Student and Contract Personnel Orientation

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Falling Leaves Program

Students and contract staff will receive training at unit level on the Falling Leaves program including, but not limited to, lifting, transferring and moving patients.


ALL patients are assessed on admission and each shift and upon change in condition for risk for falls.




Be aware that they are at high risk for falls.

If the patient becomes unsteady, wobbly, etc.

Stay with patient and call for help, DO NOT leave the patient!!!

Should a fall, or any other adverse event occur, a process is in place for electronic documentation of the event with follow up by the appropriate manager or director This might include, but is not limited to pharmaceutical errors or belongings that are unaccounted for.

Medical Equipment Management Program
The Medical Equipment Management Plan provides and maintains a medical equipment management program that promotes safe and effective use of medical equipment through the continuous evaluation, improvement and maintenance of medical equipment.

Equipment used for Therapeutic or Diagnostic means it is considered “Medical Equipment.”

*The Safe Medical Devices Law requires mandatory reporting of equipment malfunction, which result in serious injury. All equipment errors must be reported through the hospital variance occurrence reporting system. The Biomedical Department should be notified immediately in all cases of defective equipment such as clinical alarms…Systems: ventilator, apnea monitor, cardiac monitor, and elopement alarms. Students or contract personnel should notify any staff member to report equipment malfunction. Should there be a suspected malfunction, leave equipment assembled (e.g. IV pump with lines, bags, etc.); secure in Pharmacy after hours if drugs are involved.

MRI (Magnetic Resonance Imaging) Safety

The MR System has a VERY STRONG magnet field that is Always On. The magnet force cannot be seen, heard, touched, felt or smelled.

Any item that could contain iron is NOT safe to take into the MR suite.

Any equipment or tools should be tested with a hand held magnet before taken into the MR suite.

When a metal item is pulled with great force towards the magnet, this is

called the “missile effect”.

It is NOT safe for a person with certain types of metallic, electronic, magnetic, or

mechanical implants, devices, or objects to enter the MR suite. Qualified MR

personnel MUST screen ALL individuals BEFORE entering the MR suite.

The MRI unit CANNOT be quenched, or shut off easily without any major

problems at any time.

NEVER respond to a code IN the MR suite. If code occurs, you should:

  • Call out for help

  • The patient will be moved out into the holding area

  • Begin CPR

  • Not allow anyone into the MR suite

Life Safety
R.A.C.E. for Fire Safety

R- Rescue anyone in immediate danger

A- Alarm: activate the fire alarm

C- Contain the fire

E- Extinguish the fire if safety can be assured

Call 3999 on any hospital telephone and announce “Code Red”.

Each department has its own fire safety program that supports the EMC Fire Safety response plan, and is specific to that department’s specific needs (extinguisher locations, evacuation routes, etc.).

Take appropriate action:

All fire exits, fire egress routes, fire doors and walkways must be clear of equipment and obstructions at all times. Close all doors.

How to use a fire extinguisher:

P-Pull the pin located on the handle

A-Aim the hose or nozzle at the base of the fire

S-Squeeze the handle

S-Sweep the hose from side to side to put the fire out

Emergency Management Program
Emergency Paging Codes/Paging Codes:

All EMC codes are communicated by calling the PBS (Extension 3999) Operator and giving code specific information.

At the Heritage Center, self-page emergency codes by dialing 700 and slowly announcing the code and location three times.

In the case of Code Blue at EMC, activate the notification system using wall-mounted buttons located throughout patient care areas.

In the case of Code Red, wall mounted pull stations are also located throughout the Hospital and Heritage Center.
Code Blue: Someone is not breathing and /or has no pulse.

Code Red: Is the presence of a fire and or smoke. Each department/area has specific responsibilities with respect to their unit to respond and act in this emergency. Each department will act, rescuing endangered patients, and at the same time activate the fire alarms, alert other departments, and report the location of the incident. Always use RACE and PASS.

Code Pink: At EMC: an infant or child is missing. Please reference the Infant Security policy which provides complete information about this. Specifically, strategies are in place to identify newborns correctly along with the application of an infant security sensor. Parents will be educated on security awareness including staff identification as well as completing an approved visitor list and acknowledgement of a hospital issued infant safety checklist which will become part of the medical record. Additionally, you will receive any additional training during the first shift worked in a patient care area.

