2013 Student/Resident Orientation/Reorientation & Mandatory Requirements

1. 2013 Student/Resident Orientation/Reorientation & Mandatory Requirements

2. Requirements 3 - 4 Badges and Parking 5 Hospital Leadership 6 Environment Of Care 7 - 48 Risk management 49 - 65 Infection Control 66 - 110 Employee Notification 110 - 113 Management of Information 114 - 131 Ethics and Compliance 132 - 135 Clinical Practice 136 - 154 Patient Safety 155 – 175 Acknowledgement/Quiz 178 - 188 Table of Contents

3. Student Requirements Background Check Requirements: All staff, residents, students and instructors rotating through JFK Medical Center must submit an attestation of a background check. The student background Screening shall include, at a minimum, the following: •  Social Security Number Verification • Criminal Search (7 years or up to 5 criminal searches) • Employment Verification to include reason for separation and eligibility for reemployment for each employer for 7 years • Violent Sexual Offender and Predator Registry Search • HHS/OIG List of Excluded Individuals/Entities • GSA List of Parties Excluded from Federal Programs • U.S. Treasury, Office of Foreign Assets Control (OFAC), List of Specially • Designated Nationals (SDN) INSTRUCTIONS

4. Seasonal Flu: October begins the official Flu season. All staff, residents, students , interns and instructors rotating through JFK Medical Center October through March will be required to provide proof of seasonal flu vaccination. Only a doctor’s note or documentation by the administrator of the vaccination on official facility letter head will be accepted.  In the case of an individual who refuses vaccination, (for whatever reason) a signed declination form must accompany the “Seasonal Influenza Vaccination Documentation” form indicating that the individual understands the risk to self and others involved in declining vaccination and their understanding of their responsibility to wear a mask while in the hospital.

5. Student Badges and Parking: To allow for available parking for our patients and visitors, all staff, residents, students and instructors, whose rotations are one month or greater, will be required to park in the garages. An access badge will be needed to enter the parking garages. Those whose rotations are less than one month will not receive badges and are required to park in the very last row of the South Parking lot. Anyone parking outside of their assigned area will be subject to towing at their expense. To secure an access badge a check deposit will be required at time of orientation and be returned when the rotation is over and badge is surrendered. Tobacco-Free Campus JFK Medical Center is committed to creating a healthy environment for its employees and visitors and is now a tobacco-free campus. Smoking is not permitted anywhere on campus property. We ask for your cooperation and understanding to eliminate the harmful effects of second hand smoke.

6. Mission Statement The mission of JFK Medical Center is to be the community provider of high quality and compassionate healthcare that is responsive to the needs of our patients, their families, and physicians. Values Statement • Caring – compassionate, competent, committed ethical treatment for all. • Respect – for the worth, dignity, and potential of all individuals. • Responsiveness –to the needs of patients, families, employees, physicians, and members of the community. • Results – achieving/exceeding clinical, financial, and patient satisfaction outcomes, ensuring a high level of value in all services we provide. Hospital Leadership

7. Environment of Careand “New” Emergency Codes effective November 1, 2010

8. Topics Covered: • Manual Location • Emergency Numbers • Emergency Information • Code Information • Hazardous Material Spills • Fire Response • Evacuation Plan • Hazardous Materials/Hazardous Waste • Radiation Safety • Equipment Management • Utility Management • Safety and Security • Transportation Environment of Care

9. Infection Control/Employee Health Manual: • Located in each department, in the Infection Control Office, Employee Health Office, • and in the Meditech MOX Library. • Emergency Operations Manual • Located in each department and in the Meditech MOX Library. This manual includes • disaster, fire, hurricane, bomb threat, and hostage situation information and what your • responsibilities are in the event of these occurrences. • Hazardous Materials Manual • Located in all Hazardous Materials Emergency Response Team members’ offices and • in the Meditech MOX Library. Manual Location **All Manuals can be obtained by the Nursing Supervisor

