnel who manage or regularly come into contact with hazardous materials and wastes.

Monitors and disposes of hazardous gases and vapors.

Provides adequate and appropriate space and equipment for the safe handling and storage of hazardous materials and wastes.

Reports and investigates all hazardous materials or wastes spills and exposures or other incidents that involve patients, visitors, personnel, or property.

Requires an annual evaluation of the objectives, scope, performance, and effectiveness of the documented Hazardous Material and Waste Management Plan.

EC010P

Hazard Communication Program

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

HAZARD COMMUNICATION PROGRAM

YOUR Medical Center, Inc. has developed a Hazard Communication Program to enhance our employee's health and safety.

At YOUR Medical Center, Inc. we intend to provide information about chemical hazards and other hazardous substances, and to control hazards by our comprehensive Hazard Communication Program. The Hazards Communication Program will include:

Container Labeling

Material Safety Data Sheets (MSDS)

Employee Training

The following program outlines how YOUR Medical Center, Inc. will accomplish this objective:

Container Labeling:

It is the policy of this hospital that no container of hazardous substances will be released for use until the following label information is verified:

Containers are clearly labeled as to the contents

Appropriate hazard warnings are noted

The name and address of the manufacturer are listed

The responsibility has been assigned to the Director of Environmental Services. To further ensure that employees are aware of the hazards of material used in their work areas, it is our policy to label all secondary containers.

The Department Head/Supervisor in each department will ensure that all secondary containers are labeled with either an extra copy of the original manufacturer's label or with generic labels which have a block for identity and blocks for the hazard warning.

Material Safety Data Sheets (MSDS):

Copies of MSDS for all hazardous substances to which employees of this hospital may be exposed are kept in each department as well as the office of the Director of Environmental Services. Each Department Head/Supervisor will be responsible for obtaining and maintaining the data sheet system for their department.

The Department Head/Supervisor will review incoming data sheets for new and significant health/safety information. The Department Head/Supervisor will see that any new information is passed on to the affected employees.

MSDS will be reviewed for completeness by the Department Head/Supervisor. If an MSDS is missing or obviously incomplete, a new MSDS will be requested from the manufacturer. MSDS are available to all employees in their work area for review during each work shift. If MSDS are not available or new hazardous substance(s) in use do not have MSDS, please contact your Department Head/Supervisor immediately.

Employee Information and Training:

Each Department Head/Supervisor is responsible for the training of all employees in their department:

An overview of the requirements contained in the Hazard Communication Regulation, including their rights under the regulation.

Location and availability of the written Hazard Communication Program and MSDS.

How to less or prevent exposure to these hazardous substances through usage of control, work practices and personal protective equipment.

Steps the hospital has taken to lessen or prevent exposure to these substances.

How to read labels and review MSDS to obtain appropriate hazard information.

When new hazardous substances are introduced, the Department Head/Supervisor will review the above items as they are related to the new material.

Hazardous Substances:

Information on all hazardous substances with the hospital can be found in the MSDS books.

Hazardous Non-Routine Tasks:

Periodically, employees are required to perform hazardous non-routine tasks. Prior to starting work on such projects, each affected employee will be given information by their Department Head/Supervisor about hazards to which they may be exposed during such an activity. This information will include:

Specific hazards.

Protective/Safety measures which must be utilized.

Measures the hospital has taken to lessen the hazards including ventilation, respirators, presence of another employee and emergency procedures.

Hazardous Substances In Unlabeled Pipes:

To ensure that our employees who work on unlabeled pipes have been informed as to the hazardous substances contained within, the following policy has been established.

Prior to starting work on unlabeled pipes, our employees are to contact the Department Head/Supervisor for the following information:

The hazardous substance in the pipe.

Potential hazards.

Safety precautions which shall be taken.

Informing Contractors:

To ensure that outside contractors work safely in our hospital, it is the responsibility of the Director of Environmental Services to provide contractors the following information:

Hazardous substances to which they may be exposed while on the job site.

Precautions they should take to lessen the possibility of exposure by usage of appropriate protective measures.

EC011P	Abusive Patient or Visitor
Facility Type: Acute Care Hospital	Last JCAHO Survey: Due 8/98
ABUSIVE PATIENT OR VISITOR Procedures: Provide support for staff that is dealing with the person(s). Enforce all hospital rules and policies as written in manual. Mediate, if possible, and offer any helpful suggestions on settling the situation when possible. Remove the person outside, if necessary, and notify security personnel if on duty and Law Enforcement Agency if no progress is being made and if assistance is needed. Remove the person to secluded area away from other patients and visitors, if possible, to discuss situation and reach agreement.

EC012P	Aggressive and Violent Behavior
Facility Type: Acute Care Hospital	Last JCAHO Survey: Due 8/98
AGGRESSIVE AND VIOLENT BEHAVIOR Policy: Aggressive or violent behavior, or other type of inappropriate behavior by employees, visitors or others will not be tolerated. Purpose: The purpose of this policy and procedure is for YOUR Medical Center to do all that is reasonable to prevent damage to property and to protect the employees, the facility, the patients, and the public from injury or other damage. Responsibility: Security personnel if on duty at the time of the occurrence shall be responsible for initiating these procedures. If security personnel are not available, then Director of Environmental Services, Administration or Overhouse Supervisor shall be responsible. Procedure: Hospital personnel shall notify security of any aggressive or violent person that is on hospital premises. Security should not become physically involved with the person unless they endanger the safety of others. Security shall visually assess the situation. If it determined that the person either by their demeanor or conduct are not in keeping with the hospital's commitments of a safe environment to the employees, general public, and patients, the security personnel will escort the person outside the building. If the person's behavior is still posing a threat to safety of other persons or hospital's physical plant, then security personnel will notify the YOUR Police Department to have the person removed form hospital premises.

