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Emergency Preparedness Introduction Page # Introduction & Training 4 Emergency Code Names 5 Drills and Simulations 6 Chain of Command Protocols 6-7 Emergency Phone Numbers Staff 8 Contractor Emergency List 9 Emergency Contact Numbers 10 Emergency Preparedness Disaster Planning Order of Authority 11 Disaster Assignments 11-15 Disaster Planning: Evacuation and Shelter in Place 15-42 Division of Health Services Emergency Alert Hotline 43-44 Contingency Staffing Protocols 45-52 Fire Safety Fire Safety Procedure 53 Fire Safety Instructions St. Peters Nursing/RAL 53-54 Fire Safety Instructions: Garden Cottage 54-55 Fire Safety Instructions: IL Apartments 55-57 Charge Nurse Responsibilities 57-58 Methods of Fire Alarm Activation 58 Fire Extinguishers 59 Tobacco Free Environment 59-60 Ventilation Equipment Controls 60 Fire Drills 61 Fire Watch 61-62 Hot Work Procedure 62-63 Severe Weather Procedures Severe Weather Watches 63 Severe Thunderstorm Watches 63 Severe Thunderstorm Warnings 64 Tornado Watch 65-66 Tornado Warning 66 Apartment Tornado Warnings/Watches 66 Utility Emergencies Natural Gas 67 Electrical 67-70 Water Emergency 70-73 Water Supply Interruption 73-75 Refrigeration Systems Failure 76 Heat Systems Failure 76 Sewage Backups 76-77
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Resident Elopement Missing Resident Skilled Nursing 78-79 Missing Resident Assisted Living 79-80 Missing Resident Garden Cottage 80-81 Resident fails to return from Leave of Absence 82 Code Alert 82 Environmental Release 83 Environmental Release Checklist 84 Bomb Threats 85-86 Bomb threat Check list insert after Work Place Violence 87-89 Hostage Situation 89 Active Shooter 90-94 Hazard Communication Program Hazard Communication Program Policy 94 Safety Data Sheets (SDS) 94 Safety Data Sheet (SDS) Book Location 94-97 Personal Protective Equipment 97 Chemicals and Hazardous Material Location 97-99 Bio-Hazard Waste Disposal Locations 99 Resident Death Skilled Nursing 100 Assisted Living 100 Garden Cottage 101 Independent Living 102 Press Policy 103 Bed Bug Protocol 104
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Introduction
An effective Emergency Preparedness Program requires a deliberate effort by the
community staff to familiarize themselves with these procedures. Recognition of individual responsibilities is a necessity.
This Emergency Preparedness Manual is to assist you in coping with these problems should they arise, Emergency Preparedness is essential for the maximum protection of all people who you are responsible.
Emergency Preparedness Manuals are kept throughout the community and contain all of the forms required for emergency procedures. When a manual and its forms are used, return it to the Safety Officer who will issue a replacement manual.
Emergency Preparedness Training
Each employee will be oriented to the Emergency Preparedness Manual during general orientation. Further, semi-annual education will be conducted for all staff by the Director of Environmental Services. Procedure: 1.) Each employee is responsible for reading the community’s Emergency Preparedness Manual. All supervisors will ensure their department's copy of the manual is available to the staff and they understand their role and responsibilities. 2.) All new employees will be instructed in the use of fire extinguishers and fire fighting techniques by the Safety Officer. 3.) During the monthly and quarterly drills the emphasis will be on new employees. This will be accomplished by senior employees assisting the new employee. Conclusion: Employee suggestions for improvements to the facility’s Emergency Preparedness Manual is welcome. Upon review of suggestions, changes will be made during the annual update of the manual.
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EMERGENCY CODE NAMES
Throughout the Emergency Preparedness Manual, one will see code names for different emergencies. Below is a current listing that contains the incident type and THE EMERGENCY CODE NAME used to alert the staff to the situation?
INCIDENT TYPE CODE NAME FIRE CODE RED
SEVERE WEATHER/DISASTER CODE GREEN
TORNADO WARNING CODE GREEN
BOMB THREAT CODE YELLOW ELOPEMENT CODE PINK ACTIVE SHOOTER ACTIVE SHOOTER
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Emergency Contact List
Name Title Work Ext. Cell PhoneDirector of Human Resources 494 910-624-7292Executive Assistant 353 850-218-9159Director of Hospitality 290 910-315-6585Director of IT 342 910-315-6611Human Resources Admin. 431 919-356-3567Assistant Director of Nursing 496 910-258-1834Director of Life Enrichment 344 704-891-4986 Director of Marketing 386 910-964-7010Controller 432 910-695-8447Executive Chef 456 910-235-1966Admissions Director 368 910-783-5749Home Care Supervisor 493 910-528-6906Chief Operating Officer 373 910-585-1474Chief Executive Officer 354 910-690-5959Chief Financial Officer 433 816-550-3971Registered Dietician 311 360-580-5423Director of Resident Services 352 910-461-7617Executive Housekeeper 362 910-245-2604Director of Environmental 363 910-690-1177Director of Independent 361 910-603-8795Chaplain 355 617-922-9664Director of Nursing 350 910-603-5751Facilities Supervisor 364 910-315-6139Chaplain 355 617-922-9664 Healthcare Administrator 306 910-315-9244
Weekend 910-783-6833Central Security 910-692-2871 (910) 690-7698Garden Cottage 435 RAL 357 910-783-6597RAL Nurse 910-783-8679Rapid Response 1-877-350-5292Security Guard 121 910-215-2821Station 1 369 910-783-6598Station 2 444 910-783-6599
To check voicemail hold down the #1 key and it will take you straight to the voicemail.Housekeeping Week-End - Use the two-way radio on Channel OneSecurity Guard Cell # 215-2821 Voicemail ext 121 Security - 24 Hours
ADMINISTRATIVE DUTY WEEK-END CELL 910-783-6833
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Emergency Contractor Listing HEATING AND COOLING
Field’s 949-3232 4 Seasons 235-0606
ALTERNATE: South Boilers Brady Trane 800-524-4822
PLUMBING Field’s 949-3232
ALTERNATE: Ben Franklin 778-5530
ELECTRICAL Power Outage Duke 800-452-2777
Other Issues Alan Thompson 695-5439
FIRE ALARM / SPRINKLER
Fire Alarm Central Security 692-2871
Sprinkler – Yadkin 1-336-472-1630 1-336-250-8131
ELEVATOR North – Southern Elev. Village House – Kone Woodlands – Kone Parkview - Otis
800-926-6204 877-276-891 877-276-891 800-353-7770
SEWER Total Enviro & septic 919-708-5056 KITCHEN CONTRACTORS: DISHWASHER, STEAMER, OVENS, ETC
Hobart Pinnacle Development Hobart Whaley’s Authorized Comm.
424-2210 639-0912 424-2210 704-529-6242 919-212-8724
REFRIGERATION: GENERATORS: GAS LEAK:
Sure Temp Mechanical National Power Piedmont Gas
919-775-2115 888-646-8596 800-752-7504
ALARM MONITORING: 1-877-350-5292
ACCOUNT NUMBERS: 1. Code or I.D. number for the South Building – 040B051 2. Code or I.D. number for the North Building – 040B052 3. Code or I.D. number for the Garden Cottage – 040B144
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4. Code or I.D. number for the Maintenance Trailer – 040B053 5. Code or I.D. number for the Village House – 040B054 6. Code or I.D. number for the Woodlands Apartments – 040B050 7. Code or I.D. number for the Fire Booster Pump - 0403008 8. Code or I.D. number for the Parkview Apartments - 0403082
Fire Alarm System Monitoring All points of the fire alarm system activation below are monitored by NETWORK FIRE AND SECURITY. When the fire alarms sounds, a monitoring company (Rapid Response) will automatically call the fire department for immediate dispatch. In order to prevent the dispatch of the fire department, in case of a known false alarm example: “confused resident seen pulling alarm”. CHARGE STAFF MUST NOTIFY THE MONITORING COMPANY AND INFORM THEM OF THE FALSE ALARM: 1-877-350-5292.
1. Code or I.D. number for the South Building – 040B051 2. Code or I.D. number for the North Building – 040B052 3. Code or I.D. number for the Garden Cottage – 040B144 4. Code or I.D. number for the Maintenance Trailer – 040B053 5. Code or I.D. number for the Village House – 317.1887 6. Code or I.D. number for the Woodlands Apartments – 040B050 7. Code or I.D. number for the Fire Booster Pump - 0403008 8. Code or I.D. number for the Parkview Apartments - 0403082
1. Fire Department 911 2. County Sheriff 911
3. Ambulance 911 4. American Red Cross 1-800-552-5466 5. US Food Service 1-248-656-6000 6. Medical Director: Office: 910-295-1438 Cell: 910-690-2009 7. Duke Energy: 1-800- 452-2777 8. Domestic Water Pump – Engineered Fluid Inc. 618-533-1351 - Dan
9. Secure Care Doors - Signal Technologies 803-732-3030
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10. Call Bell System, Pagers - Status Solutions 866-846-7272
Order of Authority in a Disaster Emergency
During any type of disaster emergency, decisions will be made by the following persons on duty in the community as listed below. If the first person is not available or is incapacitated, the next person assumes the responsibility for making the necessary decisions in the community and for contacting the administrative staff listed below.
On Duty Community Staff
The highest licensed staff person on duty or department head will assumes responsibility to initiate all emergency procedures in an emergency. Upon arrival of the Fire Chief, he assumes command. He should be given a master copy of community keys (from resident services lock box) and is responsible to make decisions regarding evacuation and relocation of residents. The Administrative staff will be notified whenever the community is operating under any policy in the Emergency Preparedness Manual in the order listed below.
Continuity of Administrative Staff 1.) CEO/COO 2.) Healthcare Administrator 3.) Director of Plant Operations 4.) Director of Independent Living 5.) Director of Nursing 6.) Departmental Managers
Disaster Assignments
Administration • To provide overall command and control during disaster operations
• Disaster control center located in the Village House Grand Hall Person in charge: Business hours: CEO/COO After hours: Senior Unit Manager / Department Head
• Personnel - community staff and volunteers • LOCATION OF COMMAND CENTER: VH Conference Room business hours
Skilled Nurses Station 2 after business hours Procedure
1.) The person in charge will direct all disaster operations within the community. 2.) Directs all call back personnel to cope with the disaster. 3.) Activates the disaster plan and command center. 4.) Direct announcements of the disaster. 5.) Establishes communications within the community and with emergency services.
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6.) Delegates responsibilities by function. 7.) Conduct briefings with community managers. 8.) Refer all media requests to the Chief Development Officer and/or Director of Marketing.
Business Office
• To initiate simplified but adequate record system for use during disaster operation.
• Person in Charge- Business hours CFO/Controller After hours Office personnel
Procedure
1.) Secure records of the community. 2.) Maintains records of residents released, evacuated, or deceased. 3.) Assists with the transfer within the community. 4.) Keeps an administrative person in charge advised in matters relating to the office.
Dietary Services
• To provide food service to residents and personnel during a disaster operation. • Person in charge
Business hours Dining Services Director/Executive Chef After hours First food service personnel to arrive
Procedure
1.) Inventories food stores in the community. 2.) See Emergency Menu 3.) Calls back additional personnel as needed. 4.) Plan diets for residents and personnel as needed. 5.) Plans modified diets. 6.) Plans for the preparation of meals and delivery to the residents and personnel. 7.) Provides paper stock for serving in the event of loss of water or sewage.
Housekeeping Services
• To provide housekeeping and laundry services for the residents • Person in charge
Business Hours Executive Housekeeper After hours First employee to arrive
Procedure 1.) Keeps the community clean. 2.) Provides adequate supply of linen to the units and treatment areas. 3.) Provides cleaning supplies as needed.
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4.) Calls back personnel as needed. 5.) Arranges with laundry for personal laundry. 6.) Assists with the transfer of residents within the community and evacuation.
Plant Operations
• To maintain essential functions of the community equipment and arrange for alternate sources of essential supplies and utilities.
• Person in charge Business hours Environmental Services Director After hours First maintenance personnel to arrive or one on duty
Procedure
1.) Ensures the operation of essential equipment and utilities. 2.) Maintains a resource list of backup capability. 3.) Keeps the administrative person advised of plant operations.
Nursing
• To provide adequate nursing personnel to the community to care for the residents during a disaster operation.
• Person in charge Business hours Director of Nursing, Nurse Manager (Clinical Manager) After hours Unit Managers
Procedure
1.) Calls back personnel as required. 2.) Take a bed count and determines staffing levels. 3.) Set up disaster response teams and designates response areas. 4.) Prepare residents for impending disaster. 5.) Plans evacuation of residents if necessary. 6.) Prepare residents for evacuation if necessary. 7.) Keeps a list of residents evacuated from the community and where they were evacuated. 8.) Provides nursing care and infection control for residents. 9.) Provides nursing support to triage areas.
10.) Provides first aid supplies for treatment area. 11.) Keeps administrative person in charge advised of nursing services.
Independent Living & Home Care
• To provide adequate personnel to the community to care for the residents during a disaster operation.
• Person in charge
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Business hours Director of Independent Living After hours Resident Services Director/ Supervisor Home Care
Procedure
1.) Calls back personnel as required. 2.) Determine accurate census and determines staffing levels. 3.) Set up disaster response teams and designates response areas. 4.) Prepare residents for impending disaster. 5.) Plans evacuation of residents if necessary. 6.) Prepare residents for evacuation if necessary. 7.) Keeps a list of residents evacuated from the community and where they were evacuated to. 8.) Provides support for residents. 9.) Keeps administrative person in charge advised of services.
Information Technology
• To provide adequate IT personnel to the community to care for the systems during a disaster operation.
• Person in charge Business hours Director of IT After hours IT team
Procedure
1.) Calls back personnel as required. 2.) Review operating systems and any needs. 3.) Set up disaster response teams and designates response areas. 4.) Prepare systems for impending disaster. 5.) Plans offsite IT needs if necessary. 6.) Prepare systems & equipment for evacuation if necessary. 7.) Keeps a list of IT needs for onsite or offsite disaster. 8.) Provides communication systems for organization. 9.) Keeps administrative person in charge advised of needs/services.
Pastoral Care
• To provide adequate spiritual care to the community to care for the colleagues & residents during a disaster operation.
• Person in charge Business hours Chaplain After hours Chaplin/COO
Procedure
1.) Responds to disaster. 2.) Reviews and assist with any needs.
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3.) Assist with disaster response teams and designates response areas. 4.) Prepare persons served for impending disaster. 5.) Plans offsite spiritual care needs if necessary. 6.) Prepare supplies for evacuation if necessary. 7.) Keeps a list of needs for onsite or offsite disaster. 8.) Provides continued support for organization. 9.) Keeps administrative person in charge advised of needs/services.
Human Resources
• To support employees and families during disaster operations as well as maintain critical
systems such as time and attendance tracking, payroll, and benefits. • Person in Charge-
Business hours Human Resources After hours HR Admin
Procedure
1.) Secure employee files and HR systems of the community. 2.) Maintains records of employees and contact information including emergency contact 3.) Assists with the transportation of employees. 4.) Keeps an administrative person in charge advised in matters relating to HR.
Marketing
• To support operations during disaster as well as assist with communication to all persons
served through hosted outlets like Facebook, website, Instagram etc. • Person in Charge-
Business hours Marketing Director After hours Marketing team
Procedure
1.) Assist with implementation of disaster plan. 2.) Maintains marketing records 3.) Assists with communication to persons served
4.) Keeps an administrative person in charge advised in matters relating to marketing
Disaster Planning
Emergency Preparedness Guidelines
Disaster Notification
1.) Resident Services, or the Skilled Unit Manager in most cases, will receive notification of impending disaster conditions from outside the community. During business hours this information should be forwarded to administration; after hours the skilled unit
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manager will follow emergency procedure guidelines.
a.) Upon receiving notification of impending disaster conditions, the administrative staff in charge will have Resident Services alert the staff in the community and direct each department head to report for a briefing.
b.) During the briefing each department head will advise the administrative person in charge of the number of staff on duty, availability of call back employees to assist the community.
c.) After the briefing, all department heads will return to their area and insure all staff has been briefed and have an opportunity to review their assignments.
