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TME 2017 BSO_ODL_20170101 i

TME 2017 BSO_ODL_20170101 i

Table of Contents

Patient Rights, Responsibilities, and Ethical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Age Specific Competency and Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 LifeLink/Lions Organ, Tissue & Eye Donation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Patient Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Assessing for Signs of Mistreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Assessing for Signs of Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Non-Violent Practices and Restraints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Wandering and Elopement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Hypothermia, Hyperthermia and Dehydration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Regulatory Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

If you need audio assistance with this training document have your manager call Organizational Development & Learning at 727-519-1300.

TME2017_PAT

Lesson: Patient Rights, Responsibilities and Ethical Treatment

Introduction

Lesson Objectives

The medical staff, all team members and volunteers of the BayCare Health Care System are expected to treat patients with respect and dignity, and to meet their cultural, religious, ethnic and psychosocial needs to the fullest extent possible.

After you complete this lesson, you should be able to: • Recognize patient’s rights and responsibilities • Identify the process to contact the Ethics Committee, if applicable • Distinguish between Do-Not-Resuscitate (DNR) and Do-Not-Resuscitate Order (DNRO) and • Recognize the decision-maker when a patient has made an advance directive

Patient Rights and Responsibilities (Hospital Divisions and Ambulatory only)

Upon admission, receiving care, treatment and/or services, all patients are provided with information on their rights and responsibilities. You are expected to treat patients with respect and dignity, and to meet their cultural, religious, ethnic and psychosocial needs to the fullest extent possible.

Click on the link below to review your facility-specific document on patient’s rights and responsibilities.

http://training.mybaycare.org/TME2017/Documents/AHCA/PAT_CHA_PC.pdf

http://training.mybaycare.org/TME2017/Documents/AHCA/AMBULATORY.pdf

Patient Rights and Responsibilities (MPR only)



http://training.mybaycare.org/TME2017/Documents/AHCA/PAT_JKTB_MPR.pdf

Patient Rights and Responsibilities (JKTB only)



View for Assisted Living http://training.mybaycare.org/TME2017/Documents/AHCA/PAT_JKTB_ALF.pdf

View for Medical Center http://training.mybaycare.org/TME2017/Documents/AHCA/PAT_JKTB_MPR.pdf

BSO_ODL_20170101 Page 1 of 54

TME2017_PAT

Patient Rights and Responsibilities (HC only)



View for Home Health http://training.mybaycare.org/TME2017/Documents/AHCA/PAT_HC_HH.pdf

View for Durable Medical Equipment http://training.mybaycare.org/TME2017/Documents/AHCA/PAT_HC_DME.pdf

Patient Rights and Responsibilities (BH only)



View for Behavioral Health http://training.mybaycare.org/TME2017/Documents/AHCA/PAT_BH.pdf

Patient Rights and Responsibilities (BMG only)


Click on link below to review your facility-specific document on patient’s rights and responsibilities.

http://training.mybaycare.org/TME2017/Documents/AHCA/PAT_CHA_PC.pdf

Resolving Ethical Issues

Ethics

Ethics is a moral standard or value used in our daily lives to guide decision-making.

In keeping with our mission, vision and values, BayCare recognizes that we have an ethical responsibility to our patients and team members.

Ethics Committee (Hospital Divisions, JKTB, MPR, BH, HC, and Ambulatory)

Sometimes ethical issues are difficult to resolve and assistance from the Ethics Committee may be necessary.

The Ethics Committee is a resource for those individuals involved in the ethical decisions regarding patient care issues.


TME2017_PAT

In the Ambulatory setting, the Medical Executive committee acts as the Ethics committee to resolve issues. Should resolution not be possible, the Hospital Ethics Committee may be accessed for assistance regarding patient care issues.

Examples of ethical decisions in patient care issues include:

• Ethical conflicts regarding treatment of patient • Family/health care provider disputes regarding treatment decisions • Family disputes regarding acceptance of patient's end of life issues • Conflict regarding risks and benefits of patient care decisions (Informed Consent)

Individuals who can request an Ethics Committee conference include: • Physicians • Team members • Patients • Patients’ families or • Health care providers

Ethics Committee (BMG ONLY)

In the Primary Care/Physician Office setting, the Ethics Committee does not resolve ethical issues. The with Senior Management team and/or Physician Advisory Committee/Board is the resource for all team members, physicians, patients and their families, as well as external patients, involved in the ethical decisions regarding patient care issues.

Ethics Committee Members (Hospital Divisions, JKTB, MPR, BH, HC)

The Ethics Committee consists of, but is not limited to: • Chaplains/Clergy • Case managers • VP of Mission (SAH, SJH) • Nurses • Physicians • Social workers • Administrative representatives • Risk Management representatives and • Community members/ Community resource personnel


TME2017_PAT

Accessing the Ethics Committee (Hospital Divisions, JKTB, MPR, BH, HC)

Refer to the chart on this page to identify the contact for your facility’s Ethics Committee.

Who to Contact for Unresolved Issues

If at any time, you feel a patient/visitor has an issue that you are not able to resolve, report it to the appropriate personnel in your facility or program. Please refer to the chart for your specific contact person.

Facility Contact

Hospital Divisions Call the vice president of Patient Services; for Winter Haven Hospital, please contact Patient Care Administration

John Knox Tampa Bay

Call the immediate supervisor, manager on duty and/or the facility’s director

Morton Plant Rehabilitation

Call the nursing supervisor, director/administrator and/or the director of Patient Services

HomeCare Call the supervisor/manager Behavioral Health Call the program risk manager

BayCare Medical Group

Call the office manager

Ambulatory Vice President of Ambulatory Services

Consents

Informed Consent (Hospital Divisions, MPR, JKTB, BH, Ambulatory, and BMG only)

Informed consent is the education given to the patient by the physician


TME2017_PAT

Admission Consent (HC only)

Admission consent is the education given to the patient by the admitting RN or appropriate therapist.

The admitting team member's responsibility is to educate the patient and discuss: • The nature of the proposed care and services, including medications, procedures and/or

interventions • Potential benefits, risks and/or side effects • Potential problems related to recuperation • Any reasonable alternatives to the proposed care • Relevant benefits, side effects and/or risks to alternatives, including the possibility of not receiving

care • The likelihood of success in achieving goals • Any limitations regarding confidentiality of information obtained about the patient

Advance Directives

An advance directive is a designated plan by a competent adult that gives instructions for decisions related to any aspect of the patient's medical care. The plan is witnessed, and can either be a written document or an oral statement.

The plan may include, but is not limited to creating a living will, naming a health care surrogate, and if applicable, choosing to donate organs and/or tissues.

Living Will


TME2017_PAT

A living will is a statement by a competent adult as to whether or not life prolonging procedures should be provided, withheld or withdrawn. The living will must be witnessed by two competent adults, one of whom is not a spouse or blood relative.

A living will is: • An oral statement or a written document and • Used when a patient is suffering from a terminal condition, end-stage condition or persistent

vegetative state

Health Care Surrogate

A health care surrogate is a competent adult, designated in writing by the patient, who will make health care decisions on their behalf should they be unable to do so.

Using the informed consent process, the health care surrogate can: • Provide written consent for treatment on behalf of the patient • Make decisions regarding life-prolonging procedures when the patient is unable to give consent • Make decisions based on the patient’s desires if the patient is unable to make his/her own

decisions • Access the patient's medical information

Health Care Proxy

If the patient has not chosen a health care surrogate and is unable to make complex medical decisions, a health care proxy is the person(s) authorized by Florida Statute to make health care decisions for the patient.

In the absence of a health care surrogate, the health care proxy is determined based on the relationship to the patient in this order:


TME2017_PAT

Do-Not-Resuscitate (DNR)

A DNR, or Do-Not-Resuscitate, is a physician's order on a patient's medical record containing instructions for withholding cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.

DNR is based on an informed consent from the patient or patient's representative.

In the event of cardiac or respiratory failure, appropriate team members should always:

• Check the DNR status as designated by your facility, if applicable. • Confirm the patient's DNR status by checking the physician's order in the patient’s medical record.

DNR Designation (Hospital Divisions, MPR, JKTB, HC only)

Designation of the DNR status varies by facility. Refer to the chart on this page for your facility’s guidelines.