EC013P

Bomb Threat Plan

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

BOMB THREAT PLAN

Receipt of Bomb Threat (Telephone Communication):

1. Should a bomb threat be received by telephone, the person taking the call shall IMMEDIATELY institute the following procedures and complete a Record of Bomb Threat:

A. Remain calm. DO NOT panic.
B. Keep the caller on the line as long as possible.
C. Record, as near as possible, every word spoken by the person calling.
D. Listen for any strange or unusual background noises such as music playing, motors running, traffic sounds, etc., which might be helpful in providing clues to determine from where the call was made.
E. Determine whether the voice is male or female, familiar or unfamiliar, and listen for any accents, speech impairments, nervousness, etc.
F. Record as much information as you possibly can. You may not be able to get everything, but do get all you can.

2. Immediately after the caller hangs up, contact the Switchboard Operator and relay as much information as possible.

3. The Switchboard Operator will contact the Police Department and then make the following announcement over the intercom:

ATTENTION PLEASE, CODE 50 IS NOW IN EFFECT

4. Once the Police Department has been notified and the announcement made over the intercom, the Switchboard Operator will contact the following and relay to them the information received:

Fire Department

Administrator

Chief Nursing Office and/or Med/Surg Nurse Manager

Safety Director

Director of Environmental Services

Maintenance Supervisor

5. The Chief Nursing Officer or Med/Surg Nurse Manager will appoint an employee who is on duty to report to the Switchboard Operator to assist in calling off-duty personnel to report to the hospital if assistance is needed.

Evacuation Procedures:

1. When a bomb threat has been received by this facility, patients shall be evacuated until a place designated within the facility has been secured by a search team. Patients and personnel shall remain in the secured area until an ALL CLEAR has been given.

2. DO NOT use elevator.

3. The Department Heads/Supervisors of each department shall assign one personnel the duties of removing the patient's chart. All such records shall be taken to an area designated by the person in charge.

4. Preassigned personnel, or as may be assigned, shall be responsible for assuring that exit routes are safe.

5. One person must remain at the assembly area to assure that everyone remains in the area. DO NOT let anyone return to the building until ALL CLEAR as been announced.

Availability of Equipment:

1. Keys:

All keys are located in the Housekeeping Department.

Housekeeping personnel shall make available to search teams all keys to locked rooms being searched.

The Administrator, Director of Environmental Services, and Maintenance personnel shall assist search commanders during the search so that his/her knowledge of the keys and floor area can be used to expedite the search.

2. Blankets:

Additional blankets may be obtained from the Housekeeping Department.

3. Portable Oxygen Tanks:

Emergency Room
Stress Room
Respiratory Therapy (portable cart for hook-up)

4. Carts:

Ambulatory Care Unit
Emergency Room
Surgery
Radiology
Ultra Sound
EKG/Stress Room

Law Enforcement Responsibilities:

1. Immediately upon arriving at the scene, the person in charge shall relinquish all authority for the building search to the search commander and provide any assistance or information needed.

2. The local law enforcement agency, having jurisdiction over such matters, shall be responsible for the orderly search of the building and investigation of bomb threats received.

Search Teams:

1. The each commander shall assign or designate a person(s) of this facility to assist in the search when deemed necessary.

2. This facility shall authorize the use of its employees to assist the search commander. However, employees shall have the right to refrain from assisting in the search if they so choose.

3. Any employee(s) so designated to assist in the search shall answer fully any questions posed by the search commander and provide any information requested.

4. Each search team shall have a law enforcement official designated as the team leader and all instructions issued by the team leader shall be followed completely.

Searching of Premises:

1. Once search teams have been organized, a thorough search of the building and grounds shall be made.

2. During the search, particular attention shall be given to all accessible areas to the general public, i.e.; windows, behind shrubbery, platforms, lobbies, waste cans, restrooms, stairways, telephone booths, ceiling lights, corridors, closet areas, storage areas, etc.

Locating Suspicious Objects:

1. It is imperative that you remember you are only employees involved as search members in the search. It must be emphasized that your mission is only to search for and report suspicious objects to the search team leaders.

2. Should a suspicious object be located, DO NOT move, jar or touch the object or anything attached to it. Leave it exactly the way you found it.

3. Immediately upon discovering a suspicious object, notify your search team leader and follow all instructions.

4. Once the search commander or search team leader has arrived at your location, the decision shall be made as to continue searching for other objects or not.

Removal of Suspicious Objects:

1. Once the search is completed, or has been terminated by the search commander, all employees participating in the search shall leave the premises and return to the assembly areas designated during the evacuation process unless otherwise instructed by the search commander.

2. Only authorized law enforcement officials shall remain in the building during the removal of the suspicious object(s) and such agencies shall direct the removal as quickly as possible.

3. A preselected area, designated for removing the object(s) found, shall be designated by the search commander prior to the removal of such objects(s). This area shall be away from designated assembly areas, as many buildings as possible, and shall be kept clear of all unauthorized personnel at all times.

