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Updated 8-20-2009

Faculty/Student

Self-Study Orientation

MargaretR.PardeeMemorialHospital

800 North Justice Street

Hendersonville, North Carolina 28791-3410

828-696-1095

Contents of this Packet:

Welcome

Mission/Vision Statement

Values

Human Resources:

Cafeteria/Snack Shop

Harassment

Identification Badge

Lost and Found

Parking

Personal Appearance

Hospital Safety:

Infection Control:

Bloodborne Pathogens

Standard Precautions

Trash Bags

Tuberculosis

Personal Protective Equipment

Handwashing

Body Mechanics

Safety and Security

Equipment Management

Electrical Safety

Hazardous Materials

MRI Safety

Oxygen Safety

Radiation Safety

Risk Management

Sharps

Smoking

Emergency Phone Numbers

Hospital Codes

Patients’ Rights

Abuse

Advance Directives

Age Specific Consideration

Informed Consent

Cultural/Religious Consideration

Guest Relations

Informed Consent

Pain Management

Privacy

Restraints

Compliance

Completion Form

Welcome to MargaretR.PardeeMemorialHospital

We are very pleased that you have agreed to join us for this temporary assignment. We hope that as you get to know us, you will understand that it is our commitment to our patients, visitors, and to each other that motivates each of us within the Pardee Organization. Our Mission and Values statement is reflective of this motivation.

Statement of Mission—We provide quality, compassionate, and safe services that improve the health of the communities we serve.

Vision – The best people providing the best care.

Values—The hospital and its employees have an obligation to act in a way that merits trust, confidence,

and respect while safeguarding and fostering the rights, interests and prerogatives of those served.

During the time that you are members of the Pardee Organization, you will be treated as “one of us” and accordingly, will be responsible for the safety and welfare of our patients, visitors, and staff. Knowledge of the material covered in this packet is vital to assure that safety.

This vital information is provided to you in a self-study format for your convenience. However, completion of the Self-Study Orientation is not optional.

Human Resources

Cafeteria/Snack Shop—The dining room for employees and guests serves 3 meals per day. Employees on duty receive a 25% discount on meals purchased in the cafeteria when on duty and wearing their name badges. The Hospital Auxiliary operates the Garden Café, a full-service restaurant located on the first floor.

Harassment—The workplace is for work. Harassment disrupts the work environment. And this organization does not approve of harassment of any kind within the workplace. Any employee affected by any type of verbally or physically harassing conduct is urged to notify any supervisor, the Director of Human Resources or the CEO immediately. The organization will investigate any claims promptly and all claims will be held in confidence insofar as this is possible. Any employee who subjects another to harassment is subject to discipline up to and including discharge.

Identification Badge—Your student identification badge must always be properly worn while on duty to provide ready identification by co-workers, patients and visitors.

Lost and Found—Items found are to be identified as to where found, description, date and time, and name of person finding the article. The article must then be turned into Environment Services for proper storage and final disposition. The Hospital does not assume responsibility for personal articles lost or stolen on or about the premises.

Parking—Parking is provided for all employees. Please see your Clinical Supervisor for specific instructions regarding parking. However, in no case should you park in areas reserved for visitors and patients. Student Parking is in the lower parking lot across Justice Street towards the MedicalOfficeBuilding.

Personal Appearance—During work hours, at work sites, your dress should be appropriate to the nature of the work site, your position and responsibilities. You are expected to report in clean attire. Personal hygiene is important at all times.

Hospital Safety

Maintaining a safe environment at Pardee requires continual effort on the part of all employees in all departments and includes adhering to regulations and correcting or reporting potential hazards. Employee responsibilities include knowing all of the security codes, the emergency that the code represents, and the employee’s role during the code. Included below is the information you will need to meet your responsibilities.

INFECTION CONTROL: Bloodborne pathogens are small organisms that may be present in human blood and can cause disease. Hepatitis B Virus (HBV) and Human immunodeficiency virus (HIV) are two bloodborne diseases that occur most frequently. These diseases are transmitted when infected blood or other body fluids or tissues enter you bloodstream. Exposure is prevented at work through training, the practice of STANDARD PRECAUTIONS, wearing of personal protective equipment, use of engineering controls, and following established policies and procedures.

STANDARD PRECAUCTIONS are work practices that help prevent contact with patients’ blood and other body fluids. They are your best protection against bloodborne pathogens. Under STANDARD PRECAUTIONS there are 3 special categories of precautions, which require specific practice measures. These categories are:

  • Contact Precautions
  • Droplet precautions
  • Airborne precautions

Information about these types of precautions may be found in the INFECTION CONTROL MANUAL.

TRASH BAGS are available on all work areas and are designated as follows:

  • Clear bags for paper trash
  • Black Bags for any contaminated or soiled trash with less than 20cc blood or body fluids.
  • Red Bags for contaminated containers or trash with greater than 20cc blood or body fluids.
  • Yellow Bags for any material associated with Chemotherapy.