Current copies of the Emergency Preparedness Plans are kept at each nursing station and department work area
2.) Each department is responsible for call back of employees upon the direction of the administrative person in charge. Call back will be accomplished by each department head.
Evacuation and Shelter in Place Protocols
has a comprehensive Emergency Preparedness Protocol to ensure that in the event of an emergency, the community will provide the utmost care and concern to the residents for which they are responsible. The outlined plan is designed to ensure appropriate safety, care and services in an emergency situation for the residents that our served within the community.
The CEO/COO, in conjunction with the Safety Officer and Administrator, is responsible for maintaining up to date and realistic community emergency preparedness plans.
Emergency Preparedness Plan:
Each department is equipped with a “Red Book” that outlines the community’s emergency preparedness protocols within the community. Each Red Book is equipped with basic community information related to the community's Life Safety Systems (utilities, water, refrigeration, and heat systems). Loss of services requires immediate notification of CEO/COO, Environmental Services Director, and Nursing Home Administrator.
Emergency Notifications:
participates in the Alert Notification to ensure appropriate notifications regarding pending emergencies. Further, the community is equipped with appropriate weather/emergency reporting radios for immediate reporting of events. The community has first priority to prepare the community and the residents for impending emergencies.
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Locations of Emergency Exits: Each corridor and Kitchen has a noted evacuation route outlining all emergency exits. Additionally, the main entrance, South Entrance, and Health Center entrance can serve as emergency exits as well.
COOP Plan (All Hazard Continuity of Operations Plan):
Continuity of Operation during Hazards/HAZARD ASSESSMENT:
Maintaining and protecting residents within the confines of the community (Shelter in Place) will be the first choice if the community is safe to allow residents to remain during an emergency situation. The community conducts a Hazard Assessment annually to ensure an all hazards approach is considered with the development, update, and roll out of emergency preparedness within the community.
Hazard Assessment and Analysis:
Based on the Risk Assessment for the following emergencies posed greatest RISK:
Noted higher than 50% Risk
Between 50 and 25% Risk
• Hurricane 37% • Work Place Violence/Threat 33% • IT Failure 33% • Inclement Weather 30% • Active Shooter 29%
OTHER:
• Decision Criteria
In all noted circumstances, maintaining the continuity of operations within the community (sheltering in place) will be first choice, if deemed safe. If an area of the building is not safe, partial evacuations; horizontal: from Healthcare Center to Independent Living Center, East Neighborhood to West and South Neighborhood, or vertical: Skilled Nursing 1st floor to 2nd Floor or 2nd floor Assisted Living to 1st Floor Nursing will be considered first prior to ordering full evacuation from the campus. Only if determined sheltering in place is unsafe, will a full or partial evacuation be ordered. All internal and external full and partial evacuations orders will be given by the CEO/COO or designee under guidance of the Fire Department, if present on scene.
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Defined Staff Responsibilities:
In any noted emergency situation, staff will remain in their designated work area, unless otherwise directed. Once a staffing evaluation is done in each area and reported to the CEO/COO, Administrator or designee, modifications will be made to ensure appropriate contingency staffing levels are met in each area.
SHELTER IN PLACE:
Essential Functions: The following functions outline a "shelter in place" protocol for all noted hazards found in the community hazard assessment (All Hazards Approach):
1. Assessment: The Environmental Services Director in conjunction with local authorities (if applicable) will assess the community during an emergency situation to ensure it is safe to shelter residents. Infrastructure (roof, flooding, etc.) will be evaluated, and recommendations will be given to the CEO/COO for consideration in determining sheltering in place vs full or partial evacuation options.
2. Securing the environment: The community maintenance staff will be ordered to report for duty. Maintenance staff will be responsible for securing the building and making routine rounds to secure exits, ensure doors are secure, and monitor for damage.
3. Coordination with local authorities: The Environmental Services Director, under the direction of the CEO/COO will collaborate with Emergency Mgmt. Service, the County Health Dept., and local police and fire regarding the community, as they shelter in place. The EVS Director will provide updates to each department regarding disaster and any recommendations from local authorities.
4. Staffing and Hosting Procedures: During a noted hazard, employees based on job description, will be assigned to their primary department. If there is a critical staff shortage, the community will, if applicable, default to emergency staffing protocols as outlined in the Contingency Staffing Protocol for each area. Arrangements will be made for staff and families to stay onsite utilizing vacant apartments and conference rooms as sleeping areas. Staff requiring overnight accommodations and staff with family that need accommodations will report to the Emergency Command Center. Command Center staff will designate the community area currently being utilized for sleeping quarters (Theatre Room, Wellness Center, Vacant Apartments, and Education Rooms), bathing and toilet facilities (SNF Spa, AL apartment, vacant apartments, Administrative offices, and HR office) and all public bathrooms. Mattresses from storage will be re-located to the appropriate hosting area, as determined by the CEO/COO or designee. Linens will be provided to each hosting area. Staff will rotate and remain on site until determined by CEO/COO or designee. Each department is equipped with a full telephone listing for all staff. If it is determined that additional staff is warranted during an emergency, the department supervisor, under the direction of the CEO/COO will delegate employee
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callbacks to secure additional staff. All available staff will be asked to report to community. Nonessential staff may be reassigned to various duties, including housekeeping, laundry, and dining services. Transportation will be made available to staff utilizing the Van, Community Van, Community Truck and employee vehicles, if necessary. The community contingency staffing protocol outlines employee’s care for family members in the event of a local disaster impacting staff housing and transportation. Physician support will be provided by attending physicians (if applicable) or via Medical Director. The community will grant emergency access to hospital-based physicians if needed to ensure appropriate resident treatment.
5. Dining: An emergency disaster menu has been created and appropriate food remains in stock at all times for purposes of evacuation (3-day supply). The nutritional needs of the residents and staff will be considered when preparing shelter in place emergency menu. Under the direction of the Dietitian and Director of Dining Services, the department will modify menus utilizing existing perishable stock first until it is no longer possible. This would include walk-in refrigerator and freezer inventories and separate refrigeration unit inventories. Meals will thereafter be prepared from existing dry storage supplies. Lastly, the remaining three-day emergency disaster supply will be utilized. All foods utilized from the emergency disaster supply will be replaced with fresh stock from suppliers. The community routinely stocks a 7-10-day meal supply onsite in addition to the three-day emergency disaster stock.
6. Potable Water: Potable water will be kept on site for drinking water. The community estimates one gallon per resident per day with additional gallon per staff per 24 hours. The community will store onsite in excess of 500 gallons of water and/or have contract for guaranteed delivery.
7. Utility Interruption: Community has a full-service generator to run all necessary medical equipment and needed utilities for water, refrigeration, and lighting.
8. Electronic Medical Record: The community is equipped with a full downtime and disaster recovery protocol to ensure access to MAR, TAR, Advance Directives, and Physician Orders. The system became cloud based in 2018. The community maintains a FACE SHEET Binder with relevant diagnosis, DPOA info, etc. in paper form with each resident's photo.
9. Supplies (Linen, Oxygen, Medication, and Medical Supply): The community will maintain sufficient supplies (food, linen, and medication, medical supplies) to evacuate for a period of three days at a minimum. (SEE SUPPLY LIST) A three-day evacuation supply list is kept for reference if evacuation is necessary. Higher volumes are available onsite for Shelter in Place situations. The community has entered into an emergency supply contract for oxygen services. Designated staff will utilize company truck for pickup of any needed medications or medical supplies required during emergency period if not onsite, or if service delivery is unavailable. This includes linen from supplier or other community and medications from pharmacy provider. The community mutual aid
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agreement with other communities allows for additional medical supplies and medications as necessary. The community maintains a stock of all OTC medications (approximately 30-day supply) and has back up box with commonly used medications (4-6 doses of each) and narcotics (4-6 doses of each) provided by our pharmacy carrier.
10. Generator: The community is equipped with onsite natural gas and diesel (based on location) generators to run critical operations. A full load test is conducted routinely in accordance with Life Safety regulations.
11. Vendor Contracts: The community has established contracts with vendors for supplies and noted transportation:
a. US Food Service: Food / Water b. Holladay Pharmacy: and local pharmacy back up c. Advanced Home Care: Oxygen and Medical Supplies d. Agility: Emergency Provider Agreement e. Mutual aid agreements (see below)
12. Mutual Aid Agreements: The community has entered into mutual aid agreements with Scotia Village, River landing, Glenaire, St. Joseph of the Pines, and Emmanuel Episcopal Church, & a county wide agreement through MCEMA covering an excess of a 200-mile span to assist in aid being provided outside the scope of a local disaster area. This agreement outlines surge capacity areas, staff, access to EMR, and medications if needed. Physicians, staff, hospice, and therapy providers will be granted emergency privileges to see their residents in the host community.
13. Mutual Aid Local Providers: The community has entered into a Memorandum of Understanding Mutual Aid Agreement with Emmanuel Episcopal Church, SJP & MCEMA. This agreement provides access for residents to be evacuated close to community event of a disaster localized to our campus.
14. Internal Updates: The CEO/COO or designee will provide departmental briefings, as needed, to alert staff of current emergency situations and to remain abreast of needs and conditions within the community.
15. Onsite treatment area: In the event of an emergency requiring "Shelter in Place" or an IN-HOUSE Evacuation, if it is determined by the CEO/COO or designee to be safe, an onsite treatment area will be designated in a safe area (Conference Room, Office) to ensure emergency treatment and first aid is available to residents, visitors, and employees. The Director of Nursing or lead clinical staff on duty will assign clinical staff to provide coverage in the treatment area.
16. Emergency Reporting Stations: All call back employees, when reporting to work, will report directly to the following areas:
a. Skilled Nursing: Directly to the SNF Command Center located at the Main Desk b. Assisted Living, Garden Cottage, Environmental Services, Dining Services, and
all Administrative Staff will report to the Main Conference Room in the Village House, which serves as the Main Command Center.
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c. Employees will sign in and report to their department supervisor. If they are not needed in that department, they will return to the command center and be reassigned.
d. When the disaster operation is completed and employees are leaving the community, they will return to the command center and sign out. If time-keeping systems are operational, staff will be required to punch in and out on the system.
17. Alternate Communication Systems/Communication Infrastructure Contingency: In the event of a phone system failure, each area is equipped with a hard landline and a corded phone. If the entire phone service is down due to an emergency or disaster, staff cellular devices will be permitted to be used. The CEO/COO, Administrator, Director of Nursing, and Environmental Services Director will ensure cellular devices are present in all areas to ensure appropriate resident safety and access to emergency personnel. If the phone system is down for more than four (4) hours, appropriate state notifications will be made, and families will be contacted by designated staff. Alternative cellular devices with temporary contact numbers will be utilized until phone interruption is resolved. The community is equipped with walkie talkies in all clinical areas. Clinical Staff are assigned pagers with messaging systems that can be used to communicate internally via the SARA Communication System & One Call. Maintenance staff can distribute additional walkie talkies to key personnel for communication purposes, if applicable. Non-critical staff will be assigned to contact family members and staff to provide updates on community status. The community is equipped with battery operated weather and emergency alert systems in each clinical area. The community also has walkie talkie radios on site for communication.
18. Emergency Financial Needs: Community staff is authorized to use petty cash for needed purchases. Additionally, six (6) employees have assigned corporate credit cards to utilize for necessary food and supply purchases.
19. Critical Resident Care Needs: Residents with a critical care need (dialysis or other life sustaining treatment routinely provided outside of community) will be transferred to acute care in our community. The community does not have residents on ventilators.
Pandemic: In situations where community-based illness reaches pandemic levels, the community will quarantine the community, limiting visitation to medical personnel and community staff, following all Shelter in Place protocols. Additional measures for security of residents, staff and supplies will be provided by onsite maintenance staff. The community will work in conjunction with emergency preparedness providers within the community and adhere to all CDC and Health Department recommendations.
Resident Roles and Responsibilities:
Clinical staff will be responsible for the continued assessment of residents during an emergency. Staff will evaluate the appropriateness of involving residents and determining level of awareness related to emergency procedures dependent on diagnosis, potential increase of anxiety, etc.
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Provide opportunities for appropriate residents to discuss any fears and actions that can assist them in remaining calm. Offer items as needed (flash light, phone, etc.).
EVACUATION PROCEDURES: Procedures for evacuating residents
The authority to evacuate the community rests with the CEO/COO or the Administrative person in charge at the time of the disaster. If the community at large is ordered to evacuate, the CEO/COO or designee will prepare the community for full evacuation using the below noted protocols. Under normal circumstances, the CEO/COO will seek guidance from community personnel, police, fire and local civil preparedness. The final decision to evacuate rests with the CEO/COO or the designated person in charge.
Once an evacuation order is given by the CEO/COO Administrator or designated representative (IN HOUSE or TOTAL EVACUATION), the staff in each designated area will secure their emergency transport kit(s) located in the following locations:
• Skilled Nursing: Closet in Nurses Station
• Assisted Living: Clinical Suite
• Garden Cottage: Garden Cottage Back Work Room
• IL: Resident Services Desk, Park View Elevator, Woodlands Elevator 2
• Back Up: Maintenance Office & administration
Emergency Transport Kit Contents:
• Flashlights
• Sharpie markers
• Maps/driving directions to Evacuation locations
• N 95 masks
• Glow sticks
• Hand sanitizer
• Duct tape
• Gloves
• Blank MAR/TAR (Manual Process Binder for Skilled Nursing EMR)
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• Emergency Arm Bands
For either IN HOUSE or TOTAL evacuation, residents will be evacuated in the following order Ambulatory Wheel Chair Residents Bedfast residents Staff will establish a relay system for residents to evacuate. They will first transport residents to the fire door, where the next staff person will transport the resident until the resident is placed in a safe area. If a resident is unable to walk alone and a wheel chair is not available; Healthcare is at ground level allowing for egress without stairs. In IL and Village House areas of rescue are located in stairways. A two-man carry with dining room chairs can be utilized for residents needing additional assistance. During an evacuation, visitors will be asked to leave the community. Staff families that may be onsite from a Shelter in Place order may accompany residents to evacuated location. All residents will be evacuated first to ensure safety and access to medical services.
IN HOUSE EVACUATION
In house evacuation is preferred if one or more of the campus areas are undamaged and can accommodate residents. Nursing personnel in the affected area will be responsible for ensuring that all residents and records are evacuated to another unaffected area of the campus. Resident face sheets, medications, and medical records will accompany each resident to the in house evacuation location. Staff assigned to care for residents during in house evacuation will remain assigned to those residents once they are moved to the new area of campus.
If the apartment area is not part of the disaster area, SNF and AL residents are to be moved to the first floor apartment lobby and dining room.
TOTAL EVACUATION
Should the community require evacuation from the community, the following protocols will be initiated:
The CEO/COO, Administrator or designee will determine the sequence in which residents will be evacuated.
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• If it is determined that evacuation is immediate, the following announcement will be made: “IT IS NECESSARY TO EVACUATE THE COMMUNITY” via mass call system.
• For slower moving disasters, the Administrator or person in charge will call a briefing of community staff; outline the reason for evacuation, the evacuation plan and the sequence of evacuation. The community staff will then return and prepare their residents for evacuation.