Code Triage Standby: The possibility of incoming wounded exists – a disaster in the community may have occurred.

Code Triage: This page will activate the global disaster plan, and each unit will adhere to unit specific plans.

CVA Alert: A patient is experiencing the symptoms of a stroke.

Manpower Alert: Students and contract personnel are to avoid the area announced due to a potential for violence at EMC.

CPI Alert: Eastside Heritage Center Crisis Prevention Intervention trained staff to respond – students and contract personnel are to avoid the area announced due to a potential for violence.

STEMI Alert: A patient or visitor is experiencing signs and symptoms of a heart attack. They should be taken to the emergency department immediately.

Rapid Response: A patient in distress is in need of immediate care to prevent further deterioration of their condition.

The hospital will use “Plain Speech” for all other paged incidents.
Hazardous Materials
Material Data Safety Sheets (MSDS) are available in this workplace. They contain the following information:

Substance name

Hazardous ingredients

Precautions and safety equipment

First-aid procedures

Spill and disposal procedures

To obtain MSDS: Call 800-451-8346 or go online at user name HCDB

In the event of a hazardous material (Hazmat) emergency, notify any member of the

staff or call the Nursing Supervisor by contacting the hospital operator by dialing “0”.

Hazardous waste at EMC:

Chemical; Biohazardous; Chemotherapy; Radiation

How you can be harmed:

Absorbed thru skin; swallowed; splash to eyes; breathing harmful vapors.

How you can protect yourself:

Eliminate the hazard; Control Exposure; Wear personal protective equipment (PPE).

Anti-Dumping Law (COBRA)

The terms “EMTALA” or “COBRA” associated with the Anti-Dumping Law is a federal regulation providing persons equal access to health care regardless of ability to pay.

All persons presenting anywhere on hospital property seeking care must be seen and evaluated by the hospital to determine “if an emergency medical condition exists”. If the patient does have an emergency medical condition, then we must treat the patient or transfer the patient in an “appropriate” way (as defined by the regulation).

Who is responsible for making sure patients are not turned away?

Everyone associated with EMC including you. You may be approached on the hospital grounds regarding whether we see patients who are unable to pay or do not have insurance. That is never a factor in our doing an initial evaluation on a patient. You can refer the person inquiring to a member of the clinical staff or call the Nursing Supervisor by dialing “0”.
Infection Control
Eastside Medical Center invites you to become a partner in our Hand Hygiene Program. Hand hygiene is the simplest, single most effective method for preventing infection and the spread of infection in a hospital.

Reduce the risk of health care-associated infections:

Follow the hand hygiene guidelines published by the US Centers for Disease Control (CDC). This includes thorough cleansing of hands:

  • Whenever hands are visibly soiled

  • Before and after direct patient contact

  • Between procedures and after removing gloves

  • After contact with body fluids, excretions, or mucous membranes (note: follow guidelines for Standard Precautions by always wearing gloves when this type of contact is anticipated)

  • Before eating

  • After using the bathroom

When using soap and water to clean hands, the hands should first be wet, and then apply a generous amount of soap to the hands. Rub vigorously for at least 15 seconds on all skin surfaces and rinse well. Dry thoroughly with a disposable towel, and then turn faucets off with the towel before discarding it. An alcohol-based hand rub may be used instead of washing if hands are not visibly soiled and are not contaminated with blood or body fluids.
Personal Hygiene – Protect yourself:

  • Do not eat, drink, apply cosmetics or lip balms or handle contact lenses where you may be exposed to blood or infectious materials.

  • Minimize splashing, spraying or spattering if possible.

  • In addition to gloves, you may need other types of personal protective equipment (PPE) to protect against infection.

  • Your eyes, nose and mouth need protection during tasks that could splash or spray blood or body fluids. Protect yourself: Wear masks, goggles or a face shield.

  • Wear a clean, non-sterile gown to protect other parts of your body from infectious materials. If necessary, wear a gown made of material that liquid can’t soak through.

