Agency, Vendor, Instructor, Student
Riverside Community Hospital
Department of Education
4445 Magnolia Ave
Riverside, CA 92501
Dear Agency, Vendor, and Student:
On behalf of all the employees, medical staff and volunteers at Riverside Community Hospital,
welcome to our organization! We are pleased you have chosen our hospital!
We have been providing the finest quality service to our community for over 100 years, making us the
first choice for health care in the Inland Empire. Riverside Community Hospital was founded in 1901.
We are a 373 licensed bed, full-service acute care hospital in the heart of the Inland Empire. We work
with over 500 physicians on staff, representing over 200 specialties and employ over 1,800 employees.
Our fine reputation throughout the community is based upon the quality of care we provide to our
patients and visitors every day and the extraordinary level of customer service practiced by our
employees. As we continue to build upon the successes of our organization, we look to you working
alongside our employees to contribute your ideas and enthusiasm, as you conduct yourself in an ethical
and professional manner.
This orientation package is provided to help you develop into a part of the hospital team by becoming
familiar with some of our policies, guidelines, and procedures. We want you to understand your
responsibilities while in the hospital setting.
While all information is valuable, you will find that we have categorized specific information in such a
way as to use your time in the most efficient manner. You are ultimately responsible for all the
information presented in this orientation manual.
You must return all required forms (HIPPA, IT&S Security, Confidentiality Agreement, and
Attestation Forms) to the Education Department or appropriate contact person (clinical instructor),
completed in full, prior to your first work or clinical day in the hospital. You cannot report for work or
attend clinical at Riverside Community Hospital until you have completed and turned in these forms.
We hope this information will provide you with a smooth transition into your responsibilities here at
Riverside Community Hospital. Our goal is to provide outstanding care to the community of Riverside
and support your educational needs. Please provide us with feedback and follow-up in regard to ways
we can improve your experience.
Fran Paschall, MSN, RN
CNO, Senior Vice President
Riverside Community Hospital
4445 Magnolia Ave.
Riverside, CA 92501
RIVERSIDE COMMUNITY HOSPITAL
Agency, Vendor, Student Orientation Manual
TABLE OF CONTENTS
Mission Statement, Our Vision and Services ………………………………………………
Nursing Vision and Philosophy…………………………………………………………….
Key Telephone Numbers & Resources …………………………………………………….
Chain of Command…………………………………………………………………………
Pillars of Success…………………………………………………………………………..
Improving Patient Centered Treatment “iMPaCT”………………………………………..
Caring Model & AIDET…………………………………………………………………...
Ethics and Compliance (Code of Conduct)………………………………………………..
California False Claims Law Summary……………………………………………………
HIPAA (Privacy Protected Elements and Information Security)…………………………
California Privacy Act and HITECH (Health Info Tech for Economic and Clinical Health)
2014 National Patient Safety Goals…………………………………………………………
Patient Rights and Responsibilities…………………………………………………………
Advanced Directives, Organ Donation, Interpreters………………………………………..
Falling Stars Program, Suicide Precautions, Infant Abandonment, Restraints…………….
Attendance Policy (HR 157 & 157a)……………………………………………………….
Dress Code Policy (HR 174)……………………………………………………………….
Smoking Policy (GA 14)……………………………………………………………………
Influenza Vaccination and Post Exposure Follow-up Policy (EH 200)……………………
Internet, Email, Cell Phone Policy (HR 190)………………………………………………
Hospital Safety and Access………………………………………………………………....
Emergency Codes (Dial 4911)………………………………………………………………
Radiation and MRI Safety…………………………………………………………………
Ergonomics and Back Safety……………………………………………………………...
Slips, Trips, and Falls Prevention…………………………………………………………
Latex Allergies: Screening and Diagnosis…………………………………………………
Security & Workplace Violence……………………………………………………………
Infant and Child Safety……………………………………………………………………...
Clinical Patient Care & Patient Safety………………………………………………………
Supply Scan Monitors………………………………………………………………………
Reporting Errors and “Near Misses”……………………………………………………….
Notice of Asbestos-Containing Materials…………………………………………………..
Confidentiality and Security Agreement……………………………………………………
Exhibit B -Protected Health Information, Confidentiality, and Security Statement ………
Agency, Vendor, Student Verification & Attestation………………………………………
Mandatory Reporting Child & Dependant Elder Abuse……………………………………
Riverside Community Hospital is committed to the care and comfort of our patients and
improving the overall health of our community by providing healthcare services with
integrity, compassion, and excellence.
Riverside Community Hospital will be the employer and provider of choice by offering
comprehensive healthcare services whose cornerstones are quality, safety, compassion,
and service excellence.
Riverside Community Hospital values include:
Passion for Excellence
We are a 373 licensed bed, acute care hospital, some of our services include:
Level II Trauma Center,
Level IIIc Neonatal Intensive Care Unit (NICU),
Cardiac Cath Lab (CCL),
Open-heart surgery & Heart Care Rehabilitation Program (HCR),
Transplant Unit (kidney & pancreas),
Observation Unit (OBS Unit),
Radiology Oncology Center
Bariatric Care (Center of Excellence)
PATIENT CARE DEPARTMENT
As you join Team RCH, you will be collaborating with us to provide quality care to our
patients. We have developed this package to be your working reference as you orient to
your new responsibilities.
PATIENT CARE SERVICES VISION
The professional nursing practice at Riverside Community Hospital strives for
excellence in the delivery of patient care. This is accomplished through professional
collaboration and teamwork while partnering with our community.
Professional nursing practice is a caring art that employs scientific and business to
promote the health and well being of individuals, families and communities. Goals are
Incorporating professional values as articulated in the American Nurses
Association’s Social Policy Statement, Standards of Practice and Code for
Nurses, into policies and practice;
Creating a work environment that facilitates and encourages the involvement of
staff into critical thinking to enhance professional nursing practice;
Partnering with patients, families and other healthcare providers to ensure the
involvement of patients/families in the care process and the coordination of
comprehensive care and services across the continuum;
Respecting the rights and sensitivities of religious/ethical/cultural beliefs of our
diverse patient community; integrating new knowledge into our practice and
contributing to the emerging body of nursing knowledge through participation in
education, research and communication about nursing practice;
Examining individual nursing associates’ commitment to the delivery of quality
care and accountability for their practice; proactively developing the response to
our dynamic healthcare environment; managing resources cost-effectively;
collaborating and integrating with other professional disciplines and functional
Becoming involved with professional and community initiatives that are both
internal and external to the hospital.
Please visit RCH’s website to learn more about nursing and the hospital:
MICU (Angela Johnson-Director)
Administrative Liaison (Pager 278)
Mother/Baby (Robin Caston-Manager)
3331 or 3332
Adverse Drug Reaction "HOT LINE"
NICU CNS (Cindy Sessler)
All About Staffing
NICU Manager (Vicki Hirschel)
Angio & Special Procedures
North -3 CVU (Sarah Shupek-Manager)
Best Upon Request (Concierge)
North -4 ICU Overflow (Angela Johnson-Director)
Nursery - Well Baby
Chaplain / Community Outreach
Critical Care Educator (Susan Jordon-Talaska)
D-2 Med/ Surg (Pat Bridenstine- Director)
South-4 PCU (Carol Castagnola- Director)
D-2 Transplant (Pat Bridenstine-Director)
D-3 Medical (Sonia Cloninger-Manager)
Peri-operative Educator (Toni Horton)
Peri-operative Services (Barbara Bateman – Dir.)
PICC Line Nurse
Education Generalist (Christina Callanan)
Public Safety “Hot Line”
Public Safety Office
Emergency Department (Karina Kilian- Director)
Emergency Educator (Wendy McEuen)
Rapid Response Team
Rehab Services (PT/OT/Speech – Joellyn Hiller Dir.)
SICU (Cynthia Jugo-Director)
GI / Endoscopy
South -3 Telemetry (Shanala Lincoln-Manager)
South -4 Telemetry (Carol Castagnola-Director)
South -5 (Barbara Frank-Director)
South -6 Orthopedics (Anita Cox-Manager)
Information Services HELP DESK
Labor and Delivery
Telemetry Educator (Debbie Burton)
Maternal/Child Director (Debbie Salvail)
Maternal/Child Educator (Maggie Suarez)
Treadmill Stress Test Lab
Medical Records / HIM
Ultrasound & Vascular Lab
Medical Records Old Charts
Med-Surg Educator (Hilda Onsoe)
Wound & Skin Care Nurse (Rachel Pacheco / Kevin Ward)
ALL students and faculty will park off-site if on campus Monday-Friday, DAY shift. The
designated parking lot for students/faculty is the “yellow” Lot 33 located on 3rd & Market.
Shuttle service will transport to and from the parking lot to the hospital from 5:30AM to
8:30PM. Those who have weekend/night shift clinical rotations will park in the lot at
4000 14th St . or in the lot in front of Church (parking fee). Parking sticker decals are not
Chain of Command
For most staff, the first link in the chain of command is their supervisor or charge nurse.
For students, the first link in the chain of command is their preceptor and clinical instructor.
If further action is needed or an issue is unresolved, the department’s manager would be
The next level from here is the department’s director.
o If a manager or director are unavailable and the supervisor/ charge nurse is unable to
resolve the issue, there is an administrative liaison (supervisor) on premises 24 hours a
day and on weekends.
o A director and/ or manager are always available during the day, are on call, and may be
reached via the operator, in the evenings and on weekends.
Above these professionals are Famy Bialon, V.P. of Patient Care Services, Fran Paschall, V.P.
and Chief Nursing Officer, and, Dan Bowers, Chief Operating Officer.
The charts above are to acquaint you to the organizational structure and familiarize you with
our chain of command.
PILLARS OF SUCCESS
Treat Everyone with
Dignity and Respect,
Retains and Attracts
the Best People
Anticipating How to
Satisfy Patients and
Customer Needs and
Improving Access to
the Efficiency of
Delivering Care to
Quality of Patient
to Enable Investment
in People, Service,
Quality, and Growth
Growing the Number of
Patients we Serve and
the Availability of
Services we Offer to
Test & TMT
Bad Debt) Per
Improving Patient Centered Treatment
“iMPaCT” – iMproving Patient- Centered Treatment – which has to do with the patients’ entire
experience, including their clinical care and how every member of our staff interacts with them.
The logo for iMPaCT, which includes 4, increasing in size, semi-circles that flow off the “i” like a
ripple in water. They signify the impact an action we make can have on our patients and how that
action can extend well beyond our intentions.
As health industry professionals, whether we are caregivers or administrative workers or part of
the environmental services team, our actions and choices have an impact on our patients. We can
each have a positive impact at our facility by building on our tradition of caring, which means that we
all need to work together to create a positive effect that results in the best patient experience.
Some of your goals as a health team member at RCH are:
Patient-centered quality care at the heart of what we do
Work each day to have a positive impact on the patient experience.
Make a real difference in our patients’ perceptions of their experience and of RCH
To understand and respect our patients’ expectations and perceptions
“HCAHPS” stands for “Hospital Consumer Assessment of Healthcare Providers and Systems.”
Not every patient will participate in the HCAHPS Survey but patients are selected at random to
complete the survey after discharge. Survey results are submitted quarterly to the Centers for
Medicare & Medicaid (CMS). CMS then publishes the results on the internet
(www.hospitalcompare.hhs.gov) allowing patients to compare hospitals in their community on
how patients perceive the care and service they have received.
Riverside Community Hospital strives to provide the best patient experience possible through excellent
patient care and service.
By providing a level of care that meets patients’ expectations means our patients feel cared for and
cared about, no matter what area of our organization is working with them.
The HCAHPS survey measures eight categories:
Communication with nurses,
Communication with doctors,
The responsiveness of hospital staff,
The cleanliness of the hospital environment,
The quietness of the hospital environment,
Communication about medication and
Providing effective, clear discharge information.
Although all eight categories are important to the patient, we’ve found through internal research that
three of them have the greatest impact on a patient’s experience.
The three categories that produce the greatest impact are:
Communication with nurses,
Why do you think these categories have the greatest impact on a patient’s experience?
Nurses have the most contact with patients
Patients don’t always know who the nurse is; anyone in a uniform might be perceived as a
Lack of communication increases anxiety
If the room is not clean the patient may wonder what else is not clean
Fear of infection from unsanitary conditions
No one wants to be in pain
Uncontrolled pain increases patient anxiety
What’s important is that these HCAHPS categories touch on the job duties, effectiveness and
service of all employees, not just medical staff and nurses. In fact, many patients have a difficult
time distinguishing between the many different healthcare professions and roles. That’s that “ripple
effect” in the impact logo we were talking about. To them, each and every one of us is the hospital.
Take the category of “cleanliness” as an example. What’s one thing that each of us could do –
regardless of our jobs – to have a positive impact on patients’ perceptions of cleanliness at our facility?
Pick up garbage when we see it
Inform appropriate staff if an area needs attention
Keep my personal workspace clean
Keep myself clean and professional
Don’t publically complain about an untidy area
Remember: the cleanliness of a facility can be viewed by the patient as a reflection of the people that
work in the facility and how much they care.
The HCAHPS survey helps us in building up our culture of service.
First, providing an excellent care experience is the right thing to do; it’s the way we would want
ourselves or our own family treated. Our survey results help us focus on what we’re doing right and
where we can do better.
Second, HCAHPS is now the publicly-reported avenue by which we can share our commitment to
service. Through our results, consumers will be able to see our ability to create a positive care
experience, compared to other competitive facilities in our market.
Third, patient perceptions of care are related to patient outcomes. Studies show that patients who feel
more engaged in their care are more likely to ask questions, identify potential problems and raise
concerns. In other words, the better patients feel about their care, the better their outcome.
Finally, good performance is good business. Wanting to score well on the HCAHPS survey is, of
course, the right thing to do. However, HCAHPS scores are also tied to public reporting and will
likely be linked to Medicare reimbursement in the future. Employers and commercial payers are
already using this information to determine participation in premium networks. The Joint Commission
has also incorporated HCAHPS performance into their S3 hospital reports.
Put yourself in your patients’ shoes: if you’ve ever had a bad experience in a hospital, doctor’s office
or restaurant, you may have had negative feelings. So think how the patients perceive your actions day
Here are some questions to consider:
What do patients think when they see a dirty floor or room?
What do patients think when it is too noisy for them to rest?
What do patients think when they do not understand what they are supposed to do after they
leave the hospital?
What do patients think when the nurse or doctor doesn’t take the time to listen and seems in a
hurry to leave?
What do patients think when people enter and care for them without telling them why they are
there or who they are?
What do patients think when their food is not the correct temperature or is not delivered at an
What do patients think when they do not understand items listed on their bill?
What actions can you take to positively impact patient satisfaction?
Treat the patient as you’d want your family or yourself treated (i.e., with compassion and
Communicate what you’re doing in a way the patient will understand and accept
Show compassion and courtesy
Don’t assume patients know who you are and what you do
Explain things that may just seem routine to you
Be consistent – do these things always
Manage the expectations of patients and caregivers
Here are some actions that have been proven to improve our patient’s perception of care, which we call
the “Caring Model.” The Caring Model outlines key actions each of us can take to have a direct and
positive impact on the patient experience.
The “Caring Model” is the model for HCA” and at RCHs we also use the AIDET model.
The Caring Model includes five actions, they are:
Introducing yourself to the patient and discussing your role in his/her care that day;
Always calling the patient by his/her preferred name;
Sitting eye level at the patient’s bedside;
Using touch appropriately (a handshake or a touch on the arm);
Speaking positively about another caregiver in the patient’s presence.
“AIDET” (Knock First)
A = Acknowledgment
I = Introduction / Welcome
D = Duration (of time you will spend with the patient)
E = Explanation (of why you are here/what you will be doing)
T = Thank you
*Always end with, “Is there anything else I can do for you? I have the time”
We all have the opportunity to use the Caring Model, even if we don’t provide direct patient care. Each
RCH employee is essential to the care of our patients and has an impact on the patient experience
through their interactions directly with patients or indirectly through coworkers, physicians, and others
at our facility.
One important skill in any RCH team member is Active listening. Active listening is not the same as
listening. We actively listen by clarifying patient statements/questions, summarizing/paraphrasing
patient statements/questions, through body language (i.e., leaning forward, positive/responsive facial
expressions) and asking follow-up questions. Responsiveness and therapeutic communication (i.e.,
communication that helps patients and their families know that someone cares about them and
understands their needs and feelings) are very important to patient satisfaction?
The patient’s perspective on their care experience is the one that counts.
They need to feel good about the care they received
They need to feel good about the people who delivered it.
They need to feel cared for and cared about, whether they are receiving a medical procedure, or
receiving a call about their billing.
We all play a part, and we all have impact.
We have learned a lot about how our actions can impact the patient experience and their perceptions of
our service and care on a daily basis. To maintain our tradition of caring, we must ensure that our
patients, their families and the communities we serve are aware of and experience our unwavering
commitment to care. The way we do that is for everyone in our facility to use the actions we have
discussed today to have a positive impact when dealing with patients and their families. Thanks for
participating in the training and maximizing your impact on our patients!
Ethics & Compliance (Code of Conduct)
The Ethics Committee helps resolve conflicts of opinions as they relate to issues such as the end-of life
issues or risk/benefits of treatment plans. Any staff member, patient, or visitor can access the Ethics
Committee by calling Patient Care Services or Social Services.
We follow the HCA Code of Conduct, which guides our daily activities within appropriate ethical and
We all have the responsibility to report any activity that appears to violate applicable laws, rules,
regulations, or standards. If you need guidance on an ethics or compliance issue or have any concerns
about our conduct, contact:
Russ Young – Chief Financial Officer (CFO) & Ethics Compliance Officer: ext. 3360
Corporate Ethics Line: 1-800-455-1996
Janeille Kilgore – Assistant Ethics Compliance Officer: ext. 3167
Code of Conduct Session:
“Linking to Tradition…the Path to Healthy Conduct”
The purpose of our Code of Conduct is to provide guidance in carrying out our daily activities within
appropriate ethical and legal standards. The Code can help you make the right decisions at the right
times and remove doubt about questionable situations.
By signing the attestation you are acknowledging that:
You participated in this modular instruction
You understand the Code represents mandatory policies, and
You agree to abide by it.
The Code of Conduct is just one part of our Ethics and compliance
Program. The Program elements include:
Communication and Awareness
Measuring Program Effectiveness
Process for reporting concerns:
Follow chain of command
Ethics Line – 800-455-1996
HCA committed to fair resolution of issues with no retribution
…you will be given a copy of the false claims act for the State of
California. If you have questions about ‘false claims’ please see
Each individual has a “personal obligation to report” concerns.
We must take responsibility for our own actions and be
responsible to report violations of laws, rules, regulations,
standards, or this code.
There are a variety of Committees at the Corporate and facility
level dedicated to creating and implementing our Ethics
Our Ethics and Compliance Officer is:
Russ Young (ext. 3360) and
Assistant Ethics and Compliance Officer:
Janeille Kilgore (ext. 3167)
HCA’s Mission & Values:
Above all else, we are committed to the care and improvement of human life. In recognition of this
commitment, we strive to deliver high quality, cost effective healthcare in the communities we serve.
In pursuit of our mission, we believe the following value statements are essential and timeless.
• We recognize and affirm the unique and intrinsic worth of each individual.
• We treat all those we serve with compassion and kindness.
• We act with absolute honesty, integrity and fairness in the way we conduct our business and the way
we live our lives.
• We trust our colleagues as valuable members of our healthcare team and pledge to treat one another
with loyalty, respect and dignity.
HCA Stakeholders –Who are “Stakeholders”?
Stakeholders are the groups of people who count on us to uphold the Code of Conduct. . Each day our
actions can impact many ‘stakeholders’…remember that our actions and words affect those around us.
Communities we serve,
Patients: When we talk about ‘stakeholders’, it doesn’t’ get any more important than what we do for
our patients. The Code of Conduct says a lot about patients and how we can best serve and protect our
patients. It talks about:
Quality of care, patient safety and patient rights
Let’s look at each one:
1. The opportunity to provide quality and safe care are
everywhere, from how we mop the floors to how we
prepare for surgery. We can only be good at it if everyone
takes responsibility for it!