Once an evacuation order is given by the Administrator, the staff in each designated area will secure their emergency transport kit(s) located in the following locations:
• Skilled Nursing: Closet in Nurses Station
• Assisted Living: Clinical Suite
• Garden Cottage: Garden Cottage Work Room
• IL: Resident Services Desk, Park View Elevator, Woodlands Elevator 2
• Back Up: Maintenance Office & Administration
Emergency Transport Kit Contents:
• Flashlights
• Sharpie markers
• Maps/driving directions to Evacuation locations
• N 95 masks
• Glow sticks
• Hand sanitizer
• Duct tape
• Gloves
• Blank MAR/TAR and pillow cases (In Healthcare areas)
• Emergency Arm Bands
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Evacuation Process with Medications and Medical Records, Adaptive Equipment and Provision of Care during Evacuation:
Skilled Nursing: Should an evacuation order be given by the CEO/COO and / or Administrator, licensed staff will empty each resident's medication from the medication cabinet and put it into a resident pillow case. The pillow case will be clearly marked with a sharpie marker indicating resident name. Pillow cases will be tied and will accompany resident onto transport vehicle under the guidance of a Registered Nurse. Residents' adaptive equipment (wheelchair, walker, cane, transport sling, etc.) will accompany resident in transport vehicle or follow behind via company truck or staff vehicles. Narcotic cabinets will be emptied and marked per neighborhood, along with backup narcotics from medication room. Narcotics will remain in possession of licensed nurse during transport. Prior to boarding the transport vehicle, an emergency arm band with resident's name will be placed on resident to ensure correct identification. Elder Assistant working during the evacuation order will escort residents in transport vehicles to the new destination. A minimum of one staff person will accompany each group of 14 residents on standard transportation busses. Licensed clinicians will be sent with highest risk residents unless transported via ambulance. The licensed nurse will ensure all residents are evacuated from his or her assigned area. Upon complete evacuation of each neighborhood, the licensed nurse will accompany his or her residents to the designated evacuation location. Residents identified during the evacuation order that need 1:1 accompaniment of a nurse or nursing assistant, the highest-ranking clinician on duty will assign appropriate in-house staff to accompany those residents. Each door will be marked in chalk with an X indicating resident has been transported. The chalk is located in each fire extinguisher box on the wall. A designated staff person, determined by highest ranking staff person onsite when evacuation order is given, will cross reference every loaded resident against the resident roster and then cross reference with each nurse evacuating their set of residents. An updated binder of resident face sheets will be transported with residents to their designated locations. Once each resident is securely transported, the non-clinical support staff will make calls to each responsible party listed on each resident face sheet informing the responsible parties of the resident’s condition and temporary location. Should residents evacuate to more than one location, the Director of Nursing or designee will maintain a master roster of the location of all transported residents and ensure all appropriate physician orders, treatments, and clothing (if possible), reach that location so there is no interruption in medical treatment. All paper records will accompany resident if applicable. Residents' medical records (MAR, TAR, Physician Orders, Care Plans, Progress Notes) are accessible via Matrixcare Program. Paper MARs will be handwritten based on physician order for temporary medication distribution until resident is transferred to another nursing community or hospital. Blank paper MAR / TAR sheets will be available in the Evacuation Kit to use under temporary terms until Information Technology can secure remote access to Matrixcare. The Skilled Nursing team will keep a paper face sheet and picture of each resident in the FACE SHEET Binder that will be taken upon evacuation to ensure appropriate
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notification and identification of residents once transferred. Resident rosters and the Face Sheet Binder will be used at the receiving location to cross reference the arrival of all residents. If time permits, staff will take a three-day clothing supply for each resident and transport clothing after all residents have been moved out and supplies are being transferred to evacuation location(s).
Residential Assisted Living: Should an evacuation order be given by the CEO /COO or the RAL's Designated Representative; each Assisted Living resident would receive a wristband with their name. Medical records would accompany each resident aboard the transportation vehicle. The face sheet book would be secured and would be transported with the highest-ranking staff person working at the time of the evacuation order (RN, LPN, and Med Tech). A designated staff person, appointed by the CEO/COO, unit director or designee during an evacuation, will cross reference each boarded resident with a resident roster. Assigned Elder Assistant will place an X on each resident door in chalk once the resident room is empty. Once the designated staff member has ensured each resident has been boarded for transport, the employees currently assigned to the residents will accompany all Assisted Living residents to their temporary location and ensure appropriate resources are available to meet resident needs. The entire Assisted Living medication cart(s) and MARs would accompany the transport vehicles to the designated staging area for transported residents. The Assisted Living Unit will keep a paper face sheet and picture of each resident in the FACE SHEET Binder that will be taken upon evacuation to ensure appropriate notification and identification of residents once transferred. Resident rosters and the Face Sheet Binder will be used at the receiving location to cross reference the arrival of all residents.
Garden Cottage: Should an evacuation order be given by the CEO/COO, each Garden Cottage resident would receive a wristband with their name. Medical records would accompany each resident aboard the transportation vehicle. The Face Sheet Binder would be secured and transported with the highest-ranking staff person working at the time of the evacuation order (RN, LPN, and Med Tech). A designated staff person, appointed by the licensee, unit director, or designee during an evacuation, will cross reference each boarded resident with a resident roster. Assigned elder assistant will place an X on each resident door in chalk once the resident room is empty. Once the designated staff member has ensured each resident has been boarded for transport, the employees currently assigned to the residents will accompany all Garden Cottage residents to their temporary location and ensure appropriate resources are available to meet resident needs. The entire medication cart for Garden Cottage and the MARs will be transported with the residents to the evacuation location. The Garden Cottage unit will keep a paper face sheet and picture of each resident in the FACE SHEET Binder that will be taken upon evacuation to ensure appropriate notification and identification of residents once transferred.
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Resident rosters and the Face Sheet Binder will be used at the receiving location to cross reference the arrival of all residents.
Independent Living: The FACE SHEET Binders include residents name, social security number, photograph, date of birth, and name and contact numbers for responsible party, emergency contact, and guardian. Residents will be responsible for bringing their emergency bags with medications, supplies, DNR and emergency information.
Resident Information: The FACE SHEET Binders include residents name, social security number, photograph, date of birth, and name and contact numbers for responsible party, emergency contact, and guardian. The EMR that will be established post-evacuation will provide all medications, diets, allergies, diagnoses, and insurance information to provide to necessary 3rd party care providers.
Employee on Duty Time Rosters: Should a major disaster affect the community; charge personnel might not be aware of all who are on duty in each affected area. After following procedures to evacuate residents, the person designated by the Administrator or designee will account for all staff. In the event anyone is missing or believed to be missing, the police and fire department emergency personnel will be notified. Payroll records of employee time can be pulled to determine on-duty staff.
Communication with Residents and Families Regarding Evacuation:
If time permits, residents and residents’ emergency contacts will be notified of impending evacuation, reason for evacuation, mode of transportation for the evacuation, and evacuation location. These contacts will be made by support staff from administration, dining, admissions, social services, life enrichment, and the resident services department. If it is during off hours, the highest-ranking staff person onsite, under authority of the Administrator, will assign the notifications to onsite staff to begin notifications. Staff contacting resident emergency contacts will provide overview of plan, estimated time for transport, and staff accompanying residents to evacuation location. If it is unsafe to make these notifications prior to evacuation, the CEO/COO, Administrator or designee will assign staff to make the contacts upon residents’ arrival to the evacuation location. For slower moving disasters, Elder Assistant and support staff will assist residents in packing belongings (clothing, toiletries) to take with them at the time of evacuation. Staff will provide bags clearly marked with residents' name to accompany either on community transport vehicle or in vehicles following. Staff directed by the CEO/COO and/or Administrator, will provide routine information to residents about the evacuation process, locations for evacuation, and anticipated timeframe for evacuation to last as well as contact information for community and family members (via face sheet in Face Sheet Binder). The community staff preparing residents for evacuation and receiving community staff will be briefed by community leadership to help residents in the relocation process and provide assurance and support. Pastoral Care and Social Services will be available to provide supportive
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solutions to residents and staff prior to evacuation and at the evacuation location. Social Services and Pastoral care will assist in assessing resident’s psychosocial needs. Residents will be encouraged to talk about expectations and concerns. All associates should work to ensure care needs are transferred via report to new location caregivers. associates will work to ensure level of trust for all residents while evacuation protocols are taking place. staff should anticipate anxiety amongst evacuated residents. Communication should be thorough, non-argumentative, courteous and kind. Associates should maintain all care standards during evacuations as they would during traditional operations. associates, where applicable, will ensure resident is oriented to receiving community.
If time permits, family members may take the resident residing at the community home with them if conditions exist to do so safely. Upon family notification, each assigned staff member will receive approval of Director of Nursing or designated head clinical staff and document residents release to family.
Building Security during Evacuation:
If possible, the community will be locked and secured upon complete evacuation in an attempt to secure residents' personal belongings.
Residents’ emergency contacts will be informed upon plan to return to community after the emergency is over and it is deemed safe to return to the community.
Missing Residents during Evacuation:
Residents identified as missing at any point during an in house, partial, or total evacuation will be reported missing to resident's family, law enforcement, the Nursing Home Administrator, CEO/COO or designee, and employees per the resident elopement protocol.
Resident Illness/Death during Transport:
Staff members accompanying residents during transport will be responsible to monitor residents for condition changes. If noted acute life-threatening change is noted by staff accompanying transferring residents, the transportation vehicle will stop, if safe, and 911 will be called to attend to resident. If resident is noted to expire during transport, the staff accompanying transported residents will contact the Director of Nursing or designee, and that individual will make appropriate contact to police and coroner's office as well as deceased resident's responsible party.
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Evacuation Locations:
holds evacuation and transfer agreements with the following locations:
1. Xpress Medical Transport (910-722-2007) - See Transfer Agreement 2. Kirk Tours (910-295-2257) - (both for within 50-mile radius and beyond 50 mile radius)
– See Transfer Agreement • Will provide buses and bus drivers to our community to transport residents to the
selected mutual aide facility. The mutual aide community has a fully functioning kitchen that they would have available for our use. They will provide food and water as needed. They have a generator (in case they do not have power) that will run the kitchen, heat, and three (3) computers. They have landline phones available. They do not have cots/beds, so we will contact the American Red Cross local chapter for those needs. Local Area Red Cross 24/7 hotline
Red Cross (with notification) will provide cots, mattresses and blankets for our residents. The receiving locations during evacuation will first ensure resident intake and safety. Pastoral Care and Social Services staff from community will report to receiving locations as determined by CEO/COO to provide mental health and grief support to evacuated residents.
Transportation Agreements
In the event of a full or partial evacuation, the following transportation is available to transport residents:
1. passenger buses (one is wheelchair accessible) 2. minivan 3. conversion van 4. pickup truck 5. Subaru’s
Transportation Vendors: The above noted agreements for transportation will support the population that we serve within the community. They are knowledgeable on the frailty, cognitive impairments, and other noted co-morbidities that may exist.
Evacuation Routes
Each Emergency Transport Kit is equipped with MapQuest Directions (primary and secondary routes) to each approved Evacuation Center. Drivers will be designated and provided evacuation locations as each transport vehicle is filled. The highest ranking clinical staff person is responsible to take the final headcount on each transport bus and document on the resident roster the location to which each resident is being transported. The resident rosters outlining final
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evacuation locations will be provided to the CEO/COO or designee so a final list can be compiled.
Arrival at Evacuation Location Tracking
The staff person designated by the CEO/COO will cross-reference the resident rosters of residents evacuated to ensure all residents noted on the roster are at the final evacuation destination. Any discrepancies will be reported to the CEO/COO immediately.
Resident Relocation Needs:
Supplies and Equipment
Each clinical area outlines necessary supplies that are needed to accompany or be made available to residents that evacuate from the community. The van and pickup truck will be used to transport the designated par levels for linens, briefs, hygiene items, tube feed supplies, dressings, and treatments for three days. These par level sheets will be pulled from the emergency preparedness book, filled from the stock room by maintenance, and taken to the temporary relocation site.
(See attached emergency inventory sheet)
Advanced Home Care agrees to provide necessary oxygen, concentrators, nebulizers and suction machines to the temporary location of residents to ensure that care and services continue. Advanced Home Care authorizes the transport of oxygen concentrators with 02 dependent residents to the temporary relocation area. All available oxygen will be transported via rack to the temporary relocation area. For residents receiving tube feeding: pumps, formulas (3-day supply) and poles will accompany resident during transport.
If Advanced Home Care is unable to provide DME supplies, Holladay will coordinate DME delivery from additional contracted vendors.
Food Supply and Water/Transportation of Food
In the event of a full evacuation ordered by the CEO/COO and/or Administrator, Dining Services, with the assistance of EVS, will transport emergency supplies of food, water and paper products to the evacuation destination. The Director of Dining Services or highest-ranking dining services employee will direct staff on what items to transport. All TTS (Time Temperature Sensitive) food will be packed in coolers with ice, and a temperature log will be attached to the cooler. The temperatures of TTS items will be taken hourly while they are in the cooler to ensure
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safety. Items will be transported using personal vehicles, minivan and pickup truck, after all residents have been transported. The order in which the supplies will be sent is as follows:
1. Emergency Water: Potable water on site (500 gallons): All evacuation locations have water, but if water is unavailable, water will be transported first from
2. TTS foods packed in ice 3. Shelf Stable Items (bread, juice, cookies) 4. Emergency paper products
Disaster Menus and Emergency Food Supply The menus are planned for a 3-day cycle. In the event of an emergency, all in house stock will be utilized first to reduce spoilage. The menu below will be adjusted accordingly by the Director of Dining Services and approved for use by the Dietitian and Administrator. Suggested food supply lists have been developed for the following menus:
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Fruit Cocktail 2 cases (6, 10# cans per case) See master sheet
Signature Molly Koczarski, RDN *Bolded items will expire within the next 6 months
SUGGESTED EMERGENCY FOOD AND EQUIPMENT SUPPLIES
RECOMMENDED SUPPLIES:
Amounts are based on 100 residents plus 50 staff. Store supplies away from kitchen if possible. DISPOSABLES Seven Day Supply Paper/plastic plates 500/case 3 cases Styrofoam cups (use for hot or cold) 1000/case 3 cases Plastic utensils: forks, knives, spoons 1000/case 2 cases each Paper napkins 3000/case 3 cases Paper towels 30 rolls/case 2 cases Paper/plastic bowls 500/case 3 cases Plastic trash bags 250/box 3 boxes Three Day Evacuation Supply List:
Qua
ntity
per
R
esid
ent
Qua
ntity
for 3
da
ys fo
r MC
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Res
iden
ts
Qua
ntity
for 3
da
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r AL
42 R
esid
ents
Qua
ntity
for 3
da
ys fo
r 50
Res
iden
ts
Hygiene Items Body/Hair Wash (8oz bottles) 0.5 15 28 75 Lotion (8oz bottles) 0.5 15 28 75 Barrier Cream 0.5 15 28 75 Tooth Brush 1 30 56 75 Tooth Paste 1 30 56 75 Comb 1 30 56 75 Disposable Razors 1 30 56 75 Deodorant (small) 1 30 56 75 Wash Basins 1 30 56 75 Gloves Medium Gloves Large
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Incontinence Products Urinals 0.2 6 12 25 Fractional Bed Pans 1 30 56 30 Disposable Moistened Wipes (64 wipes/pack)
1 30 56 65
(Briefs – 6 per day per resident) 180/540 336/1008 Medium (10% of census) 20/pk 3 Pks 6 Pks Large (80% of census) 18/pk 22 Pks 45 Pks Extra Large (10% of census) 20/pk 3 Pks 6 Pks 10 pks Med Supplies/Stock Tylenol 500mg tabs (1000 tab bottle) 1 1 2 Tylenol 650mg Suppositories 30 Imodium 30 Robitussin 20 Med Cups 0.5 case 0.5 case 2 cases Water Cups 1 case 1 case 2 cases Spoons 1 box 1 box 2 boxes Pill Crusher Pouches 1 case 1 case 2 cases First Aid Kit 3 kits Band-Aids 20 Dressing Kit 30 kits BP Cuffs/Stethoscopes 2 sets 2 sets 10 sets Digital Thermometers/covers 20
boxes Accu Ck Strips (50 strips) 3 5 2 boxes Glucometers 4 Pill Crusher 4 MOM 4
bottles Insulin Syringes 20 Tube Feeding Tubing 15 TF Flush Syringes 15 Tube Feeding 15 Misc.