10. Biomedical Waste Plan: Located in the Infection Control Manual in the Meditech MOX Library. • Exposure to Communicable Disease Follow-up: Located in the Infection Control/Employee Health Manual in the Meditech MOX Library under Employee Health Policies and Procedures, “ Exposure to Communicable Disease Follow-Up.” • Nursing Policy and Procedure Manual: Located in each Patient Care Services Department and in the Meditech MOX Library under JFK Patient Care Manual. • Policies and procedures in the Meditech MOX Library system are the most up-to-date and are constantly being revised when rules, regulations, laws and practices are changed. • Please contact your department manager/supervisor and ask where these policy and procedure manuals are located within your department. • Manual Location

11. Biomedical Waste Plan Located in the Infection Control Manual in the Meditech MOX Library. Exposure to Communicable Disease Follow-up Located in the Infection Control/Employee Health Manual in the Meditech MOX Library under Employee Health Policies and Procedures, “ Exposure to Communicable Disease Follow-Up.” Nursing Policy and Procedure Manual Located in each Patient Care Services Department and in the Meditech MOX Library under JFK Patient Care Manual. Policies and procedures in the Meditech MOX Library system are the most up-to-date and are constantly being revised when rules, regulations, laws and practices are changed. Please contact the department manager/supervisor and ask where these policy and procedure manuals are located within that department. Manual Location

12. MEDICAL EMERGENCY: Code Blue Dial “33333” and give room number and area ALL OTHER EMERGENCIES: Dial “88888” and give room number and area Emergency Numbers to know

13. Infection Control: (548) – 3614, located in the Plant Operations Building, second floor. Hours: 8:00 a.m. – 4:30 p.m., Monday through Friday. After hours or weekends, call hospital operator. Employee Health: (548) – 3790, located on hallway across from the Library Hours: 7:30 a.m. – 4:00 p.m., Monday through Friday. After hours or weekends, call hospital operator. Environmental Services: (548) – 3780. Hours: 8:00 – 4:30 p.m., Monday through Friday. After hours or weekends, call hospital operator. Security and Safety: Ext. 44444; Hours: Security is operational 24 hours per day. Risk Manager: (548) – 3430, located on administrative hallway Hours: 8:00 a.m. – 4:30 p.m., Monday through Friday. After hours or weekends, call hospital operator. Plant Operations: (548) – 3784 Hours: 7:00 a.m. – 3:30 p.m., Monday through Friday. After hours or weekends, call hospital operator. Important Office Numbers

14. Effective November 1, 2010, all color codes are the same across all hospitals in Florida. Look on your unit/area for the “Rainbow Ring” for reference Badge Buddies with the codes will be given to all employees in January 2011 EMERGENCY CODES

15. Code Pink Infant Abduction –New • Code Pink Level 13 Child Abduction-Code Adam • Code Blue Cardiac Arrest -same • Code Green Disaster -Code D • Code Orange Bioterrorism-Code D200 • Code Red Fire • Code Black Bomb Threat /Code Dr. Search • Code White Hostage/Active Shooter • Code Yellow Facility Lockdown • Code Brown Severe Weather- Hurricane • Code Gray Security Alert - Code Dr.Strong Emergency Codes

16. Code Blue is called for ALL MEDICAL EMERGENCIES that require a rapid response. When CODE Blue is called, a team of trained personnel will arrive. If you are not required to stay with the patient, please leave the area immediately. • Activate Code Blue, dial “33333” for the PBX Operator, state the code, and your location • Get the crash cart • Flatten the patient’s bed, put the back board or head board under the patient • If the patient is pulseless or breathless, begin CPR • Primary nurse must remain to provide information about the patient • One staff member must record the events • Notify Primary physician and consulted physicians • Follow directions as authorized by the physician or caregiver in charge • Primary nurse will ensure that the patient’s family is notified of the event and transfer, if it occurs Code Blue-Respiratory/Cardiac Arrest

17. Code Green - Disaster Plan This disaster plan was designed to prepare all employees in the event of an external or internal disaster. We must be able to provide assistance when required to handle a large influx of victims regardless of the time, size, character, or duration of the emergency. • Report to your department for instructions and remain there until assigned by the Department Manager or Supervisor • Patient Care Areas are to assess and report the following information: • Current patient census • Number of probable discharges • Potential number of empty beds • Do not use the telephone or elevators unless absolutely necessary • All questions from the media should be directed to the Marketing Department • Visiting hours may need to be canceled and visitors may be asked to leave the hospital. This will be at the discretion of the Administrator/Designee or Safety Officer. Code Green-Disaster