Facility Designation of DNR status

Hospital Divisions Placement of a yellow bracelet on the patient’s wrist; Winter Haven Hospital uses a red bracelet with the letters DNR to designate DNR status


Placement of a yellow bracelet on the patient’s wrist

John Knox Tampa Bay

Medical Center - Placement of a yellow dot on the patient’s wrist bracelet; Assisted Living/Independent Living – Writing the DNR status on the Kardex in red

HomeCare DNR is represented by displaying the original yellow DNRO form in a prominent place, preferably taped to the refrigerator or placed above the patient's bed

Do-Not-Resuscitate Order (DNRO) (Hospital Divisions, BH, BMG only)

A DNRO, or Do-Not-Resuscitate Order, is a state-issued form that a patient's primary care physician completes stating the patient's wishes about resuscitation while receiving emergency medical services (EMS).

Do-Not-Resuscitate Order (DNRO) (MPR only)


Place the original Do-Not-Resuscitate-Order (DNRO) form, when completed, in the Legal Section of the medical record.

Give one copy of the completed DNRO form to the physician and another copy to the family.

Do-Not-Resuscitate Order (DNRO) (HC only)



TME2017_PAT

In HomeCare, a signed physician's order and a signed DNRO form are required for CPR to be withheld.

When providing care, treatment or services, do not call 911 when the DNRO is present. If a signed DNRO form is not present in the home, call 911 and/or begin CPR, based on your department policies.

Do-Not-Resuscitate Order (DNRO) (JKTB only)


Place the original Do-Not-Resuscitate-Order (DNRO) form, when completed, in the medical record.

Refer to the chart on this page for your facility’s guidelines.

Facility Guidelines

Medical Center A copy of the form is available for the EMS provider when transporting the patient to a health care facility.

Assisted Living A yellow copy of the form is posted in the resident’s room according to his/her preference. For example, on the inside of the door or above the head of the bed, and is available for the EMS provider when transporting the resident to a health care facility.

Independent Living Residents are requested to follow the same protocol as Assisted Living.

Withdrawal of DNR/DNRO

At any time, the patient, health care surrogate or proxy can withdraw the DNR order and/or the DNRO form. Notify the physician immediately to discontinue the DNR order and/or the DNRO form.


TME2017_AGE

Lesson: Age-specific Competency and Care

Introduction

Lesson Objectives

When caring for and talking with patients and caregivers, always remember to use clinical and psychosocial behaviors appropriate to age and developmental level. For example, you would care for and talk to an adult patient differently than you would a young child.

After you complete this lesson, you should be able to: • Identify team member actions that meet patient age-specific needs

General Clinical Behaviors

Although each age group is different, some clinical behaviors apply to all age groups.

General clinical behaviors that apply to all age groups include: • Preparing medications based on specific departmental standards related to the patient's age • Assessing for signs and symptoms of physical and emotional abuse, neglect and exploitation • Keeping beds in the lowest position with the wheels locked (if applicable) • Adapting eating utensils (if applicable) • Using appropriate equipment according to departmental standards • Providing a safe environment by removing equipment after a procedure

General Psychosocial Behaviors

Some psychosocial behaviors may also apply to all age groups.

General psychosocial behaviors that apply to all age groups include: • Introducing yourself to the patient and family to enhance rapport • Educating patient and/or caregiver about medications and their side effects • Educating patient and/or caregiver about therapy in terms they can understand • Involving patient and/or caregiver in education, planning, procedures and treatments

Age Groups

When providing care, treatment and/or services, use age-specific behaviors as guidelines, which may vary among patients and caregivers.

BayCare has established the following age groups for its patients, each with specific clinical and psychosocial behaviors.


TME2017_AGE

The age groups are as follows: • Neonate (Birth to 28 days) • Infant (29 days to 1 year) • Child (1-12 years) • Adolescent (13-17 years) • Adult (18-84 years) and • Geriatric (85 years and older)

Age-Specific Behaviors

Neonate: Clinical and Psychosocial Behaviors

The following are examples of age-specific behaviors when providing care for neonates.

Clinical behaviors for neonates include: • Ensuring warmth due to immature heat regulation and • Protecting the neonate from constant intense stimulation and noisy, brightly-lit environments

Psychosocial behaviors for neonates include: • Cuddling and hugging and • Recognizing that a frown, tightly shut eyes or a scrunched forehead can signal pain

Infant: Clinical and Psychosocial Behaviors

The following are examples of age-specific behaviors when providing care for infants.

Clinical behaviors for infants include: • Preparing medications based on specific departmental standards related to the patient's age • Assessing for signs and symptoms of abuse/neglect/exploitation and • Using appropriate equipment according to departmental standards

Psychosocial behaviors for infants include: • Cuddling and hugging • Giving age-specific toys (for example rattles, teething rings, small blocks, stacking rings) and • Using play as part of communication


TME2017_AGE

Children: Clinical and Psychosocial Behaviors

The following are examples of age-specific behaviors when providing care for children.

Clinical behaviors for children include: • Assessing thinking skills, fears and usual coping behaviors • Assessing and including food preferences in the diet when possible and • Offering bathroom breaks if the child is able and potty trained

Psychosocial behaviors for children include: • Cuddling and hugging when appropriate • Explaining procedure shortly before starting • Using play as part of communication • Providing for privacy and • Using the faces pain scale; children older than ten can use the number scale

Adolescent: Clinical and Psychosocial Behaviors

The following are examples of age-specific behaviors when caring for adolescents.

Clinical behaviors for adolescents include: • Explaining pain assessment scale in terms patient and family will understand and • Offering food choices appropriate to preference and diet restrictions (if applicable)

Psychosocial behaviors for adolescents include: • Providing for privacy and • Providing relaxation and stress management techniques

Adult: Clinical and Psychosocial Behaviors

The following are examples of age-specific behaviors when providing care for adults.

Clinical behaviors for adults include: • Explaining pain assessment scale in terms the patient and family will understand • Assessing and evaluating risk factors related to the development of health problems • Educating the patient using adult learning styles and • Offering food choices appropriate to his or her preference, eating patterns and/or diet restrictions

Psychosocial behaviors for adults include: • Providing for privacy • Knocking on the patient's door before entering the room and • Providing relaxation and stress management techniques


TME2017_AGE

Geriatric: Clinical Behaviors

The following are examples of age-specific clinical behaviors when caring for geriatric patients.

Clinical behaviors for geriatric patients include: • Preventing skin breakdown by

- Assessing for skin redness or breakdown, especially over bony areas - Avoiding the use of tape on the skin - Using pressure reduction features on beds or floating patients’ heels off bed using pillows - Changing the patient’s position frequently based on patient needs

• Assessing for loss of teeth, taste, and ability to chew and swallow • Using a number or faces pain scale to assess pain • Being aware of any unsafe situations that might cause a slip and fall • Recognizing and compensating for potential hearing loss by

- Approaching the patient from the front - Facing the patient and gaining his or her attention before speaking - Speaking slowly, distinctly and with a low-pitched voice

Geriatric: Psychosocial Behaviors

The following are examples of age-specific psychosocial behaviors when caring for geriatric patients.

Psychosocial behaviors for geriatric patients include: • Providing frequent bathroom breaks (if applicable) • Avoiding rushed care • Giving one instruction at a time • Involving the patient in decision-making about care and financial arrangements • Gaining attention before touching or moving the patient • Recognizing the use of alternative words such as aching, heaviness, tightness or burning to describe

pain


TME2017_ORG

Lesson: LifeLink/Lions Organ, Tissue & Eye Donation (Hospital Divisions only)

Introduction

Lesson Objectives

More than 110,000 individuals are awaiting lifesaving transplants in the U.S. In an effort to increase organ availability, since 1998, federal regulations affecting all Medicare-funded hospitals have been in place.

After you complete this lesson, you should be able to: • Recognize criteria for organ donation • Recognize the proper procedure when organ procurement is necessary • Distinguish between cardiac death and brain death

Regulations

The Center for Medicare and Medicaid Services (CMS), the Agency for Health Care Administration (AHCA) and The Joint Commission regulate the guidelines that apply to organ, tissue and eye donation.

These regulations require hospitals to: • Train clinical staff in critical areas related to referral procedures used in organ, tissue and eye

donation • Refer all deaths, imminent deaths and brain deaths to LifeLink and Lions Eye Institute for Transplant

and Research (LifeLink/Lions) • Notify LifeLink/Lions in a timely manner of every death and imminent brain death

Per HIPAA regulation 164.512(h), sharing information with LifeLink/Lions is NOT a violation of HIPAA regulations.

Organ Procurement

LifeLink/Lions

LifeLink is the local organ procurement organization (OPO) for determining a patient's medical suitability for donation.

Anyone approaching the family about donation must be a representative of LifeLink/Lions or a trained and approved "designated requestor.”

