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1 CRMC DIALYSIS ORIENTATION FOR NEW STAFF 2 Objectives To discuss and complete first day safety & first day orientation to the department To familiarize new staff on unit lay out Describe unit specific policies & procedures Review HR policies related to job. 3 FIRST DAY SAFETY ORIENTATION CHECK OFF LIST COMPETENCY EVALUATION Employee Name: Employee # Department: Date: Supervisor/Manager/Director: Cal OSHA mandates that all employees new to your area be oriented to specific safety requirements and procedures related to their work area. It is your responsibility to ensure that employees are presented with safety information and can demonstrate that they understand this information. Employees are not permitted to perform any duties until this material has been reviewed with them. Please have the employee initial in the space provided after the employee demonstrates they have understood the information presented. THIS FORM MUST BE RETURNED TO HUMAN RESOURCES FOR INCLUSION IN THE EMPLOYEES FILE WITHIN THE FIRST 48 HOURS OF THEIR FIRST DAY. 4 First Day Safety LOCATE AND VERBALIZE AN

UNDERSTANDING OF: FIRE (Code Red) MANAGEMENT: Employee Initials 1. Code Red Procedure (RACE) 2. Nearest fire alarm pull stations, and instruction for use 3. Nearest fire extinguisher, and instruction for use (P.A.S.S.) 4. Disaster Reference Guide 5. Evacuation Plan (Area Specific) 6. Location of Designated Smoking Areas EMERGENCY/DISASTER (Code Triage) MANAGEMENT: 1. Code TriageInternal Response 2. Code TriageExternal Response 3. Department specific role during a Code Triage 4. Call Back System (Employee phone number included) Rev. 01.14.16 5. Location of emergency/disaster equipment/supplies 6. Emergency Phone Numbers 5 First Day Safety EQUIPMENT MANAGEMENT (SMDA): Electrical safety inspection of new equipment 2. Personal electrical equipment 3. Reporting an equipment

problem 4. Reporting of patient incidents involving equipment 5. Emergency procedures if equipment fails UTILITY MANAGEMENT: 1. Reporting of problem with a utility 2. Red Outlets/Emergency Power 3. Med gas shut off procedure (What, Why, When, Who, How?) (Note: Clinical Supervisors, Managers, Hospital Supervisor, Respiratory Therapists, Plant Services, and Anesthesiologists need to complete a separate competency on Med Gas Shut Off Procedure) 4. Pneumatic Tube System Training 6 HAZARDOUS MATERIAL & WASTE MANAGEMENT: 1. Code Orange Response 2. Location of the Safety Data Sheet (SDS) 3. Review a SDS 4. When to use a SDS 5. List of chemicals used in work area, and Personal Protective Equipment (PPE) requirements 6. Disposal of RCRA

pharmaceutical waste 7. Disposal of regular pharmaceutical waste Rev. 01.14.16 8. Disposal of Chemotherapeutic Waste (Trace versus Bulk) 9. Disposal of sharps 7 SAFETY MANAGEMENT: Safety Policies and Expectation 2. Safe Patient Handling/Body mechanics (lifting techniques) 3. Location of mechanical aids for lifting and/or transporting patients 4. Forms and procedure for On the Job Injury reporting 5. Review response for blood borne pathogen exposure 6. Location of 1st aid kit, if applicable 1. 7. Unit safety issues and process to prevent injury 8. Location and use of refrigerators (medication, pt food, employee food) 9. Role in a Code Blue & crash cart location 10. Role in a Code White Neonate & crash cart location 11. Role in a Code White

Pediatric & crash cart location 12. Radiation Safety, if applicable 13. Laser Safety, if applicable 8 SECURITY MANAGEMENT: 1. Unit specific security risks 2. Contacting Security 3. Response during a security incident 4. Code Pink response (Infant Abduction) 5. Code Purple response (Pediatric Abduction) 6. Code Green response (Patient Elopement) 7. Code Yellow response (Bomb Threat) 8. Code Silver response (Person w/ weapon) 9. Discuss Run, Hide, Fight options during a Code Silver event 9. Code Gray response (Combative person) 9 Disaster Reference Guide 10 INFECTION CONTROL/BLOOD BORN PATHOGEN MANAGEMENT:

