SAFETY FAIR 2013

1. SAFETY FAIR 2013 Patient Care Module for the Environment of Care

2. Latex Allergy WHAT IS LATEX? • Latex is the milky sap from the rubber tree. • Common latex products used in the hospital include rubber gloves, adhesive tape, urinary catheters and rubber-based items such as rubber bands and rubber balloons. • Other common latex products include condoms, nipples and pacifiers, dental dams and Koosh balls and other toys. SYMPTOMS OF LATEX ALLERGY INCLUDE: • Skin rash • Hives or welts • Watery or itchy eyes • Sneezing • Itching • Fainting or loss of consciousness • Body swelling • Difficulty breathing • Wheezing or chest tightness IF YOU ARE AN EMPLOYEE WITH A DOCUMENTED NEED FOR NON-LATEX PERSONAL PROTECTIVE WEAR, FOLLOW THESE GUIDELINES: For all non-sterile procedures where contact with blood or body fluid may or may not be probable – use non-sterile or NITRILE gloves. Obtain box quantities from Central Supply. Note: Powder-free gloves are the standard glove used for both non-sterile and sterile.

3. Latex Allergy WHO IS AT HIGH RISK FOR DEVELOPING LATEX REACTION? • People with spina bifida, congenital urogenital defects, repeated exposure to latex products or fruit allergies • People who have frequent catheterization or multiple surgeries • Health care workers These patients will be observed for symptoms of latex allergy. If these symptoms develop, the physician will be notified and the patient moved to a latex-free environment and identified as “LATEX ALLERGIC”. The Latex Allergy Patient Care Policy, PC 162.1, provides the definition of latex-allergic patients, and the steps to provide them with a safe environment. Known Or Suspected Latex-Allergic Patients: These patients are defined as patients with: • Definitive or suspected allergy to latex products per patient/family report. • Diagnostic test positive, despite symptom-free when exposed to latex. IF A REACTION OCCURS: • Stop using the offending agent. • Observe for serious reactions such as bronchospasm or anaphylaxis. • Contact the physician and initiate CPR if necessary. Educate patient and family on Latex Allergy and Latex-free products before discharge, including the Medic Alert bracelet.

4. Latex Allergy Who is responsible for what in the care of the latex allergic patient? • MD: Documenting latex allergy diagnosis in the medical record. • NURSING: Assessment of patient allergies, including documenting in medical record. Noting “Latex Allergic” on front of chart and placing neon green arm band on patient. Providing a latex-free or minimal latex environment. Medications provided in a latex-free manner. • MATERIAL SERVICES: Providing latex-free supplies. Being a resource to staff and physicians regarding latex content of supplies. • PHARMACY: Providing latex-free injections and IV solutions except for TPN and chemotherapy. • PATHOLOGY, RADIOLOGY, RESPIRATORY THERAPY, PT AND OT, GI LAB, NEURODX, ULTRASOUND AND ED: Providing latex-free treatments. • SURGERY: Providing a latex-free surgical environment.

5. Summary of Changes to Blood Transfusion Record Form Transfusion Record Form: A. Current method of labeling the blood products included an unattached 2 part TRF form and an attached small TRF tag. The new method of labeling will include only a 2 part TRF which will be attached to the product. There will be no small TRF tag. B. First part of the TRF is the Chart Copy which will be put in the patients chart. Chart copy can be detached from the product once the product has the bedside verification completed and signed. C. The products will be tagged with the TRF, at least with the second part, until the transfusion has been completed. D. After the completion of transfusion, Chart copy is filed in the patient’s chart, the second part of TRF is discarded in the confidential container and the empty product bag will be discarded in the biohazard container. E. If for any reason the product needs to be returned to Blood Bank, return the product with the second part of TRF attached to the product. Chart copy is filed in patient’s chart.

6. Changes in the documentation on the TRF by the nurses: A. To be completed by physician or nurse “I certify that the recipient’s name, medical record number and blood type as shown on this form correspond to label attached to the blood bag.” This is changed to “I certify that the recipient’s name, medical record number and blood product as shown on this form correspond to the blood product ordered.” B. “Donor unit number is” changed to “Donation Identification Number” C. Vital Signs Added check box for “Document in Epic vital signs and transfusion completion time”. Check this box for documenting vitals in Epic. D. Added 1 hour and 2 hours slot to document temperature, pulse and blood pressure for those departments that do not document in EPIC. E. Reformatted to fit the form: 1. Verification of blood product, beside verification, order on chart and consent on the top left corner 2. Vital signs and report of suspected transfusion reaction on the bottom half of the form

7. Affix or write DonationIdentification Number label Receiving nurse will confirm and sign/date/time Bedside – Patient verification and second nurse/MD check Mark √ YES if orders in EPIC or √ for MD verbal order Mark √ for appropriate response for “Consent on Chart” Mark √ if vital signs and completion time in EPIC or in Anesthesia notes

8. Disruption of therapeutic intervention Self-removal of therapeutic/diagnostic/invasive lines Agitated/confused and picks at lines/tubing Forgetful and/or non-compliant to verbal instructions regarding physical limitations imposed by tubing/lines/dressings/equipment Inability to follow instruction and/or repeatedly climbs out of bed/chair Judgment impaired due to agitation/medication or alcohol Harm to self or others Combative/assaultive or displaying extreme verbal aggressiveness Demonstration of overt actions towards self, staff or others Restraint Assessment of factors that may identify risk for a need for restraint:

9. Emergent patients: Patients may present with an alteration in mental status as evidenced by violent, combative or agitated behavior due to waiting for treatment, loss of control, drug or alcohol use. Possible interventions: active listening, verbal calming and de-escalation techniques, observation close to the nurse’s station and expression of concern. Physically limited patients: These patients present with an alteration of functional status. Possible interventions: appropriate exercise, modification of the environment to facilitate navigation, and safety education. Restraint Risk Factors for Patient Populations

10. Cognitively impaired patients: May present with an alteration in mental status. Possible interventions include: increased observation and supervision, encouraging family to visit, education of the family, sitters to shadow wanderers, reality orientation, pet therapy, diversional activities, familiar items in the room, and assessment of pain status. Pediatric patients: Patients may present with separation anxiety from parents, especially in toddler and school age population. Possible interventions include: encouragement of family members to stay or use of volunteers when the family is not available. Deprived or abused children and adolescents may display aggressive behavior, as a way to signal the need for emotional reassurance. Interventions include teaching of non-aggressive behaviors or verbal cues that can be used. Restraint

11. RN can assess patient and apply restraint to keep the patient safe: e.g., pulling out tubes, lines or repeatedly attempting to climb out of bed. Physician must be notified immediately. Can obtain a telephone order for initial order. Physician order may be entered to last for up to three days. Physician order must be renewed when order expires. Psychological status and comfort shall be assessed as appropriate. Patient must be monitored & assessed every two hours minimally for skin, circulation, elimination, nutritional needs, ROM. Assessments and observations must be documented. Applies to the use of restraint in an unanticipated emergency or crisis situation where there is an imminent risk of a patient physically harming himself or herself or others, including staff. RN can assess and apply restraint. Assessment by RN or MD within one hour of initiation must include an evaluation of: Patient’s immediate situation Patient’s reaction to restraint Patient’s medical and behavioral condition Need to continue or terminate restraint If RN assessed and evaluated the patient, a telephone order must be obtained for restraint within one hour. Restraint Restraint for Violent or Self-Destructive Behavior Restraint for Non-violent, Non-self destructive Behavior

12. What is the patient’s immediate situation? Attempting to physically harm self Demonstrating overt threatening or aggressive behaviors toward staff or others, e.g., hitting, kicking, biting, etc. What is the patient’s reaction to the restraint? Continues to demonstrate aggressive behaviors Aggressive behaviors have increased Aggressive behaviors decreasing Aggressive behaviors have ceased Assessment of the patient’s medical and behavioral condition: Consideration if the patient’s aggressive behavior is related to a medical condition and not his/her emotional state, e.g., hypoxemia, hypoglycemia, delirium from increased temperature, electrolyte imbalance, chemical withdrawal, medication interaction. Does the patient have a history of drug or alcohol abuse? Does the patient have a history of a behavioral disorder? Does the patient’s behavior support the need for continuation of the restraint? Restraint The One Hour Restraint Evaluation by the RN for Violent or Self-Destructive Behavior

13. All restraint orders must specify: Type of restraint Duration of restraint order (3 days maximum for non-violent, non-self-destructive behavior: NO PRN orders) Reason for restraint (clinical justification) Date and time Criteria for early release of restraint Use the Restraint Order pathways in Epic! Violent or Self-destructive behavior Restraint Reminders: Order time limits (NO PRN orders): 4 hours for adults 2 hours for children ages 9 to 17 1 hour for children under 9 When the original order is about to expire, the RN must contact the physician for a renewal order. Physician must see patient in-person if the patient remains in behavioral restraint for greater than 24 hours. Patient must have a sitter for both restraint and seclusion. Patient must be monitored & assessed every two hours minimally for skin, circulation, elimination, nutritional needs, ROM. RN visual assessment should be documented every 15 to 30 minutes Restraint Alternative methods must always be tried before restraint is applied!

14. Restraint Documentation Requirements (all restraint): The one-hour in-person evaluation by the RN for violent or self-destructive behavior restraint must be documented on the Restraint Doc Flowsheet in the “RN Initial Face to Face” row. Description of patient’s behavior and interventions used. Alternatives attempted. Patient’s condition or symptoms necessitating restraint. Patient’s response to intervention and need for continued restraint. After applying a restraint vest, check the patient’s respiratory rate regularly. Be alert for signs of respiratory distress. Ensure that the vest does not tighten with the patient’s movement. Ensure that the size of the restraint is correct for the patient and that the restraint is applied correctly. If the patient shows distress at any time related to the restraint: Attend to the patient immediately. For a compromised airway, release the restraint immediately and assess the patient’s airway status. Implement emergency measures immediately if indicated. If the restraint is causing restriction in the ability of the patient to breathe, release the restraint immediately and check the patient’s airway and breathing status. Restraint Signs of Patient Distress:

15. Patient at high risk for aspiration: Restrain on his side when possible. Pregnant patient: Vest should be as loose as possible around the abdomen allowing for lateral positioning; never position flat on her back other than for brief periods of time if required for specific procedures. If patient must be restrained in supine position: Ensure head is free to rotate to the side and, when possible, the head of the bed is elevated to minimize risk of aspiration. Consider the Following When Initiating Restraint When possible, do not restrain a patient in the prone position due to obstruction of vision, feelings of helplessness and potential for impairment of respiration. Patient with a deformity: Ensure that the restraint can be applied properly. If a patient must be restrained in the prone position, ensure airway is unobstructed at all times. Ensure expansion of patient’s lungs is not restricted by excessive pressure on patient’s back (special caution is required for children, the elderly and the very obese).