LifeLink/Lions is responsible for all aspects of the donation process which include: • Evaluating suitability for the donation • Discussing donation options with family and providing information • Requesting and obtaining consent regarding donation • Medically managing the donor • Recovering the organ • Placing the organ • Providing ongoing education for hospital staff and community • Following-up with the donor family

* BayCare Health Systems has assigned LifeLink/Lions as the “designated requestor.”


TME2017_ORG

Potential Donors: Imminent Death Donation after Brain Death

A patient with imminent brain death must be on mechanical ventilation and meet any of the following criteria to be a potential donor:

Imminent Brain Death - A patient with severe acute brain injury, who is ventilator dependent, AND has a neurological injury/insult, such as trauma, anoxia, stroke, intracranial bleed (ICB) or intracranial hemorrhage (ICH).

Potential Donors: Donation after Cardiac Death (DCD)

Donation after cardiac death (DCD) is the recovery of organs from a donor patient meeting the following criteria: • The patient has a severe, non-survivable neurological injury/insult but will not progress to brain death • The family has decided to withdraw care from their loved one prior to the discussion of organ

donation by LifeLinks/Lions

Referral Procedure

Steps to Refer Potential Donors

The organ procurement organization (OPO) requires early referral by the patient care staff or designee for all potential donor situations. Referrals do not constitute commitment on the part of the referring individual, agency or family.


TME2017_ORG

Follow the steps listed below for the organ referral procedure.

Steps for organ referral procedure:

Communication Tips

Discretion & Sensitivity

In addition to understanding the referral process, clinical staff needs to be discreet and sensitive to the circumstances, beliefs and desires of the families and potential donors.

If brain death is declared, families require time to grieve and come to terms with the loss of their loved ones. When families are able to take the initial steps toward accepting the loss, they are more likely to consider donation.


TME2017_ORG

Communicating with Families

Use of discretion and sensitivity in communication is critical in allowing families to participate in the important decisions regarding a death or imminent brain death.

When communicating with families, use the guidelines listed on this page.

When communicating with families use the following guidelines:

• Be aware, people respond differently to loss • Choose words carefully • Provide up-to-date information in small amounts • Minimize the number of staff members who talk to the family about brain death • Set aside time for families to ask questions; allow for privacy • Be respectful of cultural, religious and other belief systems • Be sensitive to the needs of various age groups • Offer a pastoral consult (if appropriate) • Do not rush the family through the grief process

Note: LifeLink/Lions will not discuss organ donation until the family fully understands their loved one is deceased and has had enough time to absorb the loss.


TME2017_PID

Lesson: Patient Identification

Introduction

Lesson Objectives

To ensure a safe environment, all individuals involved in patient care should appropriately identify each patient to prevent medical errors.

After you complete this lesson, you should be able to: • Identify the process for patient identification per BayCare policy • Recognize how to label a specimen appropriately • Interpret color-coded bracelets used to identify patients with special risks, if applicable

Patient Identifiers

Source of Identification (Hospital Divisions, Ambulatory, MPR, JKTB, and WHH only)

Patients will be identified by two identifiers: • First and last name • Date of birth

Before providing care, treatment and/or services, all staff will verify patient identification by asking the patient his or her name and date of birth (whenever possible) and matching the name and date of birth provided by the patient to the patient identification bracelet.

Source of Identification (HC only)

At the first point of contact, all clinical staff providing care, treatment and/or services will verify patient identification by using two identifiers.

All clinical staff will ask patients to state their: • First and last name • Date of birth

For continued care, when the clinician knows the patient, facial recognition can be one of the patient identifiers. For example, on the second visit, the clinical staff recognizes the patient and asks the patient to state his/her first and last name.

Source of Identification (BH, PC only)

Patients will be identified by two identifiers: • First and last name • Date of birth

Before providing care, treatment and/or services, all staff will verify patient identification by asking the patient his or her name and date of birth (whenever possible).


TME2017_PID

Source of Identification (Hospital Divisions and Ambulatory only)

Match the name and date of birth on the identification bracelet with a second source such as the: • Medical record • Electronic Medication Administration Record (eMAR) • Meal tray requisition • Specimen label or • Diagnostic requisition

Source of Identification (HC only)

Match the patient’s name and date of birth to a second source such as agency/facility documents when: • Admitting the patient • Administering medication • Collecting lab specimens or • Providing treatment or procedures

Source of Identification (BH only)

Match the patient’s name and date of birth with a second source such as the: • Medical Record • Service Record

Source of Identification (BMG only)

Match the patient’s name and date of birth with a second source such as the: • Medical record • Specimen label or • Diagnostic requisition

Labeling Specimens (Hospital Divisions, MPR, JKTB, and Ambulatory only)

During a procedure, all containers used for specimens (blood, urine, sputum, etc.), are labeled in the presence of the patient to ensure the label on the specimen matches the name on the identification bracelet.

Labeling Specimens (HC, BMG, BH only)

During a procedure, all containers used for specimens (blood, urine, sputum, etc.) are labeled in the presence of the patient to ensure the label on the specimen matches the correct patient.


TME2017_PID

Identification Challenges

Name Alert (Hospital Divisions, MPR, JKTB only)

If two patients in the same area have the same or similar names, move one patient to a different location.

If you cannot place one of the patients in a different location, post a Name Alert.

Refer to the chart on this page for your facility’s guidelines.

Facility Areas to Post Name Alerts Hospital Divisions

• On the front of the patient's chart • At the central monitoring station (Telemetry, Labor and Delivery (L&D), Intensive

Care Unit (ICU) • On the assignment board at the nursing station

And if applicable: • On the wall above the head of the bed


• On the front of the patient's chart

John Knox of Tampa Bay

• On the front of the patient's chart • On the Medication Administration Record (MAR)

And if applicable • On the outside of the patient’s door

Patient Identification in Labor & Delivery (Hospital Divisions only)

All newborns are immediately banded with two identification bracelets after birth. The mother receives two identification bracelets matching the infant's bracelets. One bracelet is applied to the mother's wrist and one bracelet is given to a significant other selected by the infant's mother.

When Unable to Identify Patient (Hospital Divisions only)

There may be instances when identifying a patient can be challenging.

Challenge: Solution: Date of birth is unknown Use account/financial number as second identifier Patient unable to communicate verbally

Identify patient by checking name and date of birth on patient’s identification bracelet

Patient is found without a bracelet; bracelet not legible

Verify identity of patient and make a duplicate replacement bracelet immediately

Patient cannot be positively identified

Register patient as John/Jane Doe until positive identification is available Trauma-receiving facilities use trauma number until patient can be positively identified.


TME2017_PID

If a patient’s date of birth is unknown, use the account/financial number as the second identifier.

If a patient is unable to communicate verbally, identify the patient by checking the name and date of birth on the patient’s identification bracelet.

If a patient is found without a bracelet, or the bracelet is not legible, verify the identity of the patient and make a duplicate replacement bracelet immediately.

If a patient cannot be positively identified, register the patient as John/Jane Doe until positive identification is available. Trauma-receiving facilities will use the trauma number until the patient can be positively identified.

When Unable to Identify Patient (Long term Care Facility: MPR & JKTB)


Challenge: Solution:

Date of birth is unknown Use medical record as second identifier Patient unable to communicate verbally Identify patient by checking name and date of birth

on patient’s identification bracelet

Patient is found without a bracelet; bracelet not legible

Verify identity of patient and make a duplicate replacement bracelet immediately

Patients unable to verify their name and date of birth, and no other patient contacts available

Verify patient’s identification by asking another team member who knows patient or matching patient’s facial features to picture on medical chart


TME2017_PID

If the patient’s date of birth is unknown, use the medical record as the second identifier.

If a patient is unable to communicate verbally, identify the patient by checking the name and date of birth on the patient’s identification bracelet.

If the patient is found without a bracelet, or the bracelet is not legible, verify the identity of the patient and make a duplicate replacement bracelet immediately.

In the event patients are unable to verify their name and date of birth, and there are no other patient contacts available, verify the patient's identification by: • Asking another team member who knows the patient or • Matching the patient’s facial features to the picture on his/her chart

When Unable to Identify Patient (BH only)


If the patient’s date of birth is unknown, use the account/financial number as the second identifier.

When Unable to Identify Patient (HC only)

In the event a patient is cognitively unable to verify his/her name and date of birth, identify a caregiver/relative who will participate in the identification verification process.


TME2017_MTM

Lesson: Assessing for Signs of Mistreatment

Introduction

Lesson Objectives

All patients receiving care, treatment and/or services are screened or observed for signs of abuse during the assessment process.