2. Patient Health Information/Protected Health
Our Facility Privacy Officer is: Janeille Kilgore
Make sure you are doing all you can to protect
information appropriately and legally.
3. EMTALA/Emergency Treatment – Under the Emergency
Medical Treatment and Active Labor Act (EMTALA),
patients must be provided an emergency screening exam and
necessary stabilization and treatment (even if it’s been
determined they cannot pay).
HCA and Physicians
Like patients, physicians are one of our key ‘stakeholders’.
The Code discusses physicians in terms of the work
environment and business relationships
HCA’s Mission and values expected by the Code of Conduct:
The Code of Conduct asks you to:
Identify how our actions impact a patient’s perception of care provided by our facility.
List actions we can take to provide best-in-class service and promote a positive, caring patient
Begin to look at situations through a patient’s eyes.
Communication and Avoiding Conflict of Interest:
Linking to Tradition…the Path to Healthy Conduct
Code of Conduct Orientation Participant Handout
Summary of Other Code Sections
Prescription and controlled medications and supplies must be handled properly
and only by authorized individuals to minimize risks to us and to patients.
If one becomes aware of inadequate security of drugs or controlled substances or
the diversion of drugs from the organization, the incident must be reported
HCA facilities strictly enforce the reporting of any violations of diverting
medications by facility staff or privileged practitioners.
Colleagues are prohibited from taking for themselves personally opportunities
that are discovered through the use of HCA property, information or position for
personal gain and completing with HCA.
Diversity and Equal
We provide an inclusive work environment where everyone is treated with
fairness, dignity, and respect.
We create and maintain a setting in which we celebrate cultural and other
differences and consider them strengths of the organization.
HCA is an equal opportunity workforce and no one shall discriminate against
any individual with regard to race, color, religion, sex, national origin, age,
disability, sexual orientation, gender identity, genetic information or veteran
status with respect to any offer, or term or condition, of employment.
We make reasonable accommodations to the known physical and mental
limitations of qualified individuals with disabilities.
Hiring of Former and
Current Government and
Colleagues should consult with the Corporate Human Resources Department or
the Legal Department regarding such recruitment and hiring.
We do not contract with, employ, or bill for services rendered by an individual or
entity that is excluded or ineligible to participate in Federal healthcare programs;
suspended or debarred from Federal government contracts and has not been
reinstated in a Federal healthcare program after a period of exclusion,
suspension, debarment, or ineligibility.
Colleagues, vendors, and privileged practitioners at one or more HCA facilities
are required to report to us if they become excluded, debarred, or ineligible to
participate in Federal healthcare programs.
Insider Information and
Colleagues may not discuss non-public, material information with anyone
outside of the organization. Within the organization, colleagues should discuss
this information on a strictly "need to know" basis only with other colleagues
who require this information to perform their jobs.
If an HCA colleague obtains access to non-public, material information about the
organization, or any other company while performing his or her job, the
colleague may not use that information to buy, sell, transfer, gift or effect other
transactions of securities of HCA or that other company.
As a general rule, the personal use of any HCA asset without prior supervisory
approval is prohibited.
The occasional use of items, such as copying facilities or telephones, where the
cost to HCA is insignificant, is permissible.
Community or charitable use must be approved in advance by one’s supervisor.
Use of organization resources for personal financial gain is prohibited.
Personal Use of HCA
Relationships Among HCA
No one should ever feel compelled to give a gift to anyone, and any gifts offered
or received should be appropriate to the circumstances.
No one should ever be compelled to participate in fund-raising efforts
undertaken by individual colleagues.
No one should be compelled to contribute to the charitable organizations
supported by HCA.
and Clinical Trials
Physicians conducting clinical trials of investigational products and services are
expected to fully inform all subjects of their rights and responsibilities of
participating in the clinical trial.
All potential subjects asked to participate in a clinical trial are informed of:
alternative services that might prove beneficial to them; potential discomforts;
the risks, expected benefits, and alternatives; and the procedures to be followed,
especially those that are experimental in nature.
Any HCA facility or colleague applying for or performing research of any type
must: follow all applicable research guidelines and privacy policies; maintain
the highest standards of ethics and accuracy in any written or oral
communications regarding the research project; and engage in human subject
research in conjunction with IRB approval and consistent with Company policies
regarding human subject research and IRBs.
Substance Abuse and Mental
All colleagues must report for work free of the influence of alcohol and illegal
Reporting to work under the influence of any illegal drug or alcohol; having an
illegal drug in a colleague’s system; or using, possessing, or selling illegal drugs
while on HCA work time or property may result in immediate termination.
We may use drug testing as a means of enforcing this policy.
California False Claims Law Summary
FALSE CLAIMS LAWS
One of the primary purposes of false claims laws is to combat fraud and abuse in government health
care programs. False claims laws do this by making it possible for the government to bring civil
actions to recover damages and penalties when healthcare providers submit false claims. These laws
often permit qui tam suits as well, which are lawsuits brought by lay people, typically employees or
former employees of healthcare facilities that submit false claims.
There is a federal False Claims Act and a California state version of the False Claims Act. Under the
federal False Claims Act, any person or entity that knowingly submits a false or fraudulent claim for
payment of United States Government funds is liable for significant penalties and fines. The fines
include a penalty of up to three times the Government’s damages, civil penalties ranging from $5,500
to $11,000 per false claim, and the costs of the civil action against the entity that submitted the false
claims. Generally, the federal False Claims Act applies to any federally funded program. The False
Claims Act applies, for example, to claims submitted by healthcare providers to Medicare or Medicaid.
One of the unique aspects of the federal False Claims Act is the “qui tam” provision, commonly
referred to as the “whistleblower” provision. This allows a private person with knowledge of a false
claim to bring a civil action on behalf of the United States Government. The purpose of bringing the
qui tam suit is to recover the funds paid by the Government as a result of the false claims. Sometimes
the United States Government decides to join the qui tam suit. If the suit is ultimately successful, the
whistleblower who initially brought the suit may be awarded a percentage of the funds recovered.
Because the Government assumes responsibility for all of the expenses associated with a suit when it
joins a false claims action, the percentage is lower when the Government joins a qui tam claim.
However, regardless of whether the Government participates in the lawsuit, the court may reduce the
whistleblower’s share of the proceeds if the court finds that the whistleblower planned and initiated the
false claims violation. Further, if the whistleblower is convicted of criminal conduct related to his role
in the preparation or submission of the false claims, the whistleblower will be dismissed from the civil
action without receiving any portion of the proceeds.
The federal False Claims Act also contains a provision that protects a whistleblower from retaliation
by his employer. This applies to any employee who is discharged, demoted, suspended, threatened,
harassed, or discriminated against in his employment as a result of the employee’s lawful acts in
furtherance of a false claims action. The whistleblower may bring an action in the appropriate federal
district court and is entitled to reinstatement with the same seniority status, two times the amount of
back pay, interest on the back pay, and compensation for any special damages as a result of the
discrimination, such as litigation costs and reasonable attorneys fees.
A similar federal law is the Program Fraud Civil Remedies Act of 1986 (the “PFCRA”). It provides
administrative remedies for knowingly submitting false claims and statements. A false claim or
statement includes submitting a claim or making a written statement that is for services that were not
provided, or that asserts a material fact that is false, or that omits a material fact. A violation of the
PFCRA results in a maximum civil penalty of $5000 per claim plus an assessment of up to twice the
amount of each false or fraudulent claim.
California has a state version of the False Claims Act that mirrors many of the provisions of the federal
False Claims Act. The actions that trigger civil and criminal penalties are identical to those of the
federal False Claims Act. However, under the California Act, a person or entity may also be liable if
he or she is a beneficiary of an inadvertent submission of a false claim to the state, subsequently
discovers that the claim is false, and fails to disclose the false claim to the state within a reasonable
time after discovery of the false claim. The California False Claims Act also differs from the federal
False Claims Act in that it does not apply to any claim of less than $500 in value or claims involving
workers’ compensation or against public entities and employees.
The California False Claims Act also has a whistleblower provision. Like the federal False Claims
Act, the California law includes provisions to prevent employers from retaliating against employees
who report their employer’s false claims.
The State of California has also adopted several other false claims statutes that are intended to prevent
fraud and abuse in Medi-Cal, the California Medicaid program. These laws generally prohibit the
filing of any false or fraudulent claim or documentation in order to receive compensation from MediCal.
REPORTING CONCERNS REGARDING FRAUD, ABUSE AND FALSE CLAIMS
The Company takes issues regarding false claims and fraud and abuse seriously. The Company
encourages all employees, management, and contractors or agents of the Company’s affiliated facilities
to be aware of the laws regarding fraud and abuse and false claims and to identify and resolve any
issues immediately. Issues are resolved fastest and most effectively when given prompt attention at the
local level. The Company, therefore, encourages its affiliated facilities’ employees, managers, and
contractors to report concerns to their immediate supervisor when appropriate. If the supervisor is not
deemed to be the appropriate contact or if the supervisor fails to respond quickly and appropriately to
the concern, then the individual with the concern should be encouraged to discuss the situation with the
facility’s human resources manager, the facility’s ECO, another member of management, or with the
Company’s Ethics Hotline (1-800-455-1996).
Employees, including management, and any contractors or agents of Company-affiliated facilities
should be aware of related facility policies regarding detection and prevention of health care fraud and
abuse. These policies and procedures can be accessed on Atlas, the Company’s Intranet site, or the
Company website at www.hcahealthcare.com. The following are some of the policies that are relevant
to this policy and to the prevention and detection of fraud and abuse: (1) EC.012-Correction of Error
Related to Federal Healthcare Program Reimbursement; (2) EC.025- Reporting Compliance Issues and
Occurrences to the Corporate Office Policy; (3) EC.003-Self-Reporting; (4) REGS.BILL.005Confirming and Processing Overpayments; (5) REGS.GEN.001-Billing Monitoring; and (6) RB.009Errors in Reporting.
Privacy Protected Elements & Information Security
I. Health Insurance Portability and Accountability Act (HIPAA)
A federal law that ensures the protection of patient privacy rights (effective 4/14/2003). A
major goal of the law is to assure that individuals’ health information is properly protected
while allowing the flow of health information needed to provide and promote high quality
health care and to protect the public’s health and well being.
Everyone is responsible for protecting patients’ individually identifiable health information.
You must understand what is considered Protected Health Information (PHI) and remember the
requirements related to the HIPAA privacy regulations.
If you reveal any Protected Health Information (PHI) to someone who does not need to know
it, you have violated a patient’s confidentiality and broken the law. This includes information
in any form; written, spoken, on computer, texting, facebook or any other means of written or
II. Need to Know Rule
Before looking at a patient’s health information, ask the question “Do I need to know this to do
my job?” If the answer is no, STOP! If the answer is yes, use it, but don’t share it with anyone
who doesn’t need to know. Even though you may have access to the entire medical record or
admitting/billing information, you may only legally look at the information you need to
perform your job. The need to know rule applies to every individual in the organization;
employees, contractors, and volunteers. We are all responsible for following the Patient
Privacy Policies and principles.
1. If you spot someone breaking the rules, report him or her either to your supervisor or directly to
the Facility Privacy Official. If you see patient information in an open trash container, tell a
supervisor, and then place it in the proper container for disposal. No one knows who might see
the trash once it leaves the building. Discarded paper with patient information on it should be
locked in the confidential waste bin until destroyed or shredded.
III. Ways to protect patient’s Protected Health Information (PHI)
1. Don’t write patient names on boards that can be viewed by the public. Secure notebooks, logs,
test results, patient labels, anything with patient information on it from public view. Don’t
leave patient records or medication administration books open.
2. If you are logged into a computer that contains patient information, never walk away from the
computer without signing off. Never share your password. Do not access your own medical
record (against policy). Typically, employees do not have a “need to know” their own medical
information for the performance of their job. Employees may fill out the appropriate consent in
Health Information Management (Medical Records) and obtain a copy of their records.
3. We may disclose the minimum amount of information required for treatment, payment or
healthcare operations. Disclosure for any other reason is protected and requires a patient’s
4. Don’t ask PBX to page, "Smith family please call the GI Lab." The unit sometimes indicates
the medical condition. Instead, ask the operator to page "Smith family, please call Extension
5. Don’t allow PHI to be seen by others. Put discarded paper with PHI and business paperwork
confidential to RCH in locked waste bins (slit in top). This paper is shredded.
6. Do NOT leave charts open or any patient information on the top of a cart, counter or anywhere
patient information can be seen by others
7. Do not discuss a patient’s PHI in public places. That includes elevators, cafeteria, public
restrooms, gift shop, and other areas.
IV. E-mail is considered public information. HCA does NOT permit protected health information
(PHI) to be sent via e-mail outside the company. Requests received by e-mail may be accepted
and responded to via fax or mail.
V. Faxing – if you have to fax protected health information, verify the fax number and recipient
(including name, organization, and fax number). Always include a cover sheet with the
“The documents accompanying this transmission contain confidential private
information. The information is the property of the sender and intended only for use by
the individual or entity named above. The recipient of this information is prohibited
from disclosing the contents of the information to another party. If you are neither the
intended recipient or the employee or agent responsible for delivery to the intended
recipient, you are hereby notified that disclosure of contents in any manner is strictly
prohibited. Please notify sender by calling sender’s phone number immediately if you
received this information in error.”
1. If receiving FAX information, be sure the FAX is located in a secure area, not accessible to the
2. If Fax is sent in error or sent to an incorrect party, reasonable efforts must be made to obtain the
copies from the recipient and see that they are destroyed. If information is sent to a Patient
Restricted Party or recipient where there is a risk of release of PHI (e.g. newspapers), the
Privacy Official should contact Legal Services.
3. Maintain a log of faxes that were sent to the wrong phone number or in error. Include a
summary of mitigation actions taken to secure the information.
4. Wait for confirmation that the fax has been sent.
VI. Answering Machines – While you are not prohibited from leaving messages for patients on their
answering machines, you must take reasonable safeguards to ensure the individual’s privacy. If
the patient is not available and you must leave a message with a family member or other person
who answers the phone, you must use professional judgment to assure such disclosures are in the
best interest of the individual and limit the information disclosed.
Note: Patients have the right to request the facility communicate with them at an alternative
address or by alternative means, such as only being contacted at work or only being reached by fax.
VII. Verification of External Requestors
1. We must verify the identity of any person or entity outside the facility who is unknown to the
employee if they are requesting protected health information (PHI), either in person, verbally,
or via written request. Here are some approved methods to identify verification (see policy
A. Valid State/Federal Issue Photo ID (driver license, passport), agency badge or photo.
B. Requestor must provide at least 3 information items. Must have patient name, social
security number, and a third item, such as an account number or date of birth.
C. If request is made in writing, signature must match patient signature on conditions of
VIII. Requirements to Protect Patient Privacy
1. Patients will identify who their information can be discussed with, including family.
2. Patients will be assigned a four-digit passcode that will be needed before we will give out
patient information. The passcode will be the last 4 digits of their account number (changes
with each visit).
3. The patient is responsible for distributing the passcode to family or friends.
4. This may change during treatment and the patient is allowed to change his/her mind regarding
who can be given patient information. Hopefully, this will not happen too often, but should it
occur, please forward the request for change on designated form to Janeille Kilgore, the Facility
Privacy Official (FPO).
5. Be sure inquirers have the four-digit password before information is given out. The password
is the last 4 numbers of their account number (which changes with each visit).
IX. Patient’s Right to Access
1. A patient may request a copy or to inspect their medical record. This may be requested
verbally or in written form. Patient requests are forwarded to the FPO.
X. Patient’s Right to Amend
1. Although a patient cannot delete or change documentation in the medical record, the patient has
a right to write an amendment or addition to the medical record. This amendment must be
included in all future releases of the medical record. Requests to amend the medical record
should be forwarded to the FPO or HIM Department.
XI. Right to Confidential Communications
1. Patients have a right to request they be contacted at a place other than their home phone
number or than by mail to their home address. Once the form is completed, it must be used for
all future contact. The patient does not need to provide any reason for alternate
2. Patients also have the right to opt out of the hospital directory, which lists patients by name and
room number (e.g. clergy, information desk, phone operator). The patient will have a
confidential flag in the computer. Even if the patient is asked for by name, no information is to
be given out.
XII. What we may disclose
1. For Treatment – we may disclose medical information to caregivers who are involved in taking
care of you in the hospital or after you are discharged.
2. For Payment – we may give information about your treatment and services to bill and collect
payment from you or insurance companies.
3. For Health Care Operations – we may use information to help improve the quality of care, for
educational purposes, or to review the competence of health care professionals. We may use
information to assess your satisfaction with our services or to remind you of appointments for
4. Business Associates – we may disclose medical information to contracted services so they can
perform the job we’ve ask them to do (e.g. tests). We require the business associate to
safeguard your information.
5. Directory – we may include limited information in our directory to provide to members of the
clergy and to other people who ask for you by name. You may request an Opt Out Form if you
do not want your presence in the facility known.
XIV. California Privacy Act
1. A state law that works in concert with HIPAA and is actually stricter than HIPAA. If you
violate patient confidentiality and reveal patient information to someone without a “need to
know” you can PERSONALLY be fined up to $250,000! California also requires a self-report
by the facility to both the state and the patient (the federal laws do not) within 5 business days
of when it becomes known (The California Privacy Laws SB541 & AB211 became effective
XV. HITECH (Health Information Technology for Economic and clinical Health) Act
1. Title 13 of the American Recovery and Reinvestment Act of 2009 (ARRA). The development
of health information technology (e.g., electronic health records, personal health records, &
health information exchanges) has resulted in additional risks in violating a patient’s privacy or
confidentiality. The HITECH Act mandates a federal breach notification requirement for stored
health information that is not encrypted or otherwise made indecipherable, as well as increasing
penalties for violations. The regulations require health care providers and other HIPAA covered
entities to promptly notify affected individuals of a breach, as well as the HHS (Health and
Human Services) Secretary and the media in cases where a breach affects more than 500
individuals. Breaches affecting fewer than 500 individuals will be reported to the HHS
Secretary on an annual basis.
2. The Laws lists anything that would identify an individual and his health related issues as
Protected Health Information (PHI). Health Information may be considered individually
identifiable if any of the following are present:
A. Name, address, zip code
B. Names of relatives or employers
C. Birth date
D. Telephone or fax numbers
E. Fax Numbers
F. E-mail address
G. Social security or health plan number
H. Medical record or account number
I. Health plan beneficiary number
J. Reason for hospitalization, types of treatment
K. Certificate or license number
L. Any vehicle or device serial number
M. Web Universal Resource Locator (URL)
N. Internet Protocol (IP) address number
O. Finger or voice prints
P. Photographic images
Q. Any other unique identifying number or code
R. Past hospitalization visit information
XVI. Privacy Officer
Janeille Kilgore is the Privacy Official at Riverside Community Hospital. She may be reached
at extension 3167
XVII. Passwords are Private
1. Don’t share or divulge your system password to anyone, including Information Technology
staff. Don’t be afraid to say “No”. If in doubt call your manager or the Information Services
Department. Use of someone else’s password is Fraud since it represents your legal signature
in many situations.
2. Don’t walk away from a computer without logging off. If you think there has been a breach in
security – call Information Services HELP Desk (4357).
3. Report unusual events and security concerns to your RCH Security Official or the HELP desk.
4. Take time to select the correct printer – as printers are added, it changes the order of the
printers on the screen. Verify the correct printer so confidential patient information is only sent
to the correct party.
1. Social engineering is the art of manipulating people into performing actions or divulging
confidential information, usually about computer system access. This is commonly done over
the phone, but can also take place in person. How do you protect yourself from these “con
artists? Con artists are good at what they do, and they know how to make you believe them.