16. Verbal De-escalation: The Art of Persuasion • Why should we use verbal de-escalation? • Using de-escalation techniques will help you to: • Develop a systematic approach to persons displaying assaultive behavior • Use your presence and your words as options to gain cooperation • Use the energies of others to accomplish your objective (to diffuse the situation) • How can we get people to voluntarily comply with our requests? • Display a professional presence • Use words to calm individuals down • Pain control To deal with people you need to be: • Open • Flexible • Unbiased • You should not be concerned with a person’s attitude…you can only deal with their behavior.

17. Verbal De-escalation: The Art of Persuasion • Communication impressions from the receiver’s point of view: • Content of words heard make up 7-10% of the message received. • Voice of the person talking makes up 33-40% of the message received. • Non-verbal cues of the person talking make up 50-60% of the message received. • So, what a person says may not always be the same as what the receiver hears! What We Say and How We Say It Words we commonly say may be interpreted to mean something other than intended: “Come Here”: can actually mean “Go Away”. Can be perceived as threatening. “Calm Down”: Does this work when someone says it to you? Instead, use a calm face and calm demeanor. “What’s your problem?”: This makes people defensive and hostile. Instead say, “What can I do to help you?” “Why don’t you be more reasonable?”: Creates further conflict because people don’t think they are unreasonable. Better to say, “Let me see if I understand your position.” Paraphrase their frustration. “Don’t you know any better?”: This implies that the person does not know anything. It causes problems just by the nature of the words.

18. What we say and how we say it… • As you can imagine, staff play a huge role in the patient’s perception of their experiences while they are in the hospital. A staff person’s communication with the patient greatly impacts their perception of the care they receive. • AIDET is a practice that greatly enhances communication with the patient and patient satisfaction. • What is AIDET? • Acknowledge • Introduce • Duration • Explanation • Thank you • These simple words reflect practices that let the patient/family know that staff is treating them with courtesy and respect, and providing explanations and information about their care, treatment and medications. This is a powerful communication tool to use with patients and families as well as with each other.

19. Verbal De-escalation: The Art of Persuasion Tips on Active Listening Statements that draw out another’s point of view and show active listening: “I can understand how you feel about that.” “Let me see if I understood you correctly.” “Tell me what you think.” “Can you think of anything else?” “Tell me more.” You must be attentive and sincere! • The role of the voice in communication. • The voice is 93% of your delivery style. It projects: • Tone (reveals attitude) • Pace • Pitch • Modulation • The voice is the window of the speaker’s intent. Non-verbal communication impacts what a person hears: Proxcemics (people’s personal space): Can be different between cultures. If someone invades our personal space (they get too physically close to us and we feel uncomfortable), we can become distracted and unable to listen to them and hear what they are saying. Body language: Body language that shows impatience or anger, e.g., crossing arms, angry facial expression, rigid posture, can interfere with communication.

20. Verbal De-escalation: The Art of Persuasion How to Deflect Verbal Abuse Use deflecting statements after a statement from an individual. Don’t take it personally. Examples: I appreciate that but… I understand that but… I hear that but… That may be so but… Communication: What is the opposite of talking? It should be listening, but for most people, it is waiting…waiting to interrupt!!! • Be open and unbiased. • Hear literally • Interpret • Actively listen • Harmonize your actions and voice (helpful actions should be accompanied by a helping tone of voice). Words and meanings are never the same when people are upset, therefore when a person is speaking:

21. Bleach BLEACH is an economic poison, AKA “pesticide”, that kills or disinfects microorganisms. As an economic poison, the regulatory authority governing the use of bleach is the Department of Agriculture. Bleach is commonly used for cleaning and disinfecting. HEALTH HAZARDS ASSOCIATED WITH THE USE OF BLEACH: Routes of entry: inhalation, skin, ingestion. Health Hazards: Acute: Irritation of the membranes of the mouth, throat and stomach. Chronic: Constant irritant to the eyes and throat. Signs and Symptoms of exposure: Irritation to the eyes, throat and stomach pain. Signs and Symptoms most likely to occur with a bleach exposure: irritation to the eyes and throat. STEPS TO BE TAKEN IN CASE BLEACH IS SPILLED OR RELEASED: Neutralize with sodium sulfite, bisulfite or ferrous salt solution. Flush with water to dilute as much as possible, avoid heat and contamination with acid materials. Do not use combustible material such as sawdust to absorb. BLEACH

22. SAFETY PROCEDURES TO BE FOLLOWED WHEN USING BLEACH: • Wear goggles and gloves. • Work in a well-ventilated room. • Mix your workload so that you are not spending long periods with the bleach. • When you have completed the task using bleach, place the cap securely on the bleach bottle. Bleach • EMERGENCY AND FIRST AID PROCEDURES: • If a bleach exposure occurs in the eyes, copiously wash the eye for at least 15 minutes. • If bleach is inhaled, remove the person to fresh air. • If bleach gets on your skin, remove your clothing immediately, and wash with water for at least 15 minutes. • If bleach is accidentally swallowed, drink water, milk and obtain medical attention. Do not use baking soda or acidic antidotes. • Report to Employee Health or the Emergency Room (if after hours) immediately after emergency measures. DISCIPLINE: An employee who uses bleach or any other economic pesticide and refuses to wear gloves and goggles during handling of the bleach, will be subject to discipline in accordance with the discipline policy.