After you complete this lesson, you should be able to: • Recognize the signs of abuse, neglect and exploitation • Describe the process for reporting abuse, neglect and exploitation • Identify appropriate information to document in the medical records • Identify where to locate the Accounting for Disclosures documentation

Abuse

Definition of Abuse

Abuse is defined as: • The non-accidental infliction of physical or psychological injury to a child or vulnerable adult • The failure of the caregiver to take reasonable measures to prevent the occurrence of physical or

psychological injury

A relative, caregiver or adult household member is usually the one to inflict abuse.

Vulnerable Adult - A vulnerable adult is a person 18 years or older whose ability to perform normal activities of daily living or provide for his or her own care or protection is impaired due to any one or a combination of the following: • Mental, emotional and physical disability • Developmental disability • Brain damage • Infirmities of aging


TME2017_MTM

Examples of Abuse

Abuse can present itself in a variety of forms. Please review the following examples of abuse: Examples of abuse: • Excessive exposure to heat or cold • Poisoning • Leaving an individual who requires supervision alone in a hostile or dangerous situation • Abandonment • Threatening to cause death, disfigurement or harm • Excessive use of physical and/or chemical restraints • Forcing an individual to take excessive medication and/or medication that is not prescribed • Locking an individual in a room, closet or shed • Sexual assault and exploitation • Sterilization of a vulnerable adult without prior informed consent and due process of the law • Denial of civil rights entitled by law • Forcing an individual to consume excessive amounts of food or liquid as punishment

Signs of Abuse

Abuse is usually seen as: • Welts • Bruises • Untreated sores or other skin injuries • Evidence of overall poor care

Abuse involving children is most frequently seen as: • Bruises • Head injuries (shaken baby) • Burns • Spiral fractures - a key indicator of child abuse!

Neglect

Definition of Neglect

Neglect is when a caregiver fails or omits to provide care and services to minors and vulnerable adults that: • A reasonable person would determine to be essential for their well-being • Are necessary to maintain physical and mental health

Neglect includes repeated conduct or a single incident of carelessness that produces or could be expected to result in serious physical or mental harm or risk of death. Neglect can be shown in several areas including: • Medical treatment • Nutrition and hydration • Care and services • Clothing and shelter


TME2017_MTM

Examples of Neglect: Medical Treatment, Nutrition and Hydration

Neglect can also present itself in different forms. Please review the following examples of neglect.

Medical Treatment - caregiver does not provide: • Required medical services • Medical services or prescribed medications • Medication administration as prescribed • Recommended/required treatment programs • Explanation regarding care and services

Nutrition and Hydration - caregiver does not provide: • Adequate amount of food and/or liquid • Proper type of food and/or liquid • Nourishing meals regularly

Examples of Neglect: Care and Services, Clothing, Shelter

Neglect occurs when the caregiver does not provide does not provide: • Assistance with basic hygiene • Adequate care, concern, privacy and supervision • Adequate and/or clean clothing appropriate for the weather conditions

Neglect also occurs when the caregiver does not: • Repair unsafe housing conditions • Maintain sanitary living conditions • Provide adequate heating and cooling of the environment

Exploitation

Definition of Exploitation

Exploitation is the improper or illegal use or management of a child or vulnerable adult’s funds, assets, property or person.

Exploitation is also the use of a vulnerable adult's power of attorney or guardianship for another's or one's own profit or advantage.

Examples of Exploitation

Exploitation can present itself in different forms. Please review the following examples of exploitation: Exploitation can include, but is not limited to: • Cashing vulnerable adults’ checks without their permission • Forging their signature • Stealing or misusing their money or possessions • Abusing the power of attorney


TME2017_MTM

Examples of Exploitation (Vulnerable Adult)

Exploitation can include, but is not limited to: • Money taken through deceit • Property taken and/or sold through deceit • Attempts to bribe someone to do something he or she ordinarily would not do • Underpayment or no payment for work-related services provided • Sexual exploitation • Prostitution

Signs of Exploitation

Exploitation is usually seen as: • Sudden changes in banking activity, including large withdrawals from the bank or ATM • Additional names added to a vulnerable adult's bank signature card • Abrupt changes in a will or other financial documents • Disappearance of funds or valuable possessions without explanation • Substandard care or unpaid bills despite adequate financial resources • Signatures on checks, financial transactions (or other property documents) that do not resemble the

vulnerable adult's • Previously uninvolved relatives claiming rights to a vulnerable adult's affairs and possessions • Transfer of assets to a family member or someone outside the family without explanation or

permission

Abuse, Neglect and Exploitation Reporting

Reporting Abuse, Neglect or Exploitation (Hospital Divisions, HC, BMG, BH, Ambulatory, and WHH only)

You have a legal responsibility to report cases of abuse or suspected abuse, neglect and/or exploitation involving minors and vulnerable adults.

When you suspect abuse, neglect or exploitation of a minor or vulnerable adult, contact your immediate supervisor and consult with the risk manager, social services and any other appropriate health care professionals.


TME2017_MTM

Reporting Abuse, Neglect or Exploitation (JKTB, MPR only)

You have a legal responsibility to immediately report cases of abuse or suspected abuse, neglect and/or exploitation involving minors and vulnerable adults.

When you suspect abuse, neglect or exploitation of a minor or vulnerable adult, follow your facility’s procedures. Refer to the chart listed here.

Facility Contact John Knox of Tampa Bay

• Contact your immediate supervisor, abuse coordinator, director of nursing, and/or administrator

• Consult with the risk manager, social services and any other appropriate health care professionals. The assistant director of nursing is the risk manager.

If any of the above individuals are not in the building, page them immediately. Failure to report abuse, neglect or exploitation of a minor or vulnerable adult is a misdemeanor.


• Contact your immediate supervisor, director of Patient Services and/or director/administrator

• Consult with the risk manager, social services and any other appropriate health care professionals. The director/administrator is the abuse coordinator.

If any of the above individuals are not in the building, page them immediately. Failure to report abuse, neglect or exploitation of a minor or vulnerable adult is a misdemeanor.

Misdemeanor - A misdemeanor is a crime considered less serious than a felony where the punishment might be a fine or prison for less than one year.

Report Abuse, Neglect or Exploitation: Hotline (Hospital Divisions, HC, BMG, BH, WHH)

If reporting is required, team members, in conjunction with their supervisor and/or Case Management or social services, will call 1-800-96-ABUSE (1-800-962-2873).

If a report is required, the report should contain: • Name, age, race, sex and physical description of alleged victim • Names, addresses and phone numbers of alleged victim's family, caregiver and alleged perpetrator (if

available) • Name of the person reporting the alleged abuse, facility address and facility phone number

Report Abuse, Neglect or Exploitation: Hotline (MPR, JKTB)

Team members, in conjunction with their supervisor and/or Case Management or social services, will immediately report all alleged incidences of abuse, neglect or exploitation to: 1-800-96-ABUSE (1-800-962-2873)


TME2017_MTM

The report should contain: • Name, age, race, sex and physical description of alleged victim • Names, addresses and phone numbers of alleged victim's family, caregiver and alleged perpetrator (if

available) • Name of the person reporting the alleged abuse, facility address and facility phone number

Reporting Domestic Violence (Hospital Divisions, MPR, JKTB, HC, WHH)

You should always report domestic violence when it involves minors or vulnerable adults.

If the domestic violence does not involve minors or vulnerable adults, report the incident according to the wishes of the customer.

Domestic Violence – means any assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment or any criminal offense resulting in physical injury or death of one family or household member by another family or household member.

Reporting Domestic Violence (BMG & BH Only)

If you need to report domestic violence, please refer to the posted signs in your facility for all state and local numbers relating to domestic violence.

Domestic Violence – means any assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment or any criminal offense resulting in physical injury or death of one family or household member by another family or household member.

Documentation of Abuse, Neglect or Exploitation

Documentation of abuse, suspected abuse, neglect or exploitation in the medical record should tell a factual, accurate story of what was observed by the team member and stated by the customer and caregivers. Documentation should not include assumptions, opinions or assign blame.

Accounting for Disclosures

The designated person at your facility must complete an Accounting for Disclosures form for each report of suspected abuse, neglect or exploitation. The reporting form is available on the BayCare Intranet.

To locate this form, simply go to the BayCare Intranet Home page and search for "disclosures database"; complete and submit the form.