All Clear Signals:

1. After the search has been completed an ALL CLEAR shall be announced after a confirmation has been obtained from the Police Department or Fire Department stating the building has been searched and nothing found.

Telephone Procedures:

1. The person answering the telephone SHALL NOT give out any information, unless so authorized, concerning the bomb threat to any caller.

Publicity:

1. Publicity shall be avoided as much as possible for this only generates a tendency to create additional threats.

2. Only the Administrator, or his/her designee, shall answer questions concerning this matter, and only to those persons with a need-to-know basis.

Damage To The Facility:

1. Should this facility be damaged by an explosion, immediate implementation of our Disaster Preparedness Plan shall be implemented.

EC014P

Civil Disturbance or Riot

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

CIVIL DISTURBANCE OR RIOT

Procedures:

Secure entrance of the hospital nearest to location of occurrence.
Notify security, if on duty, Administrator and Law Enforcement Agency.
Provide for the safety of public leaving or arriving at the hospital.
Observe and assist Law Enforcement when they arrive.

These are only general guidelines. As the variables of the situation develop, flexibility and logical judgment should be exercised. The most important things to remember are:

Remain calm and get the facts and reason for the demonstration.
Meet and talk with the leader of the demonstration.
Make no promises or concessions without administrative authority.

EC015P

Earthquake Plan

Facility Type: Acute Care Hospital

Last JCAHO Survey: Due 8/98

EARTHQUAKE PLAN

Introduction

We sometimes forget that earthquakes do occur. Almost no area of the world is free from the dangers of earthquakes. True, some areas are more vulnerable than others, but we are all susceptible to their deadly forces.

An interesting note is that several million earthquakes occur each year throughout the world. However, not all are deadly. They range from minor quakes that are barely perceptible, to earthquakes that are so severe that entire cities and country sides are destroyed with their force.

Another factor that must be considered is the loss of power. We may be isolated and it may become necessary for us to function independently. However, we have established necessary policies and procedures that will enable us to continue operation and provide the necessary care for our patients as well.

It will be necessary for everyone to follow our earthquake procedures, as well as other disaster plans that may become necessary. It is essential that we function as a team. To do that, we must follow our established procedures as well as others that may become necessary.

Should there be any area(s) that is not clear to you, please feel free to consult with your Department Head/Supervisor. Your questions will be promptly answered.

Operational Procedures

Purpose:

The primary purpose of our Earthquake Plan is to provide a course of action to follow should our area be stricken by an earthquake. Since earthquakes are virtually impossible to predict, this plan shall be devoted to the procedures to follow during and after the earthquake.

During The Shaking:

DO NOT PANIC. The motion and violent shaking is frightening however, unless you are struck with falling debris, it is usually harmless.
If inside, remain inside. DO NOT RUN OUTSIDE.
Instruct patients, personnel, and visitors to move to the hallways.
If time does not permit, instruct all persons to take cover under beds, tables, against inside walls, etc.
Stay away from windows/glass.
DO NOT use any open flame device (i.e.; candles, matches, etc.) Douse all cigarettes and fires during and after the tremor.
DO NOT run through or near the building(s). The greatest danger from falling debris is just outside the doorway and near the outer walls.
If outside, move away from the building and utility wires. Once in the open, stay there until the shaking stops.
If you are in a moving vehicle, stop as quickly and safely as possible. Remain in the vehicle.
Follow all instructions issued.

After The Shaking:

Check for injuries.
Follow treatment procedures as instructed.
DO NOT use any open flame devices until the building has been inspected for broken gas lines and declared safe.
Check utilities. However, DO NOT turn them on until the building has been checked for broken water lines, fallen wires, etc.
If gas is smelled, open windows and shut off the main gas valve.
Evacuate the building as instructed or as may become necessary.
DO NOT use telephones except for emergencies.
If the building, or any portion thereof, has been damaged, DO NOT let anyone enter until an ALL CLEAR has been issued.
Follow all instructions issued.

Evacuation:

Should evacuation become necessary, procedures must be followed as outlined in the Evacuation Plan, unless otherwise instructed.

Fires:

Fires caused by earthquakes can be more dangerous than the earthquake itself because much equipment and water lines may be destroyed or become immobilized. During and after an earthquake be especially watchful for fires, leaking gas lines, etc. Report such activities immediately. Should a fire occur, procedures must be followed as outlined in the "Fire Safety Plan", unless otherwise instructed.

Communication:

Should our facility be damaged, require emergency assistance, etc., established communications procedures must be implemented as outlined in the Disaster Preparedness Plan.

Patient Transfers Within The Facility:

Should our facility be damaged, or it becomes necessary to relocate patients, the following steps shall be implemented:

Move all patients to a central area.
Issue extra blankets to all patients.
Close all drapes in the central area.
Close all doors to the central area including our fire and smoke barrier doors.
DO NOT use any open flame device.
Make sure flashlights are operable and extra batteries are available.
Make sure patients are as warm as possible.
Reassure patients that all is well and that they will be kept warm.

Patient Transfers To Other Facilities:

Should transfers of our patients to other facilities be necessary, the following steps shall be implemented:

If possible, notify other institutions that transfers are being made.

Keep patients in central area until transfer is made.

Keep patients warm as possible.

Follow transfer procedures as outlined in our Disaster Preparedness Plan.

Make sure all patients and personnel are accounted for.