23. Adult and Pediatric Cardiopulmonary Resuscitation (CPR) and Emergency Response • Important points related to the CPR and Emergency Response policies: • CPR POLICY (PC 066.1) • The Adult or Pediatric code team will respond to the appropriate code if *2 is initiated within the hospital. Areas where the Code Team • responds include: • Memorial West • Ground Floor • 1st Floor • Adult Tower • MCH units and MCH Pavilion • MCH clinics within the building • MRI (both within the hospital and on Columbia Avenue) • Miller Children’s West/Peds Hem,Onc • The code team is NOT able to respond to CPR in the following areas: • Administrative Building • Parking Lot • Any area outside the building that does not allow ease and timely transport to the ED, (an exception might be just outside the door of the hospital).

24. Adult and Pediatric Cardiopulmonary Resuscitation (CPR) and Emergency Response EMERGENCY RESPONSE POLICY (PC 066.6) Emergency Response in locations where the Code Team does NOT respond: Requires an immediate 911 call to dispatch paramedics to transport the person to the ED. This situation constitutes an EMERGENCY RESPONSE by the hospital. Employees must assume responsibility to render aide or perform CPR until paramedics arrive. Public Safety officers respond to all of these emergencies if called. Public Safety officers are BLS (Basic Life Support) prepared to help the person until the 911 response team arrives (the LA Fire Department response time is <4 minutes for Advanced Life Support calls or <5 minutes for Basic Life Support calls). A federal act called Emergency Medical Treatment and Active Labor Act (EMTALA) requires that LBMMC & MCH have an organized plan in place to manage medical emergencies for all hospital licensed areas within 250 yards of the building. Emergency Response within LBMMC and MCH: All employees must assume responsibility to render aide to person(s) requesting help. Obtain assistance from Public Safety to assist person(s) to the ED. If the person seeking help has suffered a cardiopulmonary arrest the Code Team should be summoned by dialing *2 and stating “I have a Code Blue” for an adult and state location, or “I have a Code White” for an infant or child and state location. The CPR policy would then go into effect.

25. HAZARD COMMUNICATION STANDARD - REVIEW The hospital provides you with information about hazardous chemicals by: labeling of containers that have hazardous materials in them, Material Safety Data Sheets (MSDS) for the hazardous chemicals that you are using, and training. WHO IS AT RISK? Everyone who works or visits the facility can be exposed to infectious or hazardous materials. Bacteria or viruses, can be transmitted by blood and other body fluids, equipment containers, paper goods, glassware, linens and people. The following is a general guideline showing where hazardous chemicals may be found in the hospital: Gases: Sterile Processing, Surgery Chemotherapeutics: Adult, Pediatric Oncology Fixatives, dyes, stains: Pathology Oils, diesel fuel, bulk oxygen: Engineering Heavy metals, radioactivity: Radiation Oncology Fixers, developers: Radiology Cold sterilants: OR’s, GI Lab Radiation: Anywhere where radiation is used It is important to know, that if you are exposed to a hazardous chemical, you must perform immediate decontamination and report to Employee Health Services or the Emergency Room if life-threatening. Refer to the MSDS and chemical container label for immediate decontamination procedures.

26. Hazardous Materials and Material Safety Data Sheets (MSDS) Departments having hazardous materials are required to have an MSDS for that hazardous material. The MSDS are filed in the Environment of Care (EOC) Manual. Exception: Because of sheer volume, Radiology, Pathology, and Pharmacy have separate binders labeled “MSDS”. Generally you can tell if a chemical is hazardous if it has a warning label on the container. Information on the warning label is usually the same as on the MSDS. If you transfer any hazardous chemical to a new container, a label must be affixed to the new container with all of the information from the original warning label. All managers must perform a yearly chemical inventory of hazardous materials in their department and ensure their matching MSDS are current and reported to the Safety Office. All chemicals brought into the hospital must be brought in through Purchasing to ensure there is an MSDS. Employee Responsibilities: *Know where your MSDS are located (can also be accessed on the Intranet under “Applications” link). *Read the MSDS before using any chemical. *Know the proper spills procedure in your area. *Know how to handle and dispose of hazardous materials properly—check with your supervisor if uncertain. *Never mix any chemicals unless you have been trained to do so. *If you receive a hazardous chemical on your unit, ensure that you have the MSDS with it.

27. Non-patient care staff (includes volunteers): External: Be on alert for activation of the Labor Pool. Report to the Labor Pool if activated (you could become involved with transporting patients, providing clerical support, tracking costs, handling phones, comforting families, assisting with patient- care as directed. Internal Assessing physical damages Assessing supplies/equipment Assessing staff/visitor count Documenting activities Tracking disaster-related costs Reporting to the Labor Pool if activated. Patient Care staff: External: Provide patient care Assist in transporting patients to another unit Prepare meds, equipment for patients who might be transported. Remain on alert for the activation of the Labor Pool. Report, if able, to the Labor Pool. Work with MDs assigned to your unit (aka PICS—physicians in charge). Internal Attend to patients and any injuries sustained. Determine if any injuries to staff, visitors. Assess physical damages Assess supplies, equipment. Document activities, costs. Implement back-up plans if systems failure occur (e.g., power outage, water or medical gas failure). Remain on alert for Labor Pool. Work with MDs assigned to your unit. EMERGENCY MANAGEMENT There are two types of disasters: External and Internal. In an External disaster, victims come to the hospital because they have been injured, such as from a mass casualty incident, (e.g., airline crash, refinery explosion). An Internal incident involves damage or threat to the medical center, as in a bomb threat, civil unrest, or an earthquake that not only brings victims to us, but equally causes damages to the hospital. Your Roles and Responsibilities CODE TRIAGE INTERNAL (paged for internal disaster) CODE TRIAGE EXTERNAL (paged for external disaster)