TME2017_STK

Lesson: Assessing for Signs of Stroke

Introduction

Lesson Objectives

Stroke is a medical emergency. In the United States, stroke is the fifth leading cause of death and the leading cause of disability in adults. Recognizing and responding to the warning signs of stroke can impact a person's survival and level of function.

After you complete this lesson, you should be able to: • Recognize the warning signs of stroke and • Recognize appropriate actions when responding to different stroke victims (patient, team member,

visitor)

Definition of Stroke

Stroke is a life-threatening situation in which part of the brain does not receive adequate oxygen.

Areas of the brain control different functions of the body such as speech or movement of arms and legs. Inadequate amounts of oxygen or interruption of blood flow to an area of the brain can cause damage resulting in loss of function or death.

Responding to Stroke

Signs of Stroke

The warning signs of stroke include:

Remember, even if these signs come and go quickly, the person could still be having a stroke. Take immediate action!


TME2017_STK

Response to Stroke Victims

The response to stroke victims will vary depending on who the patient is and where the patient is located. If at any time you notice warning signs of stroke, do not delay in responding. Refer to the chart below for the appropriate response for each type of stroke victim.

Facility Stroke Victim Response Hospital Divisions Co-worker/visitor Take to ED via wheel chair or

stretcher Patient Call stroke alert (ED) or rapid

response team (in-patient) HomeCare Co-worker/visitor/patient Call 911 Behavioral Health (Community-Based Programs & MPNB recovery Center)

Co-worker/visitor/patient Call 911

John Knox of Tampa Bay Co-worker/visitor/patient/resident Call supervisor to assess the situation and then call 911

Morton Plant Rehab Co-worker/visitor Call supervisor to assess the situation; call 911 collaboratively

Patient Call Rapid Response Team Primary Care/Physician Office Co-worker/visitor/patient Call 911 Ambulatory Sites Co-worker/patient/visitor Call 911 Winter Haven Hospital Co-worker/visitor Call Rapid Response Team

Patient Call Stroke Alert

KNOW THE SIGNS! ACT IN TIME! STOP STROKE!

BayCare Primary Stroke Centers

The Agency for Health Care Administration (AHCA) directs the Florida "Stroke Act" and requires all licensed emergency medical services (EMS) providers in Florida to use a stroke triage assessment tool and transport stroke victims to primary and comprehensive stroke centers for care.

The Joint Commission provides Stroke Disease-Specific Certification for those organizations meeting the requirements. The designated Primary Stroke Centers within BayCare are:

• Morton Plant Mease Hospitals • St. Anthony's Hospital and • St. Joseph's Hospital • South Florida Baptist Hospital • Winter Haven Hospital


TME2017_RES

Lesson: Non-violent Practices and Restraints

Introduction

Lesson Objectives

Could you handle a patient who becomes agitated, disruptive or destructive? What if a patient’s behavior escalates to a dangerous level? What would you do?

After you complete this lesson, you should be able to: • Identify non-violent practices to address stressed patient behavior • Recognize BayCare’s policy on restraints (if applicable) • Recognize the team member(s) authorized to order, apply and remove restraints, and order

seclusion (if applicable)

Behaviors Requiring Intervention

Early recognition of and non-violent interventions for increasingly stressed patient behavior can minimize the use of physical intervention.

A patient who is stressed may display the following levels of behavior:

Level of Behavior Example of behaviors Agitated Pacing; wringing hands, rapid breathing; crying Disruptive Shouting; arguing; name calling Destructive Damaging property; banging on walls; kicking furniture Dangerous Hitting others; harmful to self or others

Non-Violent Practices

Team member behaviors can affect patient behaviors. Therefore, it is important to act professionally and recognize behaviors requiring intervention as early as possible.

Use non-violent practices as the first intervention when a patient exhibits a stressed behavior.

Review the examples of non-violent practices appropriate for each level of behavior.

Level of Behavior Non-Violent Practices Agitated Use active listening; refocus on new activity; respond promptly

and positively; check for undiagnosed pain Disruptive Check for logic of situation; defuse and remove individual from

area; set limits; maintain vigilance Destructive Remove others from area; remove weapons; defuse and

separate; ensure equal access to exit; prepare for emergency response

Dangerous Protect self and others; initiate emergency response; use multiple avoidance skills; avoid rapidly closing distance between self and dangerous patient


TME2017_RES

De-escalation Techniques

Non-violent practices are considered de-escalation techniques that, when used properly, can calm and decrease a person’s stressed behavior.

The following de-escalation techniques are effective in most situations: • Maintain a safe distance – at least the patient’s arms length plus 10 inches • Maintain eye contact • Use a calm, clear and firm voice • Use an open, relaxed stance that offers you protection • Show empathy and respect • Do not ignore your instinct or compromise your ability to maintain safety and security

Immediately notify the contact listed in the chart on this page if you are unable to apply non-violent practices successfully.

Facility Contact Hospital Divisions Morton Plant Rehabilitation John Knox Tampa Bay Behavioral Health

Trained nursing support **At WHH, call security if needed**

HomeCare Supervisor/Manager Primary Care/Physician Office Trained nursing support

Restraints (Hospital Divisions, JKTB, BH, and HC only)

Types of Restraints

When a person displays a dangerous level of behavior, physical intervention, such as the use of restraints, may be necessary.

There are two types of restraints, chemical and physical.

A Chemical restraint is a medication used to restrict the patient's freedom of movement. Medications, when used as part of the patient's treatment plan, are not chemical restraints.

BayCare does not support the use of chemical restraints.

A Physical restraint is the direct application of physical techniques with or without the patient's consent to restrict his or her movement ability. The physical techniques used may be manual/hands-on, mechanical or a combination of the two.


TME2017_RES

Types of Physical Restraints

There are three types of physical restraints.

A Physical Hold: restricts movement of a person for a short period of time, either until the person calms down or other help arrives. You may need to use a physical hold until either a medical, non-violent, or behavioral, violent, mechanical restraint can be applied.

A Medical or Non-Violent Restraint: is a mechanical restraint utilized to protect healing in the patient who is not oriented and is actively pulling at essential lines or tubes, or attempting to ambulate when unable to do so.

A Behavioral or Violent Restraint is a physical or mechanical restraint used to prevent the patient from harming self or others (patient is exhibiting violent behavior, such as kicking, hitting or biting).

Trained team members will assess and implement the appropriate approaches and interventions.

Mechanical Restraint - a device that hinders a patient's movement, such as a safety vest, hand and wrist straps, mittens, and/or a stretcher equipped with belts.

Restraint Use in Assisted and Independent Living Facilities (MPR and JKTB only)

Restraints are not typically used in the Assisted Living Facility. The use of physical restraints is limited to half-bed rails for positioning purposes and only upon the written order of the resident’s physician.

Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance, is not considered a physical restraint.

Restraints are not used in the Independent Living Facility.

Education Regarding Restraints (HC only)

In the home care setting, if restraints are necessary, the appropriate team member will provide the following education and instructions to the patient and/or significant other(s) regarding restraints:

• Reason for the restraint • the Type of restraint • Proper application of restraint devices • Proper positioning of the patient • Frequency of restraint release and • Needs of the patient while in restraints


TME2017_RES

Physician’s Order and Restraint Use (Hospital Divisions, BH, MPR only)

All restraints require a physician's order.

The physician must complete restraint orders appropriately and in the prescribed time frame. The physician can only sign renewal orders at the actual renewal times following an on-site assessment of the patient and the situation.

PRN restraint orders are not permitted.

Physician’s Order and Restraint Use (JKTB only)

All restraints require a physician's order.

The physician must complete restraint orders appropriately and in the prescribed time frame.

PRN restraint orders are not permitted.

Guidelines to Use Restraints (Hospital Divisions, MPR, JKTB, and BH only)

Always implement non-violent, non-physical interventions to prevent, reduce and/or eliminate the use of restraints first.

However, special circumstances where restraints are necessary to promote the safety and well-being of our patients do exist.

If you need to use restraints, follow these guidelines: • Obtain a physician’s order for restraint use • Use only trained team members to apply and remove restraints • Use the least restrictive type of restraint for the shortest time period possible • Provide education to the patient and family • Monitor to preserve the patient's safety and dignity when restraints are used • Complete documentation requirements as prescribed in your facility’s policies and procedures

Use restraints as a last resort measure when less restrictive measures have proven unsuccessful.

Seclusion (BH only)

Use of Seclusion

When non-violent practices are ineffective and the patient continues to exhibit dangerous behaviors, seclusion may be used.

Seclusion is the limitation of a person's ability to move about freely, or the physical segregation of a person in any fashion from other patients such as an involuntarily imposed closed or locked door.