They will sound friendly and trustworthy, and sometimes they will appear to be doing you a
If you think you have witnessed an attempted or successful breach of security, please report it
immediately to the Information Security Official (FISO), or to the Information Services Help Desk
Warning Signs of Workplace Violence
All threatening comments or behaviors should be taken seriously – never dismiss them as “harmless”
or “just blowing off steam”. We take a proactive stance to prevent violence. Report the following:
Direct or verbal threats of harm
Intimidation of others by words or actions
Refusing to follow policies
Carrying a concealed weapon or flashing a weapon to test reactions
Hypersensitivity or extreme suspiciousness
Often verbalizes hope for something to happen to the other person against whom the employee
has a grudge
Expression of extreme desperation over recent problems
Intentional disregard for the safety of others
Destruction of property
RCH is committed to a work environment that is free of discrimination and maintains a strict policy
which prohibits all forms of unlawful harassment, including sexual harassment, harassment based on
race, color, religion, national origin, or age.
Harassment may occur regardless of whether the behavior was intended to harass: unwelcome sexual
advances, verbal or physical conduct of a sexual or otherwise offensive nature, any behaviors that
create a hostile or offensive work environment - it can be in the form of jokes, innuendoes, printed
Harassment Policy HR 155 applies to all hospital agents, including employees, medical staff, contract
services. The policy prohibits unlawful harassment in any form, including verbal, physical and visual
Safety Hotline Ext: 3383
Report any safety issues or concerns to your manager or liaison. If the issue is not resolved, use the
Safety Hotline (3383) to report any safety issue or concern. Patient’s families and physicians are also
encouraged to use the hotline. You may identify yourself or leave the message anonymously. Safety
issues may also be reported directly to the California Dept. of Health Services and/or then to The Joint
Commission: (800) 994-6610 or to jointcommission.org
Dependant Adult and Child Abuse
Abuse is defined as the intentional maltreatment of an individual which may cause injury (either
physical or psychological) and includes: Mental abuse, physical abuse, sexual abuse, neglect,
abandonment, fiduciary (finances), isolation, and domestic violence (assault or abuse by a family
If you are a health care professional and have knowledge of/or reasonably suspect abuse/neglect, you
must (by law) report abuse to the proper authorities to be investigated:
Child abuse-report to Child Protective Services/Child Abuse Hotline before child leaves the
Elder/Dependent abuse (any hospitalized patient 18 years or older) – report to County Adult
Protective Services, Long-term Care Ombudsman, or Police.
Domestic Violence-report to local law enforcement by telephone and in writing, while the
patient is in the hospital. Also report any possible abuse incident to Social Services
If you need information on recognizing signs and symptoms of abuse, there is a learning module
entitled “Recognizing and Reporting Abuse Across the Life Span” in the nursing library.
Please read the Employee Statement – Child Abuse Reporting and Dependant Adult Abuse
Reporting (Appendix A) and sign the form acknowledging that you have read and understand
Mandatory Reporting – Substance Abuse
RCH Policy 178/178A says that all RCH employees are obligated to report any suspicious behavior of
another employee’s condition which would impair their ability to perform their duties or which may
cause a hazard to the safety and well-being of others. Do you know what those signs are?
Signs Associated with Substance Abuse
Substance abuse (alcohol or drugs) is nondiscriminatory in nature; anyone may become addicted.
Learn to recognize signs of substance abuse. These indicators can help in early identification of
potential substance abuse problems and allow the employee to be referred to a qualified professional.
Behavior and Appearance - sudden changes in behavior
Appearance deteriorates. May come to work looking sleepy, unkempt, unshaven, or dressed
inappropriately (e.g., long-sleeved shirts in the summer, sunglasses indoors).
Quality of work is inconsistent, work pace is slower than usual or sporadic. Makes more
mistakes, sudden inability to fulfill complex assignments or meet deadlines. Safety issues arise
– carelessness in operation and maintenance of potentially hazardous materials or dangerous
equipment. May be involved in off-the-job accidents.
Mood swings - signs of irritability, impatience, depression, excessive talkativeness, moodiness,
arguing with co-workers or insubordination toward supervisors.
Other performance-related signs include: excessive sick leave or tardiness, frequent early
departures, extended breaks, excessive time on the phone, patterns of absenteeism (Mondays,
Fridays, before or after holidays, etc.
Physical signs may include:
Red, runny eyes and nose, dry throat,
Decreased coordination – lack of
Loss of appetite
Increased breathing rate
Increased body/facial hair
Decreased ability to concentrate
Paranoia; suspicious toward others
Speech problems (slurred,
Needle marks on the skin
Dilated or contracted pupils
Unexplained weight loss or gain
2014 National Patient Safety Goals
1. Improve the accuracy of patient identification.
Use of Two Patient Identifiers
Eliminating Transfusion Errors
2. Improve the effectiveness of communication among caregivers.
Timely Reporting of Critical Tests and Critical Results
3. Improve the safety of using medications.
Reducing Harm from Anticoagulation Therapy
4. Improve the safety of clinical alarms systems.
Improve the safety of clinical alarm
5. Reduce the risk of health care-associated infections
Comply with either the current CDC or WHO hand hygiene guidelines
Implement evidenced-based practices to prevent health care-associated infections due to:
o Multidrug-Resistant Organism Infections in acute care hospitals
o Central Line-Associated Blood Stream Infections
o Surgical Site Infections
o Indwelling catheter-associated urinary tract infections
6. The hospital identifies safety risks inherent in its patient population.
Identifying Individuals at Risk for Suicide
7. Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong
Conducting a Pre-Procedure Verification Process
Marking the Procedure Site
A Time-Out is performed before the procedure
Patient Rights and Responsibilities
Hospital Policy Statement
It is our policy to support a patient’s right to accept or refuse medical treatment and to participate in
health care decision-making. We encourage patients to communicate their health care preferences. We
have formal policies to ensure that your wishes about treatment will be followed and we do not
condition the provision of care or otherwise discriminate against anyone based on whether or not you
have executed an advance directive.
The hospital and medical staff have adopted the following list of patient rights. This list is posted in
each patient care area, and is available in Spanish.
1. Considerate and respectful care, and to be made comfortable. You have the right to respect
for your cultural, psychosocial, spiritual, and personal values, beliefs and preferences.
2. Have a family member (or other representative of your choosing) and your own physician
notified promptly of your admission to the hospital.
3. Know the name of the physician who has primary responsibility for coordinating your care
and the names and professional relationships of other physicians and non-physicians who
will see you.
4. Receive information about your health status, diagnosis, prognosis, course of treatment,
prospects for recovery and outcomes of care (including unanticipated outcomes) in terms
you can understand. You have the right to effective communication and participate in the
development and implementation of your plan of care. You have the right to participate in
ethical questions that arise in the course of your care, including issues of conflict resolution,
withholding resuscitative services, and forgoing or withdrawing life-sustaining treatment.
5. Make decisions regarding medical care, and receive as much information about any
proposed treatment or procedure as you may need in order to give informed consent or to
refuse a course of treatment. Except in emergencies, this information shall include a
description of the procedure or treatment, the medically significant risks involved, alternate
courses of treatment or non-treatment and the risks involved in each, and the name of the
person who will carry out the procedure or treatment.
6. Request or refuse treatment, to the extent permitted by law. However, you do not have the
right to demand inappropriate or medically unnecessary treatment or services. You have
the right to leave the hospital even against the advice of physicians, to the extent permitted
7. Be advised if the hospital/personal physician proposes to engage in or perform human
experimentation affecting your care or treatment. You have the right to refuse to participate
in such research projects.
8. Reasonable responses to any reasonable requests made for service.
9. Appropriate assessment and management of your pain, information about pain, pain relief
measures and to participate in pain management decisions. You may request or reject the
use of any or all modalities to relieve pain, including opiate medication, if you suffer from
severe chronic intractable pain. The doctor may refuse to prescribe the opiate medication,
but if so, must inform you that there are physicians who specialize in the treatment of
severe chronic intractable pain with methods that include the use of opiates.
10. Formulate advance directives. This includes designating a decision maker if you become
incapable of understanding a proposed treatment or become unable to communicate your
wishes regarding care. Hospital staff and practitioners who provide care in the hospital
shall comply with these directives. All patients’ rights apply to the person who has legal
responsibility to make decisions regarding medical care on your behalf.
11. Have personal privacy respected. Case discussion, consultation, examination and treatment
are confidential and should be conducted discreetly. You have the right to be told the
reason for the presence of any individual. You have the right to have visitors leave prior to
an examination and when treatment issues are being discussed. Privacy curtains will be
used in semi-private rooms.
12. Confidential treatment of all communications and records pertaining to your and stay in the
hospital. Basic information may be released to the public, unless specifically prohibited in
writing by you. Written permission shall be obtained before medical records are made
available to anyone not directly concerned with your care, except as otherwise may be
required or permitted by law. You will receive a separate “Notice of Privacy Practices” that
explains your privacy rights in detail and how we may use and disclose your protected
13. Access information contained in your records within a reasonable time frame, except in
certain circumstances specified by law.
14. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and
neglect, exploitation or harassment. You have the right to access protective services and
advocacy services including notifying government agencies of neglect or abuse.
15. Be free from restraints and seclusion of any form used as a means of coercion, discipline,
convenience or retaliation by staff.
16. Reasonable continuity of care and to know in advance the time and location of
appointments as well as the identity of the persons providing the care.
17. Be informed by the physician, or a delegate of the physician, of continuing health care
requirements and options following discharge from the hospital. You have the right to be
involved in the development and implementation of your discharge plan. Upon your
request, a friend or family member may be provided this information also.
18. Know which hospital rules and policies apply to your conduct while a patient.
19. Designate visitors of your choosing, if you have decision-making capacity, whether or not
the visitor is related by blood or marriage, unless:
No visitors are allowed
The facility reasonably determines that the presence of a particular visitor would
endanger the health or safety of a patient, a member of the health facility staff or
other visitor to the health facility, or would significantly disrupt the operations
of the facility.
You have told the health facility staff that you no longer want a particular person
However, a health facility may establish reasonable restrictions upon visitation,
including restrictions upon the hours of visitation and number of visitors.
20. Have your wishes considered, if you lack decision-making capacity, for the purposes of
determining who may visit. The method of that consideration will be disclosed in the
hospital policy on visitation. At a minimum, the hospital shall include any persons living in
21. Examine and receive an explanation of the hospital’s bill regardless of the source of
22. Exercise these rights without regard to sex, age, disability, medical condition, economic
status, educational background, race, color, religion, ancestry, national origin, sexual
orientation or marital status or the source of payment for care.
23. Voice your complaints. Most concerns can be satisfactorily addressed at this level. Ask to
speak to the nurse in charge or the Director of the unit. If you cannot resolve your issues on
the unit, you may speak to someone else in Nursing Administration extension 3430.
24. File a grievance. If you are still dissatisfied with your care and want to file a grievance
with this hospital, you may do so by writing or by calling:
Riverside Community Hospital
4445 Magnolia Avenue
Riverside, California 92501
The grievance committee will review each grievance and provide you with a written
response within 21 days. The response will contain the name of a person to contact at the
hospital, the steps taken to investigate the grievance, the results of the grievance process,
and the date of completion of the grievance policy process. If you are a Medicare patient and
have concerns regarding quality of care or premature discharge, you may call the Quality
Improvement Organization (QIO), Health Services Advisory Group, at 1-866-800-8749.
TTD Hearing Impaired 1-800-881-5980 www.hsag.com
File a complaint with the California Department of Public Health (CDPH)
regardless of whether you use the hospital’s grievance process. The CDPH’s phone number and
625 E. Carnegie Drive
San Bernardino, CA 92408
(909) 388-7170 or toll free (888) 354-9203
You may also report concerns with The Joint Commission (TJC) by either calling 1-800-994-6610 or
emailing [email protected]
Provision of information
A patient has the responsibility to provide, to the best of his knowledge, accurate and complete
information about present complaints, past illnesses, hospitalizations, medications, and other
matters relating to his health. The patient has the responsibility of reporting unexpected changes
in his condition to the responsible practitioner. A patient is responsible for reporting whether he
clearly comprehends a contemplated course and what is expected of him.
2. Compliance Instructions
A patient is responsible for the following the treatment plan recommended by the Practitioner
primarily responsible for the care. This may include following the instructions of nurses and
allied health personnel as they carry out the coordinated plan of care, implement the responsible
practitioner’s orders, and enforce the applicable hospital rules and regulation. The patient is
responsible for keeping appointments and, when unable to do so for any reason, for notifying the
responsible practitioner or the hospital.
3. Refusal of Treatment
The patient is responsible for his actions if he refuses treatment or does not follow the
4. Hospital Charges
The patient is responsible for assuring that the financial obligations of his health care are fulfilled
as promptly as possible.
5. Hospital Rules and Regulations
The patient is responsible for following hospital rules and regulations affecting patient care and
conduct, including complying with our non-smoking policy.
Respect and Consideration
The patient is responsible for being considerate of the rights of other patients and hospital
personnel and for assisting in the control of noise and the number of visitors. The patient is
responsible for being respectful of the property of other persons and the hospital.
Patient Self Determination Act 1990
An Advance Directive (AD) is a document that allows a person to:
Give instructions about his or her healthcare
Appoint another person (agent) to make healthcare decisions when he/she no longer can.
Give specific instructions about care and treatments without naming an agent.
All patients admitted must be asked if they have an Advance Directive and given the option to
complete one. If they do not have one, he or she must be offered written material to explain this
OneLegacy is the transplant donor network utilized to determine medical suitability for organ
donation. If, after review, OneLegacy considers the case acceptable the opportunity of donation
will be extended to the family. Experience has shown that families are not opposed to the
inquiry, but often are grateful to provide some benefit from their tragedy.
Language Service Associates (LSA) is a service that provides interpreters (by phone) for
almost all languages and dialects. The LSA Line should be used for informed consents and
in-depth assessments, treatment options and discharge instructions.
There are dual handset phones available to avoid passing the handset back and forth.
LSA also has sign-language services for the hearing impaired via laptop computer.
ALWAYS USE AN INTERPRETER FOR ANY CLINICAL SIGNIFICANT DISCUSSION.
Special considerations in selecting an interpreter:
Don’t assume anyone who can interpret is appropriate.
Same sex/age/gender as the patient is preferred.
Family members tend to censor what is said to shield the patient.
Young children should not be used.
Speak directly to the patient, not the interpreter.
Falling Stars Program
Riverside Community Hospital has a FALLING STARS Program. Each patient is assessed for risk of
falls. If the patient is judge to have a risk for falls (due to medication, weakness, memory etc.), a bed
alarm is used and they are part of the "Falling Stars" program. A magnetic star will be placed on the
door frame of the patient’s room. The Star has an A, B, or A/B, indicating which patient(s) should be
carefully observed. Bed “A” is always closest to the door. In addition, a YELLOW armband indicates
a “High Risk for Falls”. Yellow slippers will be placed on the patient to identify them as a high risk of
fall. If you see someone that has been identified as a “High Risk for Falls” walking without assistance,
please get the nurse or any available help for the patient to prevent a fall.
Suicide Precautions (Policy IND 14)
Suicide precautions must be instituted for patient who has threatened and/or tried to commit suicide. If
admitted to Med-Surgical, must have constant 24-hr. observation by a staff member or a sitter, until
psychiatrist/physician orders a transfer to an appropriate facility or documents that patient is no longer
a threat to self or others. While on unit keep all sharp objects out of patient's room. Request paper
containers and plastic silverware. If the patient becomes combative or uncontrollable, Code Gray
(imminent danger) should be called. At MD request a member of the hospital staff, certified by the
County of Riverside may evaluate a patient for placement on an involuntary psychiatric hold (5150).
A California Senate bill enables mothers to drop off unwanted newborns to an RN in a hospital
Emergency Department without risk of criminal charges. An infant identification packet is given to the
mother. The infant becomes a ward of Child Protective Services and the mother has 14 days in which
to reclaim the baby. She must have the infant identification packet with her.
Definition: Anything that restricts motion (that is not easily removable by the patient) may be
considered a restraint: soft restraints, mittens, arm splints (used at RCH).
The standard of care at Riverside Community Hospital is NOT to use restraints. This means we try
everything possible to avoid the use of restraints. If restraints must be used, they are removed as soon
If you go by a room or into a room where a patient is restrained, be aware that we have a special duty
to protect a patient who is unable to protect himself. There are also special regulations that apply to a
patient who is restrained:
Continued monitoring and assessments
Restraints must be removed 2 hours to ensure a patient’s needs for toileting, turning, fluids,
nutrition needs have been met.
Must be protected from other patients or visitors in the area
Restraint must have a quick release mechanism, so in case of emergency, the patient can be
evacuated quickly and easily.
Look to see if they are in a normal and safe position in bed or in a chair. Patients have been
known to slide down in bed or in the chair and suffocate.
Let the nurse know if the patient’s breathing seems funny or noisy, or hands or feet are turning
blue or skin is torn.
Greet the patient and respect the patient as an individual. The patient still has rights, including
the right to privacy and keeping the environment clean and safe.
Do not take a restraint off unless you have notified the nurse or there is imminent threat of
Caring for patients is what we do. It is everyone’s responsibility to ensure our patients are not at risk of
injury or harm.
If a restrained patient is in another area for testing or procedures, the patient must be observed
minimally every 15 minutes and safety checks documented on the restraint flow sheet (check with the
Everyone entering or walking by a room of a restrained patient has a responsibility to ensure
that the patient remains safe. Look in and notify the nurse if the patient is restless or wants
something. Be sure the patient is not tangled or pulling against the restraint.
RCH Policy & Procedures
You can access RCH policies via an icon on computers with internet access, via the Riverside
Community Hospital Intranet.
POLICY: HR 157 & 157a Attendance
Attendance Policy (HR 157)
All employees of Riverside Community Hospital.
The attendance policy establishes guidelines that promote fair and consistent application of basic attendance
standards. Each employee is expected to adhere to established work schedules and to arrive at and report to work
in a timely manner. Excessive absenteeism and/or tardiness may have an adverse effect on an employee’s
performance appraisal rating, transfer requests, and/or promotional opportunities, and may result in disciplinary
action up to and including termination.
A. Employees must arrive for work prepared to begin work at their scheduled start time and report to their
workstations immediately upon recording their time in Kronos or the Kronos log. Any time away from their
individual workstations during work time must be reported by employees according to established
departmental practice or procedure. Unless otherwise stated, an occurrence counts against an employee
attendance record, for the purposes of discipline, for one year. Discipline remains in an employee file for one
year, except in the case of a final written warning or suspension, which shall remain in the employee file for 2
B. In event of absence, employees must notify the charge nurse, manager, or shift coordinator of any intended absence by
phone at least 2 hours prior to the start of their scheduled shift.
1. E-mail notification is not acceptable and is not considered notice for the purposes of this policy.
2. The employee must call in each day of an absence and speak directly to the charge, shift coordinator, supervisor,
manager, or department director unless the entire period of the absence has already been communicated with
the department director.
3. Failure to provide appropriate notice may result in the absence being considered unexcused and unpaid, and
may result in disciplinary action, up to and including termination.
4. If an employee fails to report to work for two (2) consecutive scheduled work shifts without notifying their
immediate supervisor (“no call/no show”), it shall be considered a voluntary resignation without notice.
5. Department directors will require employees who are absent for three days or more and/or with chronic
attendance problems, to obtain a physician's statement prior to their return to work.
6. Employees who report for work without proper equipment or in improper attire will be considered tardy and
may not be permitted to work that day.
7. Employees who report for work in a condition deemed unfit for work, whether for illness or any other reason,
may be considered tardy and will not be allowed to work.
8. Approved time off and/or departmental flextime does not constitute an occurrence.
9. Absences must be recorded through Kronos.
10. Absences of five or more consecutive days are considered as a Leave of Absence and the employee must
submit a Leave of Absence form, available in Human Resources.
C. Occurrences—Definition and Accrual Rate
Absence occurrence: An unscheduled absence from work on one or more consecutively scheduled workdays. All
unscheduled absences due to illness, doctor’s appointments, etc. are considered occurrences under the guidelines. Preapproved PTO/Flex Time is not considered an occurrence, nor is time taken off which is covered by the FMLA or
CFRA. Excessive absenteeism is defined as three or more occurrences or unscheduled absences in a rolling three (3)
month period, or six occurrences in a twelve (12) month period.
(1 Unscheduled Absence = 1 Occurrence)
Tardiness: Arriving late or early shall be grounds for discipline if the following occur:
Clocking in more than 6 minutes late or clocking out more than 6 minutes early three or more times in a rolling
three month period or 4 times in a twelve month period;
clocking in and/or returning late from meal and break periods.