Use Of Volunteers:

Volunteers shall be used as necessary, and as outlined in the Disaster Preparedness Plan. Volunteers shall be required to follow all instructions issued.

Search Teams:

Should it become necessary to search for missing persons, search procedures shall be followed as instructed or that may become necessary. Complete details concerning search teams are outlined in the Search Team Plan.

EC016F	Safety Performance Measures
Facility Type: Acute Care Hospital	Last JCAHO Survey: Due 8/98
Files for Viewing or Downloading in pdf format: Safety Performance Measures: EC016F.pdf

EC017F	Safety Report
Facility Type: Acute Care Hospital	Last JCAHO Survey: Due 8/98
Files for Viewing or Downloading in pdf format: Safety Report: EC017F

EC018O	Environment of Care/Risk Management Annual Appraisal
Facility Type: Acute Care Hospital	Last JCAHO Survey: 1/98
Comments: This one got rave reviews from our surveyor in 1/98. Said it was the best she'd ever seen . Only suggestion for improvement is one we had planned- In 1/99, we'll import the graphics for each of the 7 plans into the actual narrative!
Files for Viewing or Downloading in pdf format: Template for EOC Annual Appraisal - Download in Word 97 format zipped in a self extracting file: EC018O
HOSPITAL ENVIRONMENT OF CARE/RISK MANAGEMENT 1997 ANNUAL APPRAISAL ENVIRONMENT OF CARE The facility anticipates triennial JCAHO survey January 15-16, 1998. In 1997 the Safety Director, Administration, Management and Committee Chairman have continuously measured and improved the Environment of Care Program. Measures of performance in each of the following sections of this annual report are summarized in the Environment of Care Indicators, provided with this report as Attachment I. SAFETY During 1997, the Safety Committee implemented the Safety Management Plan. The Safety Officer reviewed area specific safety procedures for departments and found them to be appropriate as to objectives and scope. The following opportunities were identified, and improvements resulted. Safety Committee meetings/attendance The Safety Committee membership is a core group of key people from clinical and non-clinical departments that reports to the Performance Improvement Committee. Information from Safety Committee meetings is also discussed in departmental staff meetings. Measures of performance for Safety Committee includes number of meetings held and percent of members either in attendance at the meetings or represented. Goals for number of meetings were met; however attendance for the year was 76.5%, down from 81% in 1996, against a goal of 90%. The necessity to either be in attendance or have representation will be a goal for next year. Safety Training Orientation safety training was provided to all new hires, and in May HOSPITAL held their first annual competencies fair for annual updates, including safety. During Environmental Rounds, the percentage of employees able to answer questions correctly on life safety, safety and hazardous materials remained high throughout the year. Annual review and revision of policies occurred in June 1997. Occurrence reports indicated a need to develop new policies on key control and elevator entrapment during the year. The elevator entrapment policy and monitoring of compliance has been initiated. The key control policy will be implemented with installation of new security equipment described below. Environmental Rounds A revised Environmental Rounds process was implemented during 1997, subsequent to concerns with data consistency between surveyors and training for the surveyor role. Under the Environmental Rounds process, all areas of the hospital undergo survey once a quarter. Data on findings is presented to the Safety Committee each month, and aggregate data presented to Safety Committee and the Board quarterly. Safety issues identified and addressed from Environmental Rounds include (1) improved staff knowledge of procedures pertaining to hospital procedures for fire and disaster situations (2) the need to address official employee identification badges (3) identification of a performance improvement opportunity relating to patient care equipment preventative maintenance and electrical safety checks. This was addressed with an interdisciplinary team in early 1997. The Lab Safety Committee will develop a supplemental Environmental Rounds tool specific to research labs in 1998 to assure use of consistent method of survey and to have standard answers available for surveyors on rounds. A 90% threshold will be established for answers. Employee Injuries There were very low frequencies of injuries in the categories of body mechanics, falls, and needle sticks, sharps, exposures and general incidents during 1997. These figures correlate with those reported during 1996 indicating effectiveness of the employee injury-reporting program with the exception of the Fourth Quarter when an increase was noted in body-mechanics injuries. Review of the types of injuries sustained in Fourth Quarter, 1997 resulted in identification of the need to the need to enhance awareness of lifting techniques and provide ongoing education to prevent injuries related to lifting. During 1997, the overall rate of employee lost time has decreased indicating program effectiveness in reducing severity of injury. SUMMARY: The Safety Management program is considered to be effective. Emphasis will be placed upon the opportunities for improvement identified above. In 1998, policies will continue to be placed on the shared drive in the HOSPITAL network, easily accessible from any computer terminal with network access within the facility, and the offices of the medical staff members. The system guarantees that the policy being reviewed is the most current because when a revision occurs, it is immediately transferred into the cabinet. Nursing will maintain the signed master copies and restrict access to "read only" for all users to ensure policy integrity. A "Quick Reference to Emergency Procedures" will be issued to all areas by December 31, 1997 to ensure staff have rapid reference to critical information on emergency procedures in a very easy to read format. . SECURITY During 1997, the Security Management Plan and the procedures for security of sensitive areas were reviewed and found to be appropriate as to their objectives and scope. Assessment of risks of workplace violence and staff perceptions of security of the workplace was conducted during the year. ____% of staff responding to the survey indicated they had not felt threatened or perceived a need to call Security backup. _____ % of staff indicated they had felt unsafe on occasion, with ____% identifying the period of time when they enter or exit the building at night and specifically the area around the parking garage as being of concern. Actions to address this include publishing the availability of Security escort in the Quick Reference to Emergency Procedures and covering this at Safety Committee. Other actions to improve Security are described in the summary. Security Training The security training provided during new employee orientation and annual update training was considered to be effective as evidenced by Security response to requests for assistance and reporting. Proper Identification At the midpoint of 1997, concerns with traffic from ADJACENT HOSPITAL and visitors to the cafeteria resulted in instructions to Environmental Rounds Surveyors to begin to observe whether staff were wearing their official HOSPITAL badges. By report, there were intermittent occasions of employees without badges. Security patrol rounds were