TME2017_RES

Apply the same guidelines for seclusion as restraints. However, use of seclusion requires the following additional guidelines:

• Obtain a physician’s order for all episodes of seclusion after initiation • Obtain a signed physician’s order within 24 hours of receiving a verbal order and • Apply seclusion for the appropriate length of time:

− Minors under 17 years should not exceed one (1) hour − Adults 18 years and older should not exceed four (4) hours

Non-Acute Care Settings: (BH only)

Team Member Training in Non-Acute Care Settings All Behavioral Health team members in non-acute care settings are trained in mental health/substance abuse characteristics and how to respond to an emergency. Annual training for team members includes emergency procedures and non-violent practices.

Designated team members are trained and certified in the use of safe physical management with the Non-abusive Psychological and Physical Intervention (NAPPI) model.

These team members can use trained physical holds as a protective measure in a life or safety-threatening situation. Team members will only use physical management when all other non-violent practices have failed or are not possible.

Guidelines for Seclusion and Restraints in Non-Acute Care Settings If a physical emergency occurs in an inpatient, Behavioral Health non-acute care setting and restraint or seclusion is appropriate follow these guidelines: – Use seclusion or restraint in the Behavioral Health Crisis Stabilization Units and non-hospital based

acute care inpatient units only – Call 911 for support – Use physical holds only as a time-limited emergency intervention until 911 responds

– Two trained team members must be present and agree to use a “hands-on” physical technique • Document both the attempted use of less restrictive measures along with the use of restraint or

seclusion • Restrict patient involvement in the control of aggressive behavior of other patients

Seclusion and restraint are not appropriate nor allowed as punishment or for the convenience of team members. If urgent care is requested by a patient, but the patient is not in danger to self or others, direct the patient to his/her primary care clinician.

Response to Psychiatric Emergencies in Non-Acute Care Settings

A Psychiatric Emergency occurs when a patient is a danger to self or others.


TME2017_RES

If a psychiatric emergency occurs in a Behavioral Health non-acute care setting, follow these steps:

Response to Medical Emergencies in Non-Acute Care Settings

There may be instances when patients in a Behavioral Health non-acute care setting require emergency medical services.

All patients receiving clinical services are assured medical care in an emergency. In the event of a suspected injury or medical problem, immediately survey the situation.

If the incident requires assessment or treatment beyond minor first aid, follow these steps:


TME2017_WER

Lesson: Wandering and Elopement Response

Introduction

Lesson Objectives

What would happen if one of your patients/residents wandered or eloped? How would you respond?

After you complete this lesson, you should be able to identify: • Who is at risk for wandering/elopement • Assessment measures and safety interventions • Team member’s role in an emergency response • Team member’s responsibilities to educate patients and families • The location of policies and procedures

Who is at Risk?

Patients/residents with cognitive impairment (memory loss, confusion) are most at risk for wandering or elopement.

Wandering- A cognitively-impaired (i.e. memory loss, confusion) patient’s/resident's lack of ability to move about without an awareness of personal safety needs.

Elopement - When a patient/resident who has been assessed with memory loss, decreased awareness and disturbance in judgment, reasoning and perception exits the facility without the knowledge of the staff.

Why do Patients/Residents Wander?

The following are potential reasons for wandering: • Hungry • Thirsty • Bored • Fatigued or tired • In pain or discomfort • Needing to use the toilet Why do Patients/Residents Elope?

Fear, frustration and the inability to express feelings can all lead to the patient/resident wanting to leave (elope) the facility. In addition, the patient/resident might be searching for a more secure, and familiar place.


TME2017_WER

Risk indicators for elopement include: • History of wandering/elopement • Change in mental status • Memory loss (decreased awareness, disturbance in judgment, reasoning and perception) • Side effects of medication • Disorientation • Communication (i.e. language barriers) • Assessing the Risk • Safety Issues

Falls can be associated with wandering related to fatigue, anxiety, gait and or poor balance. Stairs are a hazard, particularly for the wandering patient/resident who has poor balance, decreased strength and impaired vision.

Potential unsafe areas include: • Chemical storage area • Stairwell • Poorly lit area • Another patient’s/resident’s room Safety Assessments During the admission process, a safety assessment is conducted on all patients/residents to identify their risk for wandering and/or elopement.

Morton Plant Rehabilitation and John Knox Tampa Bay Only

Upon admission, the patient/resident is assessed and information is documented on the electronic admission form in Point Click Care by the admitting nurse. .


TME2017_WER

Safety Interventions

Identification Bracelet and Wander Guard® (MPR only)

If a patient/resident is assessed as a risk a color coded identification bracelet and a Wander Guard® (a small lightweight tracking device) are used as safety interventions.

Color-coded Identification Bracelet:

Morton Plant Rehabilitation uses a Green bracelet.

Wander Guard®

The Wander Guard® may be placed on the following locations: • Clothing • Wheelchair

Identification Bracelet and Wander Guard® (JKTB Only)

If a patient/resident is assessed as a risk for elopement, a color-coded identification bracelet and Wander Guard® (a small lightweight tracking device are used as safety interventions.

Color-coded Identification Bracelet:

John Knox Tampa Bay places Gold stars on the identification bracelet.

Wander Guard®

The Wander Guard® may be placed on the following locations: • Belt buckle • Clothing • Wheelchair or walker

Room Placement and Observation In addition, the following safety interventions may be used: • Assign a room closest to the nursing station • Increase observation of patient/resident • Use bed/chair alarms

Environmental Safety Interventions

The following environmental interventions should be available: • Safe walking areas with an opportunity to stop and rest • Uncluttered, secured and well-lit walking areas • Safety locks for drawers and cabinets that contain potentially hazardous materials • Doors with locks or semi-locks • Door alarms to alert the staff when a patient/resident attempts to leave


TME2017_WER

Team Member Responsibilities

If a patient/resident is found wandering the team member should direct the patient to a safe area or stay with the patient and call for help. Non-clinical team members should notify the supervisor for further instructions.

Team members are responsible for maintaining the safety of the patient/resident by:

Educating families and caregivers about the risk of elopement, wandering, and the related safety issues and interventions

Documenting education and visitor teaching in the Medical Record

Emergency Response

Initial Steps to Respond

All team members are responsible for ensuring the safety and security of patients/residents. If a patient/resident is missing or has eloped, time is critical.

Search immediate patient care area.

If the patient/resident is found, return the patient/resident to room.

If the patient/resident is not found, immediately notify the nursing supervisor or manager/director.

Start an initial search to locate the missing patient/resident by searching all patient/resident rooms, bathrooms and closets. Verify the patients/residents are in their correct bed. Search all common areas using facility floor plan to assure all areas are checked.

If the patient/resident is found, return to room and verify safety interventions are in place.

Responsibilities of Team Members in an Organized Search (MPR only)

If a patient/resident is not found after the initial search, begin an organized search.

Person in Charge

The person in charge will: • Overhead page Code One, three times; and then state the patient’s/resident’s name and the station

number of the command post via SpectraLink phone to assure the search is coordinated on both floors.

• Notify the Director/Administrator, Director of Patient Services and Risk Management immediately • Notify Morton Plant Hospital Security. Security will be given a description of the patient/resident and

will begin a search of parking lots and roads near Morton Plant Rehabilitation, gradually expanding outward.

Unit Secretary

Unit Secretary will call SpectraLink numbers in use and notify the Administrator on Duty (AOD) at Morton Plant Hospital.


TME2017_WER

All Team Members

Team Members should report back to the person in charge after they have searched their assigned area for further instructions.

MPR: If Patient/Resident not Found

After an organized search (no longer than 15-20 minutes) if the patient/resident is not found: • The local Police Department will be notified. • The patients/residents physician is notified. • A call is placed to the patients/residents home and to available family/significant others. • Team members will expand the search into the parking lot and surrounding areas. • Team members will drive in opposite directions on South Fort Harrison Avenue and West on Corbett

Street.

A community alert will be considered if the patient/resident continues to be missing and has a cognitive impairment.

Steps for an Organized Search (JKTB Assisted Living only) When a resident is missing: • Immediately notify the front desk • The front desk staff will notify security and the manager on duty then an organized search will begin

in the last known area the resident was seen • All areas of the campus will be checked including stairwells, restrooms and storage areas • Security will update the manager every 15 minutes. • The nurse in charge will notify the local police and the physician in the event the resident is not

located. • The nurse in charge will notify available family/significant others. • When the resident is located the front desk and the manager on duty will be immediately notified. • Nursing will return the resident back to his/her apartment and assess their condition.