28. EMERGENCY MANAGEMENT COMMUNICATIONS: Back-up communications involve the following: PBX (overhead page) and stentofones (both supplied by generator power). Other back-up communications include: Ham Radio, HEAR, Redinett (all emergency room communications to the outside), hand-held radios, Epic and runners (employees designated to “run” messages if other methods fail). EQUIPMENT AND SUPPLIES: The medical center is on a priority delivery system with Abbott for equipment and supplies. Abbott could deliver supplies by helicopter if necessary. Your role is to know how to access supplies and equipment quickly –e.g., borrow from another unit if necessary, implement conservation, identify priorities, and remember to document equipment, supplies and services as “disaster-related” so that appropriate reimbursement can be obtained if needed. RESOURCES: Be familiar with your Emergency Management Manual, unit-specific emergency preparedness plan, and disaster role boxes if you work in Nursing areas. HICS: “Hospital Incident Command System” HICS is the management-driven system at the medical center used to oversee the process of disaster management. There are pre-defined personnel and roles for the purpose of managing the disaster, using resources, coordinating efforts, treating and transporting patients and tracking information and decision-making. Managers assume their positions, and decisions and actions are made related to disaster.

29. Hospital Incident Command System – “HICS” Basic Chain of Command* LBMMC/MCH * Other positions may be added based upon need; this is a standardized approach to Emergency management used by other hospitals and organizations nationwide

30. Infant and Child Abduction - Code Pink/ Code Purple The infant/child abduction plan consists of: A Written Plan.Identifies how the medical center prevents an infant or child abduction. The plan is found in the Disaster Manual. A Committee (ICIC “Infant and Child Investigative Committee”).Meets regularly to oversee all aspects of the plan. Policies and Procedures. Unit-specific based on needs of unit (e.g., Newborn Nursery, Peds Hem/Onc, General Pediatric units, NICU). A System of Identification.Hospital personnel who are primary caregivers of infants and children are required to wear pink badges. Family and visitors are required to obtain identification stickers and or arm bands. Building Security.Consists of alarms, restricted access, and security surveillance (camera monitoring, patrolling, etc.). Response Team.A “Code Pink” is the official response to an actual or suspected infant abduction. A “Code Purple” is the official response code to an actual or suspected child abduction (>12 months of age). If a Code Purple is called it is essential that an initial search be completed simultaneously with the activation of a Code Purple. This is known as a “unit-specific diligent search plan” (see next slide). If a Code Purple or Pink is activated, key staff from the Hospital Incident Command System (HICS) will activate and respond. Public Safety staff will immediately respond to try and stop the perpetrator, and activate an overall security response plan.

31. Infant and Child Abduction - Code Pink/ Code Purple • Diligent Search occurs simultaneously with a Code Purple activation: • When performing a diligent search of your area, check for the following: • Patient bathrooms • Under counters • In closets • In adjacent departments • Hidden within hospital beds • In equipment rooms • In refreshment rooms • Common bathrooms and staff bathrooms • In cabinets • In other patients’ rooms • Under hospital beds • In waiting rooms • In procedure rooms • In break rooms • In Starlight and Child Life rooms • The manager/lead of the affected department must remain in contact with Pubic Safety throughout the diligent search. If infant/child is found, Public Safety must be notified immediately. • Staff role in Code Pink/Purple: • Observe for suspicious persons • DIAL *911 and give a description of the suspect if seen and the infant or child, and state the location. • Identify the age and sex of the baby • Without risk to yourself, follow at a safe distance, aiming to distract the suspect by saying, “Excuse me, where are you going with that baby [or child]?”, or “Is that baby supposed to be here?”, or “Stop!”. • Distraction techniques serve to take the suspect off course. • Don’t assume that another employee will take on the “tracking” of the suspect. • Enlist help along the way until Security takes over tracking. • Remain in a heightened sense of awareness, observing exits and suspicious activity.

32. SECURITY -- YOU AND YOUR ID BADGE Wear your ID badge consistently and properly and challenge others who don’t! It’s not possible for us to know everyone. A potential perpetrator is someone without an ID badge. Challenge anyone who doesn’t have one who is in an area where he/she shouldn’t be. If there is any doubt, call Security and allow them to investigate. The proper way to wear your ID badge is on your shirt or blouse, above your waist, with the picture showing. This allows all employees to recognize that you belong here. An ID badge may be clasped to a cloth or beaded necklace and worn around the neck. Do not place stickers or other material on your badge that will cover your name or picture. Your badge should be clearly seen as follows: Memorialcare Long Beach Memorial Medial Center John Doe Public Safety Officer Public Safety Every badge has a computer chip in it identifying who owns the badge. Whenever you pass through a badge reader, it registers that YOU entered that area. It is very important that only you use your badge. Can you lend someone your badge? No! An employee can be disciplined for allowing any other person to use his badge. Lost ID badges should be reported and replaced immediately. If a security officer requests an employee to surrender his/her badge, he/she must do so.