PERSONAL PROTECTIVE EQUIPMENT is specialized clothing and equipment that provides protection against contact with blood and other potentially infectious materials. PardeeHospital will provide you will any necessary PPE and the training necessary to use it properly, but it is the employee’s responsibility to ask for and correctly use the PPE. These are the guidelines for using PPE:

  • You must be trained to use PPE properly
  • The PPE must be appropriate for the task
  • You must use the PPE each time you perform a task
  • The PPE must be free of physical flaws that could compromise safety
  • Before leaving the work area, all PPE must be removed and placed in an appropriate container.

Any Exposure must be reported IMMEDIATELY to your direct supervisor for reporting and treatment. The Nursing Supervisor must also be notified immediately for coordination of care.

The Occupational Safety and Health Administration (OSHA) created the Bloodborne Pathogens Standard. Copies of this standard are located in the Infection Control and Employee Health Offices. A copy of the Hospital’s Exposure Control Plan Policy is in the Infection Control Manual. Additional manuals with explanation and interpretation of the Standard are located in Nursing Service, Infection Control Office, Education Office and Employee Health Office.

TUBERCULOSIS is a bacterial infection transmitted by air droplets. A TB skin test can be done to determine if a person has exposure to TB Infection. At Pardee, this skin test is done annually on all employees unless the employee has a previously documented positive PPD. All patients in PardeeHospital who are known or suspected to have TB are put into a negative pressure room. Everyone who enters a room of a patient with known or suspected TB must wear the hospital-approved respirator each and every time the employee enters the isolation room.

HANDWASHING--Because hospital personnel can transmit bacteria from patients with infections to other patients, handwashing is the single most important means of preventing the spread of infection in the hospital. Hospital acquired infections are called nosocomial infections and it is these infections that we all work to prevent. Handwashing with plain soaps may not remove the bacteria living in deep layers of the skin, but washing with products that contain antimicrobial ingredients may kill or inhibit them. Handcreams are not sterile and may be contaminated with bacteria that have caused nosocomial outbreaks in the past. Pardee’s Handwashing and Fingernails Policy and Procedure was written to prevent nosocomial infections. All employees should wash their hands:

  • Upon arrival to work
  • Before and after contact with each patient, the patient’s environment, and things that come in contact with the patient.
  • When moving from a contaminated body site to a clean body site during patient care
  • When hands are visibly dirty or contaminated
  • After removing gloves
  • After going to the bathroom
  • Before and after eating
  • Before going home

Pardee’s Policy suggests 2 methods for cleaning the hands: Soap and Water or Waterless (Alcohol) Agent which may only be used when the hands are not visibly contaminated. If you use the soap and water method, you must remember to wash your hands for a minimum of 15 seconds. If you use the Waterless Agent method, you must rub your hands together until the agent is completely dry. Our Fingernail policy prohibits artificial nails or extenders and limits lengths of natural nails to ¼ inch.

BODY MECHANICS: The practice of good body mechanics is required of all employees. These 10 steps will help you to protect your back when lifting:

  • Keep your feet apart
  • Bend at the knees and hips
  • Keep your chin up
  • Keep the load close to your body
  • Keep your ears, shoulders and hips aligned
  • Make multiple trips instead of one heavy one
  • Get assistance when needed
  • Push rather than pull
  • Don’t twist
  • Use a gait belt

On-the-job injuries must be reported to your direct supervisor within 24 hours of the injury. If first aid or others medical treatment is required, it must be obtained from the Employee Health office or, if the office is closed, the Hospital Emergency Department. The employee must complete a green Employee Occurrence Report within 24 hours of the injury. These forms are available on every unit.

HOSPITAL SAFETY and SECURITY is the priority of all employees. Being familiar with common threats to a safe environment is your responsibility. These threats and your role in protecting against them are as follows:

  • Equipment Management--All equipment should have an inspection tag. If you are aware of equipment in your area that does not have a tag, you must Remove it from use, Report it to Engineering Department, and Tag it for identification. Anyone who witnesses, discovers, or becomes aware of information that a piece of equipment has, may cause, or contributes to the injury, illness or death of a patient or employee has a responsibility to report the incident. This responsibility applies to medical devices used for patient care or diagnosis as well. Reporting of such incidences is done using the White Confidential Occurrence Report.
  • Electrical Safety—Never operate equipment without proper training and always be alert for electrical equipment that may be unsafe. If you are aware of electrical equipment that may be unsafe, remember to REMOVE, REPORT, TAG.
  • Hazardous Materials—MSDS sheets are available for every chemical found in individual work areas. MSDS sheets provide employees with all information regarding chemical exposure in accordance with OSHA guidelines. Contact your department manager for the location of the MSDS sheets in your area. You should make yourself aware of potential hazards, routes of exposure, and treatment for chemicals found in your area. Should you encounter a chemical spill, DO NOT PANIC. Chemical Spill Kits are located in Materials Management, Engineering, Dietary, Environmental Services, the Boiler House and Radiology.
  • MRI Systems—Use only MRI compatible equipment in the MRI suite. Metal and implanted devices hold particular risks. Screen all patients for risks.
  • Oxygen Safety—Do not use anything in the patient’s vicinity which may cause a spark or open flame. Store and transport gas cylinders in stands or carts.
  • Radiation Safety—Move at lease 6 feet from activated X-ray machines. Wear a leaded apron whenever you must be closer than 6 feet.
  • Risk Management/Accident Reporting—All accident involving patients, employees and/or visitors must be reported immediately on the appropriate accident form; the Green Employee Occurrence Report or the White Patient/Visitor Occurrence Report Form. Performance Improvement Data Reports are completed for any Patient related fall, alteration in skin integrity or medication occurrence. Completion of the reports is not considered punitive.
  • Sharps Disposal—Treat all sharps as though they are contaminated and do not recap. Careful attention should be paid to any activity related to sharps. And, sharps must be placed in rigid, closeable, leak proof containers. Exposure should be reported IMMEDIATELY to your supervisor. A green Employee Occurrence Report should be completed.
  • Smoking—Pardee Hospital is a Tobacco Free Campus. There is no smoking allowed anywhere on the campus for anyone.