(2 Tardies = 1 Occurrence).
Incomplete Shift: Leaving work prior to completion of scheduled shift, even where the absence is scheduled,
may be counted as an absence. Being sent home due to hospital convenience, or released with the approval of
a manager will not be considered an occurrence.
(1 Incomplete Shifts = 1 Occurrence)
Missed Punch: An hourly employee who neglects to punch in or out for their shift or meal break has
committed a missed punch violation. Entry in the Kronos log of the missed punch is required, but will not
count as a punch with regard to the enforcement of this policy, except where authorized by the employee’s
(2 Missed Punches in a rolling 30 day period = 1 Occurrence)
Abandoning Work Station/Assignment:—Employees found to be away from their work areas without
permission, and found in other areas of the premises (including but not limited to, the cafeteria, a break room,
coffee shop, in a parking lot) when clocked in and not on an excused break, will be found in violation of this
policy and subject to discipline, up to and including termination, for any such occurrence.
(1 Abandonment = 2 Occurrences)
D. Attendance Violation Disciplinary Action Steps
Verbal Counseling: A director, manager, or supervisor will,
conduct a verbal counseling following any combination of unscheduled absences, tardies, abandonment,
and/or missed punches which together or separately constitute reason for discipline, within a rolling 3 – month
period. Such employee counseling is not required and any such meeting will be documented by the
department manager for his/her own records.
Written Warning - Disciplinary Action Form: The 3rd Occurrence of any combination of
unscheduled absences, tardiness, abandonment, and/or missed punches within a rolling 3-month period will
result in formal written warning. Employees with four tardies in a year shall also receive a written warning.
Final Written Warning: The 4th Occurrence of unscheduled absences, tardiness, and/or missed
punches within will result in a final written warning.
Suspension: The 5th Occurrence of absences, tardiness, abandonment, and/or missed punches
following the issuance of a final written warning will result in a 3 day suspension without pay.
Termination: The 6th Occurrence of any absences, tardiness, abandonment, and/or missed punches
will be cause for immediate termination.
E. Repeated disciplinary action for attendance violations and/or failure to report to work following denial of time-off
request(s) will result in progressive disciplinary action up to and including termination.
F. ATTENDANCE ENFORCEMENT: This policy is a "no-fault" policy in that, except where otherwise noted; all
attendance occurrences are included when determining the need for disciplinary action. Exceptions to the "no-fault"
principle are as noted:
Absences or tardiness caused/necessitated or covered by enforcement of the Family Medical Leave Act
(FMLA) of 1993, Uniformed Services Employment and Reemployment Rights Act (USERRA), or of the
California Family Rights Act (CFRA) are not considered violations of this policy.
Absences and/or tardiness caused by bereavement leave, jury duty, subpoenaed court appearances, and those
directly caused by a worker's compensation injury are not considered when enforcing this policy.
POLICY: HR 174 Dress Code
All Employees of Riverside Community Hospital (RCH), students, interns and volunteers.
Riverside Community Hospital prides itself on the professional atmosphere it maintains and the favorable image
employees present as representatives of the hospital. Employees are expected to observe good habits of dress,
grooming and personal hygiene in an appropriate manner according to the nature of the job performed and specific
requirements of the assigned department. In addition, this general policy applies to all employees even where dress
code rules are already specified by the department.
Employees who have questions regarding appropriate dress and attire should direct them to their supervisor in advance
to avoid conflicts and potential problems. Any employee who is inappropriately dressed when he or she arrives for
work will be considered unsuitable to commence work and will be sent home. The employee may be asked to return to
work later in the same day in proper attire that conforms to the hospital's standards. Employees who are asked to leave
because of inappropriate dress or attire will not be compensated for any time expended in going home or returning to
work. Employees may also be subject to discipline if they continually disregard the dress code.
III. Additional Information:
C. Conservatively/modestly dressed
D. Professional dress where regular contact with public is required
EMPLOYEE IDENTIFICATION BADGE
A. RCH employee badge only.
B. Identification badges are to be worn so they are readily visible (State Law).
C. No defacing or modification of badges (i.e., pins, stickers).
PINS AND BUTTONS
A. Professional school pins may be worn as a part of the uniform.
B. Administration may authorize wearing of specific pins related to hospital activities (i.e., volunteer pins, etc.).
C. Promotional buttons/pins/ribbons and other devices bearing messages (political, humorous) may NOT be
A. Employees will:
Avoid having body odor, residual smoke odor, and bad breath.
Practice frequent and thorough hand washing.
No wearing of strong cologne, perfume and/or after-shave, etc.
A. Facial hair must be:
E. Well trimmed*.
F. Covered while working in specific areas, i.e., Operating Room, Nutritional Services.
*While the hospital does not prohibit male employees having properly groomed beards and mustaches in
general, OSHA does require employees in direct patient contact to be fit tested for a respirator mask to
prevent the transmission of TB. These respirators cannot be properly fitted with facial hair and therefore facial
hair is prohibited for these occupations.
A. Hair must be:
C. Controlled (i.e., not falling over eyes, immediate work area, onto patients).
D. Covered with specific hair covering while working in specific areas, i.e., Operating Room, Nutritional
E. No unnatural colors.
A. Must be clean.
B. Well trimmed and moderately short.
C. If nail polish is used, it must be a muted tone and in good repair.
D. HR 209 Fingernail and Hygiene Policy : Artificial fingernails or extenders will not be permitted for those
employees in positions that involve direct contact with patients which includes:
All Category One employees (example: Nursing, Respiratory Therapy,
Lab, Environmental Services)
Those who handle or reprocess equipment or instruments (like SPD)
Food service workers who directly handle food
Any contract employee who performs one of the above functions.
Anyone who prepares Pharmacy sterile products.
Category Two employees who may have indirect contact with patient supplies or equipment.
Essential elements of footwear worn at RCH:
Shoes must be:
(a) Clean, well polished, and in good repair.
(b) If clogs are worn, back strap for safety is required in patient care areas.
(b) Sandals/open toe shoes cannot be worn in patient care areas.
(c) Hiking boots (exception: where required for safety).
B. Clothing (Scrubs, uniforms, business attire, etc.)
Clothing must be:
(c) Well pressed.
(e) Sufficient length
(f) Sufficient fabric weight.
Non-acceptable clothing includes:
(a) The bare look, i.e., bare midriff, "see-through" or low cut necklines, spaghetti strap sundresses,
recreational shorts or skorts.
(b) Bib overalls.
(d) Faded material.
(e) Gym attire.
Men's clothing must include:
(a) Dress or sport shirt with collar (T-shirts, without a collar, are not permitted*).
(c) Necktie and coordinated coat or jacket where appropriate.
*Note: At director discretion, clinical employees may wear hospital sponsored t-shirts that are in
good condition, under scrub jacket and lab jackets. EVS employees may wear t-shirts under their
uniformed jacket. Night shift personnel that do not have any patient or family contact may also wear
the hospital sponsored t-shirts. These are examples of exceptions to the policy. There may be others,
but they must be approved by the division VP. Otherwise, unless the hospital designates a special
day, such as employee BBQ's or other special events, T-shirts are not considered appropriate attire,
when worn alone, or for general office and non-uniformed clinical settings.
Women's clothing must be professional looking, i.e.:
(c) Tailored pants
The following are NOT appropriate while on duty.
Hospital issued uniforms, laundered by RCH, are not to be worn to and from work.
Uniforms supplied by the hospital but laundered by the employee may be worn to and from work.
Department uniform questions should be directed to the Department Director.
Scrubs are unacceptable for business/non-patient care departments.
A. The wearing of excessive jewelry while on duty is discouraged.
B. Acceptable jewelry:
Wedding Set/one other small ring.
Limit of 3 pierced earrings per lobe.
Earring should be no more than one inch in diameter or length.
Bracelets and dangling earrings are not allowed in patient care areas.
Decorative pin/broach (exception in patient care areas).
Medic-alerts and wristwatches are not considered jewelry.
All accessories must be limited to those items which provide simple, conservative, professional
10. BODY PIERCING
No other facial or visible body jewelry is permitted; refer to I. Jewelry/Accessories, 2b above.
Tattoos must be covered and not visible.
12. CASUAL FRIDAY
For those departments that routinely wear professional office apparel a more casual business appearance is
allowed on Fridays.
POLICY: GA 14 Smoking Policy
All personnel, contractors, physicians, visitors and departments of Riverside Community Hospital.
Riverside Community Hospital is a no-smoking facility. Riverside Community Hospital is committed to
providing an environment for restoring and maintaining the health of our patients and setting an example for the
community. Smoking is both a fire and health hazard (California Health and Safety Code 1286).
A. Smoking is prohibited within any structure or area of the Hospital campus. This includes all buildings in the
main hospital, including the parking facilities, garage, automobiles, elevators, driveways, walkways and any
Hospital controlled buildings.
B. “No Smoking” signs are posted at entrances into the hospital.
C. Smoking is not allowed in any area of the Hospital and Medical Campus.
1. Patients shall not be permitted to smoke. Alternate solutions to the desire to smoke shall be pursued
through Nursing (e.g., request for Nicotine patch from M.D.).
2. Patients may not leave patient care units to smoke. Should patients do so despite interventions (notify
nursing unit, speak to patient, notify M.D). Patients should be considered to have left AMA. (See AMA
1. All personnel are responsible for providing courteous enforcement of this policy.
2. Employee discipline will be pursued as deemed appropriate for violations of this policy.
1. All inpatients are given smoking cessation information in their Admission packets. This information
includes community resources including phone numbers of National Quitlines in their area, the effects of
smoking on the physical body, medications that could help in withdrawal, and the effects of second hand
smoke on children.
2. Employees are given educational materials at every New Employee Orientation. They are also informed
that this is a non smoking facility. Resources are available.
3. Building contractors and sub-contractors will receive cessation of smoking information during their
orientation. This will be done before a project begins.
Exceptions/Clinical Alerts: N/A
California Health & Safety Code 1286
The Joint Commission Standards
POLICY: EH 200 Influenza Vaccination and Post Exposure Follow-up
Influenza Vaccination and Post Exposure Follow-Up (EH 200)
All personnel, departments, and entities of Riverside Community Hospital including Contracted employees and
Auxiliary volunteers. This also includes Licensed Independent Practitioners having close patient contact.
Influenza vaccination is the primary method for preventing the spread of influenza. The CDC’s Advisory
Committee on Immunization Practices has recommended that health care workers be immunized to prevent the
spread of this virus. Because the virus can be shed for 24-48 hours prior to influenza symptoms showing, there is
the potential to reduce further hospitalizations and physician visits and also reducing death among high risk
Any staff member or volunteer that is exposed to a patient that is positive for influenza should be educated on the
signs/symptoms, and the incubation period. If not previously vaccinated, then influenza vaccine will be offered.
Post-exposure prophylaxis will be given on a case-by-case basis after consultation with the Infectious Disease
Chairman of the Treatment and Surveillance Committee.
A. All staff will be notified via Meditech Mox, email, and flyers throughout the hospital that the annual influenza
vaccination program is being initiated. This typically occurs at the end of September with vaccinations starting
as RCH receives its annual supply of vaccine.
B. All staff will be screened for the ability to receive the vaccine, i.e. allergies or
C. All RCH personnel and volunteers will be required to either be vaccinated or declare in
writing that he/she has declined vaccination. The vaccinations will be offered during the
annual flu season which typically occurs between September and April. The vaccinations
will be offered as vaccine is available.
D. Department Directors will be notified of staff that has not been vaccinated, and disciplinary
Action will be taken if staff do not complete the consent or declination form.
Staff that have received the vaccine at another facility or outside clinic need to Complete
the consent Or declination form.
Staff receiving vaccine will be given the injection intramuscularly in the deltoid muscle of
the right or left arm.
G. Staff should be educated on the signs/symptoms of allergic reaction. If any allergic reaction
should occur, then the staff will be screened in Employee Health first, and then referred to
either the Industrial Clinic or the Emergency Room depending on severity.
H. If exposed to a positive influenza patient, the employee needs to notify Infection Control or
Employee Health or the Administrative Liaison for further follow-up to determine if an
actual exposure took place. If there was an unprotected exposure, then the Infection
Control Department of Employee Health Department will contact the Treatment and
Surveillance Chairman for his recommendation regarding post-exposure prophylaxis.
POLICY: Internet, E-Mail, Cell Phones, & Other Electronic Communications (HR 190)
All Employees, including but not limited to contract services.
Computerized information and electronic communication systems are one of the Hospital’s most valuable assets.
Our guest relations success and the privacy of our patients depend on the proper use of personal cell phones and
hospital electronic assets. This policy is designed to protect the Hospital, its personnel, its customers, and its
resources from the risks associated with the use of e-mail, the Internet, cell phone and other forms of electronic
A. Hospital electronic communications facilities (internal mail boxes, Meditech, e-mail, cell phones) are intended
to be used only for official Hospital business. Occasional use of the of the hospital’s Meditech MOX and
Outlook e-mail systems by employees for personal communications or messages of a non-controversial nature
is permitted, so long as the communication or message is reasonably limited in scope of it’s distribution. No
personal messages shall be broadcast hospital-wide, including solicitation or non-hospital event
announcements. No messages shall be sent over the hospital’s Meditech or e-mail system which contains
statements which are critical of any individual or of any policy, practice or service of the hospital or its
affiliates Users have the responsibility to use electronic communications in a professional, ethical, and lawful
manner. No messages may be sent which violate the Hospital’s Code of Conduct, ACT II Service Standards
or any other policy or procedure.
B. Every user has a responsibility to maintain and enhance the Hospital’s public image and to use the Hospital email, access to the Internet and other electronic communications in a productive manner. These electronic
communication mechanisms may be subject to discovery in the event of litigation. As with all
communications, employees should avoid saying or using anything that might appear inappropriate or might
be misconstrued by a reader.
C. Riverside Community Hospital (RCH) encourages the use of the Internet, e-mail and other electronic
communications to promote efficient and effective communication in the course of conducting Hospital
business. Hospital provided Internet access, e-mail and other electronic communications are Hospital
property, and their primary purpose is to facilitate Hospital business. Employees must understand there is no
guarantee of privacy regarding e-mail communications or Internet usage.
Employees, physicians, consultants, volunteers, and vendors may at some time be required to operate computer
equipment or have access to software systems as part of their performance or duties for Riverside Community
A. Those charged with this responsibility must understand and follow the Information Security policies in
effect throughout the Hospital, as follows:
Do not operate or attempt to operate computer equipment without specific authorization from a
Do not demonstrate the operation of computer equipment to anyone without specific authorization.
Maintain assigned passwords that allow access to computer systems and equipment in the strictest
confidence. Do not disclose a password to anyone, at any time, for any reason.
Access only computer systems, equipment and functions as required the performance of job
Contact your Supervisor, the Facility Information Security Officer (FISO), the Director of Information
Services, or designee immediately and request a new password(s) if yours is (are) accidentally revealed.
Do not record passwords in any manner as this increases the possibility of accidental disclosure.
Do not disclose any portion of the Hospital’s computerized system with any unauthorized individuals.
This includes, but is not limited to, the design, programming techniques, flow charts, source
codes, screens, and documentation created by Hospital employees or outside sources.
Do not disclose any portion of a patient’s record except to a recipient designated by the patient or to a
recipient authorized by the Hospital who has a need to know in order to provide for the continuing care of
the patient or to discharge one’s employment or other service obligation to the Hospital.
Report any activity that is contrary to the provisions of the Information Security Agreement to your
Supervisor, Facility Information Security Officer (FISO), or the Director of Information Services.
B. All employees covered by this policy must sign the Confidentiality & Security Agreement, which may be
obtained in Human Resources or the Information Services Department. Failure to comply with the above
policies will result in formal disciplinary action up to and including termination from the Hospital in the case
of employees, and the termination or cancellation of Agreements in the case of physicians, consultants,
volunteers or vendors.
C. Electronic Communications
a. The company recognizes that occasionally it is necessary for employees to make or receive personal
telephone calls during working hours. The company, however, asks that employees restrict their
personal telephone usage to emergency situations. Employees may not charge personal long-distance
calls to the company. Excessive personal telephone calls may result in progressive discipline.
Personal Electronic Devices
a. Personal Electronic Device – Any portable electronic handheld equipment that can be used for the
purposes of communication, data management, word processing, wireless Internet access, image
capture/recording, sound recording and entertainment. Solely for the purpose of example, such
devices may include but are not limited to: Smart technologies (e.g. cell phones, smart phones, etc.);
Portable Internet devices (e.g. I-Pod©, I-Pad©, BlackBerry©, Android systems); Handheld
entertainment systems (e.g. gaming systems, audio/video players); Recording devices - Digital or
analogue audio and/or video captures; Laptop computers, tablets, notebooks, netbooks, etc.; Any
other convergent communication technologies.
b. Unless properly authorized in writing by administration or designee, employees should refrain from
the use of any form of personal electronic devices during normal work hours. Employees are
Strictly Prohibited from using any recording feature of any personal electronic device while in
the hospital, whether for purposes of recording sound or images. These devices may be used during
breaks or when employees are at lunch only in non-work and non-patient care areas.
c. Employees are restricted from using these devices in work areas, including but not limited to all
patient care areas or areas containing Protected Health Information as defined by HIPAA, and during
work time. Further, employees who are found to have used these devices in violation of this policy
will be subject to discipline up to and including termination of employment.
d. Any Employee found to have used a personal electronic device to record sound or images on hospital
premises in contravention of this policy shall be subject to discipline, up to and including
e. Departmental Policies may vary from this hospital-wide policy only where such policies are more
restrictive than the policy and procedure as set forth herein.
Employees who have access to the e-mail system understand that it is for business use only, and are
encouraged to minimize the personal use of the system.
Forwarding of ‘chain’ e-mails, jokes, cartoons or any other non-business related material is strictly
Employees are required to delete any of these e-mails as they are received. Further, employees are
required to notify Information Services should they receive such an e-mail. Where the sender is not
known to the employee, said employees should not request the source to remove them from the
distribution list as it may place the hospital at unreasonable risk for security breach.
Employees who disregard this policy and continue to receive and/or forward such material, as
described herein, will be subject to progressive discipline, up to and including termination.
Electronic communications may NEVER be used in any of the following ways:
a. To communicate patient-identifiable information outside the hospital, except when using encryption
methods specifically authorized by the Hospital.
b. Communicating patient-identifiable information inside RCH must be done in compliance with RCH
Appropriate Access policies.
c. To communicate RCH confidential information to those outside of RCH, except when using
encryption methods specifically authorized by IS Security.
d. To harass, intimidate, or threaten another person.
e. To access or distribute obscene, abusive, libelous, or defamatory material.
f. To distribute copyrighted materials which are not authorized for reproduction or distribution.
g. To communicate RCH’s official position on any matter, unless the employee engaging in such
communication has been specifically authorized to make such statements on behalf of RCH.
h. To access another person’s e-mail, if not specifically authorized to do so.
i. To impersonate another user or mislead a recipient about the user’s identity.
j. To bypass the system’s security mechanisms.
k. To distribute chain letters.
l. To participate in political or religious debate.
m. To solicit goods and services.
n. To run a personal business.
Violation of this policy may result in disciplinary action, up to and including, termination.
Hospital Safety & Access
Provides escorts to any part of the campus or parking lots 24 hours a day, 7 days a week.
Manages Lost and Found. If attempts to find the owner of lost property fail, label the lost item and take to Public
Safety. If patient belongings are not picked up by the family within hours of notification, label items with the
patient’s name, room number, and date of discharge and send to Public Safety. Do not keep lost items on the unit
for weeks or months. It takes a lot less time to check a room prior to discharge than to manage lost items. Public
Safety Dept. is not permitted to accept “patient belongings” from the floors without a proper inventory of the
belongings bag and identification of who it belonged to (if known); Nursing staff is responsible for inventorying /
labeling patient belongings bags prior to sending to Public Safety.
Public Safety must always be notified when a visitor is involved in an accident or injury on the hospital premises.