Gait Belts 75 Purple Top/Bleach Wipes 30 Garbage Bags 200 Sheets 200 Blankets 200 Pillows/pillow cases 200 Disposable wash cloths 200
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Towels 200 Hand Sanitizer 200 Pill Crusher 4 Glucometers 4 Milk of Magnesium 4
bottles IV Tubing 20 IV Fluids 20 Hard Candy 20 Refrigerator to transport meds 1 Community Re-Entry Plan: Prior to the residents being returned to the community post-evacuation, the Environmental Services Director, in conjunction with local authorities, will inspect the community to determine that it is safe to return. The community will utilize the same transportation methods noted for evacuation to return residents to the community. Each Unit Manager will cross reference the community resident roster to ensure all residents have returned from their evacuation location. Staff Training and Education: Staff will receive annual training on the Emergency Preparedness Protocol along with quarterly drills and simulations to evaluate staff response. New employees will receive Emergency Preparedness training via new hire orientation. Annual review of the protocol will be done by community leadership. Changes and revisions will be reviewed with staff on an as-needed basis. Resident and Family Education: The community will provide informational meetings to residents via resident council and family information meetings to review community protocols. Families will be provided routine tips to ensure resident safety during hazards and be informed of ways to assist if applicable. At the time of evacuation, family members will be notified of the best method to meet up with their loved ones. Resident family members will be instructed to contact a community line with updated voice mail to receive recorded updates from community staff and leave messages for follow up. Residents who are able will be educated on their role in participating in an evacuation. This information will be disseminated via resident council. Residents and Family members (if able) can offer assistance during a disaster. Residents and Family Members who are able to assist will need to report to the noted Command Center and receive an appropriate assignment from a designated staff member.
a. Skilled Nursing: Directly to the SNF Command Center located at the Main Desk b. Assisted Living, Garden Cottage, Environmental Services, Dining Services, and
all Administrative Staff will report to the Conference Room in the Village House, which serves as the Main Command Center.
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Community Information Line: The community will designate the number 910-692-0437 as the information extension. The CEO/COO or designee will place updated evacuation information on this voicemail remotely. When families are informed of an evacuation, they will be instructed to contact 910-692-0437 to receive updates regarding the evacuation and community re-entry plan. The community will also use all available media outlets, website, and social media to communicate information as able. Family members can also leave messages and updates on this extension to inform community of any resident's status that may have evacuated with family members or contact information for displaced family members. Reporting to Licensing Agency: Skilled Nursing: Serious community problems that require evacuation of residents, such as fire or natural disaster resulting in loss of heat, power, water or food service for more than four hours, a critical lack of staff due to severe weather, labor disputes, widespread illness that has a critical impact on resident care all require notification to The Long-Term Care Section of the Dept. of Health Service Regulation:
Business Hours: 919-855-4520
After Hours: 919-855-4520
Upon completion of evacuation, provide location of evacuated residents to appropriate party as determined by licensing officer. Assisted Living/Garden Cottage: DHSR Adult Care Licensure Section 919-855-3765 The following people will have the responsibility for the proper notification to DHSR 1.) CEO/COO/Administrator 2.) Director of Nursing 3.) Department Managers 4.) Clinical Managers Plan Review: The Emergency Preparedness Plan will be reviewed on an annual basis, or as needed based on regulatory changes, additions or modifications to the annual hazard assessment, results of drills
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or simulations requiring modifications, or changes to the community infrastructure. The Emergency Preparedness Book is reviewed and revised as needed or on an annual basis. FEMA: The community will routinely evaluate tools and resources available via FEMA to ensure resident evacuation and shelter in place protocols are streamlined. Recommendations, modifications and guidance will be incorporated into the community Emergency Preparedness Protocol as needed. Loss of Resident Personal Effects: If necessary, the community will coordinate with Federal Emergency Management representatives to visit the evacuated residents and allow residents to report loss of personal effects consistent with a documented disaster. Collaboration with Emergency Management and Healthcare Coalitions: Under the direction of the CEO/COO, designated community members will routinely participate and receive necessary information from area emergency management. The community will participate in emergency response drills and updates.
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Emergency Preparedness Contingency Staffing Protocols
SNF Staffing Contingency Plan
For full census of 50 the minimum staffing ratio acceptable per state guidelines is one (1) to eight (8)-day shift, one (1) to 12 afternoon shifts, one (1) to 15 midnight shifts. The SNF Staffing book holds minimum hour requirements that would be calculated to ensure appropriate coverage per shift by nurse. Contingency staffing would include the following:
• Days – Two (2) nurses and eight (8) Elder Assistants or three (3) nurses and six (6) Elder Assistants
• Afternoons – Two (2) nurses and 8 Elder Assistant or three nurses and six Elder Assistant
• Midnights – One (1) nurse and four Elder Assistants
The nurses can include CRM, CCC and DON. The CRM, CCC, and DON will also be able to perform as an ELDER ASSISTANT if needed. Any licensed or certified staff person is qualified to perform ELDER ASSISTANT duties in an emergency with minimal training.
Garden Cottage Staffing Contingency Plan
For full census of 10 elders:
Days – Two (2) Med Techs Afternoons – Two (2) Med Techs Midnights – One (1) Med Tech Each person on the unit will be responsible for the care of the elders. The Med Tech and/or Nurse will complete the medication pass and work along with the other staff on the floor to ensure patient care. The leader of Garden Cottage can work as a Med Tech. Anyone is qualified to perform (non-medication administration) duties in an emergency with minimal training.
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Staff available to perform Med Techs (non-medication administration) duties in GC: Activity Assistants, Managers, Elder Assistant from SNF, Med Techs from Assisted Living. Staff will be pulled from other areas to ensure above minimum counts.
RAL Staffing Contingency Plan
For full census of 32 elders: Days – Three (3) Med Techs or one (1) nurse and two Elder Assistants. Afternoons – Three (3) Med Techs or one (1) nurse and two Elder Assistants. Midnights – Three (3) Med Techs or one (1) nurse and two Elder Assistants. Each person on the unit will be responsible for the care of the elders. The Medication Technicians and nurses will complete the medication pass and work along with the Elder Assistant on the floor to ensure patient care. The nurses can include the Assisted Living Nurse. Assisted Living Nurse can also work as an assistant on the floor. Staff that is already cross-trained for nursing is the skilled nursing staff. Anyone is qualified to perform Nursing Assistant duties in an emergency with minimal training. Staff available to perform nursing assistant duties in RAL: Activity Assistants, Managers, Elder Assistant from SNF, cross-trained dietary staff and any nurse in the building. Staff will be pulled from other areas to ensure above minimum counts.
Dietary Contingency
Staffing Plan
Staffing Emergency Contingency Plan
In the event of a staffing crisis, the Village House dining room
would be closed and the staff from those areas would be re-assigned
To the North. Elders from the Apartments would receive 1 boxed
Meal produced in the main kitchen per day until the crisis subsides.
In the Health Center, service may continue as normal, or pending the health
Of the community, may be reduced to tray service to the rooms (quarantine).
In this situation, assistance will be required for tray pass and clearing from
Nursing and all available managers.
Depending on the extent of the staffing crisis, it may be necessary to begin
Using disposable plates, utensils and trays in the community (less than 3 FSA's).
Additionally, the emergency menu may need to be implemented if deliveries
Are impacted or if the staffing level falls below 3 cooks in a day.
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POSITION HOURS GENERAL RESPONSIBILITIES:
AM Cook 5a-1:30p Health Center Production, Therapeutic Diets
AM Asst Cook 5a-1:30p Health Center Cold Food & Beverage Production & Cook Assistant
FSA 1 6a-2:30p Pots & Pans, SNF Service, Bussing, Dish line
FSA 2 6a-2:30p SNF Set-up, Service, Bussing, Dish line
FSA 3 6a-2:30p SNF Set-up, Service, Bussing, Dish line
PM Cook 11a-7:30p Health Center Production, Therapeutic Diets, Serve SNF & RAL
FSA 6 2p-7:30p Village Set up, Service, Bussing,
FSA 4 3:30p-7:30p Set-up, Service, Bussing, Dish line
FSA 5 3:30p-7:30p Set-up, Service, Bussing, Dish line Both Wait staff/tray lines 11a-7:30p Pots & Pans, Sanitation
A.M 630a-3p Breakfast Service, Deli Prep and Relief
Cook 1 10a-6:30p Production, Health Center Prep
Cook 2 10a-6:30p Production, Service, Health Center Prep
Waiter A 9:30a-6:00p Waited Service
Waiter B 11a-7:30p Waited Service
Waiter C 11a-7:30p Waited Service
Waiter D 3:30p-7:30p Waited Service
Deli 7:30a-4p Deli Production and Service
Waiter E 630a-230p Breakfast Waited Service
AL FSA 630a-3p Al Breakfast and Lunch Service
AL2 FSA 11a-730p AL Lunch and Dinner Service
POSITION HOURS CONTINGENT RESPONSIBILITIES:
AM Cook 5a-1:30p Health Center Production, Therapeutic Diets
AM Asst Cook 5a-1:30p Health Center Cold Food & Beverage Production & Cook Assistant
FSA 1 6a-2:30p Service, Bussing, Dish line
FSA 2 6a-2:30p Service, Bussing, Dish line
FSA 3 6a-2:30p , Service, Bussing, Dish line
PM Cook 11a-7:30p Health Center Production, Therapeutic Diets, Serve SNF & RAL
FSA 5 330p-7:30p Set up, Service, Bussing, Dish line
FSA 4 3:30p-7:30p Set-up, Service, Bussing, Dish line
FSA 6 3:30p-7:30p Set-up, Service, Bussing, Dish line Both Wait staff/tray lines 11a-7:30p Pots & Pans, Sanitation, Expediting
A.m. 630a-3p Cross trained in Cooking Roles – Apt. Box Lunch Production
Cook 1 10a-6:30p Cross-trained in all Cooking Roles - Apt. Box Lunch Production
Cook 2 10a-6:30p Cross-trained in all Cooking Roles - Apt. Box Lunch Production
Waiter A 9:30a-6:00p Can fill in as Food Service Aide or Wait staff/tray line
Waiter B 11a-7:30p Can fill in as Food Service Aide or Wait staff/tray line
Waiter C 11a-7:30p Can fill in as Food Service Aide or Wait staff/tray line
Waiter D 3:30p-7:30p Can fill in as Food Service Aide or Wait staff/tray line
Deli 7:30a-4p Can fill in as Food Service Aide or Wait staff/tray line
AL1 630a-3p AL Breakfast and Lunch Set up and Service
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AL2 11a-730p AL lunch and Dinner Set up and Service
Contingency Work Plan: Social Services The following persons will be covering for me: 1. All Social service required assessments and tracking 2. MDS Coverage 3. Discharge Plans 4. NHO—section I (Ethics/Quality of Life/MDQI) 5. NHO---section II (Resident Rights/Abuse) 6. Care Conferences 7. Family/Resident Issues Nursing Team Management 8. Medicaid Issues 9. Psych services
Life Enrichment Emergency Contingency Plan
Part 1 In the event that the majority of the Life Enrichment Staff has been unaffected by the emergency
the following will take place:
1. Life Enrichment will have preassembled boxes containing disposable items for individual
neighborhoods on Skilled Nursing to use and give to the elders in the event a hall is closed,
i.e. books, decks of cards, word puzzles, trivia games, videos, magazines
2. Life Enrichment staff is cross-trained for the different areas of the continuum to provide
activities in small groups or one-on-one visits
3. All Life Enrichment staff is trained to do SNF Life History Assessments
4. All group events will be canceled.
5. All contracted or volunteer performers and scheduled visiting groups will be contacted and
made aware of the situation. They will be contacted again when the building is reopened to
the public.
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6. All volunteers will be contacted and made aware of the situation and contacted when they
may return.
7. There are five drivers in the department with certification who can drive any of the
community vehicles if needed to transport elders or supplies.
8. Life Enrichment staff will be available to help in other departments, as needed.
Part II
In the event that the majority of the Life Enrichment Staff have been affected by the emergency
the following will take place:
1. A box with a supply of Life History Assessments, a list of activities, including directions
and necessary supplies that anyone can do with the elders will be in the Director of Life
Enrichment closet.
2. The MDS nurse or the Administrator will complete Section F of the MDS 3.0 if the Life
Enrichment Director is unavailable.
3. All contracted or volunteer performers and scheduled visiting groups will be contacted
and made aware of the situation. They will be contacted again when the building is
reopened to the public. A list of phone numbers will be available in the Life Enrichment
office in a binder marked Emergency Plan.
4. All volunteers will be contacted and made aware of the situation and contacted when
they may return. List of names and numbers will be in the Emergency Plan Binder in the
Life Enrichment Department.
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HR Contingency Plan
In the case of emergency: Payroll: Managed by Payroll Department, back-up is remote access HR Functions: managed in house or by remote access
Frequent Contacts:
1) HR Back-Up 910-692-0494 (office)
910-624-7292 (cell)
MAINTENANCE CONTINGENCY PLAN
TOTAL STAFF OF SIX PLUS DIRECTOR = 10
1. Pull staff from each shift to cover to have at least one person per shift.
2. If needed two people working 12 hour rotating shifts.
3. The Director of Environmental Services will stay on site, if needed.
4. IN EXTREME CASES, contracted electrician is available to act as maintenance support.
Housekeeping Contingency Staffing Plan We cancel all apartment cleanings for the day. 1. We are to focus on all bathroom cleaning, filling the supplies, pulling the trash, running compactor and covering laundry. 2. Divide up two housekeepers per floor on skilled and Assisted Living. One person will cover Village House. One person will be covering laundry.
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3. Any and all admit or discharge rooms will be done as a team of both housekeepers in order to get it done quickly and get back on task. 4. Housekeeping supervisor can take a role as either a housekeeper or a laundry aide. 5. Office personnel are expected to pull their own trash if needed. Everyone is responsible to pick things up off the floors and keep all common areas clean. 6. Nurses and Elder Assistants are expected to help maintain the resident rooms and their trash throughout the day.
Independent Living Contingency Plan Resident Services
Resident Services Staff are cross-trained for the following areas:
§ Resident services § Assisted Living nurse aide § Some Housekeeping § Some Kitchen work, food service aide on SNF
Resident Services Functions: § Back up for SNF/Healthcare admissions: Marketing Director, Resident Services Director
and Administrator § Tours - Any member of Resident Services, any department leader § Phone Calls - All Marketing and Resident Services staff § Faxed Referrals - All Marketing and Resident Services staff § Referrals - Resident Services, CCC, DON, Administrator § Admission Paperwork/sign in - All Resident Services staff, Social Services, Business
Office § Insurance checks/computer admit- Business Office, Resident Services staff,
Administrator § MDS face sheets- CRM § Go to Person - Admissions Director
Home Care (North) will provide additional staffing from their team as needed. Resident Services team will work off Home Care Binder (kept at front desk) to ensure that elders who get services from them are being helped as required and assigned. Director of IL will keep Resident Services informed if they are unable to provide services needed. Resident Services department will work with Dining Services to ensure meal delivery of boxed lunches. Resident Services and Life Enrichment will cancel scheduled activities and make sure elders are aware.
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Resident Services department would work with EVS to schedule any necessary apartment cleaning as well as common area cleaning.
Home Care Contingency Plan Home Care Staff are cross-trained for the following areas:
§ Resident Services § Assisted Living nurse aide § Some housekeeping § Some kitchen work, food service aide in SNF § Discharges § Unit Clerk § Apartment Marketing
Home Care Functions: § Back up for SNF/Healthcare admissions: Resident Services Director, Marketing Director,
Administrator § Home Care south building will provide additional staffing from their team as needed.
Resident Services team will work off Home Care Binder (kept at front desk) to ensure that elders who get services from them are being helped as required and assigned. Director of IL will keep resident services informed if they are unable to provide services needed.
Additional Information
will make available temporary sleeping arrangements via short stay, model, and guest apartment, if needed. Conference Rooms can be transitioned to temporary sleeping areas for staff. Red Cross will provide cots upon request. Mattresses from storage can be brought to conference room to set up temporary sleeping arrangements. Staff instructed to work during emergency situations, may bring children/family to community. Staging areas in IL living room, Dining Room and 2nd floor conference rooms will be made available to families of employees if emergency is deemed severe in nature and is impacting the home and health status of employees’ families. Red Cross has agreed to provide additional sleeping cots if deemed necessary. Administrator and DON will remain on site, if necessary, to oversee contingency staffing operations. Staffing and illness reporting will be done to appropriate agencies by only the designated Leader Staff currently assigned during emergency situation and will remain on site until replacement personnel is secured. Administration will provide for sleeping and bathing necessities for staff staying during an emergency.
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FIRE SAFETY Fire Procedure:
1.) The fire procedure outlined below, contains basic information which all staff
should know and keep in mind if a fire occurs in this community.
2.) The community is protected by a system of automatic smoke detectors, water
flow alarms for the sprinkler system and fire alarm pull stations. When these
systems activate, the fire alarm bells will sound, flash and all smoke barrier doors
will close automatically.
3.) The fire alarm system is equipped with both audible and visible strobes for
hearing impaired. Resident rooms are equipped with visible strobes. Residents
with hearing impairment will be instructed by staff that the alarm is sounding.