performed and documented as required. The wearing of the official HOSPITAL badge and enforcement of visitor identification policies has been targeted for improvement in 1998. Security Equipment The closed circuit television and security radio systems operated properly during 1997. An assessment of the effectiveness of traffic control on the second floor bridge connecting ADJACENT HOSPITAL with HOSPITAL resulted in a decision to order another closed circuit television camera. Addition of an intercom and remote locks will also occur to eliminate non-patient care access use of the bridge. Installation is pending. Effectiveness of traffic control is also targeted for improvement in 1998. Security Incident Reporting All security related incidents were reported within 24 hours and reviewed by Risk Management within three days. Security Incidents All security incidents were evaluated for trends. Issues with key control were identified starting in June 1997. Contributing factors were lack of a process for retrieval of keys from exiting employees. A new key control policy will be implemented in January, 1998. SUMMARY: The Security Program is considered to be effective. In addition to the opportunities and improvements identified above, the Administrative Council conducted an assessment of potential for workplace violence in May 1997. As a result of this, nonviolent crisis intervention is being taught to targeted staff in November and December 1997 and it is predicted that ___% of all employees will be certified at the end of the year. HAZARDOUS MATERIALS/WASTE MANAGEMENT During 1997, the hazardous materials and waste management (HAZMAT) plan was reviewed and found to be appropriate as to its objectives and scope. Opportunities identified included changes in personal protective equipment worn by employees responding to spills of unknown liquids and development of a respirator protection program for staff who need to work in respirators pending completion of engineering controls. HAZMAT Training The staff’s knowledge level of the hazardous materials in their area and the location of the MSDS book in their area have improved during the year during Environmental Rounds. This continues to be an ongoing focus for improvement and the data collection methodology for missing MSDS sheets and NFPA labeling will change, effective First Quarter, 1998 so precise baseline data and effectiveness of interventions can be measured. The Laboratory Safety Committee developed a format for Hazardous Chemical training that is area specific and began implementing this in September 1997. Hazardous Materials Monitoring Annual reporting of amounts of specific chemicals required under Texas law and corporate policy was accomplished in May and June 1997. Continued emphasis on hazardous material handling and employee response in Environmental Round will continue in 1998. Ethylene Oxide monitoring was performed and reported as outlined in hospital policy. Gluteraldehyde monitoring was performed by an Industrial Hygienist in August 1997. Although no exposures were documented, given the risks of gluteraldehyde, a decision has been made to request a gluteraldehyde free closed washing system for bronchoscopes. Waste Disposal During 1997, waste disposal was tracked from generation to disposal. No issues were identified. Reporting/Clean up of spills During 1997, there was one mercury spill, which was properly reported and cleaned by members of the ADJACENT HOSPITAL hazard response team. An overflow of a neutralization basin in June 1997 resulted in changes to spill cleanup policies to require Environmental Services staff responding to unknown spills to wear glove and boots during cleanup. The Laboratory Safety Committee developed a new format for hazardous chemical communication and is in the process of implementing this at the conclusion of the year. SUMMARY: The Hazardous Materials/Waste Management Program is considered to be effective. Priorities for 1998 include completion of implementation of the new Hazardous Materials Communication format, implementation of a new, more precise method for collection of data on MSDS sheets and labeling, with continued emphasis on employee preparedness and education in Environmental Rounds. EMERGENCY PREPAREDNESS During 1997, the Emergency Preparedness Management Plan was reviewed and updated. Hospital procedures were revised to include updating of emergency numbers, development of a transportation roster of staff with 4-wheel drive vehicles and implementation of a process to notify staff on hire of their essential versus non-essential status based on their job title. A comprehensive review of all external disaster policies was undertaken prior to the External Disaster Drill which was conducted in April in collaboration with the NDMS on 20 "patients" from an external disaster arrived after 15 minutes advance notice. The plan was fully implemented, and the drill was completed in one hour, with "disposition" of the last patient. Opportunities to improve communications were identified and addressed with decision to deploy maintenance staff with radios to each triage and treatment area in the plan. The Severe Weather policy has been reviewed in May 1997 and hospital wide training provided in June 1997. It was not necessary to implement the plan during hurricane season (June 1 through October 31) in 1997. An internal Disaster Drill requiring implementation of the Bomb Threat process was held on December 10, 1997.. ____ 80% of all areas reported "clear" after searches within 24 minutes of announcement of Code Yellow. Opportunities for improvement including how Code Yellows are announced. This will be resolved in Safety Committee, December 15, 1997. Emergency Preparedness Management Program Training. The training provided during new employee orientation and annual update training was considered to be effective as evidenced by the fact that staff were able to answer questions correctly during Environmental Rounds and responded appropriately during program implementations. Reporting Procedures Reporting procedures during program drills were properly followed for initial implementation of the plan in April 1997. Update reports to the Emergency Operations Center as patients moved through the building were judged to be in need of improvement, which was addressed with assignment of a clerk and maintenance staff with radios to each patient care area specified in the plan. Communications during the internal disaster drill in December will be assessed and added to the final report. Inspection of Emergency Equipment 100% of all communications equipment and stand-by supplies were inspected and available as required by the plan. SUMMARY: The Emergency Preparedness Plan and its implementation are considered to be effective. However, realizing that emergency situations are not "standard", ongoing monitoring of emergency preparedness and teaching during environmental rounds will continue in 1998. There will continue to be at least two implementations of the Emergency Preparedness Plan annually with post-implementation assessment and improvements as required. LIFE SAFETY During 1997, the Safety Committee reviewed the Life Safety Management Plan including life safety procedures for all departments and found them to be appropriate as to objectives and scope. Life Safety Training The life safety training during new employee orientation and annual update training was considered to be effective. Employees were able to answer questions correctly during Environmental Rounds, with increased accuracy as the year progressed after changes in the