They will secure the area, take pictures, and ensure witness reports are taken. Visitor falls or injuries must always
have an RIR (Risk Identification Report) completed. Do not make any statements or promises that the hospital will
pay the bill as each case is unique and will be assessed and followed by Risk Management or Administration.
Call boxes are located by the parking structure elevators and in parking lots throughout the campus to report
emergency situations directly to the operator. Push the button to talk, release it to hear the operator
If Public Safety is called to help with a patient, medical and nursing staff, need to direct the safety officer in
exactly what needs to be done to manage the patient and medical equipment safely.
Employee ID badges give you access to the designated employee entrance and other perimeter points of entry based on the
individual needs of the employee / job position; they provide access to all floors and most hospital areas. It also is the badge
used at the time clocks.
Quick Do's and Don'ts:
Do wear your badge at all times while in the hospital. Wear it between the collar and waist, picture facing out.
Do challenge anyone who is found in any patient care area or restricted area without a badge or identification
Do report any violations immediately to the Public Safety Department.
Do report any lost or misplaced badge to the Public Safety office @ x3329. The badge will be deactivated.
Don't loan your badge or use your badge to grant access to anyone for any reason. Each badge is programmed
differently and may have sensitive area access (Pharmacy, Cashiers, OB, etc) that another individual may not be
permitted to enter.
All patient visitors must sign-in at the front lobby desk and are issued a colored wrist band (colors vary day by day
with NO predetermined schedule) and/or a visitor “badge” if they are being sent to a secure area (e.g. Maternal
Child). Don't allow visitors to remain on the floor without the appropriate visitor badge and/or wrist band, direct
them to the main lobby to wait or to obtain a visitor badge and/or wrist band.
Don't puncture your badge with pins or decorate your badge in any way. This will damage the internal components
of the badge and may affect your ability to access badge readers throughout the hospital.
RCH has open visiting hours. Children under the age of 14 are discouraged from visiting. When a child visits, the visit
should be limited to 10-15 minute intervals and under direct adult supervision, not including the patient. During flu season,
special restrictions apply & the Liaison must approve.
Access to the 2nd Floor and 3rd Floor (Pediatrics) is controlled by badge (includes door access, stairwells, and elevators).
Visitors, vendors, and contractors are required to check in at the Information Desk in the Main Lobby.
I. General Safety at RCH
If an Emergency Code is occurring in one building, do NOT use the elevators in that building. It is OK to use the
elevators in other buildings. Dial 4911 for ALL CODES: The PBX Operator will announce the “CODE” and the
building it is located in.
When any CODE has ‘ended’, the “ALL CLEAR” will be announced 3 times by the PBX operator. Normal
activities may then be resumed.
*4911 for ALL Emergencies*
Rescue (people from imminent danger)
Alarm (call ext. 4911;
pull Fire Alarm Box)
Confine / Contain (close doors)
Extinguish / Evacuate (smother; water; fire extinguisher)
Pull the Pin.
Aim the nozzle
Squeeze the handle
Sweep the base of the fire.
Please take the time to find the Fire Alarm Box in your department.
Know your closest evacuation route!
Fire Safety: Prevention
Prevention is the best defense against fire.
Smoking is the most common cause of fires.
To help prevent these:
Follow the RCH facility “Smoke Free Campus” Policy
Instruct visitors and patients of the NO smoking policy
To help prevent fires related to the common cause of Electrical malfunction:
Remove damaged or faulty equipment from service
Submit malfunctioning equipment for repair
To help prevent fire related to the common cause of Equipment Misuse:
Do not use any piece of equipment that you have not been trained to use
Fire Safety Safeguards in the Event of a Fire
RCH is equipped with fire safety features.
These features include:
Fire alarm systems
Emergency exit routes and doors
Smoke and fire doors and partitions
A fire plan
Never block automatic fire doors with gurneys, wheelchairs, or other items. In a CODE
RED, these fire doors close automatically for safety.
Keep hallways clutter-free
HOT PINK DOOR TAGS (stored in the fire hose cabinets) are used to indicate that a
room is empty, once tagged; the room should only be opened by the fire dept.
RED DOOR TAG is placed on the door of the fire room, after it has been evacuated.
Code Blue -Medical Emergency (Cardiac or Respiratory Arrest).
The code team – 2 ACLS trained nurses from critical care, a respiratory therapist, and an ER
physician respond. Exceptions: ED, NICU, CCL, and OR will handle their own codes unless
staff is limited.
Code pink indicates an infant or baby (under 1 year of age) is missing and possibly abducted.
o RCH Policy says: Infants are always transported off OB in bassinets -they are never
carried off the unit in the arm of parents or staff outside of their room.
Code Purple indicates a child (over 1 year of age) is missing and possibly abducted. Code
Purple + (age) is announced.
For both Codes:
o Report to the charge nurse who will ask staff to monitor exits/stairwells, stop and
tactfully question anyone leaving with a baby/child or a suspicious bundle. Staff
will also need to check empty rooms or storage areas where an abductor might hide.
Combative person and dangerous security problem
All Security and male employees respond to area (show of force).
Any staff member confronted with or witnessing a combative situation should initiate a Code
Weapon or Hostage
Code Silver indicates a person with a weapon and/or a hostage situation. If you see a person
brandishing a weapon, seek cover, and warn others.
Call 4911 and report Code Silver. Give information such as: location, type of weapon, and
number of suspects/hostages. The PBX operator will call the local Police Department. The
Police Department will be in full control of the situation upon their arrival on the scene.
Upon hearing a Code Silver:
DO NOT go to the area specified. This is an extremely dangerous situation that should
only be handled by trained authorities.
Staff should close ALL patient and unit exit doors and take cover behind locked doors if
Any staff members in the area specified by Code Silver:
Seek Cover/protection and warn others of the situation
Try not to panic
When “Code Silver all clear” is announced three times, you may return to normal work
duties, unless otherwise directed.
Code Orange is an accidental release or spill of a hazardous material.
Call 4911 and request RCH HazMat assistance. If you hear the PBX operator make the
following announcement: “Attention Please” – Code Orange (Location)”:
Clear problem area immediately, all those in the immediate area should evacuate to the
next smoke compartment. Ensure all door are closed as you exit.
Unauthorized staff should stay away from the area.
Notify the supervisor who will call the MSDS Contact 3E number (1-800-451-8346) for
precautions and clean-up information.
ER will be notified and advised whether decontamination procedures are needed.
Public Safety will determine if the Riverside Fire Dept. will be called.
Facilities engineering will respond to the area.
Code Yellow is paged to inform staff of a bomb threat. If you receive a bomb threat call, do
NOT put the caller on hold or transfer the call:
Though it may be a hoax, we treat all threats as real.
Motion to a co-worker to notify PBX.
Keep the caller on the line as long as possible and get as much information as possible.
Use the yellow Telephone Bomb Threat Checklist card located in the department’s
Emergency Preparedness Manual to help you ask the right questions and document the
If you find something out of the ordinary, do not touch it or move it. Evacuate and close off
the area and immediately call 3329 or have PBX contact Public Safety.
When a Code Yellow is paged:
Close all patient room doors and all fire/smoke compartment doors.
Report to your manager for your search assignment.
All areas in your department should be scanned for items that are not usually found in
your area or for objects that are arranged in a different manner than usual.
Look around the room three times:
First, start at the floor level and look at parts of the room from the floor to about
three feet up.
Second, move your eyes to the midpoint of the walls to the ceiling.
Third, check the ceiling area, light fixtures, and top shelves.
Finally, put a note/marker on the door that the room was searched and notify Public
Safety your area is clear.
“Triage” is a process used to sort and classify the sick or injured. When the need exceeds our
capacity to care for the sick or injured you may hear “Triage codes” announced by the PBX
operator. There are three types of triage codes:
Triage Alert announces an impending disaster mode for the hospital. Preparations
should be made to activate your department’s disaster plan. Report to your supervisor for
Triage External announces a disaster has occurred and the hospital expects a large
number of casualties to come through Emergency.
Triage Internal announces a disaster that has occurred inside the hospital (fire, flood,
etc.) and people are needed to respond to a designated floor or department.
When a Code Triage is paged:
All direct patient care services departments will continue to provide the highest level of
service possible. Managers will complete an Inventory Labor Pool slip and determine
which staff can be directed to assist with the disaster.
All other services will focus efforts towards direct inpatient care needs. Non-essential
operations will be discontinued until Triage All Clear is announced.
If your supervisor assigns you to report to the People (Labor) Pool, report to the cafeteria
unless an announcement states otherwise. Nursing staff should bring a blood pressure
cuff and stethoscope.
All unused patient movers (wheelchairs and gurneys) should be taken directly to the
hallway between ER and Radiology.
Designated team members report to assigned duties.
The Control (Command) Center is located in the Emergency Department lounge (unless
otherwise announced). If your department needs additional supplies or equipment during
an emergency, you should contact the Command Center at 1911.
II. Emergency Preparedness
1. Hospitals must be prepared to respond to disasters such as:
A. Natural disasters…earthquakes or hurricanes
B. Technological disasters…electrical failure
C. Major transportation disasters… trains, planes
D. Terrorism…Sept. 11th
E. Nuclear, biological, chemical & radiological events…anthrax, dirty bombs, etc.
2. To prepare for such disasters, each hospital must:
A. Identify events that could occur internally or in the area
B. Be prepared for events that might occur
C. Develop strategies for dealing with each event and develop an Emergency Operations Plan
D. Hospitals must have an Emergency Operations Plan that centers on six key elements:
F. Resources and assets
G. Safety and security
H. Staff responsibilities
J. Clinical activities
3. In Order to be Prepared, Staff Must Be:
A. Educated on the procedures in the Emergency Operations Plan
B. Trained and drilled to respond to disasters according to the plan.
C. Make sure YOU participate in RCH’s disaster drills, and
D. Read your department Emergency Preparedness Manual
III. Electrical Safety
1. Most equipment in the
2. Healthcare setting is electric.
3. This means there is risk of electric shock from medical equipment.
4. Electric Shock can cause:
B. Muscle Spasms
C. Ventricular fibrillation
D. Respiratory arrest
5. Remove and report hazards
6. Remove electrical equipment from service if it:
B. Shows signs of damage
C. Shows signs of unusual heating
D. Produces a burning smell during operation
E. Shocks staff or patients
F. All Medical equipment should have a current inspection tag on it, if not, notify BioMed.
7. Use equipment safely.
A. Learn proper equipment operation before use.
B. Do not use equipment on which liquid has been spilled or handle with wet hands.
C. Turn equipment off before plugging in or unplugging.
D. Maintain, test, and inspect
E. All medical equipment should be inspected and tested on a regular schedule
F. Use power cords and outlets properly
G. Do not use outlets or cords with exposed wiring.
H. A hot outlet can be an indication of unsafe wiring. Unplug cords from the outlet. Report the
I. Do not bend, stretch, or kink, power cords excessively
J. Do not jerk cords from outlets. Pull on the plug.
K. Do not staple, tack, or nail power cords to walls or floors. Use tape, if necessary.
L. Do not rest equipment on power cords.
M. Use only power cords with three-prong plugs. Never use adapters, two-prong plugs, or
broken three-prong plugs.
8. Protect patients
A. Place electrical equipment at a distance from patients.
B. Maintain patient areas, keep floors dry at all times.
C. Do not touch patients and electrical equipment at the same time
IV. Radiation Safety
1. Exposure to radiation can increase the risk of cancer, therefore it is important to protect against
2. The three key factors for limiting exposure are:
A. TIME. Minimize the amount of time that you are exposed.
B. DISTANCE. Maximize your distance from the radiation source.
C. SHEILDING. Use appropriate shielding to absorb the energy of radioactive particles.
3. The goal is to keep radiation exposure As Low As Reasonably Achievable (ALARA).
4. Nuclear Medicine
A. When a patient is injected with a radioactive isotope, Nuclear Medicine will place a sticker
on the patient’s chart noting:
Name of isotope
Dose of isotope
Date of decay
Nuclear Medicine will also place a door tag on the patient’s door which states:
(a) Environmental Services do not remove trash/linen from room until
(b) Date: __________________
(c) Time: __________________
V. Magnetic Resonance Imaging MRI Safety
1. An MRI system is not an inherent biological hazard.
2. However, hazards can arise when certain items enter the MRI systems:
A. Ferromagnetic objects are attracted to the magnet at the center for the MRI system. They
can become dangerous projectiles (“the projectile effect”).
B. Electronic devices that enter the magnetic field of the MRI system can malfunction due to
C. Metal implants or wires can conduct electrical currents resulting in burns.
3. MRI safety is largely a matter of ensuring that potentially hazardous items stay outside the
magnetic field. Therefore:
A. Control access to the magnetic filed
B. Remove metallic objects from clothing and pockets before entering the magnetic field.
C. Thoroughly screen patients prior to MRI. Ensure that patients do not have MRI-unsafe
implants or embedded objects.
D. Properly position patient for MRI so that electronically conductive loops are not formed.
This will prevent burns.
1. Ergonomics means designing work equipment and tasks to fit the “natural law” of the human
2. Good ergonomic practices can lead to fewer work-related injuries.
3. Ergonomic best practices are:
A. Avoid fixed or awkward postures.
B. Avoid lifting without using proper devices or lift equipment.
C. Avoid highly repetitive tasks, if possible.
D. Provide support for your limbs.
E. Use proper posture and body mechanics when sitting, standing, or lifting.
F. Avoid reaching, twisting, and bending.
G. Respond promptly to aches and pains to prevent slight injuries from becoming severe or
Healthcare is a high-risk setting for back pain and injury.
Healthcare workers who lift and move patients are at especially high risk for injury.
Injury may be prevented through:
A. Proper care and operation of the spine
B. Proper posture
C. Regular exercise
D. Back Safety & Proper Posture
E. Maintain proper posture and head alignment.
F. Ears over shoulders, shoulders over hips.
G. Maintain slight curves of the neck and back
4. Maintain the three curves of the spine while:
D. Lifting a static load vertically
E. Lifting or transferring a patient
F. Lifting & Transferring Patients
5. Healthcare staff who lift and transfer patients are repeatedly exposed to the three major risk
factors for injury during physical task:
A. Awkward posture
Manual patient handling often involves awkward postures. For example, bending and
reaching while lifting or lowering creates an awkward position.
Force refers to how hard the muscles have to work. A lot of force is required to lift
patients who typically weigh 100 pounds or more
This risk factor refers to performing the same motion or series of motions over and over
again. Nurses and aides might perform dozens of lifts and transfers in a single shift.
They might perform thousands of lifts over a lifetime of nursing
6. Lifting &Transferring Patients
A. Slide objects as close as possible before lifting
B. Test before lifting; ask for help if heavy
C. Tighten stomach muscles without holding breath
D. Use smooth movements; do not jerk.
E. Distribute load evenly
F. Do not bend, use your legs to lift
G. Do not twist at the waist
H. To minimize or eliminate manual lifting, use devices to help with patient lifts and transfers.
Available devices include:
(a) Motorized lifts - ARJO
(b) Non-motorized transfer devices such as, transfer boards, maxislide, etc.
(c) Step up on a stool to reach surfaces that are too high to reach without arching your
I. Bend at the knees and hold the object close to the body
J. Use 2 people to lift or move heavy or bulky objects
K. Push instead of Pull
VIII. Slips, Trips, & Falls: Prevention
1. Slips, trips, and falls in the workplace cause injuries and deaths every year.
2. To help prevent Slips, Trips, & Falls:
A. Keep floors clean and dry
B. Increase the friction of floors with abrasive coatings, non-skid strips, or rubber mats.
C. Secure rugs with skid-resistant backing.
D. Choose slip-resistant shoes.
E. Post safety signs around slip hazards (icy sidewalks, wet floors, etc.
F. Keep your feet flat and slightly spread apart.
G. Point your toes slightly outward.
H. Keep your center of balance under you.
I. Make wide turns at corners.
J. Keep your arms at your sides
K. This gives additional balance.
L. It keeps your arms available for support if you fall.
3. Most falls in the workplace are foot-level falls. In a foot-level fall, a person slips or trips on a
walking or standing surface. This results in a short-fall.
4. Falls from a height carrier a higher risk for injury. These include:
B. Keep staircases clean and well lit.
C. Staircase should have sturdy handrails on both sides
D. Maintain your center of balance when stepping.
F. Use a ladder of the proper height
5. FALLING STARS Program.
A. Each patient is assessed for risk of falls.
B. If the patient is judge to have a risk for falls (due to medication, weakness, memory etc.), a
bed alarm is used and they are part of the "Falling Stars" program.
A magnetic star will be placed on the door frame of the patient’s room.
(a) The Star has an A, B, or A/B, indicating which patient(s) should be carefully
observed. Bed “A” is always closest to the door.
In addition, a YELLOW armband indicates a “High Risk for Falls”
Yellow slippers will be placed on the patient to identify them as a high risk of fall.
C. If you see someone that has been identified as a “High Risk for Falls” walking without
assistance, please get the nurse or any available help for the patient to prevent a fall.
IX. Latex Allergy: Screening & Diagnosis
1. Latex allergy means sensitivity to contact with certain protein in latex.
2. Latex allergy is becoming more and more common. Most reactions to latex are mild. But some
can be life threatening.
3. Screen questions provide good tools for identifying patients at risk for latex allergy. This can
help prevent future problems.
4. Review the questions: (If you or a patient answers “yes” to one or more of these questions, the
patient may be at risk for latex allergy.)
LATEX ALLERGY SCREENING QUESTIONS
Have you ever had an unexplained problem during surgery?
Have you ever experienced breathing problems during a
Have you ever experienced swelling or wheezing when
blowing up balloons?
Are you allergic to any foods, especially bananas, avocados,
Medical Exam/ Condoms
Have you ever developed a rash or discomfort after having a
medical exam or using a condom?
Allergy/ Skin Problems
Do you have a history of allergy or skin problems?
A careful and thorough latex screening is performed on all patients.
Latex Allergy: Management
Healthcare workers are at elevated risk for latex allergy.
If you or your patient are allergic to latex:
The patient should inform the nurse and you should inform your supervisor or
RCH provides many latex-free products are possible.
Use silk or plastic tape instead of adhesive tape.
Use non-latex gloves only.
X. Security & Workplace Violence
1. Workplace violence is any violence committed in a work place setting.
2. To help keep your workplace safe from violence:
A. Recognize aggressive behavior and warning signs of potential violence.
B. Respond appropriately to the level of aggressive behavior.
C. Report all unsafe situations immediately.
3. Warning Signs of Workplace Violence:
A. All threatening comments or behaviors should be taken seriously – never dismiss them as
“harmless” or “just blowing off steam”. We take a proactive stance to prevent violence.
Report the following:
B. Direct or verbal threats of harm
C. Intimidation of others by words or actions
D. Refusing to follow policies
E. Carrying a concealed weapon or flashing a weapon to test reactions
F. Hypersensitivity or extreme suspiciousness
G. Often verbalizes hope for something to happen to the other person against whom the
employee has a grudge
H. Expression of extreme desperation over recent problems
I. Intentional disregard for the safety of others
J. Destruction of property
4. When Violence Erupts…
A. Call for help. Page CODE GRAY if necessary or cal the PBX Operator to have security
stand by. A show of force may curb angry/violent behavior.
B. Move bystanders to a safe location.
C. Use physical restraint as a last resort.
D. Wait for police to deal with weapons.
5. Harassment Free Workplace
A. Harassment Policy HR 155 applies to all hospital agents, including employees, medical
staff, and contract services. The policy prohibits unlawful harassment in any form,
including verbal, physical and visual harassment.
B. RCH is committed to a work environment that is free of discrimination and maintains a
strict policy which prohibits all forms of unlawful harassment, including sexual harassment,
harassment based on race, color, religion, national origin, or age.
C. Harassment may occur regardless of whether the behavior was intended to harass:
unwelcome sexual advances, verbal or physical conduct of a sexual or otherwise offensive
nature, any behaviors that create a hostile or offensive work environment - it can be in the
form of jokes, innuendoes, printed materials, emails.