TME2017_WER

Steps for an Organized Search (JKTB Medical Center only)

When a patient/resident is missing:

• All Medical Center staff will be alerted and begin an initial search of the Medical Center. • The Security Department will be notified to be on alert for the patient/resident and assist in the

search. • If the patient/resident is not found in the Medical Center, the front desk will be notified and a search of

the campus will be started by Security.

If Patient/Resident not Found (JKTB only)

In the event the patient/resident is not located on John Knox property the: • Search will be expanded • Patient/resident’s family, physician, and the local Sheriff’s Department will be notified • The patient’s/resident’s description will be faxed or called to University Hospital, USF Psychiatric

Center and H. Lee Moffitt Hospital by the charge nurse

When a Missing Patient/Resident is found after an organized search

When the patient/resident is found after an organized search it is the team member’s responsibility to: • Return the patient/resident back to his/her room • Have the nurse assess the patient’s/resident’s condition and perform a safety reassessment • Implement the appropriate safety interventions (place elopement bracelet on patient/resident) • Document the event in the medical record • Complete the event report

Policies and Procedures

Policies and Procedures: Policies and Procedures can be found in the Policy and Procedure Manual located on each unit and the Emergency Response Manual.

If there are any questions, contact your immediate supervisor/manager on duty and/or the facility’s director.


TME2017_HHD

Lesson: Hypothermia, Hyperthermia and Dehydration

Introduction

Lesson Objectives

Team members need to be alert to the signs and symptoms of the most common heat-related emergencies and take appropriate action to treat the patients’/residents’ immediate needs. After you complete this lesson, you should be able to: • Identify symptoms of the most common heat-related emergencies • Select the correct steps to treat a patient/resident with hyperthermia • Recognize appropriate precautions to prevent hypothermia • Recognize signs and symptoms of dehydration • Identify team member responsibility in caring for the at-risk patient/resident if environmental controls

(heating or air-conditioning) fail

Hypothermia

What is Hypothermia?

Hypothermia is a condition that occurs when body temperature drops below 95° Fahrenheit. Hypothermia can be caused by prolonged exposure to cold temperatures, or when the body begins to lose heat. Risks for exposures to low temperatures include exposure to cold and wet weather, sitting under air-conditioning vents and failure of the heating system.

Some potential causes of hypothermia include: • Medications • Memory disorders • History of diseases • Substance abuse • Age

Some over the counter mediations, supplements and herbal remedies can cause hypothermia. Certain medications such as but not limited to anti-depressants, barbiturates, tranquilizers.

Patients/residents with memory disorders may forget to drink fluids.

The following diseases may increase the risk for hypothermia: Hypothyroidism, Addison’s Disease, Diabetes Mellitus, Congestive Heart Failure, Renal Failure, Stroke.

Alcohol and drug abuse can dilate blood vessels near the skin, which decreases the body's ability to compensate for cold exposure.

The very young and very old may be less able to generate heat.


TME2017_HHD

Signs and Symptoms of Hypothermia Review the signs and symptoms of hypothermia listed here.

The following are signs and symptoms of hypothermia: • Uncontrollable shivering • Loss of memory • Fumbling hands • Drowsiness • Exhaustion • Disorientation • Confusion • Purple toes and fingers • Cool skin to the touch • Slurred or incoherent speech

Responding to a Patient/Resident with Hypothermia If you suspect the patient/resident is suffering from hypothermia, notify the nurse who will assess the patient’s/resident’s: • Level of consciousness • Behavioral symptoms • Appearance • Skin condition • Vital signs After the assessment, the nurse will give supportive care and document the treatment, response, vital signs and nurse-to-physician communication in the medical record. Vital signs which may indicate hypothermia: • Slow heartbeat • Irregular heart rhythm • Slow breathing • Weak pulse • Low blood pressure • Abnormally low body temperature (below 95°Fahrenheit)

Note: Severe hypothermia can cause an irregular heartbeat leading to heart failure and death.


TME2017_HHD

Treatment for Hypothermia

If the patient’s/resident’s temperature is below 97° Fahrenheit, perform the following actions: • Recheck temperature to verify • Remove patient/resident from drafts • Close all doors, drapes and windows • Cover patient/resident with extra clothing and warm blankets • Encourage warm non-alcoholic and non-caffeinated drinks orally, • Check temperature every 4 hours • Notify attending physician for any change in condition • Call 911 in the event of an emergency • Remove wet clothing and replace with warm dry covering, including covering the head

How to Reduce Risk for Hypothermia

To reduce risk for hypothermia, team member responsibility is to make sure the patient/resident is: • Dressed appropriately • Wears warm, dry clothing • Uses additional layering of clothes/blanket when weather is cold • Toileted frequently • Kept away from drafts

Responding to Heating System Failures

Upon failure of the heating system in the facility, notify in the following order: • Supervisor/Director/Administrator • Facility Services • Director of Patient Services (MPR) • Director of Nursing (JKTB) If the temperature of the patient’s/resident’s area falls below 60 degrees: • Alert all team members in the area • Check for extra supplies (e.g. blankets, clothing) • Close all windows and drapes • Monitor the patient/resident temperature every 4 hours

If evacuation is ordered, follow the supervisor’s directions. Complications

If left untreated, hypothermia can lead to: • Frostbite • Gangrene • Heart failure • Respiratory failure • Death


TME2017_HHD

Prevention

Remember this simple acronym COLD to prevent hypothermia: C - Cover O - Overexertion L - Layers D - Dry Hyperthermia

What is Hyperthermia?

Hyperthermia is defined as an increase in temperature beyond what is normally found in the human body. (The normal oral body temperature is 98.6° Fahrenheit.)

People suffer heat-related illness when the body's temperature control system is overloaded. The body normally cools itself by sweating. Very high body temperatures can damage the brain or other vital organs. The risk of heat-related illness may be higher in patients/residents with dietary salt restrictions.

Patients/residents at greatest risk include those with: • Heart or blood vessel problems • Poorly working sweat glands • Changes in skin caused by normal aging • Heart, lung or kidney disease • Any illness that causes weakness or fever • High blood pressure or other conditions • Obesity • Dehydration • Sunburn • Drug /alcohol use

Prevention and Treatment of Hyperthermia

To prevent hyperthermia, educate the patient/resident to avoid excessive activity in the heat and to drink plenty of fluids. If the patient’s/resident’s temperature is above 100.6, follow the steps listed on this page to reduce the temperature.


TME2017_HHD

If the patient’s/resident’s temperature is above 100.6, follow these steps to reduce the temperature: • Monitor vital signs and level of response every 2 hours • Monitor intake and output of fluids every 4 hours • Encourage fluids if patient/resident is able to drink – avoid alcohol • Offer supportive care to patient/resident/families • Provide intravenous fluids as ordered • Document treatment given, response, vital signs and any other pertinent information in the clinical

record

Responding to Air-Conditioning System Failures Upon failure of the air-conditioning system in the facility, notify in the following order: Director/Administrator, Facility Services then Director of Nursing. If the temperature of the patient/resident area reaches 85° Fahrenheit, follow these steps: • Alert staff • Obtain extra supply of ice • Situate fans to promote circulation of air • Open doors and windows • Remove covers from patient/resident • Move patient/resident near windows or hallways with increased air circulation • Offer patient/resident plenty of fluids and record intake and output • Check patient/resident temperature every 4 hours and record (Temperatures over 100° must be

reported to the physician.)

Heat Exhaustion and Heat Stroke

Heat-Related Illnesses

The body's inability to cope with heat is the main cause of such heat-related illnesses as heat exhaustion and heatstroke. Heat exhaustion is a heat-related illness caused by high temperatures and dehydration. If heat exhaustion is not treated, it can lead to heat stroke. Review the signs and symptoms of heat exhaustion listed below.


TME2017_HHD

Signs and symptoms of heat exhaustion include: • Thirst • Dizziness • Weakness • Muscle cramps • Nausea • Sweating profusely (may not be present in elderly) • Uncoordinated movement • Headache • Fainting Vital Signs associated with heat exhaustion include: • Temperature within normal limits • Normal or rapid pulse rate • Cold and clammy skin (may not be normal)

Treatment for Heat Exhaustion

Heat exhaustion may be treated in several ways: • Relocate the patient/resident out of the sun into a cool place • Offer fluids like water and fruit juices, but avoid alcohol and caffeine • Urge the patient/resident to lie down and rest in a cool place • Encourage the patient/resident to sponge off with cool water or take a shower • Wear light weight clothing

Heat Stroke

Heat stroke is physical exhaustion caused by prolonged exposure to high temperatures and can be life threatening. Heat stroke is more dangerous than heat exhaustion and requires immediate medical attention; always involves dangerously high body temperature and is more common in summer during a prolonged heat wave. Review the signs and symptoms of heat stroke listed below.