Environmental Rounds questions, and distribution of answers.. We will maintain this level of awareness during 1998. Fire Drill Performance The required number of fire drills was conducted. Overall, the facility performed well during the drill scenarios. Fire drill observer forms were redesigned to assure consistent evaluation and answers to observer questions during drills. Both observers and participants have expressed feeling better prepared after the new observer forms were introduced and distributed. Life Safety Support Systems All life safety support systems were inspected as required by the plan. In October 1997 an employee of X COMPANY was added to the fire drill team for all day-shift drills. X COMPANY maintains our life safety support systems. During the drill, X COMPANY staff observes how the system functions under actual alarm operations. This was productive; resulting in identification of minor system issues that would not be apparent under normal monthly testing procedures. Interim Life Safety Full interim life safety measures were not implemented in 1997 since there was no construction that would interfere with the fire suppression systems. Repairs planned in 1998 will require implementation of interim life safety measures and planning for this has been done at Safety Committee Meetings. Life Safety Incident Reporting All life safety incidents during 1997 were identified correctly, investigated and reported to Safety Committee. This included one minor kitchen fire extinguished by the staff in the area, two fire alarms (steam release from the dishwasher in the kitchen, and high pressure in the building steam supply lines), plus eight false alarms, individually assessed and addressed by X COMPANY. SUMMARY: The life safety management plan is considered to be effective. This will continue to be monitored closely. VI. MEDICAL EQUIPMENT During 1997, the medical equipment management plan was reviewed and found to be appropriate as to its objectives and scope. However early in the year multiple pieces of equipment needing preventive maintenance (PM) were identified collaborated by reports from Biomedical and Electrical Engineering during environmental rounds. An interdisciplinary Performance Improvement Team was formed early in the year and found opportunities to improve in: Inventory control (addition of new equipment removal of old equipment being Abandoned from the inventory) Increasing staff awareness of their role in safe use of medical equipment Advance notice to areas of equipment in need of PM’s in the next month. Equalization of the volume of equipment needing PM's over twelve months. Currently, some months have no equipment due PM's, while other months have ___ pieces due! After education, an action plan has been partially implemented as outlined and improvements are being sustained. This area will be closely monitored and remains a performance improvement focus for 1998. Medical Equipment Training In 1997, during Environmental Rounds staff responded correctly to questions on equipment management, indicating effectiveness of training. The Safety Committee monitors user errors as an indicator of effectiveness of training. In most months this has been "0". During 1998, the Safety Committee will continue to monitor this closely. Scheduled Preventative Maintenance During 1997, an average of 88% of scheduled services were completed on a timely basis. After implementation of an action plan developed by a Performance Improvement Team, a positive trend has been identified. This will continue to be a focus in 1998. Unscheduled Equipment Maintenance During 1997, all unscheduled services were performed within the performance guidelines required in the contract with ADJACENT HOSPITAL Biomedical and Electrical Engineering. Safe Medical Devices Act There were no device failures during 1997, which resulted in significant patient injury; thus there was no required Food and Drug Administration reporting. However, voluntary reports to the Food and Drug Administration were made as deemed appropriate by SMDA regulations. SUMMARY: The medical equipment management plan and its implementation were determined to be effective during 1997. We will continue to closely monitor employee training and preventative maintenance during 1998. VII. UTILITIES During 1997, the utility management plan was reviewed and found to be appropriate as to its objectives and scope. There were no problems in implementation. Utilities Training The utilities training provided during new employee orientation and annual update training was considered to be effective. Employees were able to answer questions correctly during Environmental Rounds. Scheduled Preventative Maintenance on Utilities During 1997, all services were accomplished as scheduled. Unscheduled Utility Outages During 1997, there unscheduled outages in steam supply from University of Texas Medical Branch and in elevator service. Elevator Outage Elevator outages were reported 9 times, and staff entrapped 5 times. A policy was written concerning response with Entrapment and Maintenance and Security trained on implementation. The Safety Committee receives reports of staff adherence to the new policy with improvement demonstrated. Steam Supply Outage A gas supply line to ADJACENT HOSPITAL was severed resulting in the loss of natural gas supply to their physical plant in November 1997. HOSPITAL uses steam for heating, HOSPITAL was without the ability to heat the building for eight hours. In evaluation of this event, the Safety Committee found that the loss of steam had Not been reported by ADJACENT HOSPITAL and that emergency contact numbers for ADJACENT HOSPITAL Physical Plant had changed without notice several months before the event. Emergency numbers in Maintenance and Engineering have been updated and discussion with ADJACENT HOSPITAL has occurred to develop a process for communications. Emergency Generator Testing The testing of the emergency generators was accomplished as required by hospital protocol and JCAHO standards. The monthly load testing was accomplished and the generators were able to meet the load criteria. HOSPITAL has annual load bank testing done, and this was reported as complete without problems in 1997. We plan to add criteria for observation of smoke for evidence of incomplete combustion of diesel fuel to generator testing in 1998. SUMMARY: The Safety Committee deems the Utilities Management Plan and its implementation effective during 1997. We will continue to monitor employee training, particularly in response to elevator outage and entrapment. RISK MANAGEMENT CLAIMS Frequency This information is reported to the Board of Governors. II. PATIENT FALLS (See Attachment I) ___ patient falls occurred during 1997 Falls rate was ___% III. Other occurrences IV. STAFF EDUCATION Education provided to Medical Staff SMDA Performance Improvement Method New Occurrence reporting form Other staff Performance Improvement Method Protective equipment for ethylene oxide (Maintenance) Respiratory protection programs New elements of Risk Management added to New Hire Orientation and annual re-in-servicing. Review occurrence reports process and investigation of underlying causes of occurrences Special In-services based upon identified need Critical Incident Stress Debriefing Non-Violent Crisis Intervention During 1998, Risk Management will provide an in-service each quarter to employees and the medical staff. Topics selected will be based upon identified opportunities for improvement. Signatures: Chairman of Safety Director, Performance Improvement Administrator Safety Officer