18. CodeRED The operator will call “CODE RED” and give the location of the code. When Code Red has been activated, it will be your responsibility to remain calm and perform duties assigned to you. You must maintain control of the situation. Close all doors, inform patients that we are having a Fire Drill, move all items out of the corridors to allow for clear passage, make sure visitors remain in rooms, do not pass through fire/smoke doors unless instructed to do so, and do not use elevators. Wait for the “CODE RED RECALL” to be announced before opening doors or returning to routine activities. Code Red- Fire

19. Fire Response Fires are only possible when fuel, heat, and oxygen are combined in the fire triangle. Smoke detectors and automatic fire sprinkler systems are used at JFK Medical Center to assist in detecting fires. When one of these is activated, an automatic alarm is sounded and a signal is sent to the switchboard who in turn will contact 911 and activate the Code Red procedure. Before an incident occurs: Review your fire safety policy and procedure know where the exits are in your department know the location of all fire alarms in your area know the location of fire extinguishers in your area Be alert to possible fire hazards and have them corrected immediate

20. If you spot a fire before detectors are activated, do the following: “RACE” RESCUE the persons from immediate danger ACTIVATE the fire alarm closest to you CONTAIN the fire to an area by closing all doors. EVACUATE the area if the fire or smoke is beyond your control. Evacuate to the next smoke compartment EXTINGUISH the fire if you have been trained to use a fire extinguisher. Never attempt to fight a fire that is too big for you to handle!

21. When using a fire extinguisher, remember “PASS” PULLpin from handle of extinguisher AIM hose at base of the fire SQUEEZE handle to discharge extinguisher SWEEPing motion with short bursts • Remember that any staff member may shut off medical gases upon direction from the charge nurse, nursing supervisor, respiratory therapist, or cardiopulmonary manager

22. If a fire alarm is activated and it is not in your area, do the following: Close all patient doors. Explain to patients that a fire drill is in progress and for them to remain in their rooms. Clear hallways of visitors Move all equipment out of the corridor. Make sure that passageways in rooms and in corridor are not obstructed. Do not open fire doors unless instructed to do so. Stop traffic except for Code Red and Code Blue Response Teams. Do not use elevators Do not call operator to find out if fire is real Stay alert and await further instructions Operator will announce “CODE RED RECALL”. You may resume your regular duties at this time. 

23. Bioterrorism Response: If bioterrorism event is suspected, immediate notification should be given to administration, Non-Emergency Spill Response The employee discovering the spill shall take the following action: • Evacuate the area of unnecessary patients and personnel • Contain the spill, seal off the area, protect any drains • Identify hazardous material, safely secure source • Get help, notify your supervisor • Consult the appropriate Material Safety Data Sheet (MSDS) • Decide on a plan of action as per MSDS • Use appropriate Personal Protective Equipment (PPE) • Follow prescribed spill and clean up precautions, use spill kit, if appropriate • Complete an Occurrence Report on any hazardous spill • Inventory and restock any spill kit used Code Orange- Bioterrorism

24. Emergency Spill Response: If the chemical spill is dangerous and deemed too large, or too hazardous by supervisory personnel for immediate staff to clean up, notify the Hospital’s HAZMAT Team through the Operator “88888”. This code is called if there is a chemical spill. In general, if there is a small chemical spill (one gallon or less), use proper technique as outlined in the Material Safety Data Sheet for the specific chemical spilled. For large spills (greater than one gallon), or if a chemical spill is dangerous and deemed too large or too hazardous by supervisory personnel for immediate staff to clean up, Call the hospital operator and explain the type of spill and the operator will notify the Hazardous Materials Response Team who are trained to use the chemical spill kit. These kits are located in Plant Operations. Laboratory, Oncology, and Radiation Departments have spill kits specific to their areas and personnel are trained in managing spills. Code Orange - Chemical Disaster or Spill