XI. Safety Hotline Ext: 3383
1. Report any safety issues or concerns to your manager or liaison. If the issue is not resolved,
use the Safety Hotline (3383) to report any safety issue or concern. Patient’s families and
physicians are also encouraged to use the hotline. You may identify yourself or leave the
message anonymously. Safety issues may also be reported directly to the California Dept. of
Health Services and/or then to The Joint Commission: (800) 994-6610 or to
XII. Mandatory Reporting
1. Elder/Dependent abuse, Domestic Violence, and Child Abuse
A. Abuse is defined as the intentional maltreatment of an individual which may cause injury
(either physical or psychological) and includes: Mental abuse, physical abuse, sexual abuse,
neglect, abandonment, fiduciary (finances), isolation, and domestic violence (assault or
abuse by a family member).
B. If you are a health care professional and have knowledge of/or reasonably suspect
abuse/neglect, you must (by law) report abuse to the proper authorities to be investigated:
C. Child abuse-report to Child Protective Services/Child Abuse Hotline before child leaves
D. Elder/Dependent abuse (any hospitalized patient 18 years or older) – report to County
Adult Protective Services, Long-term Care Ombudsman, or Police.
E. Domestic Violence-report to local law enforcement by telephone and in writing, while the
patient is in the hospital. Also report any possible abuse incident to Social Services
F. If you need information on recognizing signs and symptoms of abuse, there is a learning
module entitled “Recognizing and Reporting Abuse Across the Life Span” in the nursing
2. Substance Abuse
A. RCH Policy 178/178A says that all RCH employees are obligated to report any suspicious
behavior of another employee’s condition which would impair their ability to perform their
duties or which may cause a hazard to the safety and well-being of others. Do you know
what those signs are?
XIII. Hazardous Materials
1. Chemical products and medical gases are necessary in health care. When handled incorrectly
they can burn, explode, cause tissue damage, or lead to acute or chronic health hazards.
2. To protect workers from exposure to hazardous chemicals, the following groups of people have
hazard communication duties:
3. MSDS (Material Safety Data Sheet)Material Safety Data Sheets (M.S.D.S.) provide:
A. Detailed information on hazardous materials provided by manufacturer
B. Specific hazardous of a chemical
C. Hazardous ingredients
D. Fire, explosive, and reactivity data
E. Health hazards
F. Special precautions for handling
G. Any required Personal Protective Equipment (PPE), such as gloves and eye protection
H. Proper storage and disposal
4. Your Responsibilities During a Hazardous Spill
A. Know the hazards of any product you work with.
B. Read all container labels.
C. Use any specified Personal Protective Equipment for handling/clean-up (gloves, mask, etc.)
or call Environmental Services.
D. Safely handle, store and dispose of hazardous materials.
E. Immediately notify your Supervisor and Public Safety of any spill or release of a hazardous
F. Public Safety will request HazMat assistance, if necessary.
G. Report any hazardous material exposure to your Supervisor and complete an Employee
Injury-Exposure Report (on Meditech).
H. Reporting Incidents (RIRs)
XIV. Infection Control
1. Healthcare-Associated Infections (HAI’s)
A. An infection that develops in the hospital or after treatment is considered a healthcareassociated infection (HAI) if it appears 48 hours after contact with the healthcare system.
B. HAIs may be caused by bacteria, viruses, fungi, or parasites.
C. These ”germs” may come from:
Environmental sources (dust, etc.)
D. Many HAIs are related to invasive procedures, especially:
IV line placement
E. The most common type of HAI is urinary tract infection (UTI), associated with indwelling
(a) High-risk procedures such as catheterization should be performed only when
(b) Catheters should be removed as soon as possible.
(c) According to SCIP guidelines, a catheter must be removed by Day 2 post-op or the
physician must document the continued need in the progress note.
(d) Instruments and equipment used for invasive procedures should be properly
sterilized before use.
F. Best practices for preventing HAI are related to:
Environmental hygiene/Equipment Cleaning
Personal protective equipment
2. Hand Hygiene
A. The single most important factor for preventing the spread of infection is proper hand
B. Hands should be washed or decontaminated before and after each direct patient contact.
C. Current CDC guidelines recommend the use of:
Soap and water for washing visibly soiled hands
Waterless hand sanitizer is used for Routine Decontamination hands in all clinical
situations, even after contact with intact skin or contact with inanimate objects in a
D. When washing with soap and water:
Remove rings, jewelry, and watches
Pre-wet hands with water
Use an appropriate amount of soap
Rub all surfaces of the hands and wrists for 15 seconds
Rinse thoroughly under running water
Dry hands with a disposable towel
E. When decontaminating hands with waterless hand sanitizer:
Apply the amount of rub recommended by the manufacturer
Rub all surfaces of the hands and wrists until hands are dry
3. Environmental Hygiene
A. Best Practices for Environmental Hygiene
Maintain a visibly clean environment (no visible dust or soiling)
Clean, disinfect, or sterilize medical equipment after each use
Dispose safely of clinical waste
Launder used and infected linens safely and effectively
Follow appropriate guidelines for kitchen and food hygiene
Maintain an adequate pest-control program
B. Equipment Cleaning
All clean patient equipment will come up from the Sterile Processing Department (SPD)
with a “I’m Clean” tag. Take the tag off prior to patient use.
SPD Equipment - includes (but is not limited to) IV pumps, wound vacs, CPM
machines, SCDs, PCA pumps, Gomco pumps etc,
NON-SPD Equipment – includes but not limited to – gurneys, wheelchairs, blood
pressure cuffs/machines, thermometers, blood glucose machines, etc.
When a piece of equipment is discontinued:
(a) Nursing is responsible for removing all disposable equipment such as suction
tubing, suction canister, IV tubing, etc.
(b) Nursing is also responsible for placing All reusable patient equipment originating
from SPD in the dirty utility room of that unit to be picked up by SPD for cleaning
(c) Patient equipment coming from an isolation room will be cleaned by nursing staff
using germicidal product prior to placing the equipment in the dirty utility room to
be picked up by SPD.
(d) SPD equipment that is excessively and visibly soiled will be placed into a clear bag,
placed into the dirty utility room, and SPD will pick up for cleaning. It will not be
cleaned by nursing.
(e) Non SPD equipment - If equipment is taken from room to room (BP machine,
glucose meter, E-MAR cart, thermometer, stethoscope), clean with equipment
germicidal wipe prior to using it on another patient.
If you do NOT see the “Clean” Tag attached to the equipment, it means that the
equipment is DIRTY, and has not been cleaned by SPD.
If you need to use this equipment, you MUST first clean it, following the correct
(a) Don gloves
(b) Obtain disinfectant (spray/pour bottle) and washcloth from the designated area of
the dirty utility room.
(c) Spray/pour 3ml disinfectant on washcloth, making sure the cloth gets fully
(d) Using the wet cloth, wipe equipment, making sure all surfaces are wet including the
(e) Allow to remain wet for 1 minute, let air-dry.
(f) Remove and discard gloves.
(g) Perform hand hygiene.
(h) After 1 minute equipment is ready for patient use.
(i) If using bleach wipes, the contact time is 5 minutes.
4. Antibiotic Use:
A. Antibiotic Resistance
Antibiotics have been used to treat Bacterial illness; however, bacteria are very
adaptable and have the ability to change genetically to resist the effects of antibiotics.
The more antibiotics are used, the more common resistant strains of bacteria become.
Clinically important examples are:
(a) Methicillin-resistant Staphylococcus aureus (MRSA)
(b) Vancomycin-resistant Enterococci (VRE)
(c) Multidrug-resistant Mycobacterium tuberculosis (MDR-TB)
B. Impact of Resistance
Antibiotic resistance is a significant health problem and it adversely affects:
(a) Drug choice
Less effective against the bacteria
More toxic to the patient
(b) Patient health
Higher medical bills
Greater risk of death
(c) The healthcare system
Antibiotic-resistant strains contribute significantly to HAI.
More the 70% of all bacteria that cause HAI are found to be resistant to one of
more commonly used antibiotics
C. Prevention of Resistance
Healthcare professionals must take an active role in preventing the spread of antibiotic
(a) Preventing illness through vaccination
(b) Diagnosing & treating infections effectively
(c) Using antibiotics prudently
(d) Preventing spread of infection
5. Bloodborne Pathogens
A. Bloodborne diseases are spread from person to person as a result of unprotected exposure
Other bodily fluids
Most body tissue
B. Important bloodborne diseases include:
C. Bloodborne Pathogen Standard
The Bloodborne Pathogens Standard (BPS) helps protect workers from exposure to HIV
and other bloodborne pathogens... The BPS include:
(a) Cover any worker who might come in contact with blood or other potentially
infectious materials (OPIM) as part of his or her job
(b) Requires employers to take certain steps to help protect these workers
One of the key parts of BPS is to require the use of Standard Precautions:
(a) Standard Precautions should be used in the care of All patients, regardless of their
These precautions apply to patient:
(b) Body fluids
(c) Secretions & excretions (except sweat)
(d) Non-intact skin
(e) Mucous membranes
D. Standard Precautions
Mask, Eye Protection, Face Shield, Gown
Patient-Care Equipment and Linens
E. Needlestick Prevention
RCH has a no recapping policy (needles/sharps). If recapping is unavoidable, use the
one-handed method to replace the cap.
Replace or report any needle container that is filled 2/3rds or more, so it can be
Contaminated needles and other contaminated sharps should not be bent or recapped.
Shearing or breaking of contaminated needles is prohibited.
Contaminated sharps should be place in appropriate containers. These containers must
be puncture-resistant, appropriately labeled or color-coded, and leak-proof on the sides
Should you be exposed to blood or other potentially infected materials by needle stick,
by sharps injury, or by splashes to mucous membranes (eyes, nose, mouth), report the
incident immediately to your supervisor! Best treatment results occur when follow-up
care is started within one hour of exposure.
6. Airborne Precautions:
Airborne diseases are transmitted from person to person via infectious droplet nuclei.
These tiny particles:
(a) Are produced when an infected person sneezes, coughs, or talks
(b) Can remain suspended in the air for long periods of time
(c) Can travel long distances on air currents
Transmission occurs when a health person inhales an infectious particle.
Infection & disease symptoms then may occur.
B. Common organisms isolated in Airborne Precautions
Important airborne disease include:
(a) Chickenpox & Shingles
(c) Tuberculosis (TB)
Other disease that may be spread by airborne route include:
C. Summary Table
To prevent the transmission of airborne disease in the healthcare setting, Airborne
Precautions are used for patients known or suspected to have illnesses transmitted by
Airborne Droplet nuclei (small-particle residue, 5 microns or smaller in size).
(a) Patients are isolated in private rooms with special air ventilation systems. Airbornediseases require isolation in a room capable of having negative pressure ventilation.
(b) Place an "airborne precautions" sign on the door.
(c) When a private room is not available, place the patient in a room with a patient who
has active infection or is colonized with the same organism within a similar
(d) Consult Infection Prevention & Control for any questions regarding cohorting
(a) Healthcare staff must wear an N95 mask or PAPR whenever entering the patient
room with a known or suspected airborne disease.
(b) Susceptible persons should not enter the room of patients known or suspected to
have measles (rubeola) or Varicella (chicken pox).
(c) Persons immune to measles or Varicella do not need to wear respiratory protection.
Patient Transport – Limit patient transport as much as possible, when transporting the
patient have them wear a surgical mask.
TB Exposure Control Plan (IC 401) and Emerging Respiratory
Disease Plan (IC 402) for information TB, SARS, and Pandemic Influenza.
7. Contact Precautions:
Contact transmission of disease occurs via direct or indirect person-to-person contact
(hand-to-skin or skin-to-skin).
This form of transmission is the most important & common cause of HAI.
Examples of contact disease are:
(a) clostridium difficile (C-Diff)
(b) Hepatitis A
(c) E. coli 0157:H7
(e) Respiratory syncytial virus infection (RSV)
(h) Viral hemorrhagic infections
(i) Scabies and Lice
(j) Chicken pox and disseminated (full body) shingles
(k) Many others
C. Summary Table
MRSA guidelines: we no longer isolate patients with history of MRSA, VRE,
Acinetobacter or shingles unless they have large wounds that are uncontained by
dressings. The Infection Control Policy is on every unit – see Infection Control Manual.
All patients will be cleaned with CHG (chlorhexidine gluconate) on admission. No
rinsing is required. It is required daily in place of the traditional bath. However, if a
patient desires a bath or shower, the CHG will be applied after the bath or shower.
CHG bathing cloths replace soap for routine daily bathing for all areas below the
jawline. Use shampoo caps and hospital supplied cleansing/soap products above the
jawline as per IC 201 Patient Bathing. Please do not flush bathing cloths down the
(a) Patients are isolated in private rooms or cohorted for C Diff (with active diarrhea)
Open and draining wounds uncontained by dressings, Salmonella/Shigella, RSV, cDiff, Scabies/Lice, Hepatitis A.
(b) Consult Infection Prevention & Control for any questions regarding cohorting
(c) Place a "contact precautions" sign on the door. Partially close the door so the sign is
(d) Gloves, Gowns, & Hand Antisepsis – Healthcare staff must don a gown and gloves
when entering a room on Contact Precautions.
D. Patient Transport – Transport should be limited as possible.
E. Patient Care & Equipment
(a) During patient care, change gloves after having contact with infective material that
may contain high concentrations of microorganisms (fecal material or wound
(b) Remove gloves inside the room, and immediately decontaminate hands.
Personal Protective Equipment:
(a) Wear a gown every time you enter the patient's room. You must wear a gown and
gloves whether they are colonized or infected. If the patient is coughing AND you
will be in close contact with them, a regular mask will also be appropriate.
Non-critical equipment should be dedicated to a single patient.
Equipment should be cleaned and disinfected between patients.
8. Droplet Precautions:
Droplet transmission happens via large respiratory droplets.
(a) Are generated during coughing, sneezing, talking, etc.
(b) Travel a short distance through the air (up to three feet).
(c) Droplets may land on the mucous membranes of a nearby person’s eyes, nose, and
(d) Droplets may also contaminate surfaces.
(e) Disease transmission then may occur.
Examples of droplet disease are:
(a) Bacterial meningitis or meningitis cause unknown,
(b) Pertussis (whooping cough)
(c) Pneumonic plague
(e) Rubella (German Measles)
(g) Many others
C. Summary Table
(a) Place patient in a private room
(b) Place a "droplet precautions" sign on the door.
(i) Partially close the door so the sign is visible.
(c) When a private room is not available, place the patient in a room with a patient who
has an active infection with the same organism but with no other infection
(d) Check with Infection Prevention & Control for cohorting issues
(e) Wear gloves, gowns, and surgical mask for every entry into the room
(a) Limit the movement and transport of the patient from the room to essential purposes
(b) If transport or movement is necessary, minimize dispersal of droplets by putting a
regular surgical mask on the patient.
9. Personal Protective Equipment (PPE):
A. Personal protective equipment (PPE) is an important component of infection control. PPE
helps to prevent the spread of microorganisms both:
From patient to healthcare worker
From healthcare worker to patient
B. PPE includes gloves, gowns, mask, eye shields, lead aprons, thyroid shields, etc.
Face shields, masks, gloves, and gowns to use any time you suspect there may be a
potential exposure to body fluids.
(a) Remember anything that splashes to the eye level will also expose the nose and
(b) Carry goggles and a mask in your pocket, so you will have them when needed.
Lead aprons and thyroid shields any time you suspect there may be a potential exposure
C. Every crash cart has a resuscitation bag and cardiac board on the outside of the cart. We
also have Latex-Free carts for patients allergic to latex.
D. DOUBLE BAGGING of linens is not required unless the leakage is likely.
E. TUBERCULOSIS: If you suspect any patient has symptoms of TB (weight loss,
unexplained loss of appetite, cough, fatigue, night sweats, fever), notify the charge nurse
immediately. The Aerosol Transmissible Disease Plan can be found online in the Infection
F. SPECIAL MASKS, called the N-95 mask, is used for patients with known or suspected TB
or other organisms that are airborne. If you have been identified as a healthcare provider
who may care for these patients, you must be fit-tested (annually) in order to wear the N-95
mask. This is to ensure it works properly and protects you!
10. RCH Specific Infection Control Policies
A. Food or drinks may not be taken to the nursing station or to any patient care area.
B. All refrigerators should have daily log entries to indicate that correct temperatures are
maintained for safe food storage. Note: If temperatures do not fall in acceptable ranges,
write on the log what was done to correct it!
C. All stored patient food items should be dated.
D. Gloves should not be worn in the hallway. When leaving a room, remove gloves and wash
Gloves worn outside a patient room are considered to be contaminated.
E. Shoe covers should not be worn outside of the operating room (or other work areas) into the
general hospital environment. This is hospital policy and an OSHA violation.
Shoe covers are used to keep the environment clean. Wearing shoe covers out of the
department and back in again potentially "contaminates" the environment! If shoe
covers are "soiled" they can transmit infectious material to other departments.
F. It is everyone's responsibility to maintain a clean, safe environment.
Remember to pick up your own trash, clean up your spills, keep your environment clean
and uncluttered, and have pride in your hospital.
11. Personal Responsibility
A. As a healthcare worker, you have personal responsibility for infection control in your
B. Maintain immunity to vaccine-preventable diseases such as:
C. Report all unprotected exposures, such as accidental needle sticks.
D. Stay home from work when you are sick.
E. During influenza season (Oct 1st to March 31st) if you decline influenza vaccination or do
not have proof of receiving vaccination you will be required to wear a mask in patient care
XV. Medical Waste
1. Proper disposal of medical waste is important for many reasons.
A. First and foremost, it allows for the safe handling of potentially dangerous items. A needle
in a trash can result in a person getting a needle stick and developing a deadly disease.
B. Secondly, disposal of these products is expensive and is often measured by the pound. If all
trash is thrown into Biohazardous Waste (red bags) the additional cost of healthcare could
rise tens of thousands of dollars. We want to be good stewards of our healthcare resources.
C. Third, EPA, OSHA, and other government organizations levy fines against hospitals for
inappropriate disposal of hazardous waste or personal information.
D. Finally, it protects our community.
2. Regular Trash (clear bags)
A. Empty bedpans, urinals, IV bags (block out labels over patient information), dressings,
chux diapers, peripads with bodily fluids that are dried or “non- dripping”. Also personal
care items such as basins, cups, or toothbrushes.
3. Biohazardous Waste (red bags)
A. Blood tubing, blood bags, hemovacs, pleurevacs, soaked/dripping dressings, intact glass or
plastic bottles with body fluids inside, foley bags that cannot be completely emptied. All
items from biohazardous waste are treated, before going to landfill.
4. Sharps Waste (designated Sharps container)
A. All sharps, such as needles, scalpels, razor blades, clips, staples, staple removers, scissors,
syringes (with less than 2cc of fluid), tubexes, carpujects, trocars, guide wires, biopsy
devices and broken glass.
5. Pharmaceutical waste (white container with blue lid)
A. No needles. Medications must be rendered as unrecognizable or unusable. IV bags/tubing
that cannot be emptied, glass vials and broken ampules with meds still inside, partially used
(even over the counter meds) in capsule, powders, lotions, creams, and suppositories.
Narcotic patches must be folded on self. Controlled substance caps must be crushed prior
to disposal. Injectable amounts greater than 2ml. IV fluids of Profpofol (Diprivan) and
TPN with lipids.
B. Pharmaceutical waste is incinerated.
6. Chemotherapy Waste (yellow container – marked special disposal)
A. Everything used to make and administer chemo medication e.g.: tubing, bags, bottles, vials,
syringes, gloves, masks, gowns wipes, clean up kits.
7. Hazardous Pharmacy Waste (black container)
A. Medications that are identified as hazardous to the environment are flagged with a black
label and/or are identified in Pyxis/Meditech when dispensing/administering medications.
Proper disposal includes pill wrappers, inhalers, contrast bottles, etc.
8. Confidential Paper Trash (locked bins)
A. Any papers, labels, scratch paper, or documents that contain a patient’s name or any patient
information. This even includes a medical record number and any business paperwork
confidential to RCH. We pay to have these papers shredded, so don’t throw everything in
there, just what should be kept private – that should not go to regular landfill.