EC019P	Elopement Policy
Facility Type:	Last JCAHO Survey:
Files for Viewing or Downloading in pdf format: Elopementt: EC019P.pdf Download in Word 6.0/95 format: EC019P.exe
Elopement Policy CLINICAL MANUAL Page __ of ___ Effective: December 1, 1996 SUBJECT: Elopement Prepared By: (Staff) Director of Security Approved: _____________________________________________ (Staff), M.D. President, Chief Executive Officer, and Medical Director PURPOSE: To describe the procedures to be followed when an inpatient leaves the Hospital grounds or a supervised area without permission. POLICY: When any patient elopes or is believed to be missing, it is the policy of the Hospital to act in accordance with the welfare of the patient and the public while respecting the patient's rights. GUIDELINES/PROCEDURE: A. When it becomes reasonably certain that a patient is missing, either through observation of elopement or recognition of absence from a supervised activity or area of the Hospital without authorization, the person making the observation (in most cases this will be nursing staff) or having knowledge of the situation must initiate action to locate the patient. In the event that an employee unfamiliar with the patient observes the elopement, the employee should contact the Security Department and give them all the information that they have on the elopement. The Security Office will in turn notify the Associate Director of Nursing (Monday through Friday) daytime--and at all other times Nursing Shift Coordinator, to inform them of the situation. B. The Security Office should be notified immediately of the patient's elopement, and they will assist in a search for the patient. Unit staff familiar with the patient will be required to accompany Security on any search. The scope of the search will be determined by the Security Officer(s) conducting the search. C. When the Police are notified, a (Your Health System) Missing Persons Report must be completed by a member of the clinical staff familiar with the patient. This report is given to a Security Officer for action. The Security Department is responsible for contacting the (Local) Police, who will dispatch a car to (Your Health System). The Police will take missing patient calls from members of the (Your Health System) Security Department only. I. Adult A. Involuntary Patient 1. Definition: A patient who has been ordered by the court to undergo psychiatric treatment; any patient on observation status (scheduled for a certification hearing); or any patient who has been certified, either prior to admission or while at the Hospital. 2. Security will provide the Police with a copy of the (Your Health System) Missing Persons Report to be attached to the file copy of the police report. A copy of a photograph of the patient will be provided by unit staff. Security will also notify the Office of Planning and Public Information ("OPPI") or call the ("OPPI") designee after hours. 3. The signed (Your Health System) report indicating involuntary status provides the Police Department's legal authority to take the patient into custody against his/her will. 4. If the patient is located by Police within close proximity of the Hospital then the Police will provide transportation back to (Your Health System). However, in many instances Hospital personnel (Security) will be notified that the patient is in police custody, and the Hospital must make arrangements for transportation back to (Your Health System). 5. If the patient returns without police involvement, or is discharged prior to return, Security must be notified immediately so that they can inform the Police Department. B. Voluntary Patient 1. Definition: Any patient who has signed himself/herself into the Hospital and when, upon elopement, there are not certification papers or other documentation on file which would change their status to involuntary. 2. Security will provide the police with a copy of the (Your Health System) Missing Persons Report to be attached to the file copy of the police report. Security will also notify the Office of Planning and Public Information ("OPPI") or leave a message on the Office of Planning and Public Information's voice mail. 3. A signed (Your Health System) Missing Persons Report indicating voluntary status will indicate to the Police that they are being asked to assist in locating the patient. The following are the conditions under which they may legally apprehend a voluntary patient: a. The Police are given a Petition for Emergency Evaluation completed by someone who has had significant contact with the patient within a reasonable period of time and who has determined that the patient is dangerous to himself/herself or others. Psychiatrists licensed in the State of Maryland, or psychologists who are licensed under the Maryland Psychologists Act and listed in the National Register of Health Service Providers in Psychology may complete a petition. Other staff members or family members can complete a petition but the petition must then be taken to a District Court. Petition for Emergency Evaluation forms are kept in the Security Office and the Hearing Coordinator's office, Division of Quality and Evaluation Services. b. The police officer, upon locating the patient, determines that the patient meets the legal criteria for an emergency evaluation. In this case the officer will complete the Petition for Emergency Evaluation. If either of the above (a or b) occurs, the police will be responsible for transporting the patient to a designated emergency facility. (Your Health System) Security will then be notified. The Hospital will be responsible for coordinating efforts with the emergency facility. c. If the patient does not meet the criteria for emergency evaluation, the officer will only notify Hospital Security as to the patient's whereabouts and ask the patient if he or she would like to return voluntarily. If the patient wishes to return voluntarily, the Patient will arrange his or her own transportation or will call the hospital to provide transportation. If the patient does not wish to return, the officer can take no further action. 4. If the patient returns without Police involvement, Security must be notified immediately so that they can inform the Police Department. II. Child and Adolescent Patient A. If a patient has been signed into the Hospital by his or her parents and elopes, the officer responding to (Your Health System) will make a report and send a teletype requesting custody. If the child is located, his or her parents will be contacted to respond to take custody of the child. It is then the parents' responsibility to return the child to the Hospital. The treating therapist or designee will determine if (Your Health System) staff shall be involved in the return of the child to the Hospital. B. If the patient is undergoing treatment at the Hospital by some type of court order or commitment order and elopes, he or she can be taken into custody as a runaway. The patient is considered an involuntary patient and procedures regarding a missing involuntary patient apply. If the patient is also under the jurisdiction of a probation officer the probation officer should be immediately notified of the patient's elopement and wherever possible become involved in any police intervention to assure the patient's return to the Hospital. C. If a child or adolescent patient elopes and is discharged prior to being located, Hospital Security must be contacted immediately so that they can contact the Police Department. Additional Policy Reference: - Hospital Boundaries for Inpatients Cross-Reference Listing: Elopement; Involuntary; Voluntary Review and Revision History: 8/1/93 5/7/90 3/27/89 11/12/85