33. Code Silver – Person Brandishing a Weapon or Hostage Situation Introduction: A code silver is called when a person is observed brandishing a weapon or has taken a hostage and is threatening others in some way (wants cash, an infant, a child, etc.). It is not necessary for the person to actually use the weapon, but ownership and visibility of the weapon will constitute the need to activate a code silver response. Correct Staff Response: Protect patients and yourself, and do not to respond to the scene. Under no circumstances should you try to talk to the person with the weapon or to the person who has taken a hostage. Immediate Steps to Take: Close and lock doors if possible, and remain barricaded behind the closed doors. Immediately dial *911 to notify Public Safety if at LBMMC/MCH. You may also dial 9-911 and notify the police directly. If you are at OCMMC or SMMC, or SMMC-SC, you should do the following: Orange Coast Memorial Medical Center: Call PBX at x1111 Saddleback Memorial Medical Center: Call PBX at X2111 San Clemente Memorial Medical Center: Call PBX at X2111 Provide the following information: the location, the number of suspects and hostage, the type of weapon involved.

34. Ensure you observe EPIC and electronic mail for directions from Hospital Command Center personnel. Overhead page may be used for general information, such as the announcement of a Code Silver when activated and when the Code Silver has been resolved (an “all clear” will be announced by the PBX operator). • Unified Command: Once the police arrive, the incident becomes their responsibility. They will work in collaboration with trained medical center personnel to apprehend the person with the weapon or hostage. • Safeguards in Place: There are multiple safeguards in place to minimize the risk of a Code Silver. These include, but are not limited to: • Strong partnership with the local police, Department of Homeland Security and local FBI. • State-of-the Art camera surveillance • Canine program (LBMMC/MCH only) • Training Public Safety and staff regarding the correct response to take • De-escalation Technique Training for Staff • Assault Training for Public Safety and Emergency Room staff

35. Fire Prevention • FIRE DRILLS: Each department is responsible for having a unit-specific fire plan. It is your responsibility to know the fire plan, or to ask your supervisor if you have questions. The medical center conducts one planned drill each month per smoke compartment. Each “rehearsal” includes drill instructors who are involved with specific monitoring activities. These include: • Monitoring at the fire’s point of origin. • Monitoring in one of the adjacent smoke compartments. • Monitoring in the smoke compartment above or below the fire’s point of origin. • EXAMPLE: FOOD SERVICE BASEMENT (Smoke Compartment Below) WOMEN’S 2ND FLOOR (Smoke Compartment Above) RADIOLOGY DEPARTMENT (Fire’s Point of Origin) MAIN RECOVERY ( Adjacent Smoke Compartment) EMERGENCY DEPARTMENT (Adjacent Compartment)

36. Drill Instructors will be monitoring: At the Fire’s Point of Origin: Did a staff employee activate the nearest pull station? Was PBX notified of the location, using *2? Did he/she implement R.A.C.E.? Rescue endangered patients/persons Activate the fire alarm system (activate the pull station, and call PBX--PBX will state “Code RED”) Contain the fire, i.e., close the fire doors Extinguish the fire, i.e., obtain the proper fire extinguisher. Did other staff members: remove obstacles from the corridor system, state where their patients would be evacuated, and state how/who would be evacuated? Away from the Fire’s Point of Origin: Drill Instructors will additionally monitor the adjacent smoke compartment, and the smoke compartment above (or) below (point of refuge). If you are in one of these smoke compartments, during a drill or actual fire, you should: Clear obstacles (e.g., equipment, storage) from their corridors Close doors in the unit, to contain the spread of any smoke or fire. If possible, have one member go to the fire’s point of origin (in the example pictured, it would be Radiology), and ask if help is needed. Determine bed availability, and triage of patients—be ready to accept patients if evacuation is necessary. Fire Prevention Smoke Compartment: Separated by 1 or 2-hour smoke walls. If you had to evacuate your patients--it would be to the adjacent smoke compartment, and it would be a horizontal evacuation.

37. HOW TO USE A FIRE EXTINGUISHER • ABC fire extinguishers are in place throughout our hospitals in the event a fire occurs. The ABC fire extinguisher can be used on the following categories of fire: • Trash, wood, paper, cloth and rubbish • Oil, paint, grease, propane and flammable liquid fires • Electrical equipment fires How to Use a Fire Extinguisher: There are four easy steps in remembering how to properly use a fire extinguisher: • Pull the pin (at the top of the fire extinguisher) • Aim the nozzle (the rubber hose part) • Squeeze the trigger (the handle at the top) • Sweep from side to side (move the fire extinguisher as a whole unit, from side • to side). • The diagram below represents how an ABC fire extinguishers looks: USE ON ALL FIRES A C B

38. SAFE MEDICAL DEVICE REPORTING • Medical Device: This is defined as an instrument, apparatus, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part or accessory, which is : • Recognized in the official National Formulary, or in the United States Pharmocopedia, or any supplement to them. • Intended for use in the diagnosis of disease or other conditions, or in thecure, mitigation, treatment or prevention of disease. • Intended to affect the structure or any function of the body, and which does not achieve its primary intended purposes through chemical action within or on the body and which is not dependent upon being metabolized for the achievement of any of its intended purposes. Examples of medical devices include, but are not limited to the following: catheters, infusion pumps, hospital beds, patient restraints, suture materials, syringes, defibrillators, pacemakers, wheelchairs, imaging equipment, etc. • Serious illness and Serious Injury are defined as: • Life threatening. • Results in permanent impairment of a body function or permanent damage to a body structure. • Necessitates immediate medical or surgical intervention to preclude permanent impairment of a body function or permanent damage to a body structure.