  • PPE is available to you on every unit. Proper use of PPE is your responsibility.

  • Remember that when you remove PPE, it can become a source of infection. Be sure to discard it in an appropriate container to prevent contamination of anyone or anything else. Then, wash your hands to prevent the spread of infections!

Housekeeping – Good housekeeping is the next step to effective protection. Everyone is responsible for maintaining a clean work area. If you discard contaminated material improperly, you may injure yourself or a co-worker. Make sure you discard contaminated materials properly.

Biohazard Labels

Biohazard labels are the most obvious warning of possible exposure to bloodborne pathogens. These items are labeled with the appropriate Biohazard logo that is color-coded in red/orange background with a black symbol and lettering. Red Biohazard plastic bags are used throughout the hospital as a signal for regulated waste materials present.

  • Containers of regulated waste

  • Refrigerators/freezers containing blood or other potentially infectious materials

  • Sharps disposal containers

  • Other containers used to store, transport or ship blood and other infectious materials.

Reducing Risk of Exposure to Bloodborne Pathogens

Every day you are at some risk for exposure to bloodborne pathogens. These pathogens include Hepatitis B (HBV), Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV). Possible exposure to these pathogens is a dangerous reality for everyone. Good work habits are no longer an option. They now mean the difference between life and death.

  • What is HBV? Inflammation of the liver.

Hepatitis B is a disease carried in the blood and is a serious threat to healthcare workers. Caregivers are at higher risk than that of most people because of greater exposure to potentially contaminated blood and other body fluids. Practice infection control guidelines and get vaccinated - you can protect yourself and others from contracting and spreading this dangerous disease. HBV is much easier to transmit than HIV and can remain viable up to seven days on contaminated surfaces.

  • What is HIV?

Human Immunodeficiency Virus is the virus that causes the disease AIDS. AIDS stands for Acquired Immune Deficiency Syndrome. HIV damages the immune system and makes a person with AIDS more likely to get serious infections and diseases. To become infected with HIV, the virus must get into your body and enter your bloodstream.

Persons who are HIV infected (with or without symptoms, diagnosed with AIDS, or recently exposed with a negative HIV antibody test) can spread HIV to others. A person is not diagnosed with AIDS until certain criteria are met, which may include certain lab work or the development of one of the rare infections or cancers (opportunistic diseases), which are uncommon in persons with a healthy immune system.

HIV Symptoms

  • Low grade fever

  • Fine rash

  • Enlarged Lymph Nodes

  • Or No Symptoms at all

  • Conversion can occur up to 6 months after exposure

Hepatitis B Symptoms

  • Abdominal Pain/Nausea/Vomiting

  • Low grade fever

  • Malaise

  • Jaundice

  • 50% of patients have No symptoms

  • 6 month incubation

Hepatitis C Symptoms

  • Jaundice

  • Fatigue

  • Dark Urine

  • Abdominal Pain

  • Loss of appetite

  • Nausea

Think TB

What is TB?

Tuberculosis (TB) is a disease that is spread from person to person through the air. TB usually affects the lungs, although other parts of the body can be affected, including the brain, spine, and kidneys. TB germs are spread when an infected person coughs, sneezes, laughs, talks, or sings. The germs are so small regular air currents within a building can keep them airborne for hours. You many become infected with TB if you inhale these small germs. One of the easiest ways to prevent the spread is for all patients and staff to cover all coughs and sneezes with a tissue.
TB Infection vs. Active TB:

There is a difference between TB infection and active TB. If you are infected, you will have reactive (positive) skin test and…

  • Will NOT be contagious

  • Will have no symptoms

  • MUST be alert to the signs and symptoms of active TB.

A person with active TB

  • Is contagious

  • May have signs and symptoms of the active disease

  • Will need to take medication to prevent serious illness or death from the disease.

High Risk Groups:

  • Anyone who is HIV positive

  • Other immunosuppressed patients such as chemotherapy patients and patients with diabetes, silicosis and malnutrition

  • Foreign-borne individuals from regions where TB is widespread

  • Economically and socially depressed people like the homeless, alcoholics, drugs users, and current or past prisoners.