EC020P	Violence Management Policy
Facility Type: Not submitted	Last JCAHO Survey: Not submitted
Downloadable Files: View or Download in Adobe Acrobat Reader Format: EC020P.pdf Download in Word95 format zipped in a self extracting file: EC020P For Windows 95 hold down the shift key as you click on the file. After downloading the file, double click on the file to cause the files to self inflate.
SUBJECT: MEDICAL CENTER VIOLENCE MANAGEMENT POLICY I. POLICY The Medical Center strives to maintain an educational and working environment free from violence and intimidation. Workplace violence and threats will not be tolerated. Weapons are prohibited on all Medical Center property. Violent acts and/or threatening behavior may result in disciplinary action, termination and legal action. II. PURPOSE For the purposes of this policy, workplace violence is defined as: written, verbal and/or nonverbal threats of bodily harm, or intimidation: physical assault and/or battery. These acts can be directed: to an employee from a co-worker to an employee from a supervisor to a supervisor from an employee to an employee from a vendor, patient, visitor, family member or other person to a vendor, patient, visitor or other person from an employee Examples of workplace violence include: written, verbal or physical threat to harm, physically touching another in such a way that is unwelcome and/or with intent to cause distress or injury, approaching or threatening another with a weapon, causing or attempting to cause injury or intimidation to another person. III. PROCEDURE A. EMERGENT SITUATIONS REQUIRING POLICE- If the violence is of such a nature that serious bodily harm is imminent or likely, a call should be placed directly to the Winston-Salem Police Department (911). These incidents include situations involving weapons or extreme force that by its nature would inflict serious bodily harm. As soon as practical after notifying the Police, contact Medical Center Safety/Security (6-3305) so that they can respond and document the incident as well. EMERGENT SITUATIONS NOT REQUIRING POLICE- This addresses Emergent cases that, require Security response, and making a direct call to Security is dangerous or impractical because the threat is still present: Use the *Emergency Code-"DOCTOR ARMSTONG.* Call 6-3305 and announce that you need *Doctor Armstrong* at your location. This code will indicate that you require immediate assistance without placing you at further risk by announcing the nature of the crisis. B. In instances where there is not imminent serious bodily harm or the incident has passed or occurred over the telephone, contact Medical Center Safety/Security (6-3305) to file a report. Employees should notify their supervisor of any occurrence in their work area. Supervisors may find it helpful to contact their respective human resource department for guidance on any disciplinary issues arising from a threatening or violent incident. If there is any question if an incident should be reported, call 6-3305 for clarification. C. All incidents of workplace violence covered under this policy will be reported to Medical Center Safety/Security so that a proper investigation can be conducted. All investigations will be reviewed for completeness, location, persons involved and any other necessary criteria in order to monitor trends and design a more effective program of safety for our employees, patients, and visitors. D. Complaints of violence, assault, threats and intimidation will be treated seriously and will be promptly investigated with reasonable steps to protect the safety and confidentiality of all persons involved. Individuals who, in good faith, report these incidents or present evidence in an investigation are protected from any retaliatory actions or any negative administrative or academic action.