4.) All staff of this community will be responsible for practicing fire prevention,
by watching for conditions that could cause fires, enforcing the Nonsmoking
Policy, securing flammable items and ensuring that combustible decorations are
not brought into the community.
5.) When a fire is discovered, the following steps should be taken by the
following people and departments:
In case of a fire in your area, remember to R.A.C.E.
Rescue Remove residents and visitors from the affected area.
Alarm Pull the nearest fire alarms pull station. Page - CODE RED to affected area.
Contain Contain the fire, close all doors and widows turn on all lights.
Extinguish Extinguish small fires with an appropriate extinguisher or evacuate.
IF YOU DISCOVER A FIRE - - -
SNF and RAL • Evacuate residents in immediate danger.
• Close immediate area fire doors and windows.
• Pull fire alarm – report to SNF Charge Nurse the location of fire.
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• Instruct and assist residents and/or visitors to a secure location. Residents in
their rooms should remain in their rooms with doors closed. Residents/Staff
should never pass through a fire door.
• Turn off O2 equipment and electrical appliances.
• Remain on your assigned wing to wait further instructions.
• No visitors shall be permitted into the building until the “ALL CLEAR” is
announced.
Dietary:
• Evacuate all residents in immediate danger.
• Close all doors and windows.
• Pull fire alarm – report to SNF charge nurse the location and type of fire.
• Remain in location and assist residents to safety.
• Turn off all equipment in dietary.
• Turn off all lights.
• Evacuate Dietary Department by reporting to the Village House Dining
Room.
Garden Cottage:
o Remove resident in immediate danger.
o Call 911 and report a fire at Garden Cottage.
o Pull the Fire Alarm – call the skilled unit x444 and Maintenance on radio.
§ Evacuate all residents/visitors through the entrance door.
Evacuation may be necessary into the north parking lot. This
can be accomplished by routing staff, residents, and visitors
through the north end of the hallway. The exit is clearly marked
with an exit sign.
§ If evacuation is required into the courtyard, keypads for the door
walls are located by the door wall frame. Once in the courtyard,
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move residents, visitors, and staff to the entrance gate of the
courtyard and unlock the gate.
o Fire Drills: (Garden Cottage) Fire drills are conducted at irregular
intervals on a monthly basis. Fire Drills, per regulations, require a
complete simulated evacuation.
General:
• Salon: Shut doors and stay in Salon, unless fire is located in Salon.
• Housekeeping: Remain in their assigned area and assist staff with the Unit Procedures.
• Maintenance: Shall respond to the alarm area and assist in the fire fighting and or evacuation.
• Physical Therapy and any other professional staff on SNF: Report to the Nurses Station 2.
Apartment Side Alarms: If the panel for fire goes off on the apartment side of the community, it will ring to Rapid
Response. The Charge Nurse during off hours and Resident Services during Business
Hours should contact maintenance immediately and report the alarm.
If Maintenance does not respond, contact 911. APARTMENTS: Emergency Fire Procedure: If a fire occurs in a resident's apartment:
• Fire/Smoke detector will sound.
• Leave apartment immediately.
• Go to the nearest fire alarm box and pull fire alarm lever.
• Have a neighbor call the fire department and report which apartment the
fire is in.
• Take the nearest stairwell down to the nearest lobby/wait in lobby for further
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instructions.
• Do not use elevator.
• If you are unable to travel down the stairwell, go through hallway fire door
and wait on other side for further assistance.
Apartment/cottages Residents: IF YOU HEAR THE FIRE ALARM:
• Check your hallway for smoke or fire.
• If hall is clear, go to the area of rescue.
• Close the apartment door and wait for instructions
• Wait in hallway until instructed by fire monitors or fire department that
“ALL IS CLEAR” and you may then return to your apartment.
• If you do not have a hall monitor, wait for the overhead “ALL CLEAR” page
on the public-address system.
IF YOU HEAR THE FIRE ALARM AND SEE SMOKE IN YOUR HALLWAY: • If it is unsafe to travel through the halls, remain in your room and pull your
emergency pull cord. It is very important at this point to close your door and
stop the smoke from spreading.
• If it is safe to travel through the hallways, go to nearest stairwell and exit
down to the lobby.
• If you are unable to ambulate down stairwell, and the path is safe to travel,
go to the Areas of Rescue in your stairwell and wait for assistance.
• If further instructions are needed, they will be given by the Fire Department.
PLEASE LISTEN FOR INSTRUCTIONS DURING FIRE ALARM CONDITIONS.
APARTMENT AREA EMERGENCY FIRE PROCEDURE: MAINTENANCE
RESPONSIBILITY
• Go to the apartment fire alarm panel in main lobby 1st floor.
• The area in alarm will be brightly lit by a red indicator light.
• Go directly to the area and check for problem.
• If fire is found:
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o Call 911
o Page!!! CODE RED STATE APARTMENT SIDE WITH
LOCATION.
o Page for floor captain monitors to start evacuation of specific area.
o Return to area of fire and assist with evacuation or assist fire dept.
If it is found to be a false alarm:
o Silence alarm panel and wait for fire Dept.
o Make announcement over Public Address
Sample: Fire alarm is a false alarm ALL CLEAR, announce your name and
that you work at and repeat, “ The Fire Alarm is a False Alarm, ALL
CLEAR.”
CHARGE NURSE RESPONSIBILITIES:
If alarm is ringing, the Charge Nurse will phone the Fire Department (911) and state
clearly: “This is Health Care Side, there is a fire (give exact location and type of
fire). The charge nurse will possibly receive a call from another building location to report
location of the fire.
If the fire location is not known the Charge Nurse will tell the fire department that the
location is not known at this time – but the fire alarms are ringing.
Stay on the line and answer any questions.
The Charge Nurse Will Announce “CODE RED” and give location of fire. If paging
system is not working, Charge nurse will send a messenger via stairway to RAL and
Ground Level to relay the information. If location is unknown, announce CODE RED
Location Unknown.
Call maintenance and RAL to assure notification.
Call front desk (during business hours) no notify them the fire alarms are ringing.
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Charge Nurse shall remain at the nurse's station 2 to direct emergency procedures.
Once the fire is extinguished or directed by Fire Department, the Charge Nurse will allow
the “ALL CLEAR”.
Methods of Fire Alarm Activation
Fire Alarm System Monitoring All points of the fire alarm system activation below are monitored by NETWORK FIRE AND SECURITY. When the fire alarms sounds, a monitoring company will automatically call the fire department for immediate dispatch. In order to prevent the dispatch of the fire department, in case of a known false alarm example: “confused resident seen pulling alarm”. CHARGE STAFF MUST NOTIFY THE MONITORING COMPANY AND INFORM THEM OF THE FALSE ALARM: 1-877-350-5292.
1. Code or I.D. number for the South Building – 040B051 2. Code or I.D. number for the North Building – 040B052 3. Code or I.D. number for the Garden Cottage – 040B144 4. Code or I.D. number for the Maintenance Trailer – 040B053 5. Code or I.D. number for the Village House – 040B054 6. Code or I.D. number for the Woodlands Apartments – 040B050 7. Code or I.D. number for the Fire Booster Pump - 0403008 8. Code or I.D. number for the Parkview Apartments - 0403082
Contact the Fire Department and notify them of the False Alarm 911 Fire Alarm Pull Station Located near all exits of the community. Pull the handle down for alarm activation. Smoke Detectors and Thermal Detectors 1.) Smoke detectors (ionization or photoelectric types) in the main lobby and near each set of smoke barrier doors. 2.) Thermal detectors (activate on a temperature rise above a preset temperature) in the kitchen and boiler rooms. Evacuation Maps
Evacuation Routes are posted on each Hallway and inside the Dietary Department
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1.) Showing all fire alarm pull station. 2.) Fire extinguisher locations. 3.) Locations of emergency exits.
Fire Department Arrival
The fire department is to be called even if the fire is thought to be out. Follow all instructions given by the fire department personnel.
Fire Extinguishers
Types of Fire Extinguishers: Fire Extinguishers are rated: ABC. Dietary Department had one Extinguisher Rated “A” Fire Extinguishers Locations:
1.) Fire Extinguishers cabinets in each of the Unit corridors. 2.) Laundry Room 3.) Kitchen
4.) Boiler Room 5.) Maintenance Shop
6.) Activities Gathering Rooms 7.) Salons
Tobacco Free Environment • Residents, visitors, associates, volunteers, and contractors are prohibited from the use of
tobacco at this community except in designated location.
• This is inclusive of cigarettes, cigars, pipes and all smokeless tobacco and e
cigarettes (electronic cigarettes).
• Visitors, residents and staff shall not be permitted to smoke in building including inside
any rented apartment or resident room, on any grounds, or in any cars parked on
community property.
• A Nursing Home, Home for the Aged, and / or Assisted Living Care licensed under this
article shall retain a copy of the smoking policy, which will be available to the public
upon request and provided to each new resident or designated representative upon
admission to the community.
• The only designated smoking area on campus is located outside of North building
laundry.
Fire Blanket Locations:
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• North Building outside of Laundry
Fire Drills
Purpose: To train the personnel in the procedures used in a variety of fire situations to protect the lives of residents, visitors and the personnel in the community. Policy:
1.) Fire drills will be conducted on a monthly basis. They will be at irregular intervals on all shifts. Records will be maintained for two years.
2.) Fire Drill records will be reviewed in Monthly Safety Committee Meetings
3.) Monthly inspections will be made of all exits and smoke barrier doors to make sure they are operational.
5.) Semiannual inspections by approved community vendors will be made of the fire alarm system. Certification of results and corrective actions taken will be kept on file for seven years.
Procedure: Health Care Side 1.) All fire Drills will be unannounced. 2.) A “Red Lantern” will be placed somewhere in the community. The first person discovering the lantern should treat it as if it were a real fire.
Maintenance Personnel will:
• Contact the Fire Department and inform them of the Drill.
• Notify resident services during business hours to hold calls to the units.
• Complete report identifying: time lantern was placed, time alarm was sounded,
time Charge nurse contacted fire department, time a fire extinguisher was brought
to the scene.
• Review and evaluate procedures, staff responses, etc. Note any problems or
suggestions.
• Reset fire alarms.
• Contact Fire Department to confirm drill is over and to get response time from
monitoring company.
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Fire Watch/Impairment Protocol (SEE ATTACHED FIRE IMPAIRMENT
PROTOCOLS)
POLICY
The community will notify the authorities having jurisdiction whenever the automatic fire sprinkler system and / or the fire alarm system is out of service.
GUIDELINES
When the automatic fire sprinkler and / or fire alarm system is out of service for more than 15 minutes. The authority having jurisdiction shall be notified. An Approved Fire watch system will put into effect immediately to all unprotected areas. The fire watch will remain in effect until the Automatic fire sprinkler System and or Fire alarm system is operational. Evacuation of the community will occur in the event that the fire watch cannot be effectively implemented
PROCESS
The Administrator or their designee will:
1. Implement an approved Fire Watch (See note and attachment ) 2. Notify Fire Department 911 for dispatch
3. Notify Environmental Services and Administrator
4. Notify all of the above when systems are back and operational
5. Document the unplanned occurrence; retain rounds logs of fire watch
NOTE A fire watch will involve additional action beyond normal staffing levels. This may be assigning a responsible individual to walk around the area where the systems are not in service. The person (s) assigned the fire watch duties shall have No Other Responsibilities. The person (s) will keep a fire watch log and will have specific training in the following areas.
• Community emergency and evacuation plans • Fire prevention training • Demonstrated ability to use a fire extinguisher
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• Means and effective procedure to notify the fire department in case of fire (cell phone) • An alternative method to notify staff and elders of fire
Hot Work Procedure
Flame or arc cutting, welding, brazing, smoldering and other work that produces flame, sparks or arcs are common and useful maintenance, renovation, construction and demolition methods but they introduce hazards that must be controlled.
• Design production areas and specifically designated areas of the maintenance shop where hot work is routinely done to minimize hazards
• Properly control the hazards of portable hot work equipment, establish a comprehensive hot work control that includes the following elements
o The open flame of a torch
o Metals being cut or welded
o Molten slag or metal that flows from the work
o Sparks that fly from the work
o Appropriate handling of smoldering iron or propane torches
o Dropped hot rivets
o Electric arc welding grounding clamps
• Appropriate approvals should be received by Director of Environmental Services or designee before the initiation of any hot work.
• This process applies to all employed and contracted workers
Hot Work Procedures:
1. Hot Work procedures is the overall responsibility of the Environmental Services Director and should be supervised by a qualified, experienced individual with hot work methods.
2. The Director or designee should examine and approve the location of the hot work prior to initiation of hot work.
3. All workers conducting hot work will be instructed on safety precautions prior to the initiation of work.
Safety Precautions for Hot Work
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1. Preference is given to hot work in a properly arranged maintenance shop except if the work cannot be moved there.
2. Avoid using hot work equipment in areas that is not protected by a working sprinkler system.
3. Remove all combustibles at least 35 feed from the hot work location.
4. Floors should be swept and clean prior to initiation of hot work. If applicable combustible flooring should be wetted before hot work starts.
5. Floor and wall openings within 35 feet should be protected with flame proof covers.
6. Do not work on or in vessels containing combustible or flammable materials until all materials and residues have been completely cleaned or purged.
7. Ensure atmospheres are free of flammable vapors prior to initiating hot work.
8. Use equipment that is in good working condition and has been thoroughly checked.
9. Prohibit hot work until an independent fire watch has been placed to watch for sparks in the areas around, above and below as necessary.
Severe Weather
Severe Weather Watches
A severe weather forecast is an indication the weather conditions are favorable for the development of severe thunderstorms, heavy rains, high winds, hail, flooding or heavy snowfall accumulations etc..
1.) Upon receiving notification from Weather Radio of severe weather forecasts, the Environmental Services director or administrative person in charge should alert all department heads who in turn will notify the employees.
2.) The community staff should inform without alarming or causing panic to the resident when practical and prepare the community for the potential disaster.
3.) Keep televisions tuned to local stations, radios should be tuned to local stations.
4.) Nursing staff should check the emergency go kits and emergency medications and locate them where you can reach them easily.
5.) Check the operation of flashlights. We keep three flashlights at each nurse's station (emergency go kits), one in laundry, one in administration one in dietary, and one in
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maintenance. Batteries will be changed by maintenance in April and September. Additional batteries are kept in the Maintenance shop. 6.) Wheel chairs should be opened and near residents, a supply of linens and blankets available to cover residents if needed.
Severe Thunderstorms
Severe Thunderstorm Watches 1.) A severe thunderstorm watch can be issued anytime of day.
2.) At the time of a severe thunderstorm is forecast, the person in authority will alert staff
members of the situation. 3.) Be watchful for inclement weather. 4.) If the weather becomes threatening, close windows and pull blinds or curtains. 5.) Follow the same duties as a tornado watch.
Severe Thunderstorm Warning
When the public authorities have issued a severe thunderstorm warning and its location is in the immediate area of the community follow the guidelines listed below.
1. Monitor the weather radios on each unit or local radio and television stations. EVS staff will contact units regarding all weather updates.
2. Tornadoes often start out of severe thunderstorms.
3. Be sure windows, blinds or curtains and cubicle curtains are closed.
4. Pull unnecessary electrical plugs. Except life support equipment. Ensure life
support equipment (oxygen, tube feeding, etc.) are plugged into RED Plugs.
5. The person in charge will inform you if it has been determined that it is necessary to follow Tornado Warning Procedures.
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Tornadoes Tornado Watch: is a weather forecast for which conditions are right for the development of a Tornado. Tornado watches are frequently issued between 1:00 p.m. and 5:00 p.m. It is the responsibility of nursing employees to inform and prepare the residents for the watch. Utilize weather radios.
Tornado Warning: means a tornado has been detected and may be approaching the community.
A tornado warning is broadcast over the weather alert radio at designated Weather Radio Locations
1. Most tornadoes hit between 3:00 p.m. and 7:00 p.m. in the evening (during the second
shift) although many have occurred in the early morning hours of the following day.
2. Should a tornado warning occur during a shift change, staff is required to stay until the tornado warning has been canceled.