Symptoms of TB:

  • Fatigue

  • Fever

  • Weight loss

  • Night sweats

  • Prolonged cough (with or without bloody sputum)

Patients in Isolation
Check with nursing personnel before entering an isolation room. Isolation is designated by signage and an isolation equipment bag on the door.

Types of Isolation: Contact; Droplet; Airborne; Enhanced Droplet/Contact Precautions.

Personal Protective Equipment (PPE)

  • Gowns, gloves and masks are donned prior to entrance

  • Gowns, gloves & masks remain in patient’s room

  • Never wear PPE outside patient’s room (except for TB masks)

  • Dispose of PPE in regular trash

Red Bag Trash is for items contaminated with blood.

Abuse and Neglect
Abuse is non-accidental injury (physical, sexual, emotional or financial) by a person in authority.

Neglect involves inattention to basic needs such as food, clothing, shelter, medical attention, and supervision.

Reporting Abuse or Neglect

Healthcare providers who suspect a non-accidental injury (e.g. assault, suicide attempt, etc.) are responsible for notifying the police. To report abuse or neglect at Eastside speaks with any nurse caring for the patient or to the Nursing Supervisor by dialing “0” on any hospital phone. Case Management/Social Services will involve the police and other reporting processes and in accessing community and other support and protective agencies.

Any person participating in the making of a report of suspected child or disabled adult abuse is immune from civil or criminal liability, providing the report is made in good faith. The identity of the reporter is not required when making a report.

Family violence can happen to anyone regardless of age, race, religion, sex or socioeconomic status.

A disabled adult refers to a person 18 years of age or older who is mentally or physically incapacitated.

Child Abuse or Neglect

Physical Indicators: Unexplained or poorly explained bruises; Welts; Burns; Fractures; Lacerations; Abrasions; Abdominal injuries; Human bite marks; Child is wary of physical contact with an adult or demonstrates extreme behavior.

Sexual Indicators: Includes any contacts or interaction between a child and an adult in which the child is being used for the sexual stimulation of the perpetrator or another person. Vaginal bleeding; Rectal bleeding; Sexually transmitted diseases; Torn or bloody underwear.
Age Appropriate and Culturally Sensitive Care

All students and contract personnel are expected to provide age appropriate care to patients. Consider the following issues when planning and providing care: Physiology; Growth & Development; Medication Administration; Nutrition; Medical Equipment; Invasive Procedures; Restraints; Special Treatment and Procedures; Patient and Family Education.
The following statements reflect a desire to provide sensitive cultural and spiritual care:

  • Increased awareness of the cultural and spiritual groups in the communities we serve. Never assume English proficiency. Utilize the AT&T Language Line to limit patient distress and increase satisfaction. Access information on line on Eastside’s Intranet or contact the Chaplain for assistance in identifying and meeting spiritual and cultural care needs.

  • Ask about privacy needs such as being touched or being unclothed. Age, gender, sexual orientation, socio-economic status or the presence of a physical or mental disability may affect patient care.

  • A patient’s religion may affect his or her consent to treat, schedule of care or room arrangement (because of prayer practices for example) and birth and death practices.

  • If you don’t know - ask the patient if he/she has concerns – demonstrate sincere consideration and respect to open the lines of communication.

Carefully read, complete and sign the following documents in this packet and turn them in as directed. (Page 19 – 23)

Facility Orientation Sheet

Protected Health Information, Confidentiality and Security Agreement

Confidentiality and Security Agreement

Thank you

By signing below, I attest that I have reviewed and understand the information presented within the Facility Orientation for Contract and Student Personnel.
Mission and Values

General Hospital Information

Patients Rights and Responsibilities

National Patient Safety Goals


Magnetic Resonance Imaging Safety

Falling Leaves Program

Medical Equipment Management Program

Magnetic Resonance Imaging Safety

Life Safety

Emergency Management Program

Hazardous Materials


Infection Control

Biohazard Labels

Blood borne Pathogens

Think TB

Patients in Isolation

Abuse & Neglect

Age Appropriate & Culturally Sensitive Care

Company/School Name: ____________________________________________
Employee Name: __________________________________________________ (PLEASE PRINT)

Date: __________________________________________________
Department: ___________________________________________________

Student/Contract Personnel Signature: _________________________________

HR/Education Representative Signature: _____________________________



  • Protected health information (PHI) includes patient information based on examination, test results, diagnoses, response to treatment, observation, or conversation with the patient. This information is protected and the patient has a right to the confidentiality of his or her patient care information whether this information is in written, electronic, or verbal format. PHI is individually-identifiable information that includes, but is not limited to, patient’s name, account number, birthdate, admission and discharge dates, photographs, and health plan beneficiary number.