39. SAFE MEDICAL DEVICE REPORTING • STAFF ROLE: If a medical device causes serious illness, injury or death to your patient, your specific role is: • 1. Isolate the equipment • 2. Do not change any of the controls. • 3. Identify the patient’s name, date, time of incident, patient’s room, and place a red defective tag on the equipment. • 4. Begin the reporting procedure: • Notify your supervisor/lead. • Notify Biomed immediately • Notify Risk Management immediately • Complete an Employee’s Confidential Report of Unusual Occurrence on-line for theRisk Management Department. • The supervisor or lead is responsible for assuring the reporting occurs as soon • as possible after the occurrence, but no more than eight hours after the occurrence.

40. UTILITIES MANAGEMENT There are several components to the emergency power system that supplies alternate power to our hospital buildings in the event there is a failure with the city’s power grid that feeds our electrical systems. These include: Source of Power: The emergency power system provides sufficient power to designated areas and maintains essential functions during power failures thereby reducing the risks associated with such failures. It takes less than 10 seconds to “kick in”. Inspections: The emergency power system is inspected, tested and maintained properly so that it will function reliably when the need arises. The emergency generators are tested monthly to ensure operational ability. Written Program: There is a written preventive maintenance (PM) program along with written documentation of inspections, testing, and maintenance of the generators. The emergency electrical system program also includes documentation of training and education for the individuals who use, operate or maintain the emergency power system.

41. UTILITIES MANAGEMENT EMERGENCY POWER SYSTEM. The emergency power system is served by four 350KW diesel-powered generators and four 450 KW diesel-powered generators, making a total of eight generators. These are tested monthly for reliability under specified conditions. • All life safety systems are provided with electricity by the emergency power system. These include: • Alarm Systems • Egress Illumination (Stairwells and corridors) • Elevators • Emergency Communications • Systems (PBX) • Illumination of Exit Signs • All critical service areas are provided electricity by the emergency power system. These include: • Blood, bone and tissue storage • Emergency, Intensive Care, PICU, NICU’s, Newborn, Obstetrical Delivery areas • Operating and Post-Operative Recovery rooms • Medical Air Compressors • Medical/surgical vacuum systems • Your Role: • Know the locations of your red plugs; know that they afford an alternate source of power to your area, and know how to perform emergency clinical interventions within your scope of practice in the event of a power failure when emergency power is not available. • RED PLUGS: A red plug means that the emergency generator supplies alternate power to that area in the event of a power outage. If there is a failure and we need to use our emergency generator power, it can last 7-10 days, depending upon how much we use, how long we use it, and measures we take to conserve it.

42. Protective Services Child Abuse and Neglect: What is it? It is the mistreatment of children either by hurting them physically, emotionally, sexually or by neglecting them. Many times, abused children experience a combination of these types of abuse. If a parent or care provider fails to keep a child safe and free from harm, it is neglectful, abusive and illegal and must be reported to the police or the Department of Children Services immediately. What does it look like? Most abused children will not tell anyone they are being hurt. An abused child may become depressed, may withdraw, think of suicide or become violent. An older child may use drugs or alcohol, try to run away or abuse others. The following signs may signal the presence of child abuse or neglect. The Child: • Has unexplained burns, bites, bruises, broken bones • Has fading bruises or other marks that are unexplainable • May have multiple emergency room visits to several different hospitals • Has not received help for physical or medical problems brought to the parents' attention • Lacks adult supervision • Is overly compliant, passive, or withdrawn • Is unusually quiet around of the parent or seems frightened of the parent • Reports injury by a parent or caregiver

43. Protective Services The Parent/Caregiver: • Offers conflicting, unconvincing or no explanation for the child’s injury • Blames the child for being clumsy or highly active and uncontrollable • Shows little concern for the child and/or rarely visits child while in the hospital • Speaks to the child in a mean, degrading tone • Talks for the child and does not let him/her speak What should you do? • ACT • A: Assess your patient for bruises and physical signs of injury as well as mood and injury history. Always ASK Safety and Role Relationship questions found on the Patient Profile and document your assessment. • C: Contact the Social Work department to assist you with further assessment and your reporting duties. • T: Tell the Department of Children and Family Services (DCFS) immediately about your concerns and suspicions AND write the required report that will be sent to DCFS. ACT

44. Protective Services Domestic Violence: What is it? It occurs when one person (male or female) in an intimate relationship tries to dominate and control the other person through physical harm, emotional and/or verbal abuse, isolation, threats and intimidation. This type of violence can occur between married people, lesbian and gay relationships, roommates and dating couples, which include teenagers. Domestic Violence is illegal and must be reported to the police immediately. What does it look like? There is no way to tell for sure if someone is experiencing domestic violence unless they tell you they are being abused. Those who are battered and those who abuse come in all personality types and are of all shapes, sizes, ethnic backgrounds and income brackets.