25. A New Policy Related to the Outcomes of Healthcare Violence Events • It is for the ability of the Safety and Security Department (with assistance from staff and ancillary departments) to secure the building immediately • Lockdown will occur by security officers at the main entrances immediately • Areas that may have high risk potential will also be locked down • Administration • Nursery and Pediatric Units ( if apply) • Emergency Department • Intensive Care Units Code Yellow-Lockdown

26. The Medical Center’s Safety Officer will implement this code The Incident Commander will retain ultimate authority and control over all operations with the hospital for Stage 3, 2 and 1. In the unlikely event that evacuation of the Medical Center is necessary, the Incident Commander will make that determination after consultation with the President of the Medical Staff, PBC-EOC, Director of Security, and Safety Officer. Director of Plant Operations and others as he deems necessary. Evacuation will be to other area hospitals, home and/or shelters which may be available. Staff support to the DCC shall continue as normally as possible until otherwise directed by the Incident Commander and Safety Officer. Each Department Head or Unit Manager is responsible to carry out their department specific plans and support the DCC actions. The Safety Officer is responsible for all utility systems and structural damage assessments and operations. Code Brown- Severe Weather

27. Formerly Code Dr. Strong • Situation where security is needed for combative /violent patient • Any threatening situation can prompt a call • Call Operator (PBX) at “88888” • State that you need a Code Gray • Give name and location or patient room • Police assistance may also be needed as determined by the Security Department Code Gray –Security Alert

28. Hostage - a person being held by force by one or more individuals. • Hostage situation is a person being held by force, by one, or more individuals • Active Shooter - an individual or person actively engaged in killing or attempting to kill people in a confined and populated area • Call 88888 • Evacuate if immediate threat in your location • Hide if at all possible in same place if not safe to relocate • Remain as calm as possible • Protect patients • If shooter is in the building and not an immediate threat to you, stay in place Code White - Hostage /Active Shooter

29. This code is activated when a call or note that a bomb has been planted somewhere in or around the Medical Center is received. The operator will announce “CODE BLACK – ALL EMPLOYEES RETURN TO YOUR DEPARTMENTS OR WORK STATIONS”. • If you are the one to receive the threat, do the following: • have someone else call the operator; • keep the caller on the line as long as possible; • listen for background noises, accents, speech patterns; • attempt to determine if the person has knowledge of the Medical Center • ask where the bomb is and when it will explode. • Review your department-specific policy for your duties so you know what to do when this code is activated. • Code Black- Bomb Threat

30. Upon receipt of bomb threat message, the individual receiving the threat should record all the details of the call. Try to identify: • Location of the device • Time set for detonation • Type of device or appearance • How the device can be deactivated • Why the device was placed Try to identify the following characteristics of the caller’s voice: • Tone: Calm, angry, excited, slow, soft, crying, familiar accent, etc. • Threat Language: Well spoken, foul, irrational, taped, etc. • Background Sounds: Street noises, kitchen noises, voices, PA system, Engines Dial “88888” and notify PBX who will contact Police and/or Fire Rescue under the direction of the Administrator/Designee or Safety Officer. • Staff in each department may be asked to look in their areas for any unusual objects. Code Black- Bomb Threat

31. Response to potential emergencies from disruptive to disastrous • Testing the hospital emergency response at least twice a year • Identify hazards, threats, adverse events, and high patient volumes and assess the impact on care, treatment , and services • Know what to do in the event of a disaster or Six critical elements in every disaster event : • Utilities • Staff Responsibilities • Safety & Security. • Resources & Assets • Patient Clinical & Support Activities • Communications Emergency Preparedness Plan

32. Emergency Preparedness Plan • Each department has an individual plan that must be followed. • The employee must know what his or her responsibilities are before the disaster occurs. This plan will be activated by the “CODE D” announcement upon notification by the administrator on call, the safety officer, or the nursing supervisor that a disaster has occurred and a large number of victims are expected to arrive at JFK Medical Center’s Emergency Department within minutes. • The Emergency Operations Team members will meet immediately upon notification to set up a command center. All directions will be given from this center to allow control of the situation. • Hurricane Season: June 1through November 30 of each year is designated as hurricane season. Review your disaster plan before hurricane season begins.