  • Medical records, case histories, medical reports, images, raw test results, and medical dictations from healthcare facilities are used for student learning activities. Although patient identification is removed, all healthcare information must be protected and treated as confidential.


Initial each individual policy upon review.

______ 1. It is the policy of the school and facility to keep protected health information confidential and secure.

______ 2. Any or all protected health information, regardless of medium (paper, verbal, electronic, image or any other), is not to be disclosed or discussed with anyone outside those supervising, sponsoring or directly related to the learning activity.

­­­­______ 3. Whether at the hospital or off site, students and contract personnel are not to discuss protected health information, in general or in detail, in public areas under any circumstances. This would include places such as hallways, cafeterias, elevators, or any other area where unauthorized people or those who do not have a need-to-know may overhear.

______ 4. Unauthorized removal of any part of original medical records is prohibited. Students and contract personnel and supervisors may not release or display copies of protected health information. Case presentation material will be used in accordance with healthcare facility policies.

______ 5. Students and contract personnel and supervisors shall not access data on patients for whom they have no responsibilities or a “need-to-know” the content of protected health information concerning those patients.

_____ 6. A computer ID and password may be assigned to individual students and contract personnel and supervisors. Contract personnel and supervisors are responsible and accountable for all work done under the associated access.

______ 7. Computer IDs or passwords may not be disclosed to anyone. Students and contract personnel and supervisors are prohibited from attempting to learn or use another person’s computer ID or password.

______ 8. Students and contract personnel agree to follow the healthcare facility’s privacy policies.

______ 9. Breach of patient confidentiality by disregarding the policies governing protected health information is grounds for dismissal.





_________________________________________________ ______________

Student and/or Contract Employee Signature Date

Confidentiality and Security Agreement
I understand that the facility or business entity (the “Company”) for which I work, volunteer or provide services manages health information as part of its mission to treat patients. Further, I understand that the Company has a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality of their patients’ health information. Additionally, the Company must assure the confidentiality of its human resources, payroll, fiscal, research, internal reporting, strategic planning information, or any information that contains Social Security numbers, health insurance claim numbers, passwords, PINs, encryption keys, credit card or other financial account numbers (collectively, with patient identifiable health information, “Confidential Information”).

In the course of my employment/assignment at the Company, I understand that I may come into the possession of this type of Confidential Information. I will access and use this information only when it is necessary to perform my job related duties in accordance with the Company’s Privacy and Security Policies, which are available on the Company intranet (on the Security Page) and the Internet (under Ethics & Compliance). I further understand that I must sign and comply with this Agreement in order to obtain authorization for access to Confidential Information or Company systems.

General Rules

  1. I will act in the best interest of the Company and in accordance with its Code of Conduct at all times during my relationship with the Company.

  2. I understand that I should have no expectation of privacy when using Company information systems. The Company may log, access, review, and otherwise utilize information stored on or passing through its systems, including email, in order to manage systems and enforce security.

  3. I understand that violation of this Agreement may result in disciplinary action, up to and including termination of employment, suspension, and loss of privileges, and/or termination of authorization to work within the Company, in accordance with the Company’s policies.

Protecting Confidential Information

  1. I will not disclose or discuss any Confidential Information with others, including friends or family, who do not have a need to know it. I will not take media or documents containing Confidential Information home with me unless specifically authorized to do so as part of my job.

  2. I will not publish or disclose any Confidential Information to others using personal email, or to any Internet sites, or through Internet blogs or sites such as Facebook or Twitter. I will only use such communication methods when explicitly authorized to do so in support of Company business and within the permitted uses of Confidential Information as governed by regulations such as HIPAA.