3. When a tornado warning is received, the person in charge will announce over the
Paging System Attention Staff we are under a Tornado Warning to alert the staff. 4. When you hear a page Attention Staff we are under a Tornado Warning Do not
panic. All staff should remain calm and do the following.
a.) Move as many residents as possible to the Hallways. Place residents along the interior walls with all doors closed.
b.) DO NOT USE RESIDENT LOUNGES, DINING AREAS, KITCHENS, THERAPY GYM, ACTIVITY CENTER, OR AREAS WITH LARGE ROOF SPANS AND NUMEROUS WINDOWS.
c.) KEEP RESIDENTS AWAY FROM ELECTRICAL OUTLETS.
d.) Push bed bound residents' beds to inner walls. Place blankets over the residents (including head). Close privacy curtains around them.
e.) CLOSE THE RESIDENTS ROOM DOORS.
f.) CLOSE THE FIRE DOORS IN THE CORRIDORS.
g.) CEO/COO, environmental staff, administrator or the person having authority will determine if it is necessary to shut the natural gas and electricity.
h.) Reassure everyone that the person in charge is ready to help with ambulances,
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rescue units, fire, police, physicians, and utility companies.
i.) If evacuation is necessary, the person in charge will follow policy for all disaster evacuation.
j.) During a tornado warning all available personnel report to the SNF, Assisted Living and Garden Cottage Units to provide additional support
k.) Residents may return to their normal activities once an All Clear has been issued over the weather radio or broadcast by local radio and television stations.
Note: In the event a tornado hits the community. All off-duty personnel should report to the community.
Apartment/Cottage Tornado Procedures:
1. If a tornado watch is issued, the designated maintenance staff will use a mass communication system and go up and down each hall way to advise residents that the community is under a tornado watch.
2. Residents on higher floor apartments, if able should move to an inward hallway and
down to the lowest floor interior hallway. Residents unable to move from their apartments should move to their interior bathroom.
3. First floor residents should move out to their interior hallway. 4. All apartment corridors should be closed and all apartment doors should be closed.
5. Residents will be escorted from the Village House Restaurant, and living room
common spaces to interior hallways on the first floor behind closed corridor doors.
6. Should a tornado warning be issued: Residents should remain sheltered and await further instruction from Maintenance staff? Maintenance staff, private duty staff, restaurant staff and resident services staff should assist apartment residents to corridors if needed and provide updates to residents as needed sheltered in place.
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Utility Emergency Communications Procedures
Gas Line Leak / Break
1.) Clear the area. 2.) Call Piedmont Gas 1-800-752-7504 3.) Call the fire and police departments 911 4.) Contact Environmental Service Director 5.) Initiate Emergency Phone tree to contact all leadership MAIN GAS SHUT OFF:
1. May need to shut off MAIN when there is a gas leak that cannot be controlled at the point of origin.
2. North – To the left of kitchen loading dock 3. South – Rear to left of maintenance shop entrance 4. Village House – Right of building entrance through gate arms.
Located on left by Riser Room door 5. To Turn Off Valve: Turn handle clockwise until the handle of
valve is perpendicular to valve. Electrical Failure
1. Call Maintenance Personnel on the Radio
2. Call the Environmental Service Director 910-690-1177
3. Activate the Emergency Phone Tree to contact all leadership staff
4. Call Duke Energy 800-452-2777
In case of a power failure the auxiliary generator will automatically begin operation after a 5-
second delay. Limited operations can continue indefinitely with power such as heat, fire alarms,
limited lighting and red outlets. Electrical panels that feed the boiler room and limited dietary
equipment are manually transferred to the generator. In the unlikely event of both power and
natural gas loss the community a review of Evacuation Protocols will be initiated.
EMERGENCY POWER / FAILURE
Contact National Power at 1-888-646-8596.
Utility Emergency Communications Procedures
Gas Line Leak / Break
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1.) Clear the area. 2.) Call Piedmont Gas 1-800-752-7504 3.) Call the fire and police departments 911 4.) Contact Environmental Service Director 5.) Initiate Emergency Phone tree to contact all leadership MAIN GAS SHUT OFF:
6. May need to shut off MAIN when there is a gas leak that cannot be controlled at the point of origin.
7. North – To the left of kitchen loading dock 8. South – Rear to left of maintenance shop entrance 9. Village House – Right of building entrance through gate arms.
Located on left by Riser Room door 10. To Turn Off Valve: Turn handle clockwise until the handle of
valve is perpendicular to valve. Electrical Failure
5. Call Maintenance Personnel on the Radio
6. Call the Environmental Service Director 910-690-1177
7. Activate the Emergency Phone Tree to contact all leadership staff
8. Call Duke Energy 800-452-2777
In case of a power failure the auxiliary generator will automatically begin operation after a 5-
second delay. Limited operations can continue indefinitely with power such as heat, fire alarms,
limited lighting and red outlets. Electrical panels that feed the boiler room and limited dietary
equipment are manually transferred to the generator. In the unlikely event of both power and
natural gas loss the community a review of Evacuation Protocols will be initiated.
EMERGENCY POWER / FAILURE
Contact National Power at 1-888-646-8596.
• The following equipment will operate during a power failure:
o Illumination of hall lights and exit signs.
o Resident Corridor receptacles RED PLUGS
o
o Elevator 1 Health Care Side (manual throw over)
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1.) Clear the area. 2.) Call Piedmont Gas 1-800-752-7504 3.) Call the fire and police departments 911 4.) Contact Environmental Service Director 5.) Initiate Emergency Phone tree to contact all leadership MAIN GAS SHUT OFF:
11. May need to shut off MAIN when there is a gas leak that cannot be controlled at the point of origin.
12. North – To the left of kitchen loading dock 13. South – Rear to left of maintenance shop entrance 14. Village House – Right of building entrance through gate arms.
Located on left by Riser Room door 15. To Turn Off Valve: Turn handle clockwise until the handle of
valve is perpendicular to valve. Electrical Failure
9. Call Maintenance Personnel on the Radio
10. Call the Environmental Service Director 910-690-1177
11. Activate the Emergency Phone Tree to contact all leadership staff
12. Call Duke Energy 800-452-2777
In case of a power failure the auxiliary generator will automatically begin operation after a 5-
second delay. Limited operations can continue indefinitely with power such as heat, fire alarms,
limited lighting and red outlets. Electrical panels that feed the boiler room and limited dietary
equipment are manually transferred to the generator. In the unlikely event of both power and
natural gas loss the community a review of Evacuation Protocols will be initiated.
EMERGENCY POWER / FAILURE
Contact National Power at 1-888-646-8596.
• The following equipment will operate during a power failure:
o Illumination of hall lights and exit signs.
o Resident Corridor receptacles RED PLUGS
o
o Elevator 1 Health Care Side (manual throw over)
1. Code or I.D. number for the North Building – 040B052
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2. Code or I.D. number for the Garden Cottage – 040B144 3. Code or I.D. number for the Maintenance Trailer – 040B053 4. Code or I.D. number for the Village House – 040B054 5. Code or I.D. number for the Woodlands Apartments – 040B050 6. Code or I.D. number for the Fire Booster Pump - 0403008 7. Code or I.D. number for the Parkview Apartments - 0403082
Cottages PASS CODE: *1 1234
We will need to report loss of power upon their call to check the system.
8. The generator alarm panel at nurses station 1 to illuminate and annunciate. Push
silence button on alarm. If this does not stop the light, call maintenance.
9. A Power failure may cause the FIRE DOORS to close automatically and the alarm to
ring one time. This is a result of a voltage change.
ELECTRICAL SHUT OFF BY MAINTENANCE ONLY North Main Shut Off:
The electrical shut off is located in North Basement Boiler Room
Electrical room is on the right. Panel is on the right. Silver handle next to floor marked “Main”.
Pull to the right.
WATER EMERGENCY:
Boiler Failure:
There are 5 boilers located in North Basement Boiler Room. The Burnham boiler controls the
heat for common areas and office space. The other four boilers control the hot water for locations
throughout the North building. If any should fail the maintenance on call person should be
contacted. The director of Environmental Services, CEO/COO, Administrator and Director of
Nursing should be contacted in that order.
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Water Main Shut Off:
The main water valve is located in North Basement Boiler Room.
Straight ahead on the right. Green pipe with a black gate valve located approximately eight feet
off the floor marked with an orange tag.
The keys for the PIV (post indicator valve) are located in the maintenance supervisor’s office in
the North Building on top of box #4
To turn the valve off, turn handle counter clockwise until the stem of the valve is all of the way in. Do NOT over tighten North Fire Sprinkler Main Shut off:
The PIV (post indicator valve) for the front of the building is located on the grass area outside on
East Rhode Island Ave against the fence near the kitchen dumpster.
The PIV (post indicator valve) for the rear (Nursing/Assisted Living) of the building is located
on the grass area outside on East Rhode Island Ave near the generator.
Village House Fire Sprinkler Main Shut off:
Sprinkler valve is located in the Riser Room on right side of building past the gate arms near the
gas meter.
There are four vertical pipes. Going left to right:
1st pipe- 1st floor – 2nd pipe – attic – 3rd pipe – Chapel canopy – 4th pipe – 2nd floor
All valves have blue handles.
Garden Cottage Fire Sprinkler Main Shut off:
Sprinkler valve is located at the driveway entrance left hallway. Blue handle marked “Control
Valve”.
Parkview Apartments Fire Sprinkler Main Shut off:
Sprinkler valve is located at the right front corner of the building. Back wall left corner
approximately 5’ off the floor. Red valve marked Main Control”.
Woodlands Apartments Fire Sprinkler Main Wet System Shut off:
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Sprinkler valve is located in the Riser Room at the corner of Furth Lane and Van Dusen Way.
1st control valve blue handle – 1st, 2nd, 3rd floor wet system
2nd control valve blue handle – attic dry system
Woodlands Apartments Fire Sprinkler Main Dry System Shut off:
Sprinkler valve located ground floor stairwell 2:
Lower valve blue handle – attic
Upper valve blue handle – ground floor
Woodlands/Village House Fire booster pump:
Located at 508 East Maine Ave. Supplies added pressure to the sprinkler system. Large black
wheel marked “City Side Control”.
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Water Supply Interruption
Introduction: The community water supply may be interrupted in one of two ways; with or without notice and could affect the entire building. This procedure needs to be done in both cases.
Emergency Potable Water Supply
1. The community is equipped with a 500-gallon tank of potable water on site. The community will utilize potable water on site first along with all bottled water.
2. US FOODS OFFICE: 1-919-404-4117 3. FIRE DEPARTMENT: CAN ASSIST WITH POTABLE WATER
SUPPLY OR DIRECT TO A SITE
4. WATER DEPARTMENT: 692-2206
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WATER SUPPLY INTERRUPTION WITH NOTICE
This may occur due to announced repairs by the City Water Department or because of a building repair.
Announced City Repairs
1. Determine the estimated time for the interruption.
2. Notify administration and all departments.
3. Make arrangements with water suppliers if needed.
4. Arrange baths and showers to be completed before the scheduled shutdown
5. Fill bathtubs with water for cleaning and flushing toilets. Dietary is to fill all
available containers with cold water.
6. At the time of the interruption is to occur close the water off on the down stream
side of the back-flow preventer to eliminate contamination from entering the
system. Isolate the Domestic Hot Water Storage tanks by closing the supply and
distribution lines, close off all gas line to heaters and turn off their power.
Community Repairs
1. In house repairs typically would affect small clearly defined areas. Repairs may
affect only the hot or cold water. Water will be readily available in the unaffected
areas. Notification to the affected users and departments will be made as early as
possible.
2. If the water outage is caused by an internal building plumbing failure call the
plumbing contractor: Ben Franklin Plumbing: 420-0903 or Field’s Plumbing
& Heating 949-3232
WATER SUPPLY INTERRUPTION WITHOUT NOTICE This may occur as the result of a water main break in the area because of an accident (car into a fire hydrant) frost shear, or other unforeseen event.
Proceed too immediately:
o Notify maintenance staff.
o Activate Emergency Phone Tree for all Leadership
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o Do not use water from water heater, coffee pots, juice machines or pitchers until
administration staff has been notified.
o Make arrangements for delivery of potable water from emergency water supply
on site and commercial sources listed above.
o Use water sparingly from potable resources within the community.
o Maintenance with administration will contact the City Water Department to
determine the probable duration of the water interruption and will determine if it
is necessary to evacuate the community.
o Determine if personal laundry can be done, if not, contact Linen / Laundry supply
about making arrangements to send out personal laundry.
o When in doubt about the quality of the water, boil it for 15 minutes. This will kill
all pathogens and once cool the water can be used for drinking and cooking.
o If water is off throughout the building, call the Fire Department and ask that they
stand by. They can hook up to the sprinkler system to pump water in an
emergency. Make sure they understand you are not reporting a fire, just
requesting a standby.
Notify the Health Department of the loss of water supply.
1. Contract for providing Emergency Water Supply: US FOODS OFFICE: 1-919-404-4117 agree to provide emergency potable water supplies in the event of any type of water supply interruption at the community. There is a 500-gallon tank of potable water in receiving.
Method of Distributing Water:
o Maintenance will distribute non-potable water for toilet flushing o SNF staff and RAL staff will utilize potable water through normal
distribution policies. o Dietary staff to use potable water through normal distribution policies. o Apartment residents: will be supplied with potable drinking water
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Refrigeration Systems Failure
In the event of problems associated with freezer/ refrigeration units the following procedure is be followed. Procedure:
o Thermometers are to be placed in all freezer / refrigeration units at all times.
o Temperatures should be monitored daily by the cook on each shift and recorded
on the monthly logs provided by the dietitian.
o Problems in noticed temperature need to be brought to the attention of the Food
Service Director, Environmental Services Director, CEO/COO and Administrator.
Refrigerators not holding appropriate safe temperatures will be emptied into
existing refrigeration units within the kitchen.
o In case of long-term power or equipment failure US Food Service will be called to
provide a refrigerator truck, until the equipment is back in service.
Heat Systems Failure
1. First check all on off switches, located in each unit, for proper position.
2. Notify Maintenance Personnel and Environmental Service Director.
3. Notify CEO/COO and Administrator
4. Maintenance will contact Fields Plumbing & Heating in an emergency 949-3232.
Give detailed information of the problem.
5. If heating problems exist, CEO/COO or Designee will determine need for partial
evacuation out of effected area(s)
Sewage Problems
Noted below are operational guidelines in the event of sewage backup or sewage disposal system failure. Sewage Backup (Universal Precautions to be used)
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o Notify maintenance staff, they will then close off water supply to the affected area
to prevent further sewage spillage until repairs are made. Contain the sewage to
the smallest area possible. Notify the affected users of the line as to the problem
and the length of time it is to be down. Make repairs as required if needed use
community approved vendors. Notify the affected users when the area is ready to
be used again.
o Notify environmental services of the affected area that will then sanitize all
affected areas and surfaces as needed. All items that have come into contact with
sewage affluent that is single usage or that cannot be sanitized will be inventoried
and disposed appropriately. Notify the affected users when the area is ready to be
used again.
Sewage Disposal System Failure
1. The Environmental Service Director will determine the extent of the failure and the
length of time to repair. (Such as community sewer line failure or Public Works
Department problem etc.)
2. Determine the affected areas of the community and remaining bathing and toileting
facilities remaining in operation. The maintenance will contact the CEO/COO or person
in charge to inform them of the situation, also the affected departments, so they can
continue to care for residents in unaffected areas until repairs are completed.
3. In the event of a sewage disposal system failure, determination is made by the
administrator or person in charge that the care of residents and sanitation of the
community cannot be met, the community will be evacuated according to the Evacuation
Procedures.
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Resident Elopement/CODE PINK
(Missing Resident) Definition: Elopement refers to residents leaving the community without supervision or knowledge of The staff.
Introduction: Once it has been determined a resident appears to have left the community without Supervision or knowledge of the staff, the following procedure must be followed. These procedures assume that all supervisors and administration are out of the community. When supervisors or administration are in the community, they will coordinate the search. Procedure: Verify that the resident is not in the community by conducting a community search. The search will be coordinated by the unit manager for the section the resident is missing. 2-way radios are available for communication during a search. Each area is equipped with radios. Skilled Nursing:
1. The Charge nurse shall initiate the search of the entire skilled nursing unit.
2. The Charge nurse on the SNF Unit will page Code PINK
3. The Charge nurse shall notify RAL staff and to search the RAL unit, also notifying Home
Care at 370. Contact Home Care Staff with Name and description of resident. They will
assist search of independent living hallways, common areas, and inside apartments if
necessary.