45. Protective Services Most people experiencing violence in a relationship do not tell others what is going on at home, so how do you tell if your patient might be a victim of domestic violence? • Patient may have bruises/physical injuries that are not clearly explainable • Patient may report a history of repeated injuries at different times • Patient may talk about being “clumsy”, in an attempt to explain injuries • Patient may offer vague or elaborate stories of how the injuries occurred • Patient may have multiple related emergency room visits with injuries of increasing severity • Patients may not seek medical attention in a timely manner • Patients may talk about being hopeless, tired, and fearful and have multiple suicide attempts • Typically in a hospital setting, the abuser refuses to leave the bedside of the abused. The abuser may appear to be overly controlling and answer all questions directed towards the patient. What should you do? • ACT • A: Assess your patient for bruises and physical signs of injury as well as mood and injury history. Always ASK safety questions found on the Patient Profile and document your assessment. • C: Contact the Social Work department to assist you with further assessment and your reporting duties. • T: Tell the police immediately about your concerns and suspicions AND write the required report that will be mailed to the police department. ACT

46. Protective Services Elder and Dependent Abuse: What is it? It is any mistreatment that harms an adult who is usually disabled, frail or dependent on another for care. An elder adult is any person between the ages of 18 and 64 who is admitted as an inpatient in an acute care hospital. Elders and dependent adults can neglect themselves by not caring about their own health or safety, which may lead to illness or injury. Failing to keep the elder or dependent adult safe and free from harm is neglectful, abusive and illegal and must be reported to Adult Protective Services immediately. What does it look like? Most victims of elder/dependent adult abuse rely on the people who hurt them, sometimes for food, shelter, personal care or companionship. Victims of this type of abuse know their abusers and are often related to them. Elder abuse usually occurs in either the home or in a nursing home.

47. Protective Services Some warning signs to look for are: • Physical abuse, such as bruises, burn marks, broken bones and other injuries which cannot be adequately explained. • Malnourishment and lack of physical care including dehydration, poor hygiene, bed sores or over sedation. • Many times this type of abuse includes misuse or the persons money or finances. This usually happens when a family member is dependent on the victim for money or a place to live. • Frequently the victim cannot communicate clearly what is happening due to confusion, fearfulness or mental capacity. What should you do? • ACT • A: Assess your patient for bruises, bed sores and physical signs of injury as well as mood and injury history. Always ASK safety questions found on the Patient Profile and document your assessment. • C: Contact the Social Work department to assist you with further assessment and your reporting duties. • T: Tell the police or Adult ProtectiveServices immediately about your concerns and suspicions AND write the required report that will be mailed to the agency. ACT

48. RESPONSIBLE USE OF TECHNOLOGY RESOURCES AND INFORMATION • WHAT IS APPROPRIATE AND RESPONSIBLE USE OF INFORMATION RESOURCES? • This means that you must use the resource in a manner that is consistent with the specific objectives of your task or project, for which the use was intended. • SECURITY OF DATA--USER RESPONSIBILITY • Even though the Info Systems department provides and preserves the security of files, account numbers, authorization codes, user names and passwords, sometimes the security can be broken through actions or causes beyond their control. Your responsibility when using information resources is to: • Safeguard your data, personal information, passwords, authorization codes and confidential data. • Choose your passwords wisely. • Change your passwords as requested by IS. • Follow the security policies and procedures established to control access to, and use of data. • Do not make copies of licensed computer programs. • Do not share passwords, user names, transactions, data and processes assigned to you. • Respect the privacy of others, e.g., forged electronic mail, intimidating or harassing mail and chain messages are strictly prohibited. • Alterations to any system or network software or data can be made only when authorized. • No changes can be made to charges levied by MHS.

49. RESPONSIBLE USE OF TECHNOLOGY RESOURCES AND INFORMATION A WORD ABOUT PRIVACY AND WORK AREAS: • LBMMC/MCH’s computer systems and other technical resources, including any voice mail or E-Mail systems, are provided for use strictly in the pursuit of LBMMC/MCH business. • Any electronically stored communications that an employee either sends to, or receives from others, may be retrieved and reviewed by the medical center. • Employees do not have a right of privacy as to any information on file, or maintained in, LBMMC/MCH property. • Desks, storage areas, work areas, lockers, file cabinets, credenzas, computer systems, office telephones, modems, FAX machines, copy machines and LBMMC/MCH vehicles are hospital property and must be kept clean, and are to be used only for work purposes. • Any work on these systems can be searched or monitored at any time by administrative authority.

50. CODE OF CONDUCT Memorial Health Services has a Code of Conduct by which all employees will conduct themselves in order to protect and promote organization-wide integrity, and to enhance MHS’ ability to achieve the organization’s mission. The Code of Conduct can be illustrated as follows: • Legal Compliance • Includes issues relating to: • fraud and abuse • tax antitrust • lobbying • environment of care (safety), • discrimination • sexual harassment • drugs, narcotics, alcohol • accurate recording of employee • information. Business Ethics Behavior relating to professional conduct, honest communication and misappropriation of proprietary information. Code of Conduct • Confidentiality • Behavior relating to the protection of: • patient information • proprietary information • personnel actions/decisions. • Protection of Assets • Action relating to: • Internal Control • Financial Reporting • Travel and Entertainment • Personal use of corporate assets • Conflicts of Interest • Activities relating to: • outside financial interests • services of competitors/vendors • participation on boards • honoraria. Note: The Ethics and Compliance Hotline allows you to call an occurrence or situation you feel is unethical, illegal, or irresponsible and one that could cause loss or harm to MHS, our employees or our patients. HOTLINE: (888) 933-9044 • Business Interests • Issues relating to: • gifts and gratuities • workshops, seminars and training • contracting • business inducements