33. The purpose of an evacuation plan is to move patients from a dangerous or potentially dangerous area to a place of comparative safety. If you have been instructed to evacuate your area, you will be told what type of evacuation will be required. Evacuation (with the exception of PARTIAL EVACUATION) is only done on the order of the administrator on call, the Safety Officer, or the nursing supervisor The following types of evacuation are used at JFK Medical Center. • PARTIAL - moving patients from a dangerous area to safety in another room • LATERAL - moving patients to another smoke compartment on the same floor • VERTICAL - moving patients downward from one floor to another • COMPLETE - moving all patients out of the facility Evacuation Plan

34. Under the Hazardous Communication Act, chemical manufacturers and distributors are required to evaluate the hazards of their products and provide the purchasers with the information necessary to ensure safe handling, use, and storage of chemicals. When using chemicals in your workplace, review the content label for this information: • the name of the chemical • who makes or sells it • the address of the maker or seller • why it is hazardous • how exposure to hazard occurs • what conditions would increase hazard • precautions to take while handling substance • what to do if you are exposed to a substance • how to handle a spill or emergency spill Hazardous Materials

35. Everyone should be aware of hazardous materials in the workplace. Hazardous Materials information is available on the Poison Control Database (Poison-Dex) in the Emergency Room (548-3751) and on the TOMES Database in the Pharmacy (ext. 44260). It is available to all employees’ 24 hours per day. Hazardous Material Spill Team If a hazardous material spill occurs, the Hazardous Material Spill Response Team will coordinate all details. Minor Spills • Security Department Ext. 44444 • Engineering Department (548)–3784 • Haz-Mat Coordinator Pager 313-8037 - Office 548-3455 • Radiation Spill Haz-Mat Coordinator Pager 326-1378 Office 548-3455 • Administrator on call • Hospital Operator - 0 • Safety Officer Office (548)-3700 • Security Supervisor Spectra link - 87340 Hazardous Materials

36. Hazardous Waste Hazardous waste: is material that is no longer in use that is considered to represent a threat to human life or health. The categories of hazardous waste with which a healthcare facility must deal with are: • Biomedical waste: any solid or liquid waste that may present a hazard of infection to humans. • Chemical waste: any chemical that is toxic, flammable, corrosive, reactive, or “extraction procedure” toxic Hazardous Materials

37. Cytotoxic waste: any waste resulting from the preparation and administration of medications used in the treatment of cancer or benign tumors, with few exceptions, themselves mutagens and carcinogens. • Radioactive waste: any waste that contains characteristics of radiological emissions as defined by the Nuclear Regulatory Commission as being hazardous to humans, animals, and the environment. • Physical hazard waste: Any objects capable of puncturing or lacerating theskin such as broken glass, opened cans, etc Hazardous Materials

38. It is important to realize that all of us receive radiation everyday whether we work in a hospital setting or not. There are many sources of naturally occurring background radiation (radiation from the sun and elements found in the earth). In a hospital setting, personnel have the potential to be exposed to radiation from two primary sources: • One source of radiation within the facility is from fixed or portable x-ray machines. Radiation Safety

39. The most important things to remember when working around this type of equipment or any other type of radiation are time, distance, and shielding. • Time: the less time you are around radiation, the less you are exposed • Distance: the farther away you are from radiation, the less you are exposed • Shielding: if possible, use a lead apron or lead door to stop ionizing rays Radiation Safety

40. The second source where radioactive materials are normally present is the department of Nuclear Medicine. The primary function of the Nuclear Medicine Department is diagnostic, and therefore radiation levels are very low. Radioactive materials may be found is a nursing unit where a patient may have a radioactive implant or is admitted for a radioactive iodine treatment. Instructions are posted in the patient’s room clearly defining the precautions needed for safe interaction levels for personnel and visitors. The telephone number of the Radiation Safety Officer is posted in case an emergency should occur. Radiation Safety

41. It is important to be aware of the radiation symbol that is magenta or red trefoil (propeller) shaped symbol on a yellow background. When that symbol is displayed on a container, package, or door, its purpose is to alert individuals that radioactive materials are present. Do not handle any radioactive materials unless you are an authorized user on the state license. State and federal regulations require healthcare personnel who routinely work around radiation to wear monitors called film badges. This is a small rectangular badge worn by personnel in departments such as Nuclear Medicine, Radiology, Endoscopy, Cardiac Catheterization Lab, CAT Scan, and Outpatient Surgery. Each month, the badge reports are reviewed by the Radiation Safety Officer to ensure that all healthcare personnel are keeping within the state and federal guidelines for radiation exposure. Contact the Nuclear Medicine Department at ext. 83669 to obtain additional information concerning the effects of ionizing radiation and matter. Radiation Safety