4. Maintenance staff shall be notified to search all public areas of the apartment side
5. One staff person shall be assigned to remain on the hall, all others shall be assigned to
check the basement and outside. One person shall check towards the Apartments
and cottages, the second person checks the parking area, and the third person makes a
vehicle loop around the community.
6. The staff checking outside will check with the Charge nurse after 15 minutes, in the mean
time, inside staff should be checking every room, including bathrooms, closets, and usual
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non-access areas.
7. Staff should notify Charge nurse of inability to locate resident upon completion of their
search.
8. The charge nurse shall then contact the Administrator and Director of Nursing to report a
missing resident
9. After completion of ground and community search: The Charge nurse will contact the
family/responsible party. The charge nurse will also notify 911 of a missing resident.
The Charge Nurse will provide police with a complete description including clothes
worn, physical and behavioral characteristics and cognitive status.
10. After initial search, a new set of employees will repeat checks done in steps 4 and 5.
11. Incident report must be completed by the Charge Nurse. Upon finding resident the
12. Director of Nursing will notify the Administrator.
13. Begin to record as much information as possible. Include clothes the resident was last
seen in, who saw them last? Where they were last seen? What were they doing? Record
who was called and when. Add progress notes, times and other steps taken as the search
progresses. Record the information on an Incident Report Form and in the residents
Clinical Record.
14. Appropriate State reporting will be conducted within designated time frame.
RAL:
1. The Charge nurse or designated staff person shall initiate the search of the entire RAL
Unit.
2. If there is no Charge nurse on the unit, the RAL staff will initiate the search.
3. Page Code PINK
4. The designated staff shall notify SNF charge nurse to search the SNF unit, also notifying
Home Care at 370
5. Maintenance staff shall be notified to search all public areas of the apartment side
6. One staff person shall be assigned to remain on the Unit; all others shall be assigned to
check outside and the basement. One person shall check towards the apartments
and cottages, the second person checks the parking area, and the third person makes a
vehicle loop around the community. If there are not enough staff members on the unit to
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complete the above, SNF staff or any ancillary staff members (housekeeping, activities,
and maintenance) shall be informed of their responsibilities.
7. The staff checking outside will check with the Charge nurse or RAL Staff Person after 15
minutes, in the mean time, inside staff should be checking every room, including
bathrooms, closets, and usual non-access areas. The charge nurse / RAL Staff person
will notify RAL Director and the Administrator.
8. Staff should notify Charge nurse / RAL staff person of inability to locate resident upon
completion of their search.
9. Upon completion of ground and community search: Under the direction of the
Administrator of Designee: The Charge nurse / Department Director will contact the
family/responsible party. The charge nurse, or RAL staff person will also notify 911 of a
missing resident. The Charge Nurse / RAL staff person will provide police with a
complete description including clothes worn, physical and behavioral characteristics and
cognitive status.
10. After initial search, a new set of employees will repeat checks done in steps 4 and 5.
11. Incident report must be completed by the Charge Nurse / or RAL staff person.
12. Upon finding resident the Director of RAL will notify the Administrator.
13. Begin to record as much information as possible. Include clothes the resident was last
seen in, who saw them last? Where they were last seen? What were they doing? Record
who was called and when. Add progress notes, times and other steps taken as
the search progresses. Record the information on an Incident Report Form and in the
residents Clinical Record.
14. Appropriate State reporting will be conducted within designated time frame.
Garden Cottage:
1. Garden Cottage staff will initiate the search of the entire units. Page Code PINK. This
includes every bedroom, bathroom, and closet. If it is unknown where the resident exited
the unit, the search will begin on the apartment side of the community checking hallways,
stairwells, restrooms, ground level apartments and meeting rooms.
2. Garden Cottage staff will notify the maintenance staff to initiate the search.
3. RAL, SNF and Home Care will be notified at 370.Units will be notified and provide
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additional staff to search if necessary.
4. Contact Administrator and DON
5. Maintenance and all available Garden Cottage staff members will check outside. One
person shall check towards the apartments and cottages, the second person checks
parking area, and the third person makes a vehicle loop around the community if there are
not enough staff members on the unit to complete the above, SNF staff or any ancillary
staff members (housekeeping, activities, maintenance) shall be informed of their
responsibilities.
6. The staff checking outside will check with the Garden Cottage Staff after 15 minutes, in
the mean time, inside staff should be checking every room, including bathrooms, closets,
and usual non-access areas. The Garden Cottage Staff shall contact the Unit Director.
The Unit Director will contact the Administrator.
7. Staff should notify staff person of inability to locate resident upon completion of their
search.
8. The Unit director will contact the family/responsible party.
9. The Garden Cottage staff will contact 911 and notify them of a missing resident. The
staff person will provide police with a complete description including clothes worn,
physical and behavioral characteristics and cognitive status.
10. After initial search, another set of employees shall be sent to repeat step 4 and 5.
11. Unit director to contact CEO/COO when resident is found.
12. Incident report must be completed by Unit Director. Appropriate State reporting will be
conducted within designated time frame.
Resident fails to return from a Leave of Absence
1. If a resident does not return at the scheduled leave of absence and gives no notice of an
intent to return to the community, the following protocol should be initiated:
2. Two hours after the expected return time, the unit manager will contact the family or
responsible party who took the resident, or legal guardian.
3. If the family, responsible party or legal guardian who took the resident, cannot be
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reached, the unit manager will notify the Administrator and the Director of Nursing,
follow the elopement procedures listed above.
4. If it is determined that the resident has not been returned to the community, and no
further communication is occurred with resident, family or guardian, a notification to the
police will take place and appropriate state notifications will be initiated.
Code Alert & Code Lock:
The community has a Code Alert wandering resident system. It utilizes transmitter bracelets
attached to residents determined to be at risk of eloping. The transmitters will be detected when a
resident pass through a door protected by a Code Alert sensor. Once detected, an alarm is
sounded at the door-passed through and via pager system. Staff is to react immediately to an
alarm / received page to locate the resident which has left, then reset the alarm.
In, addition the wandering system some doors are equipped with a Code Lock. Which
magnetically holds the door closed unless released by the fire alarm or is bypassed with a preset
code. Staff is to react immediately to an alarm to locate the resident which has left, then reset the
alarm.
Code Alert Locations
o RAL main entrance
o SNF elevator (no code lock)
o RAL / Apartment Double Doors
o All stairwell doors on Health Care Side
o Garden Cottage Entrances
o Garden Cottage Emergency Exits
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Environmental Air Releases (EAR)
Purpose: To protect and minimize the exposure of residents, visitors, and staff in case of a
chemical air release.
Procedure:
Upon notification of a chemical air release the person in authority will activate this policy.
1. The Skilled Nursing unit manager or highest licensed staff person will:
2. Immediately assign someone from maintenance to shut down all air handling systems.
Direct staff members to close all windows and doors, including those in the support
departments work areas.
3. Activate the emergency treatment area and supplies.
4. Assign a staff person to lock each exterior door and seal it with tape. The staff member
will be required to stay at the door.
5. Upon hearing all staff will report to their respective nurses' station for assignments by the
unit managers. Ancillary staff (administrative, housekeeping, maintenance, activities)
will report to RAL office or SNF Nurses station.
6. All residents, visitors and staff will be notified that they are not to leave the community,
because of a chemical air release in the area.
7. Anyone seeking entrance to the community should be directed to the emergency
treatment area.
8. Complete the Check List in the Emergency Preparedness Manual.
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EAR Checklist
Charge Person Date Time 1.) Activate EAR Procedures. 2.) Page EAR twice on the paging system. 3.) Direct the staff. 4.) Obtain supplies for the treatment room, have full Oxygen cylinders on stand by, use the Emergency Preparedness Manual Checklists. 5.) Notify Administration if needs are identified. 6.) Inform residents, visitor, and staff they are not to leave the community. Staff Assignments 1.) Shut down all ventilation units and close windows and doors. 2.) Staff assigned to all entrances to seal doors and monitor exits.
3.) Staff assigned to answer telephone and telephone alert list. 4.) Remaining staff to return to work areas to continue to provide care and
services to residents. Remain alert for updated information. All Clear Notification 1.) A senior charge person will page �EAR All Clear when given
instructions by the Administrative staff. 2.) Staff will turn on all ventilation units and open all doors. 3.) Staff will remove all tape used to seal doors. 4.) Inform residents, visitors, and staff it is now safe to leave the community. 5.) Complete forms and notes for the emergency for later review.
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Bomb Threats
Policy: The community will follow established procedures in case of a bomb threat.
A bomb threat against the community may be received by telephone, mail, E-mail, packages or
messages anytime. Preserve any documents / packages believed to be a threat for the Police
investigators. Telephone threats may be received at the resident services, offices, public
telephones on the property, or may be directed to the home phones of staff. Any staff receiving a
bomb threat should make every attempt to follow the procedure outlined below. Always take a
bomb threat seriously.
Telephone Threats:
The employee answering the telephone call which consists of a bomb threat should:
1. Remain on the line.
2. Immediately have someone call the police at 911. Upon finishing 911 call contact
CEO/COO, Administrator, Environmental Service Director, and Director of Nursing.
3. Try to keep the caller on the line by talking and recording anything they ask.
COMPLETE BOMB CHECKLIST (SEE INSERT)
Record on paper the exact words used by the caller. Record exact time call was received.
Describe the caller's voice: male, female, young, middle aged, old. Identify accent, background
noise or if voice is familiar.
The employee calling the police should:
1. Explain that the staff has been trained to follow a bomb procedure.
2. Remain on the line with the police. (They may plan an alternate plan of action, if
circumstances become complex.)
3. If not, continue the sequence that follows:
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o Once police have been notified, use overhead paging system Announce Code
Yellow All employees should respond to the announcement by meeting at the
Assisted Living Office or Skilled Nurses station for a briefing and further
instructions.
4. If a bomb has been located, evacuate residents and visitor from the immediate area.
Known Bomb Location:
The person in charge should coordinate all available staff to initiate the evacuation of residents,
visitors and staff. When evacuating the community always remember:
1. Only staff and emergency service agencies should perform the evacuation.
2. No one will touch or disturb the bomb or suspicious object.
3. Staff should transfer residents in a calm and orderly manner.
4. Post guards at all entrances of the bomb area, only permit members of the community
staff or emergency services to enter.
5. All radios, paging, public address, and cellular phones will be turned off. Staff members
will be assigned to bring messages to and from the command center and search teams.
Detonation:
In case of a denotation with or without warning, the situation will be handled as any other
disaster. Police. Fire and Emergency Services procedures will be initiated immediately.
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employment or agency relationship, while on property or while acting as a representative.
o A threat or threatening behavior may consist of words or actions that create a perception that there may be intent to harm persons or property, or actions or words that actually bring about harm.
o A threat can be explicit or implied.
o A threat can be the result of verbal, written or non-verbal actions.
o Statements made in the guise of a joke may be considered threatening in
appropriate circumstances. Examples of threats include but are not limited to:
o Verbal or written statements that express intent to harm another person. o Comments such as “you’ll get yours” or statements that acts of violence may
occur here or in other workplaces.
o Gestures implying that physical contact will be used, such as gestures of punching, choking, stabbing or shooting someone with a gun.
o Possessing a weapon in the workplace or on property.
will not retaliate against any colleague who makes a good faith allegation of violence in
the workplace. Any colleague who feels that he or she has been subjected to retaliation as a result of filing a complaint or cooperating in an investigation should contact an on-site Human Resources. These examples are not all-inclusive; they are merely to assist the reader in understanding what behavior is prohibited and what may be construed to be threatening behavior in appropriate circumstances. Actual physical violence is the unwanted touching of a person or their possessions with an intent to create fear or harm, or which does create fear or harm. An act may constitute physical violence even if no injury or harm occurs. The use of an object to cause unwanted touching may also constitute physical violence. Colleagues should notify their supervisor of any threats, which they have witnessed, received, or has been told that another person has witnessed or received. Colleagues may also immediately contact Human Resources, any supervisor or manager who is advised of a threat or threatening behavior must contact Human Resources. In appropriate circumstances, as determined at the sole discretion of the Human Resources
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Department, a colleague against whom a complaint is made may be suspended pending the outcome of an investigation. Any employee found to have engaged in threatening or violent behavior will be subject to disciplinary action up to and including termination. Any colleague who fails to cooperate in an investigation is subject to disciplinary action up to and including termination. All investigations will be handled in as discreet and confidential fashion as possible. No person will be adversely affected in employment as a result of bringing complaints or participating in an investigation under this policy. Any colleague found making false accusations (subsequent to the investigation) is subject to discipline up to and including immediate termination. Hostage Situation
Policy: The community will follow established procedures in case of Hostage Situation Procedure:
o Any person made aware of a Hostage situation must do the following. The three
types of hostage threats ate: Phone call, written document, or physical.
o Immediately call the police at 911. Have someone notify the administrator or person
in charge, of the situation.
o Remain calm, take no threatening actions against the individual holding a hostage.
o Let the individual know if someone is expected to arrive. Such as a shift change,
Ambulance arrival etc. To avoid startling the individual.
o Ask what the individual wants?
o Is there someone they would like to call or speak with?
o Is there something they would like food, drink etc.?
o Ensure notification of CEO/COO, Director of Environmental Services and
Administrator.
o Upon the arrival of the Police Officers brief them of the current situation, location of
the individual, person/s being held and any notes or actions taken to this point. Police
will provide direction upon their arrival.
o Reassure staff and residents.
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Active Shooter: PURPOSE: To supply training and guidance to our colleagues in planning for, preventing,
responding to, and recovering from an active shooter/hostage incident.
DEFINITION:
Active Shooter will be announced when any person threatens with a weapon or holds another
person(s) against their will.
An Active Shooter is an individual actively engaged in killing or attempting to kill people in a
confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern
or method to their selection of victims. Active shooter situations are unpredictable and evolve
quickly. Typically, the immediate deployment of law enforcement is required to stop the shooting
and mitigate harm to victims. Because active shooter situations are often over within 10 to 15
minutes, before law enforcement arrives on the scene, individuals must be prepared both
mentally and physically to deal with an active shooter situation.
Hostage taking involves the act of securing total control over another human-being. Hostage
incidents usually involve people who are in conflict with the law, who feel themselves aggrieved,
or who are mentally ill. Hostage-taking is a criminal offense and must be reported to the police.
Immediately upon arrival, the local Police Department shall assume full responsibility for the
investigation and resolution of the situation. It is imperative, for all colleagues to be aware of this
fact, for once the police arrive on the scene, all colleagues are to submit to their authority and
extend to them their fullest cooperation.
PROCEDURE:
To maximize security measures for an active shooter/hostage crisis situation, the community has
established guidelines, conducts training in new hire orientation as well as annually conducts
training and simulations to effectively prepare to respond and help minimize loss of life. The
Incident Command team is appointed and trained to manage the situation until local authorities
arrive. An All Hazards Emergency Operations Plan is developed to respond immediately to
unexpected adverse events.
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Active Shooter Outside of the Building: Near Campus Response
a) If notification of an individual(s) displaying or using a weapon and/or a hostage situation
near campus occurs by way of local authorities immediately notify the
CEO/COO/Administrator. Report your name, describe the situation (location, subject,
weapons etc.) and remain calm.
b) If observation is made of an individual(s) displaying or using a weapon and/or a hostage
situation near campus call 9-911 and if possible designate a nearby colleague to
immediately notify the CEO/COO /Administrator and Safety Officer. Report your name,
describe the situation (location, subject, weapons etc.) and remain calm.
c) Incident Command System is initiated and all officers report to the VH Conference room
and utilize the All Hazards Emergency Set-up. Incident Command team will assess the
situation and determine whether to enact a Shelter in Place directive.
d) If a determination is made to Shelter in Place, lockdown of the community is initiated
ensuring all points of entry are sealed until the "ALL CLEAR" is called. Including the
following:
• Main Entrance – Resident Services
• North Entrance – Administrator or Staff
• South Entrance- Housekeeping
• Receiving Entrance – Maintenance Staff
• Assisted Living Entrance – Director or Assisted Living Staff
• Garden Cottage- Colleague
• Food Service Entrance – Dining Staff
e) If a determination is made to Shelter in Place, all colleagues and residents are to lock
down department, closing all doors and locking if possible. Turn off lights in the room(s)
and close window shades. Advise all residents and visitors to remain within the secured
area and continue to Shelter in Place.
f) The Incident Command team will ensure staff is updated regarding the situation as it
progresses and call an "ALL CLEAR" if the Shelter in Place procedure is enacted.