9. Linen hampers (clear bags)
A. All linen regardless of moisture content or type of fluid. Remove all chux and tape
prior to placing in linen hamper. Linen does not have to be double-bagged unless it is
likely to spill. All linen is treated at the highest level, whether it comes from an isolation or
XVI. Cultural Diversity
1. Rapidly changing ethnic demographics in the U.S. and healthcare systems that are difficult to
navigate are forcing hospitals to make sure that their staff members become culturally
2. What does it mean for me?
A. When delivering care to a patient or their family, the healthcare professional must attend to
and respect the cultural needs and beliefs of each individual. This applies to all hospital
3. The first step to cultural competence is to examine your own values and beliefs.
A. Answer these questions about you and your family:
How do you define health?
What do you do to maintain & protect your health?
What do you do when you experience a noticeable change in your health?
Do you diagnose your own health problems?
From whom do you seek healthcare?
What do you do to restore your health?
Do you use over-the-counter medications or herbs?
Do you use meditation, prayer, spirituality, religion, or magic in your care?
4. Culture often determines people’s health practices, as well as the way they respond to illness,
injury, and pain.
5. A person’s culture affects his or her beliefs about communication, health, and nutrition.
6. In order to provide high-quality care to all of our patients, we must have an understanding of
their cultural backgrounds, religious beliefs, and be able to communicate with them.
A. Determine your patient’s or patient’s families beliefs
What is the family’s ethnic background?
What is their country of origin?
What is their religious belief?
What do they do to maintain health?
What did their mothers do?
What do they do to protect health?
What home remedies do they use and what ones did their mother use.
7. In addition to having an understanding of cultural differences, we must provide competent
interpretation for our non-English-speaking patients.
A. RCH utilizes Language Service Associates to obtain professional interpreters for hundreds
of languages. Special Phones are available for all nursing departments.
B. The Language Service Associates phone should be used for informed consents, legal, and
in-depth assessments, treatment options, and discharge instructions.
C. Language Service Associates also has a Sign Language Service (for the hearing
impaired) a designated laptop computer is used for interpreting. (available in the PBX or
8. Assessing Health Literacy – patients should always be assessed for their ability to learn and
understand health material such as consents, medication use, and any patient teaching.
Infant and Child Safety
9. Abductor Personality
A. The “typical” abductor is usually female between 12 and 50 years of age. She is frequently
overweight, may be nervous, compulsive, appear to be in a hurry and carrying a bundle, a
satchel, or large purse.
B. A woman may abduct an infant to replace the one lost by miscarriage or she may be
incapable of childbearing. She may be married and have other children at home.
C. Seventy percent of the time, the abductor will preplan the abduction; however, the abductor
usually does not target a specific baby. In many cases she will visit the nursery prior to the
abduction and familiarize herself with the routines and layout of the unit.
D. Abductors focus on facilities with little or no security.
E. The abductor may pose as a hospital employee, such as a physician, nurse, volunteer, lab
worker, or photographer.
F. On pediatric units, the abductor usually poses as an aunt or relative of the child.
G. Most kidnappers wear some type of hospital attire, e.g., scrubs or a lab jacket and maybe a
stethoscope. If the abductor was a former employee, a hospital ID badge may even be
H. After the abductor has identified easy access to an exit, she waits for an opportunity. She
will then go into the mother’s room, call the mother by her first name, even call the baby by
name as if she knows them and tells the mother she needs to take the baby to the nursery.
The reason she gives for taking the baby are varied according to whom the abductor is
impersonating. She will use excuses, such as, it’s time:
To weigh the baby
To draw a lab test
For a physical exam
To photograph the baby
I. Abductions also occur when the mother leaves her child unattended in the room to go to the
bathroom or take a shower. The abductor is usually off the unit within 4 seconds and on the
way out of the hospital with the infant in a matter of a few more seconds.
10. Parent Education
A. As soon as possible (do not wait until discharge), parents should be taught what to do to
safeguard their baby:
Check the employee’s ID badge and make sure the photo matches the employee’s face.
Nurses in the maternal/child area wear ID badges with a pink frame around the picture.
This is a second form of ID.
Never leave the baby unsupervised, even to go to the bathroom.
Become familiar with the unit routines and the nurse assigned to take care of you and
your baby. If in doubt, ask.
Relinquish your baby only to a nurse with a photo ID badge with a pink frame.
If you become uncertain of a person’s motives, or someone unfamiliar comes into your
room and requests your baby, notify your primary nurse. Anyone can put a lab coat on
and look like a professional.
Infants will only be transported off the unit by bassinets. Anyone carrying a baby will
RCH utilizes a four-band system: 2 bands for the baby and 1 band each for the mother
and a significant other. Only the 2 people wearing these bands will be allowed to take
the baby from the nursery.
As another means of infant identification, an additional set of footprints besides the
souvenir set will be taken at the time of birth. It is very important that these are done
correctly. Do not press too hard. The ridge marks on the ball of the foot have to be
When “ROOMING-IN”, request your infant be taken to the nursery whenever you
cannot attend to the infant, e.g. when showering, going to the bathroom.
11. Staff Education
A. Prevention is the best defense against infant abductions.
B. Anyone who sees a baby being carried in the hall by an unknown person must enforce the
policy that infants must be in a crib or bassinette.
C. Be alert to people who may be wearing partial hospital dress such as a scrub top over street
D. Verify identification of anyone requesting to “borrow” scrubs.
E. Strangers should not be given information about unit routines.
F. Exits should be in view from the nurse’s station, if possible.
G. Any exit not in view of a nursing unit should be locked or connected to a security device
such as a surveillance camera or alarm.
H. Look for the unusual, e.g., anyone hanging around the nursery or postpartum unit that has
no reason to be there. Visitors should be walking with the patient or a “banded” person, be
in the patient’s room, or be in the waiting room. Visitors gathered in the hall need to be
directed to the waiting room. People grouped together can be used as a screen to hide an
I. Educate parents about infant safety on admission. More than half of the infants abducted
from hospitals since 1983 were taken directly from their mother’s room. Increasing
parental awareness is a key factor in the success of an infant safety program.
J. Parents need to be educated on infant safety not only while in the hospital, but also after
they go home. Newspaper articles announcing births and signs posted outside homes alert
abductors to a new baby.
K. All staff working in a maternal/child area (physicians, nurses, volunteers, housekeeping,
and lab) should be educated on infant safety and on what to do to prevent abduction.
L. Become familiar with infant safety policies and procedures.
M. Supervise babies at all times, especially during visiting hours. Be aware that a disturbance
down the hall (or in another part of the hospital) may be a diversion to draw attention away
from a baby.
N. Whenever a maternal-child emergency exit alarms, staff will perform an infant count and
report to mother-baby charge RN/Director of Maternal-Child.
O. Don’t post full names of mothers and babies where visitors can see them. Post the first 2
letters of last name of the infant on the board in nursery.
P. Examine all large packages leaving the maternity floor.
Q. Mothers and newborns leave the hospital in wheelchairs accompanied by hospital staff.
Immediately report to Public Safety, anyone leaving on foot with an infant/child in hospital
pajamas or blankets.
R. Staff should be in-serviced routinely on RCH’s Policy “Response to Infant/Child Abduction
(Code Pink/Code Purple)”. It is important that everyone know his/her role; what to do and
who to notify should an abduction or suspected abduction take place.
12. When a Code Pink or Code Purple is called
A. All staff and volunteers should immediately go into action. Monitor any exits or stairwells
in your area and tactfully challenge any person(s) that may be carrying a baby, bundle, bag,
or any item large enough to conceal an infant. Most people, who are told that an infant or
child is missing, will gladly open their bag or bundles for you to look inside.
B. Should the person refuse or if you are suspicious, but feel you should not confront the
person, ask a co-worker to notify Public Safety and cautiously follow at a safe distance.
Take note of:
Race, sex, age, height, weight, hair color and style, complexion, identifying
marks or features, color and type of clothing.
Should you see the vehicle, take note of:
Make, model, color, year, license number, and any special identifying features.
C. Hospital departments are to monitor exits and stairwells, whenever a Code Pink or Code
Purple is called. As additional staff becomes available, they should check restrooms,
storage rooms, or any other areas an abductor might hide.
13. MyChild System
A. RCH now has the MyChild Infant Protection System in place to help provide a safe and
secure environment for newborn and pediatric patients. The system alerts Nursing Staff and
Public Safety when an infant has been transported beyond the designated boundaries of the
Nursery, Labor and Delivery, or Pediatrics.
B. Shortly after birth, an electronic monitoring device is placed on the newborn’s left upper
arm. This device will trigger the alarm, when it goes through any of the entrance/exits or
elevator containing sensors.
C. In Pediatrics, the sensor is place on the patient’s arm on admission, and will activate when
the child is taken beyond the boundaries of Pediatrics.
D. An automatic code pink or code purple and location will be announced overhead if the
alarm goes off. The newborn tags will also alarm if removed from skin. This infant/child
security tag will remain on the infant and children under 13 years of age until discharged
from the hospital.
Volunteer Services at Riverside Community Hospital
Juniors: Female white pants with Royal Blue Apron
o Male black pants white polo shirts
Adults: Ladies white pants ceil blue vest or smock
o Men white paints Royal Blue shirt or polo
Contact Person: Lillian Reyes-Maples Ext. 3109
Under the direction of the charge nursing staff or unit
secretary, the volunteer will assist the nursing staff with nonnursing duties and provide no hands on comfort care to the
Clinical Care Extender (CCE/ COPE)
Navy Blue Polo Shirt & Khaki Pants
Contact Person Ext. 3139
Clinical Care Extenders (CCEs) are pre-health professional
students from local colleges and universities, graduates,
seasoned professionals seeking a second career as well as
those re-entering the health profession. The program is a
yearlong clinical internship. These volunteer interns are
looking to interact with Clinical Staff (Nurses, Physicians, etc)
as well as other hospital staff. They received formal training on
1. Discharging patient with exception of obese patients,
patients with a cast from the waist down, patients
2. Answering the phones & call lights as needed.
3. Relay patient messages & needs to nursing staff.
4. Assist staff with filing, coping, and clerical tasks.
5. Run errands for staff within the facility.
6. Assist nursing staff to transport patient’s belongings.
7. Providing nursing staff with supplies as requested,
replacing or restocking as needed.
8. Feeding a patient under the supervision of nursing
9. Visiting with patient (Not as a Sitter).
10. Greeting, directing, and escorting visitors.
11. Assist patient with ordering their meals.
12. Instructing patient on using TV remote control.
13. Providing reading material.
14. Entertain the patient with music, a song, or magic
15. Provide fresh water, beverage, and blankets under
the supervision of nursing staff.
16. Other tasks following the facility Policy & Procedures.
1. Assist in the transport of patients as requested by the
nurse via gurney, hospital bed, or wheelchair with or
without oxygen; except when the patient is cardiac
monitored which requires an RN or a pregnant
woman which requires a staff member. NEVER
transport a patient without the nurse’s permission or if
you do not feel safe transporting the patient for any
2. Assist in repositioning of patients in bed and in
transfers of patients to and from gurneys,
wheelchairs, cardiac chairs, and patient beds as
instructed by the nurse.
3. Assist the patient to the restroom or with a bedpan or
urinal, with the permission of the patient’s nurse.
4. Assist the unit secretary with paperwork, answering
phones/call lights as needed.
5. Know the location of supplies and replace ore restock
6. Relay patient request/concerns to nursing staff (for
medication, bedpans, questions, etc.).
7. Assist nursing staff to provide patient care including
bathing, shaving, brushing teeth, feeding, changing
patients and bedpans.
8. Refill water for patients with the nurse’s permission.
9. Distribute food trays to patients after receiving
permission from the patient’s nurse and collect them
after the patient is done.
10. Inform patient’s relatives of the patient’s progress of
condition ONLY with the permission of the nurse or
11. Assist hospital staff and physicians as requested.
12. Make rounds on the floors and talk with the patients
that would like to talk, addressing their needs.
13. Take discharged patient’s charts to medical records.
14. Help maintenance of patient rooms & restocking
Clinical Patient Care/Patient Safety Policy Review
I. Patient Identification
1. Use 2 patient identifiers before all tests, procedures, meds, blood administration;
Patient name and birthdate
-or Patient name and medical record number
2. Never scan the barcode from patient label when doing blood glucose or giving medications,
always scan the patient’s armband (patient safety). If there is a problem scanning, get a new
armband from the Meditech label sheet in the patient’s chart.
3. Arm Bands:
A. Red = Allergy
B. White = inpatient and outpatient identification
C. Yellow = High Risk of Falls
D. Green = Latex Allergy
E. Blue = temporary when computer is down
F. Pink = Limb Alert (do not use limb with pink band for injections, BP, etc.
G. Red Barcoded Blood Band (Securline)
II. Physician Orders and Documentation
1. Documentation is done through the Meditech Electronic medical record for all clinical staff
A. Areas not converted to Meditech
2. All physician’s orders are only recorded on approved hospital order sheets
3. No verbal orders accepted unless in a code or when MD is involved in sterile procedure.
Students are not able to take verbal orders. Students are not able to verify orders or perform 12
and 24 hour chart checks.
4. The nurse should Read back all phone orders (after written on medical record).
5. Faxed order must be re-written on the physician order sheet with the original Fax attached as a
6. LVNs, lab technologists, physical therapists, radiology technologists, and respiratory therapists
may take orders from physicians for medications limited to use in their specialty.
7. Range Order Medication orders may have a range in dose (75-100mg) or schedule (2-3 hrs),
but not both. Only one variable allowed. An order may be written for 1-2 tabs or 4-6 hours,
but not both in the same order.
8. Only Use Approved Abbreviations
A. Anyone who documents or reviews medical records can easily access the RCH approved
abbreviation list - It is in the MOX Library. Highlight ABBREVIATIONS LIST and right
arrow in, they are listed alphabetically. Pay close attention to upper and lower case (e.g. PT
is Prothrombin Time while pt is the abbreviation for patient. You can even print the lists,
just press shift/right control to checkmark all the text files, then P for print.
Current Do Not Use Abbreviations List
U or u
IU or iu
Lack of a leading zero
before a decimal point (i.e.,
Use of a trailing zero after
a decimal point (i.e.,
Read as a zero (0) or a four
(4), causing a 10-fold overdose or greater (4U seen as
“40” or 4u seen as 44”).
Misread as IV (intravenous) or
“I” as “1”
Misread as 1 or 11
Misread as 10.
Every other day
Mistaken for each other.
For half-strength or
Latin abbreviation for
For three times a
S.C. or S.Q.
For cubic centimeter
A.S., A.D., A.U.
Latin abbreviation for
left, right, or both ears
Misunderstood or misread
(symbol for dram misread for
“3” and minim misread as
Mistaken for mg (milligrams
resulting in one thousand-fold
Mistaken for either halfstrength or hour of sleep.
Q.H.S. mistaken for every
hour. All can result in a dosing
Mistaken for three times a day
or twice weekly resulting in an
Mistaken as SL for sublingual,
or “5 every.”
Interpreted as discontinue
whatever medications follow
(typically discharge meds).
Mistaken for U (units) when
Mistaken for OS, OD, and OU,
Use the metric system.
Don’t use this
“Unit” has no
ALWAYS use a zero
before a decimal point.
DO NOT use a trailing
zero after a decimal
Don’t use this
Write daily or every
Write out “half-strength”
or “at bedtime.”
Write “3 times weekly”
or three times weekly”
Write “Sub-Q”, “subQ”,
Write “ml” for milliliters.
Write: “left ear”, “right
ear” or “both ears.”
Do not use these abbreviations or accept them from a physician. Clarification must occur and the
proper order must be placed in the chart.
III. White Boards
1. In an effort to increase patient satisfaction and communication, the nurse and student nurse will
place their name and relevant information on the white board at the foot of every patient bed. If
answering a call light and you are not the caregiver for that patient, the nurses phone number
should be on the whiteboard for easy access.
IV. No-Passing Zones
1. All staff and students are required to stop at a room with a call light on, whether they are the
care giver or not. They should introduce themselves and ask if they can be of assistance. If they
cannot help or answer the question, the person should call the nurse on the white board and
inform them of the patient’s needs. Then communicate the information to the patient. Our goal
is again to increase patient satisfaction and communication, as well as decrease the length of
call light responses.
V. AIM for Zero and I-Trace
1. Goal is to decrease central line and IV infection, as well as, decreasing the risk of medication
error. Aim for zero requires appropriate documentation of insertion, dressing changes and
discontinuation of IV lines in the Meditech system to ensure best practices that decrease
catheter associated infections. I-Trace means to trace all IV lines from insertion to source upon
admission, transfer, hand off report, and any time necessary to insure the proper medication is
delivered through the correct line.
VI. Hand-Off Communication
1. Occurs when a patient is transferred from one unit/area to another or at end of shift. During
“hand offs” there must be an opportunity for active communication between the person who is
handing off and the person who is receiving the patient. "Hand-off" or transfer information
should include all pertinent information about the patient’s condition, significant history, vital
signs, test results, diagnosis and response to treatment. This is completed in Meditech.
2. Staff and students should use the SBAR Tool to give report – see attached SBAR Shift Report
1. S = Situation
2. B = Background
3. A = Assessment
4. R = Recommendation
3. The written SBAR report is handed to the next shift. Review any patient care highlights and
4. There is also a SBAR Communication Tool to help organize information before calling the
Critical lab values
5. The nurse caring for the patient will receive a call from the lab within 15 minutes of the critical
6. The nurse is then required to notify the responsible physician within 30 minutes with the result.
A. There is a chain of command to follow if unable to reach nurse or requesting physician.
VII. Universal Protocol
1. Required for all surgeries and invasive procedures (exceptions: venipuncture, urinary
catherization, and NG tube insertion). All other procedures require the protocol which
A. Pre-Op verification
B. Marking the operative site by physician
C. “Time Out” immediately before the procedure
Complete the Universal Protocol Pre-Procedure Checklist
before every invasive procedure (Policy IND 364).
VIII. Medications and Pharmacy
1. All medication orders must be scanned to pharmacy for entry.
2. Pharmacy enters all meds and IV orders. There is a 7-day automatic stop date on narcotics,
hypnotics, sedatives, and antibiotics, (only if a stop date is not specified by MD).
3. Pyxis System: You must have a code to use the Pyxis medication system. Pharmacy approves
all codes. Students do not have access to the Pyxis system. Students should contact their
instructor or assigned nurse for assistance.
4. All PRN orders must have a stated purpose for administration, e.g., Compazine 10 mg IM
every 6 hours PRN nausea
5. Medication Reconciliation
A. The process of obtaining the most complete and accurate list of each patient’s current home
medications (name, dosage, frequency, and route) and obtaining a physician’s order to
continue, discontinue, or modify each home medication.
B. Information from the Institute for Healthcare Improvement states that poor communication
of medical information at transition points is responsible for as many as 50% of all
medication errors in the hospital and up to 20% of adverse drug events.
C. Take time to document herbal supplements patients take at home. An order needs to be
written if they continue taking herbal medications while in the hospital. Some herbs are
known to interact with medications, such as St. John’s Wort, which can reduce digoxin and
D. Each time a patient moves from one setting to another, clinicians should compare previous
medication orders with new orders and reconcile any differences.
E. This list is used to provide correct medications for patients anywhere within the healthcare
system. Reconciliation involves comparing the patient’s current list of home medications
against the physician’s admission, transfer, and/or discharge orders.
F. All inpatients will have their medications reconciled within 24 hours of admission.
G. The medication history may be obtained from the patient and/or family members.
H. The admitting nurse will obtain this information during the admitting process and will input
it into Meditech while completing the admission history screens.
I. The information should be as complete and accurate as possible as this information will be
used throughout the patients’ hospitalization.
J. Upon discharge, along with the discharge orders, you will now obtain a physician’s order to
continue or discontinue home meds as listed on the “Medication Admission & Discharge
Reconciliation Order Form”.
K. After making sure all discharge orders are complete and the patient’s home medications
reconciled one final time, the patient will sign the chart copy and it will become a
permanent part of the medical record.
6. Medication Transfer Order Sheet
A. Patients who are transferred from one level of care to another (e.g. from Critical Care to a
Med-Surg. Unit) need a Medication Transfer Order Sheet printed.