42. The Biomedical Department checks all clinical electrical equipment brought into the Medical Center. Look for the following items to determine if equipment in your area has been checked: • Control sticker – this sticker contains information such as date and technician who checked equipment. If this information is not on equipment, contact Plant Operations before using. • “Defective Do Not Use” stickers – used to tag failed units Equipment Management

43. Electrical shocks, burns, or electrocution can be the result of operating machines improperly or in unsafe conditions. Fire can also be the result of poor electrical safety habits, including poor maintenance of electrical equipment. Prevent injuries by following these simple rules: • report any frayed wired immediately • report any broken cords immediately • do not yank plugs from wall sockets • do not work on any electrical apparatus. Electrical Safety

44. Utility Management JFK Medical Center has contingency plans for each of our major utility systems. All staff members need to be aware and know what their departments’ responsibilities are during an interruption. Utility Failure / Power Failure If the power fails in your department, immediately check the following: All life sustaining /critical equipment is plugged into red emergency outlets Infusion pumps have battery backup – check to make sure it is still functioning properly If the power fails in your department, contact Plant Operations to see if problem is facility-wide or local, and reassure patients that they are in no danger and that their care will not be jeopardized

45. If the water is shut off on your unit, the following will apply: • Notice is sent to all departments if water is to be turned off for any length of time. If you have not received a notice, contact Plant Operations immediately to determine cause. • Bottled water is available to all areas if water is to be turned off for only a few hours. • If, during a hurricane, water will be shut off for a longer period of time, portable water will be brought in and bottled water and waterless hand cleaners will be utilized in affected areas. Water Failure

46.  If telephone systems fail, the following procedure will occur: • Administration and key personnel will utilize hand-held radios • Extra personnel will be on hand to assist with communications • Communications may be continued by using the “SEND MESSAGE FUNCTION” in the Meditech system (internal only) • Cellular phones may be used only at the direction of the Emergency Operations Center (EOC) Communications Failure

47. The Safety and Security Department is committed to providing a safe and secure environment for all persons that interact within the Medical Center Complex. • Safety and Security Contact Information: Ext. 44444 for Non-Emergencies, operates 24 hours daily Ext. 88888 for Emergencies, operates 24 hours daily • Courier Service: Ext. 44444. Provided to Medical Center departments at both on and off campus locations. • Identification Badges: Ext. 44444. Badges are processed for staff, physicians, volunteers, contract staff and associates. • Hours of Operation: Monday through Friday, 6:30 a.m. – 7:30 a.m. and 12:30 p.m. – 5:00 p.m.Weekends, 6:30 a.m. – 2:30 p.m. Safety and Security

48. Please assist the Security Department in maintaining a safe and secure environment by observing the following: • Call immediately if you notice any suspicious behavior or witness an incident. • Secure all money and purses out of sight or in a locker or locked cabinet. • Observe speed limits in parking lots. • Leave parking areas closest to the hospital for visitors and outpatients • Ensure patients’ valuables are taken home or secured in the Business Office safe. Do not allow patients to keep valuables in bedside tables or in pillowcases. • Hearing aids, dentures, etc., should be transferred with the patient. • Have patient ready before transporter arrives. • Clean up spills. • Do not obstruct passageways. Maintaining a Secure Environment

49. Risk Management Section 3 Incident ReportingProfessional LiabilityLoss Prevention Patient Confidentiality

50. A successful Risk Management Program depends on each and every employee. The following information is provided to assist you in learning about Risk Management and your role in the Risk Management process. Overview The Risk Management Department of JFK Medical Center is responsible for managing a program of preventative assessment and identification of risks as well as handling claims of injury or property loss Risk Management also can put procedures in place for responding to unusual clinical events- Call the Risk Manager if ever in doubt Risk Management