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Active Shooter Outside of the Building: On the Campus Response
a) Upon observing an individual(s) displaying or using a weapon and/or a hostage situation
call 9-911 and if possible designate a nearby colleague to dial ext. To alert the Command
Center on Skilled Nursing. Report your name, describe the situation (location, subject,
weapons etc.) and remain calm.
b) The command center will immediately complete the following:
• Notify Police Immediately
• Overhead Page – ACTIVE SHOOTER OUTSIDE OF THE BUILDING
three times and every 10 minutes until the ALL CLEAR is given from the
Incident Commander.
c) Incident Command System is initiated and all officers report to the Maintenance Shop
and utilize the All Hazards Emergency Set-up. Incident Command team will attempt to
alert inbound residents.
d) Lockdown of the community is initiated ensuring all points of entry are sealed until the
"ALL CLEAR" is called. Including the following:
• Main Entrance – Resident Services
• North Entrance – Administrator or Staff
• South Entrance-
• Receiving Entrance – Maintenance Staff
• Assisted Living Entrance – Director or Assisted Living Staff
• Garden Cottage-
• Food Service Entrance – Dining Staff
e) All colleagues and residents are to Shelter in Place. Shelter in Place is to lock down
department, closing all doors and locking if possible. Turn off lights in the room(s) and
close window shades.
f) Advise all residents and visitors to remain within the secured area and continue to Shelter
in Place.
g) All colleagues are to listen for additional overhead page announcements and follow
procedures after announcements are made.
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h) Only local law enforcement will respond and neutralize the offender
i) All colleagues are to wait for "ALL CLEAR" before resuming normal operations.
j) Once the "ACTIVE SHOOTER ALL CLEAR" is called the Incident Command Team is
to engage in their Disaster Protocol.
Active Shooter Inside of the Building: Inside the Community Response
a) Upon observing an individual(s) displaying or using a weapon and/or a hostage situation
call 9-911 and if possible designate a nearby colleague to dial ext. 388to alert the
Command Center on Skilled Nursing. Report your name, describe the situation (location,
subject, weapons etc.) and remain calm. If the Skilled Nursing Command Center is
compromised contact the front desk at ext. 388 and initiate the activation button and
command notification.
b) The command center will immediately complete the following:
• Notify Police Immediately
c) Colleagues located near the ACTIVE SHOOTER "LOCATION" shall make every
reasonable attempt to assist residents and visitors in a department evacuation. If
colleagues and residents evacuate and the North Parking Lot has been designated as safe,
it will serve as the Assembly Area to wait for further instruction.
d) In some cases it may be necessary to close and lock doors to resident rooms or areas to
allow to Shelter in Place. Silence all devices such as pagers and telephones. If evacuation
is not possible, help residents, visitors and staff find a place to hide that the shooter is not
likely to find. Hiding Spots should:
• Be out of the shooter/hostage taker's view
• Provide protection if shots are fired in your direction
• Not trap or restrict your options
e) Once in a safe place call 9-911 to report the active shooter/hostage taker and your
location. If you cannot speak, leave the line open and allow the dispatcher to listen.
f) All colleagues are to listen for additional overhead page announcements and follow
procedures after announcements are made.
g) Only local law enforcement will respond and neutralize the offender. All associates are to
follow the instructions of the local law enforcement.
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h) All colleagues are to wait for "ACTIVE SHOOTER ALL CLEAR" before resuming
normal operations.
i) Once the "ACTIVE SHOOTER ALL CLEAR" is called the Incident Command Team is
to engage in their Disaster Protocol.
Hazard Communication Program
Purpose: will furnish employees with a place of employment which is free from
recognized hazards that are causing, or likely to cause, death or serious physical harm to the
employees, has implemented the following procedures in compliance with Right –to Know (Act
154) and the Federal Hazard Communication Standard.
Safety Data Sheets:
This law provides for specific employee rights. They include:
1. The right to be notified (by employer posting) of the location of Safety Data Sheets, (SDS)
2. The right to be notified (by employer posting) of new or revised Safety Data Sheets, (SDS)
3. Employees have the right to request Safety Data Sheets from their employer.
Procedures
1. For each chemical, the chemical manufacturer or wait staff/tray line shall determine the
hazard class, and where appropriate, the category for each class that apply to the chemical
being classified. This information will be placed in the Safety Data Sheet / Data Sheet and
on all product labels.
2. relies on the SDS’s from suppliers to meet the hazard determination requirements.
The following people are responsible for obtaining SDS’s on all new or revised hazardous
chemicals: Central Supply Coordinator, Dietary Manager or Designee and Environmental
Services Director.
3. A Chemical Inventory Log and copies of SDS for all hazardous chemicals will be kept in a
Yellow Note Binder labeled Material Safety Data Sheets located at the following locations:
• Skilled Nursing Nurses station 2
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• RAL
• Garden Cottage
• Administration
• Housekeeping
• Salons
• Apartment buildings
• Dietary Department
• Environmental Services Office
4. SDS’s will be available for review to all employees during each work shift.
5. All labels will be checked for:
o Product identifier
o Signal word
o Hazard Statement(s)
o Pictogram(s)
o Precautionary Statement(s)
o Name, address, and telephone number of the chemical manufacturer, imwait staff/tray
line, or other party
6. Required SDS Signage is located in the Employee Break Room. They indicate the location
of the Safety Data Sheets and notify employees of new or revised SDS’s.
7. At no time shall any label be removed or defaced on containers of hazardous chemicals.
8. If the chemical is to be put into another container, the employee doing so must properly label
the transfer container with the identity of the hazardous chemical’(s) and appropriate hazard
warnings.
9. In the event that a task required of employees that is non-routine, such as a chemical spill
cleanup, the use of a new chemical/or product, the procedures need to complete that task
shall be evaluated by the Safety Officer and the Safety Committee. The affected employees
will be notified of the hazards and required personal protective measures by their department
manager.
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10. Contractors will be informed of the location of the SDS’s. In the event that a contractor
employee’(s) will be working in an area were chemical hazards exist, the Safety Officer will
notify the contractor of chemical hazards and advise on the appropriate protective measures.
11. Contractors will provide with appropriate SDS’s on any chemical used on the
premises, upon request.
12. Employees shall be provided with training which covers the following:
o The requirements set forth in the OSHA Right –to know requirement (Act 154).
This training is conducted at General Orientation for all new staff as well as
annually each year. Staff members are required to attend training on Hazard
Communication at least once each year.
o The location and availability of the written Hazard Communication Program,
including the required list of hazardous chemicals, and SDS’s.
o Methods and observations that may be used to detect the presence or release of a
hazardous chemical in the work area.
o The physical and health hazards of the chemicals in the work area.
o The control measures that employees can take to protect themselves from these
hazards.
o An explanation of the labeling system.
o How to use the Safety Sheets
o Safe Handling and storage of hazardous chemicals.
o Spill response procedures.
12. Additional training by the department manager or designee shall be provided before a new
hazardous chemical or replacement chemical is introduced into the area.
Safety Data Sheets
Purpose:
To give employees information about the products which they are exposed too in the workplace
during their normal daily routines. The sheets contain information relating to exposure limits,
health issues, safety equipment requirements, reactivity with other products and fire fighting
requirements along with other information.
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Procedure:
1.) Any person who has the authority to purchase products, receive samples etc. Will be
required to have a current copy of the product SDS sheet before ordering or receiving a
new product.
2.) A new SDS sheet will be forwarded to the Environmental Service Director for review
and distribution to all SDS books in the community. It will also be posted in the
Employee Break room as required.
3.) All staff that will be using a new product will be shown the SDS sheet for the product
and be informed of its location in the SDS binder prior to using the chemical.
4.) SDS sheets for products which have been removed from approved purchasing lists
and inventories depleted will be removed from the SDS binder and kept on file in the
maintenance office indefinitely.
5.) The safety committee will review the SDS binder annually to ensure compliance.
Product Labels
All products which require a SDS sheet in the community, should remain in their original labeled
container or have a proper manufacturer label on the container to which it has been transferred
into.
Personal Protective Equipment
1.) The community will provide all necessary protective equipment to staff required to
safely handle products and limit exposure during their normal use.
2.) Departmental Supervisors will determine the policies to be used when handling
products and provide the proper equipment by referring to the SDS sheet for the product.
3.) Employees will use the appropriate provided safety equipment when handling
products and will follow established procedures during use.
Chemicals and Hazardous Material Locations
The following is a general list of potential types of products or hazardous materials that are
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stored and used in the community by various departments. It lists the storage area, location and
potential products which may be encountered.
Central Supply Room: Located in receiving hallway Ground Level Health care
• Ready to use Personal Care Items
• Medical Supplies
• Office Supply Chemicals
Nursing / Assisted Living:
• Ready to use housekeeping chemicals: Shower Room / Storage Closets / Housekeeping
Carts
• Ready to use housekeeping chemicals: Rehab Room
• Ready to use housekeeping chemicals: Activity rooms
Maintenance / Environmental Services: Located in Receiving Hallway Ground Level
Health Care
• Concentrated and Ready to use Housekeeping/ Laundry Chemicals HSKP Room
• Paints (Oil and Latex) Maintenance Shop
• Various Lubricants Maintenance Shop
• Various Adhesives Maintenance Shop
Dietary Ground Level Health Care
• Concentrated Washing Chemicals Dietary Dept
• Ready to use Housekeeping Chemicals Dietary Dept.
Laundry Processing Ground Level Health Care
• Concentrated Laundry Processing Chemicals Laundry Room
• Ready to use Housekeeping Chemicals Housekeeping Room
Bio-Hazardous Waste Disposal Locations
Sharp Containers
o SNF / Assisted Living / Garden Cottage Resident Bathrooms
o Soiled Utility Rooms & Shower Rooms
o Specified Resident Rooms
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o Medication Carts: Assisted Living
o Medical Office: Garden Cottage
o Dietary
o Laundry
Sharps Collection Site: Trash Room Ground Level Health Care
Sharps are disposed of by authorized maintenance personnel only. When sharps container is full,
contact the maintenance department for proper disposal
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RESIDENT DEATH
Skilled Nursing
o Protocols specific to response of resident that has expired directly correlates to the
Treatment Directive Protocol for each resident.
o Residents requesting aggressive treatment (Code) immediately contact 911.
o Residents DNR status should be immediately reviewed. If resident is FULL Code, Staff
will initiate CPR
o The Charge Nurse or designated representative shall immediately notify the resident’s
responsible party or designated representative and the attending physician.
o The Unit Manager will pronounce the resident as expired.
o If resident is under Hospice care: Contact Hospice.
o The designated funeral home or mortician will be notified.
o If no funeral home is designated, community will provide necessary assistance in
transferring remains to appropriate location.
If the death appears to be a suicide: The charge nurse will notify the Director of Nursing and Administrator immediately.
The Administrator or designated representative will:
o Initiate all above noted steps
o Contact the sheriff or police department.
o Contact the Medical Director
o Contact the Immediate Supervisor
The Charge nurse will provide a complete signed record of all the notifications made, including
the names of the persons notified and the times of the notification.
Assisted Living Should a resident in the Assisted Living expire, staff will:
o Call 911 (Residents under Hospice care: Hospice notification made first)
o Determine if resident has active DNR, if NO initiate CPR
o staff will contact the Director
o Director or designated representative will notify the physician, family/responsible
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party, funeral home, and CEO/COO.
1. If the resident has expired in their room, resident shall remain in the room, unmoved,
until EMS, Sheriff and or Coroner has arrived.
2. If the resident has expired outside of their room, the resident shall not be moved. Other
residents may be redirected out of site if possible. A privacy screen shall be brought to
the area and the resident shall be screen from view of other residents until EMS, Sheriff,
and or Coroner has arrived.
3. Resident is to remain clothed as found and personal effects untouched.
4. The sheriff and/or Coroner will give further instruction to staff as to when resident's body
can be released to the family and funeral home.
5. Assist family as needed, with collecting personal effects, provide support to family.
6. The following documentation shall be completed by Charge nurse or designated RAL
staff person:
o Incident report
o Personal Care Notes
Garden Cottage:
Should a resident in the Garden Cottage Unit expire, staff will:
o Call 911 (Residents under Hospice care: Hospice notification made first)
o Determine if resident has active DNR, if NO initiate CPR
o Staff will contact the Director of Garden Cottage.
o Garden Cottage director or designated representative will notify the physician,
family/responsible party, funeral home, and CEO/COO.
1. If the resident has expired in their room, resident shall remain in the room, unmoved,
until EMS, Sheriff and or Coroner has arrived.
2. If the resident has expired outside of their room, the resident shall not be moved. Other
residents may be redirected out of site if possible. A privacy screen shall be brought to
the area and the resident shall be screen from view of other residents until EMS, Sheriff,
and or Coroner has arrived.
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3. Resident is to remain clothed as found and personal effects untouched.
4. The sheriff and/or Coroner will give further instruction to staff as to when resident's body
can be released to the family and funeral home.
5. Assist family as needed, with collecting personal effects, provide support to family.
6. The following documentation shall be completed by Charge nurse or designated Garden
Cottage staff person:
o Incident report
o Personal Care Notes
7. Notification to appropriate licensing consultant to take place by Licensee or
Administrator.
Independent Living
In the event that a resident of IL should be found in their home having expired, the
following steps should be followed:
o Call 911
o Do not move the body or anything in the apartment
o Contact the maintenance department
o The Sheriff will determine if the coroner is to be called.
Leadership responsibilities:
o Leadership staff / Private Duty staff to give emergency contact information to
Sheriff so Sheriff can contact family member.
o Check home to be sure that no appliances or electrical equipment have been left
on.
o Secure the room until the coroner arrives.
o Locate the Emergency Information Sheet on the resident
o Notify CEO/COO
8. The family is informed that the resident was discovered, that the death had occurred some
time recently, and that the Sheriff and or Coroner has been notified and that the funeral
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home should be notified.
9. Upon removal of body: Request name of Coroner, Funeral Home.
10. Following removal, secure apartment, turn off lights and lock apartment.
PRESS POLICY
Purpose: To be prepared and knowledgeable in handling situations involving media at the community. Procedure: The following procedure shall be instituted in situations involving media coverage at the community: In the event of a disaster, emergency, accident, or any other event:
1. The CEO/COO shall be notified by staff on duty (any staff member).
2. The CEO/COO will instruct staff on responding to media issues.
3. The CEO/COO will designate the appropriate person to handle Media.
Rules of Confidentiality must be observed at all times. Any personal or medical information regarding the resident cannot be released without their written permission. Media statements will be directed by the CEO/COO In an actual disaster or accident, the Fire Chief, Fire Marshall, or Police may be called in. When these individuals arrive at the scene, allow them to make any official statements. They are aware of the limits set by protocol in such instances and are skilled in handling media questions.
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Bed Bug Protocol In the event that any location is concerned about possibility of a bed bug infestation, the
following procedure will be used for detection and appropriate management of any bed bug
infestation.
1. Contact Maintenance to evaluate the location. Conduct announcement in a confidential
matter.
2. Maintenance to evaluate the situation. If further evaluation is needed or suspicion is
noted, contact Director of Environmental Services.
3. Environmental Services director will contact COO and other relevant community staff.
4. Keep all residents and associates out of room with noted suspicion if possible.
5. Maintenance staff to call for emergency visit by licensed Pest Control contractor.
6. Prepare plan to temporarily relocate resident(s) affected.
7. Confirmed cases of bed bugs: Maintenance will provide full protective suite and PPE for
staff to be able to enter the room.
8. Maintenance staff will bag all belongings for appropriate process to remove all bed bugs.
9. Maintenance will instruct all staff on procedures for entering and exiting room
10. Affected residents in the health center areas will have responsible parties informed of
infestation and plan.
11. The community will work with designated Pest Control Contractor to develop
appropriate plan for removal of bed bugs.