1. Hand washing procedures & expectation 2. How to follow Standard Precautions 3. How to follow Respiratory Droplet Precautions 4. How to follow Contact Isolation Precautions 5. TB Fit Test 6. PAPR use 7. Disposal and handling of Biohazardous Waste and Sharps 8. Use of negative air flow rooms 11 NEW EMPLOYEE ORIENTATION TO DEPARTMENT 1. Working Hours Explain the starting and ending times, lunch and break periods, and the total number of hours expected to work per pay period; and if necessary, that the shift and/or number of hours may be changed to meet staffing needs. 2. Time and Attendance Explain the time and attendance system and the clocking procedures. Provide specific instructions on clock codes applicable to your employees needs. Explain exempt clocking to exempt employees. Also explain the procedures for correcting clocking errors. Emphasize that employees must never clock for another person nor allow anyone to clock for them. Inform them that falsification of the time record may result in immediate dismissal. 3. Pay Schedule and Pay Rate Tell employee the hourly pay rate of their job with the minimum and maximum salary range

for the position. Explain employees bi-weekly pay schedule and pay check delivery policy. Explain the 8/80 hour option (i.e., employee will be paid overtime at a rate of time and a half over 8 hours in any one day and for all hours worked over 80 in a consecutive 14 day pay period). Explain that all overtime must be authorized in advance by the supervisor. 4. Benefits Notify benefit eligible employees that a benefits packet will be sent to them Encourage the employee to come to you with any questions regarding benefits and advise the employee that they may also consult Human Resources. 12 NEW EMPLOYEE ORIENTATION TO DEPARTMENT 5. Introductory Period Explain that the introductory period ends after 90 days of employment for non-exempt employees and 180 days for Registered Nurses and exempt employees, but may be extended for justifiable reasons. Discuss that during this time the employee is to become acquainted with their position and the organization. If at any time during the introductory period an exempt employee feels they do not wish to continue employment, they will be expected to give two weeks notice. If we feel that the employee is not going to adjust to our work group for any reason, the employee will be terminated. Upon completion of the introductory period, the employee will be considered a regular employee.

6. Education and Training Explain that the Corporation strives to maintain a continuing education environment. Relevant educational programs and meetings will be scheduled which the employee will be encouraged to attend. 7. Employee Identification Badges Remind the employee that it is the organizations policy that all employees must wear their ID at all times while on company property. Employees need their badges for obtaining employee discounts; prescriptions filled in the hospital Pharmacy, and during time of disaster or disaster drills. . 13 NEW EMPLOYEE ORIENTATION TO DEPARTMENT 8. Annual Performance Annual performance reviews will be done on the anniversary of their hire date, with the exception of Managers and Directors who are reviewed annually in October. Be sure to let the employee know who will be responsible for conducting the performance review. Explain the organizations competency and market systems. 9. Complaints and Grievances Explain that if the employee has a misunderstanding or complaint, he/she should first discuss it with their supervisor/manager. If it is not settled at this level,

encourage the employee to discuss it with their director. If it is not settled at this level, encourage the employee to use the grievance procedure outlined in the Employee Handbook. Review the entire grievance procedure with the new employee. Human Resources will assist in the resolution of complaints and explanation of the grievance procedures. 10. Important Data Ask employee to be sure to inform their supervisor/manager and Human Resources immediately of any change of name, address, telephone number, license renewal, or marital status. A change in number of dependents or insurance beneficiaries are made with Human Resources. Tax deduction changes (W-4 form) are made with Payroll. 14 NEW EMPLOYEE ORIENTATION TO DEPARTMENT 11. Personal 13. Parking Explain Explain the parking procedures and that all employees are expected to adhere to the dress code. Explain any department