  3. I will not in any way divulge copy, release, sell, and loan, alter, or destroy any Confidential Information except as properly authorized. I will only reuse or destroy media in accordance with Company Information Security Standards and Company record retention policy.

  4. In the course of treating patients, I may need to orally communicate health information to or about patients. While I understand that my first priority is treating patients, I will take reasonable safeguards to protect conversations from unauthorized listeners. Such safeguards include, but are not limited to: lowering my voice or using private rooms or areas where available.

  5. I will not make any unauthorized transmissions, inquiries, modifications, or purgings of Confidential Information.

  6. I will not transmit Confidential Information outside the Company network unless I am specifically authorized to do so as part of my job responsibilities. If I do transmit Confidential Information outside of the Company using email or other electronic communication methods, I will ensure that the Information is encrypted according to Company Information Security Standards.

Following Appropriate Access

  1. I will only access or use systems or devices I am officially authorized to access, and will not demonstrate the operation or function of systems or devices to unauthorized individuals.

  2. I will only access software systems to review patient records or Company information when I have a business need to know, as well as any necessary consent. By accessing a patient’s record or Company information, I am affirmatively representing to the Company at the time of each access that I have the requisite business need to know and appropriate consent, and the Company may rely on that representation in granting such access to me.

Using Portable Devices and Removable Media

  1. I will not copy or store Confidential Information on removable media or portable devices such as laptops, personal digital assistants (PDAs), cell phones, CDs, thumb drives, external hard drives, etc., unless specifically required to do so by my job. If I do copy or store Confidential Information on removable media, I will encrypt the information while it is on the media according to Company Information Security Standards

  2. I understand that any mobile device (Smart phone, PDA, etc.) that synchronizes company data (e.g., Company email) may contain Confidential Information and as a result, must be protected.  Because of this, I understand and agree that the Company has the right to:

    1. Require the use of only encryption capable devices.

    2. Prohibit data synchronization to devices that are not encryption capable or do not support the required security controls.

    3. Implement encryption and apply other necessary security controls (such as an access PIN and automatic locking) on any mobile device that synchronizes company data regardless of it being a Company or personally owned device. 

    4. Remotely "wipe" any synchronized device that:  has been lost, stolen or belongs to a terminated employee or affiliated partner.

    5. Restrict access to any mobile application that poses a security risk to the Company network.

Doing My Part – Personal Security

  1. I understand that I will be assigned a unique identifier (e.g., 3-4 User ID) to track my access and use of Confidential Information and that the identifier is associated with my personal data provided as part of the initial and/or periodic credentialing and/or employment verification processes.

  2. I will:

    1. Use only my officially assigned User-ID and password (and/or token (e.g., SecurID card)).

    2. Use only approved licensed software.

    3. Use a device with virus protection software.

  3. I will never:

    1. Disclose passwords, PINs, or access codes.

    2. Use tools or techniques to break/exploit security measures.

    3. Connect unauthorized systems or devices to the Company network.

  4. I will practice good workstation security measures such as locking up diskettes when not in use, using screen savers with activated passwords, positioning screens away from public view.

  5. I will immediately notify my manager, Facility Information Security Official (FISO), Director of Information Security Operations (DISO), or Facility or Corporate Client Support Services (CSS) help desk if:

    1. my password has been seen, disclosed, or otherwise compromised;

    2. media with Confidential Information stored on it has been lost or stolen;

    3. I suspect a virus infection on any system;

    4. I am aware of any activity that violates this agreement, privacy and security policies; or

    5. I am aware of any other incident that could possibly have any adverse impact on Confidential Information or Company systems.

Upon Termination

  1. I agree that my obligations under this Agreement will continue after termination of my employment, expiration of my contract, or my relationship ceases with the Company.

  2. Upon termination, I will immediately return any documents or media containing Confidential Information to the Company.

  3. I understand that I have no right to any ownership interest in any Confidential Information accessed or created by me during and in the scope of my relationship with the Company.

By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditions stated above.

Employee/Consultant/Vendor Signature

Facility Name and COID


Employee/Consultant/Vendor Printed Name

Business Entity Name

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