TME2017_HHD

The following are signs and symptoms of heat stroke: • Headache • Confusion • Fainting • Bizarre behavior • Muscle cramps • Unconsciousness • Possible delirium or coma • Permanent brain damage • Combativeness • Staggering or dizziness • Shock and death Vital signs associated with heat stroke: • Hot dry skin • Flushed skin (red in color) • Rapid pulse • Rapid breathing • High body temperature above 104°

Treatment for Heat Stroke

If the patient/resident is exhibiting signs of heat stroke, seek emergency assistance immediately. Call 911! Without medical attention, heat stroke can be deadly. Heatstroke can cause shock, brain damage, organ failure and even death.

Prevention

Precautions for the patient/resident to take to prevent heat exhaustion or other heat-related illnesses include: • Wearing loose fitting, lightweight, light-colored clothing • Avoiding sunburn • Seeking a cooler environment • Drinking plenty of fluids • Taking precautions with certain medications • Avoiding the inside of a hot vehicle • Avoiding strenuous activity in the heat Additional Heat-Related Illnesses • Heat Cramps

Heat cramps are muscle pains or spasms (usually in the abdomen, arms, or legs) caused by a depletion of the body's salt and moisture. Heat cramps may also be a symptom of heat exhaustion.


TME2017_HHD

Treatment for patient/resident with heat cramps includes: • Stopping all activity • Sitting quietly in a cool place • Drinking clear juice or a sports beverage • Seeking medical attention for heat cramps if they do not subside in 1 hour • Seeking immediate medical attention for those residents with heart problems or on low sodium diets • Do not allow patient/resident return to strenuous activity for a few hours after the cramps subside

because further exertion may lead to heat exhaustion or heat stroke. • Heat Rash

Heat rash is a skin irritation caused by excessive sweating during hot, humid weather. Heat rash looks like a red cluster of pimples or small blisters. It is usually found on the neck and upper chest, groin area, under the breasts, and in elbow creases. Treatment for patient/resident with heat rash includes: • Providing a cooler, less humid environment • Keeping affected areas dry • Using dusting powder to increase comfort Treating heat rash is simple and usually does not require medical assistance. Avoid using ointments or creams because they keep the skin warm and moist and may make the condition worse. Sunburn

Sunburn is caused by over exposure to the sun. Minor sunburns damage the skin causing minor discomfort, and healing often takes about a week. Severe sunburns usually require medical attention. Symptoms of sunburn include: • Reddened skin • Severe pain • Fever • Blisters (from severe sunburns)

Certain medications such as antibiotics may increase the skin's risk to reddening and burning from the sun. Treatment for patient/resident with sunburn includes: • Avoiding repeated sun exposure • Applying cold compresses to area • Immersing area in cool water • Applying moisturizing lotion to affected areas • Do not use salve, butter, or ointment on the affected area or break blisters.


TME2017_HHD

Dehydration

What is Dehydration? Dehydration is a dangerous lack of water in the body resulting from inadequate intake of fluids or excessive loss through sweating, vomiting, diarrhea, diabetes or burns. Dehydration can be caused by losing too much fluid or not drinking enough fluids. Patients/residents at greatest risk for dehydration include: • Older adults who may eat less or forget to eat or drink • Patients/residents with diabetes • Patients/residents with high fevers • Patients/residents with an increased use of certain substances/medications (alcohol, diuretics,

steroids) Signs and Symptoms of Dehydration Review the signs and symptoms of dehydration listed on this page.

The following are signs and symptoms of dehydration: • Increased thirst • Dry mouth and swollen tongue • Dry cracked tongue • Lack of tears and inability to sweat • Weakness or fatigue • Lightheadedness and/or dizziness • Diminished coordination • Sunken eyes • Decreased urination (urine may appear dark yellow or amber) • Decreased level of consciousness • Muscle cramps • Nausea and vomiting • Heart palpitations

Complications of dehydration include:

If left untreated, dehydration can lead to: • Swelling of the brain • Seizures • Shock due to low blood volume • Kidney failure • Coma and death


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Treatment for Dehydration

If the patient/resident is dehydrated, apply the following treatments: • Weigh daily • Measure fluid intake and output • Increase fluids (frequent, small amounts of oral fluids versus large amounts of fluid at one time)

Prevention To prevent dehydration have patient/resident: • Drink plenty of fluids • Eat foods high in water such as fruits and vegetables • Avoid scheduling activities during the heat of the day

Preventing dehydration is one step to avoidheat cramps,heat rash,heat exhaustionandheat stroke.


TME2017_REG

Lesson: Regulatory Standards

Introduction

Lesson Objectives

The safety of the health care services we provide is enhanced by following the laws, rules and guidelines set up by regulatory agency’s that service BayCare.

The agencies include: • Agency for Health Care Administration (AHCA) • Occupational Safety and Health Administration (OSHA) • Centers for Disease Prevention and Control (CDC) • Health Departments

After you complete this lesson, you should be able to: • Identify the role of the regulatory agencies

Regulatory Agencies

Agency for Health Care Administration (AHCA)

AHCA regularly performs inspections of our facilities to ensure accessible, quality health care for patients/residents and is responsible for: • Facility licensure • Inspection • Regulatory enforcement and • Investigation of consumer complaints

Ombudsman Program

Florida’s Long-Term Care Ombudsman Program is a volunteer-based organization seeking to improve the quality of life of frail and vulnerable elderly who are 60 years of age or older and reside in nursing home and Assisted Living facilities.

The program: • Offers direct assistance to patients/residents who need help to resolve concerns • Assesses each long-term care facility in Florida annually to ensure the health, safety and welfare of

the patient/residents

Patients/residents have a right to file a complaint with the Agency for Health Care Administration or the Ombudsman Council.


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Occupational Safety and Health Administration (OSHA)

OSHA's role is to assure safe and healthful working conditions.

OSHA monitors: • Hazard communication standards (handling of hazardous waste, MSDS) • Indoor air quality standards • Ergonomics standards

OSHA regularly performs inspections of facilities to ensure a safe and secure environment for team members and patients/residents. Areas that OSHA monitors include: hazard communication standards, indoor air quality standards and ergonomics standards.

County Health Department

Florida County Health Departments protect all Floridians through the detection, control, and eradication of diseases which can be transmitted to people.

Health Departments monitor and regulate: • Food inspection • Waste disposal • Other inspections

Health departments monitor and regulate food inspection, waste disposal and other inspections.

Centers for Disease Control and Prevention (CDC)

The primary role of the CDC is to ensure quality health care by monitoring and preventing disease outbreaks. The CDC focuses on protecting health through the following programs: • Environmental health • Health information services • Emergency response • Terrorism preparedness • Injury prevention • Infectious diseases

Elder Affairs Regulation

Reporting Suspected Crimes under the Elder Justice Act

Staff (Covered Individuals) Reporting Requirement: • Staff must report if they suspect or have suspicion of a crime against a resident

All Covered Individuals are defined as owner, operator, employee, manager, agent or contractor and have the following rights and responsibilities under the Elder Justice Act (EJA).


TME2017_REG

The report must go to the state survey agency (SSA) and at least one local law enforcement entity within the designated time frame by email, fax, or telephone.

The report must include information from each team member about the suspected crime. • The obligation to report will be met if the report is filed by a single team member or filed by multiple

team members jointly

This is a new policy on complying with the Elder Justice Act (EJA) on reporting a reasonable suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act (ACA).

An original report may be supplemented by additional staff who become aware of the same incident.

Supplemental information must include: • Name of the additional staff • Date and time of awareness of such incident or suspicion of a crime

Staff member must report: • Suspicion immediately if event results in serious bodily injury, but not later than 2 hours after forming

the suspicion • Suspicion not later than 24 hours after forming the suspicion if the reportable event does not result in

serious bodily injury • Suspicion of an incident to the Administrator, Director Patient Services, and/or the Abuse

Coordinator/Risk Manager

Failure to report any suspected crime in the required time frames may result in disciplinary action, including up to termination.

Reporting Suspected Crimes

Staff Rights: • Staff may file a complaint with the state survey agency against a long-term care facility that retaliates

against an employee for filing

• Any complaint can be called to (888) 419-3456


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