Emergency Phone Numbers:

  • Hospital Switchboard for Emergencies4444
  • Security4730
  • Hendersonville Police9911

Hospital Emergency Codes related to Safety/Security and your role during the emergency:

Name of the CodeReasonYour role______
  • Code RedFireR.A.C.E.

Remove the Patient

Activate the Alarm (Pull the alarm/Dial #4444)

Confine the Fire (Shut all doors)

Extinguish or Evacuate

Never use elevators during a Code Red

  • Code YellowBombIf you receive the threat, keep the caller

on the phone, obtain as much information as possible. Notify the supervisor immediately.

  • Code WhiteEvacuationFollow directions of command center.
  • Code GreySecurity AlertIf you need Security immediately, dial

#4444 and tell the operator where

Security is needed.

  • Code TriageDisaster ReadinessFollow directions of command center.
  • Code OrangeHazmat DisasterIf you find someone in the hospital with

chemical contamination, ask them to go outside of the building immediately. Notify Security who will escort the patient to the decontamination area near the Emergency Department.

  • Code BlackUtility FailureFollow directions of command center.
  • Code SilverWeapon/HostageIf you are directly involved in the

situation, remain calm and cooperative.

Call Police @ 9-911 if able to make

phone call. If you are not directly

involved in the situation, continue with

duties, avoiding the critical area unless or

until redirected by the command center.

  • Code BlueMedical Emergency See Department Specific Guidelines
  • Code Pink/Code Teddy BearInfant/Child Abduction All employees not involved in patient

care will begin a search for the missing

infant or child.

  • Code 300Combative Patient See Department Specific Guidelines.
  • Code SearchPatient ElopementAll employees not involved in patient

care will begin a search for the missing

patient.

Patients’ Rights

Our patients have the right to ethical and respectful care at all times and under all circumstances, and PardeeHospital has a “Zero Tolerance” Policy for the infringement of a patient’s rights. The Ethics Committee at Pardee may be notified if any ethical concerns regarding patients’ right arise.

Abuse—All patients at Pardee are protected against any form of abuse. If you suspect a patient may be a victim of abuse, contact your immediate supervisor.

Advance Directive—Patients 18 years of age or older have the right to make an Advance Directive. This includes both a Living Will and the Designation of a Healthcare Power of Attorney. We encourage patients to exercise their right to Advance Directives and will assist them to do so. However, employees of PardeeHospital may NOT witness such statements of patient’s wishes.

Age Specific Consideration—All patients at PardeeHospital are treated with consideration to their developmental and age specific needs. The care you give your patients should reflect those specific needs.

Cultural/Religious Consideration—Cultural Awareness means being aware of the differences in people and understanding and respecting those differences. In Healthcare, Cultural Awareness also means understanding how a person’s culture affects their behavior when they are sick. Because Cultural Awareness and Respect is for everyone, including co-workers, the Hospital encourages all staff member to learn about and to appreciate individual differences. Employees should:

  • Never force their own value system or religious beliefs on others
  • Never assume a person is identified exclusively with any cultural group
  • Always treat all people with respect and dignity
  • Always welcome the opportunity to learn about other cultures and people

The Education Department is a resource for information about many different cultural and religious beliefs, and the Hospital provides a translator for Spanish speaking patients. A listing of translators for other non-English speaking patients can be obtained from Nursing Service.

Guest Relations—Guests of Pardee Hospital include patients, visitors, and co-workers. Because of our commitment to Customer Service, this Hospital expects all employees to provide thoughtful consideration in meeting the needs of all of our guests.

Informed Consent—Patients of Pardee Hospital have the right to receive complete and current information regarding their diagnosis and treatment options (to the degree known). This information should be communicated in terms the patient can understand. They then have the right to accept or refuse medical treatment to the extent permitted by law and to be informed of the consequences of refusal.

Pain Management—Our patients have the right to a respectful and considerate approach to pain management. We use a multidisciplinary approach to pain management with awareness of the complexities of a subjective and individualized patient care issue. Please see your Department Manager for your specific role in the care of our patients’ pain management needs.