B. You can find it on the Main Nursing Meditech Menu #32.
C. Print it off for the MD when the transfer order is written. It lists all the patient’s
medications with boxes to indicate if it should be continued, discontinued or modified.
D. The transferring nurse will review the “Medication Transfer Order Sheet” and list of home
medications. Medications which do not have an order to resume or suspend on the
“Medication Transfer Order Sheet” will require reconciliation.
E. The transferring nurse has the responsibility for this and should contact the physician for
F. The transferring nurse is responsible for printing, reconciling, and signing the sheet.
G. Transfer Medication Orders should be reviewed by the receiving nurse and then faxed to
pharmacy for updating the medication profile.
H. The Medication Transfer Order Sheet becomes a permanent part of the medical record.
7. Always use the “7” Seven Rights when administering medication:
A. Right medication
B. Right Dose
C. Right Route
D. Right Time
E. Right Patient
F. Right Documentation
G. Right Education
8. High Risk Medications
A. High risk medications require additional precautions for their delivery.
B. Some special precautions include:
A. Prepared by Pharmacy when possible or under direct control of prescribing MD during
emergency situations (OR, ED)
2 individuals prepare med and verify order and dose prepared
B. 2 nurses check med, dose, and patient ID prior to administration and both complete EMAR screen (or sign MAR during downtime).
C. Where indicated, drug level or lab level checked prior to administration to ensure
nontoxic levels (e.g. digoxin, theophyllin, warfarin and phenytoin).
D. Chemo agents (parenteral) No verbal or telephone order (written by credentialed MD)
Double check by 2 pharmacists and by 2 certified chemo nurses for administration
E. Coumadin: Dev. system to check INR prior to each dose of Coumadin.
F. Digoxin: Apical pulse check, if less than 60 per min, hold dose, notify MD
Record apical pulse regardless if med given.
G. Neuromuscular Blocking Agents
All have 24-hour stop policy; reordered on daily basis
All have precautionary label “Must Be On Assisted Ventilation”
H. Epidural Med. Admin.
Programming for pump must be double checked by 2 licensed professionals familiar
with device (on initiation, at change of shift, during dosing changes)
Monitor per policy
I. Concentrated K, Na, Phosphate injections
No floor stock except OR-CV.
Use premixed solutions, following RCH guidelines
J. TPN solutions Mixed by pharmacy. Standard order form required.
Administer via central line (if more than 10% dextrose and/or 5% protein.)
Micron filter required
Bag hangs no more than 24 hours.
Monitored with blood glucose, weights, intake and output.
K. Narcotic PCA pumps Same as Epidural Med
L. IV Heparin
Premixed solutions only for floor stock.
Venous and arterial solutions stored separately
M. Insulin All doses double checked by 2 licensed nurses
Vials kept separate from heparin
Units written out on order and MAR
Only regular insulin for IV injections and drips
IV drips require pump, prepared by pharmacy and double-checked
Patient blood sugar monitored
9. Double Check
A. SQ heparin, insulin, parenteral chemo, PCA and Epidural pumps require a double check by
2 nurses prior to administration. Do not tell the 2nd nurse what they are checking. Have
them communicate to you what they find. This practice helps prevent “confirmation bias” –
seeing only what one expects to see.
10. Height, weight and allergies
A. Pharmacy depends heavily on height, weight, and allergy information, in order to ensure
that patients are receiving correct medication and medication doses. By policy, they will
NOT send medications until these have been entered in Meditech.
B. The computer program in pharmacy automatically can give a warning e.g., Dosage
Warning: Dose exceeds maximum dose. The computer also gives allergy and cross
sensitivity warnings if allergies are entered in the computer e.g. a patient has had an
anaphlactic reaction to Cefzil, the warning screen will pop up if Augmentin is ordered (1
C. Food allergies are also important to document in Meditech. If a patient is allergic to eggs,
he or she may also be allergic to lipid products as they contain phospholipids (derived from
11. Expiration Dates
A. Insulin: is only good for 28 days once opened. Label the vial with date opened and date it
B. Multidose vials: Good for 28 days once opened and according to the CDC you must date
the vial with the date opened, “discard multidose vials when empty, when suspected or
visible contamination occurs, or when the manufacturer’s stated expiration date is reached.”
C. Sterile water/saline for irrigation: Good for 24 hours once opened. You must date the bottle
with the date opened. They contain no preservatives.
D. IV bags of 50cc or less are good for 15 days after the outer wrap is removed.
E. IV bags of 100cc or more are good for 30 days after the outer wrap is removed.
A. The person who opens a multi-pack of IV bags is responsible for labeling all the IV
bags with an expiration date. White labels are provided on the units – do not write
directly on the bags (ink can leach in through the plastic). If a multi-pack of 50cc IV
bags was opened on 9/7, all of the bags should be labeled with a white label that says:
B. On Sept. 7th, a multi-pack of 100cc IV bags was opened. Any not used immediately
should be labeled with a white label that says: EXP 10/6
IX. Scanning Patient Items
1. Point of Use areas are replenished by Sterile Processing & Distribution staff. Only the items
scanned will be replenished. It is vital that each and every one scans properly!! If items are not
scanned, the Supply Scan system does not know what’s been used and doesn’t tell supply chain
that these items need to be replaced.
2. Remember, you must SCAN for IV’s.
3. If your Supply Scan monitors or “scan guns” are not working call I.S. at ext. 4357. for all
A. Many calls regarding the scan guns not working are because they were not properly
returned to their cradles and have lost their charge… make sure you return them and that
they are inserted correctly for recharging.
4. You can scan supplies to an empty room! Select the room number… you will hear “room is
empty”… say “yes”. Scan the supplies to the empty room, then hit “save transaction”. The
room selected will now go from blue to yellow.
A. Later, after the patient is admitted to the room, you can go back and select their room
(which is highlighted in yellow), and hit “save transaction” again. The supplies will be
deleted from inventory at that time and transferred to the patient.
5. After you scan an item, remember to push “Save Transaction”. If you don’t, whatever you’ve
scanned will be lost,
6. If you find that you are out of a particular item
A. It is usually because the items aren’t being scanned “Scan none, get none.”
B. The fastest way for you to get what you need is to go to the nearest unit and borrow from
A. Push “change department”, enter your department, find your patient, and scan!
7. Questions? Comments? Cost savings ideas? Contact Supply Chain Services Ext. 3394
1. Numbered stickers from the Securline blood band are placed on the blood sample, blood
authorization slip, and transfusion record.
2. Must take a copy of the MD order, Signed Consent for Blood Transfusion, and Authorization
for release of blood products (with two nurses signatures) form to Blood Bank to pick up a unit
3. Bar Coded Transfusion Administration (BCTA) - All blood products must now be scanned into
the documentation record and the appropriate screens filled out in Meditech.
4. Vital signs for blood transfusions are: Baseline, 15 min. after slowly starting blood, and every
hour while it’s running. .
XI. Physician privileges
1. Verify by calling Medical Staff or checking the computer icon on computer desktop.
XII. Report Errors and “Near Misses”
1. It is the responsibility of any licensed professional who prescribes, dispenses, or administers
medication to report any medication error or “near misses” via Meditech Risk Management,
promptly and accurately.
2. “Near misses” are errors that are identified before they reach the patient or reached the patient
but did not cause harm.
3. RCH believes that medication incidents are NOT intentionally caused by individuals, but are
usually the result of a “system” that needs to be improved. The goal is to identify and address
problems in the system.
A. “System” problems that you can be aware of and prevent:
Professional practice (order misinterpretation,
Read back and Clarify the order
order transcription errors
No verbal order unless emergency
Drug stocking or delivery problems
Double check and scan what is removed from the
Inadequate patient ID checking
Always scan and check the patient’s 2 identifiers
Confusing or unclear prescription
Clarify the order
Confusing or look-alike product labeling
Clarify the order with physician or pharmacy
Sound-alike drugs (product nomenclature)
Clarify the order with physician or pharmacy and
know the goal of your therapy
Look-alike drugs (product packaging)
Double check and scan what is removed from the
Pharmacy should mix all meds unless an
emergency and then the med should be double
Follow policy and practice for RCH
Inadequate patient monitoring
Follow up with your patient and educate them
Education – inadequate drug/dosage information
Follow up with your patient and educate them
Inadequate patient information or medical history Utilize all approved sources available without
4. RCH promotes a blame-free CULTURE, which does not focus on individual blame for errors
or near misses. We focus on procedures and overall system processes that allow errors to occur.
Please report all errors, near misses, and unsafe practices. Complete an RIR (Risk
Identification Report) for any unusual events involving a patient or visitor. There is also a
Non-Patient Related RIR for a “potential” problem or interdepartmental issues, supply
problem, damage to property, staffing concerns, etc.
XIII. Chaplain services are available 24 hours/7days a week via pager 222 or PBX.
XIV. Rapid Response
1. A Rapid Response can be called on any patient having a change in status that requires
2. Vocera – call Rapid Response Nurse/RT
3. Criteria for calling RRT
A patient is experiencing a change in medical condition that may result in cardiac and / or respiratory
arrest; direct caregivers may notify the Rapid Response Team to intervene until the physician is
Usual call criteria (but not limited to these reasons):
Significant change in vital signs
Altered Level of Consciousness
Oxygen saturation less than 90 with or without O₂
Respiratory rate of less than 10 or greater than 28
Heart rate of less than 50 or change of 20 from baseline
Heart rate of greater than 120 or change of 20 from baseline
Change in telemetry pattern for which the RN feels need for assistance
Systolic BP less than 90 or change of 20 from baseline
Acute significant bleeding
New, repeated or prolonged seizures
Failure of patient to respond to treatment for an acute problem/symptom.
MEWS score is 5 or greater or a 2 point change from previous recorded measure.
4. Primary Nurse Responsibilities:
A. Get the complete chart and MAR together and bring to the bedside.
B. Notify charge nurse that RRT was activated.
C. The primary nurse is a vital member of the RRT and must remain at the patient’s bedside
and assist the RRT team.
D. Using SBAR format be prepared to provide the following information upon arrival of the
What prompted the RRT call? (e.g. Acute change in: Resp. status, Cardiac status,
Vital signs, Mental Status, other)
Pertinent history, surgeries, procedures
Names of physicians caring for the patient
Current HR, RR, BP, Temp - IV fluids
Recent diagnostic tests
Interventions already attempted and results.
How can the RRT help you?
E. Primary RN retains responsibility for:
A. Physician contact.
B. Assisting the RRT RN in obtaining and administering needed medications and
interventions within his/her scope of practice (per protocol)
C. Overall care of patient.
5. Call the patient's family to notify them of change in patient's condition/status. Rapid Response
A. The ICU RN and RT will perform a complete patient assessment.
B. They will collaborate with the patient's nurse to determine the status of the patient and their
findings will be promptly reported to the physician for medical orders.
C. Gather information from the primary RN, assess patient, document on RRT record.
D. The RRT RN will perform the initial assessment to include and investigate the SBAR report
from patient's primary nurse.
Review of chart, Lab values, Diagnostic test results as available
Fluid status (I & 0),
Recent medication history
Communicate w/patients physician- report assessment, interventions, response, and
discuss plan of care for any significant intervention.
E. The RRT RT will perform the initial respiratory assessment to include and/or consider:
A. Breath sounds,
B. Respiratory pattern and status
C. Chest assessment
D. Airway clearance
E. Recent respiratory history
F. Apply & monitor 02 sat
G. Work of breathing
H. Place oral airway, as needed
I. Oxygenation, Ventilation
J. Past respiratory history (last treatment given).
K. Perform Nasotracheal suction
XV. Core Measures
1. What are core measures?
A. They are the use of standardized – or “core” – performance measures in treating an
identified illness or core measure set also known as “Hospital Quality Measures” or “Care
2. How many core measure sets are being participated in by RCH and most accredited
A. RCH submits information to (The Joint Commission (TJC) and Centers for Medicare
and Medicaid Services (CMS) for multiple core measure sets. They include but are not
Acute Myocardial Infarction (AMI)
Heart Failure (HF)
Surgical Care Improvement Project (SCIP)
Children’s Asthma Care (CAC)
Women’s & Children [Early Elective Delivery], Breastfeeding, Pediatric Asthma
ED Measures (inpatients & outpatients)
B. A hospital’s performance will be measured by its adherence to the core measure
guidelines. This means that for each diagnosis, there are sets of evidence-based treatments,
diagnostic tests and standards to follow. The facility’s practitioners and nursing staff are
expected to comply with these guidelines.
3. What are the MDs and nursing staff’s role in core measures?
A. Use of order sets by MDs guarantees that all diagnostic and treatment components of each
measure set are completed and documented at a precise time.
B. Nursing staff must also ensure that these orders are carried out and documented at the right
time on the right document (ex. Nurses notes, eMARs, t-system, OR records, etc).
C. Remember—no documentation means no intervention was done and negative scores are
given to set measures.
4. What does it mean to receive high scores on core measures?
A. The goal is 100% in our core measure compliance.
B. This means that patients with core measure diagnoses were given timely and appropriate
C. Our scores are publicly reported as well as for all hospitals in the surrounding area. The
goal of core measures is to have evidence-based care for our patients because it’s the right
thing to do!
5. Acute Myocardial Infarction (AMI)
A. Aspirin on arrival (unless contraindicated, document)
B. Aspirin/beta blocker at discharge (unless contraindicated, document)
C. ACEI or ARB for LVSD (Ejection fraction <40%)
D. Smoking Cessation Counseling (smoker within prior 12 months - cigarettes only)
E. PCI within 90 minutes OR Fibrinolysis within 30 minutes
F. Statins at discharge (unless contraindicated, document)
Heart Failure (HF)
A. Discharge instructions on:
A. Medications (reconciliations must match)
D. Symptoms Worsening
B. LVS function evaluation (ejection frunction)
C. ACEI or ARB for LVSD (Ejection fraction <40%)
D. Smoking Cessation Counseling (smoker within prior 12 months—cigarettes only)
7. Pneumonia (PN)
A. 1st Dose of Antibiotic within 6 Hours
B. Pneumococcal and/or Influenza Vaccines
C. Blood Cultures Prior to Antibiotics in ED expected. Blood cultures with 24 hrs. of arrival
for patients transferred or admitted to ICU
D. Smoking Cessation Counseling (smoker within prior 12 months—cigarettes only)
E. Appropriate Antibiotic selection
A. Non-ICU admissions
B. ICU admissions
C. Pseudomonas Risk (Pseudomonal risk, Bronchiectasis, Structural Lung Disease with
chronic corticosteroid or repeated anti-biotic use documented by MD)
8. Surgical Care Improvement Project (SCIP)
A. Appropriate Antibiotic Selection
B. Antibiotic within 1 Hr before surgery start/incision time (done by anesthesia)
C. Prophylactic Antibiotic discontinued within 24 Hours After Surgery (CABG within 48
Hours) unless infection is documented
D. Beta blocker taken prior to admission (document estimated time of last dose taken)
E. Beta blocker perioperative tx (pre & post-op)
F. Appropriate perioperative Hair Removal
G. VTE Prophylaxis order (mechanical/chemical)
A. VTE Therapy ordered and given within 24 hours of surgery end time
H. DC Foley cath by POD1 or POD2
I. Documented postop temp >36C/96.8F 30 mins prior anesthesia to 15 mins post anesthesia
J. Postoperative blood glucose – cardiac surgery patients; less than or equal to 180 in the time
frame of 18-24 hours after anesthesia end time
9. Children’s Asthma Care (CAC)
A. Relievers for Inpatient Asthma (age 2 years through <18 years).
B. Systemic Corticosteroids for Inpatient Asthma (age 2 years through <18 years).
C. Home Management Plan of Care—(HMPC) Document Given to Patient/ Caregiver
with a copy in the chart.
10. Global Immunizations
A. Patients assessed and received pneumococcal vaccine ages 6-64 that are high risk or all
patients over 65 years of age.
B. Patients will be assessed and receive influenza vaccine between September – March.
A. VTE prophylaxis by day 2 of admission
B. Discharge with antithrombotic and statin medication
C. Patients with atrial fibrillation/flutter will be discharged with anticoagulation medications
D. Acute Ischemic stroke patients will receive t-PA within 60 minutes of arrival to ED
E. Patients and/or their caregivers will receive stroke education materials prior to discharge
F. Stroke patients will be assess for rehabilitation prior to discharge
A. Patients will receive VTE prophylaxis the day of or day following admission
B. If no VTE prophylaxis is ordered the reason must be clearly documented in the record
C. Patients diagnosed with VTE receive anticoagulation overlap therapy (bridge from IV to
sub-Q to PO)
D. Patients discharged from the hospital on warfarin will receive written instructions on
medication use, monitoring, adverse drug reactions/interactions
13. Perinatal Care
A. No elective c-sections
B. Patients at risk for pre-term delivery at 24 to 34 weeks will receive antenatal steroids
prior to delivery
C. Preventative measures to prevent healthcare associated bloodstream infections in highrisk newborns
D. Exclusive breast-milk feeding while in the hospital and educating new mothers to
encouraging continued exclusive breast-milk feeding upon discharge
14. ED Measures
A. Transition record
B. Pain management in long bone fractures
C. Head CT scan results for stroke interpreted within 45 minutes of arrival
Core Measures Resources:
Notice: Presence of Asbestos-Containing Materials in Riverside Community Hospital
The California Health and Safety Code Section 25915 require that we provide you information on the known existence of
asbestos-containing building materials in Riverside Community Hospital. The information provided relays our knowledge
as to the presence of asbestos-containing materials and our understanding of the threat posed by those materials.
Because of the age of Riverside Community Hospital, it is reasonable to assume that certain types of the materials used in
its construction are asbestos containing materials. The assumption was proven true by laboratory test of materials taken
from the remodeled portion of the building. Contracted firms specially trained in the safe removal and disposal of asbestos
containing materials remove those materials. Some laboratory tests have been conducted throughout the hospital to
determine the presence of asbestos. However, such materials were in common use when the building was constructed and
may exist in the other areas of the hospital. Typically, then asbestos-containing materials are divided into two categories.
Friable: Easily broken or crushed. Readily releases fiber in to the air
Non-Friable: Not easily broken. Does not readily release fiber into the air
Because of the danger of asbestosis or lung cancer come from breathing asbestos fiber, non-friable and encapsulated
asbestos post no hazard. Only when asbestos-containing material is disturbed to the extent that the fibers are released that
can be inhaled is there a hazard.
While no specific surveys have been conducted to identify asbestos-containing materials throughout the entire hospital,
listed below are materials previously found in the Riverside Community Hospital to contain asbestos and are known or
suspected to exist in other areas of the hospital.
Known Asbestos-Containing Materials
Pipe Insulation- Friable
Used to insulate pipe throughout the hospital and is generally visible in basement areas.
This type of asbestos-containing material is encased in cloth or plastic wrap. With casing intact there is no hazard. When
the casing is broken the asbestos-containing material appears as a white chalky plaster with fine hairs of fibers projecting
form it. The dust from this material should be avoided.
Sprayed on Insulation – Friable
Used to fire proof structural steel, metal roof decks, and also as sound insulation.
Having a cottony or spongy, white or gray appearance, this material breaks and crumbles under very little pressure and
should therefore be avoided. If work is necessary in an area containing this material, caution should be used not to disturb
Floor Tile – Non-Friable
Used as a common flooring material and carpeting to the floor. No specific location of its use is known.
Generally 9” X 12” vinyl titles do contain asbestos. These tiles, however do not post an asbestos hazard unless they are
sanded or ground to produce dust.
Roofing Asphalt and Felts – Non-Friable
Used as common roofing materials. No specific locations of its use are known.
These materials do not pose an asbestos hazard unless ground to produce a dust, as during removal of an old dried roof.
Proposed room removals should be preceded by a laboratory test of the materials.
Riverside Community Hospital has taken actions to contain and limit any potential exposure to asbestos; however, it is
important that you recognize potential exposure is possible if appropriate safety procedures are not followed. If you have
specific questions on the presence of asbestos, you may contact Jose Torres, Directors of Engineering at ext 3140. If you
wish to know more about the effects of asbestos, you can contact Riverside County Health Department, Environmental
Health Services Division at (951) 358-5050.