specific requirements. Also explain that chewing gum is not permitted, nor eating in the work area; why smoking is not permitted within 50 feet of the hospital entrance, and where it is permissible to smoke. 12. Supplies Show employee where equipment and/or supplies are kept, and explain procedures for obtaining needed items. escort services for your facility. Ask if the employee received a map of the parking areas, permits, and decals required for their vehicle. If not, they are to notify Security. 14. Safety Complete the First Day Safety Orientation Competency Evaluation and send to Human Resources with this New Employee Orientation to Department within 48 hours. Keep a copy in the employees department file. 15 NEW EMPLOYEE ORIENTATION TO DEPARTMENT 15. Absenteeism and Illness 16. Time Off Advise employee that unscheduled Advise employee that if they want a frequent absences or tardiness will result in disciplinary action. Ask employee to call you or another

supervisor/manager/person in charge as soon as possible if they are unable to report to work. Ask employee to make every effort to make the call personally and not to depend upon others to call for them. Advise employee that they may need to provide a doctors verification upon their return if the use of sick leave has been lengthy or frequent. special day off or time off during a work day, they must first discuss this matter with the supervisor/manager/director for prior approval. 17a. Paid Time Off Explain that all regular full-time employees participate in CMCs Paid Time Off (PTO) program. PTO combines time for vacation, holidays, and discretionary leave, which can be used with the supervisor/manager approval for short-term illness, vacation, holidays, personal business, etc. 16 NEW EMPLOYEE ORIENTATION TO DEPARTMENT 17b. Paid Annual Leave 19. Elevators Explain that all regular part-time employees Explain that

participate in CMCs Paid Annual Leave (PAL) program. PAL combines time for vacation and holidays, which can be used with supervisor/manager approval for shortterm illness, vacation, holidays, personal business, etc. 18. Reporting Injures Tell employee to report all injuries (however slight), complete an accident report (Occupational Injury/Illness Report), a Worker Compensation Benefits Claim Form, and to seek first aid from the Employee Health Center or Emergency Room at their facility. Show and explain the Occupational Injury/Illness form and the State Claim Form. Inform the employee that an accident investigation will be conducted. employees are asked to use the elevators only if they are going up more than one floor or down more than two floors. Patients and visitors should precede employees in and out of elevators. 20. Use of Telephones Explain the policy regarding use of telephones, method of obtaining telephone messages, etc. Let employee know that they should give their phone extension to those who may need to contact them, since personal calls will not be transferred, except in case of an emergency. 17 NEW EMPLOYEE ORIENTATION TO

DEPARTMENT 21. Purchasing Explain the purchasing procedure for your department and review the policy, as it would pertain to the employee. 22. Productivity Discuss with employee the concept that our business is taking care of patients, and while it is important for the employee to do a reasonable quantity of work, our greatest concern is to provide the highest quality of patient care. 23. Confidentiality Discuss with the employee that a patients condition is confidential and should not be discussed with anyone unless that person is directly participating in the patients care or treatment. Even then, the patients condition should not be discussed where the conversation may be overheard. Also, discuss that all hospital records and employee records are confidential. Explain that hospital employees are civilly liable for any breach of confidence with regard to a patient. 24. Guest Relations Explain the emphasis the organization places on warm and courteous interactions with patients, physicians, and fellow employees.

. 18 NEW EMPLOYEE ORIENTATION TO DEPARTMENT 25. Solicitation/Distribution of Literature Explain to employee that solicitation for any purpose during working time is not allowed. Employee may not distribute literature for any purpose during working time or in work areas. 26. Fellow Workers Show employee their work area and have them meet all co-workers. Also, introduce employee to people in other departments with whom they will be working 27. Tour Provide a tour of the facility so the new employee is familiar with the major areas and can assist patients and visitors. 28. Co-Worker Assign new employee to a co-worker/mentor for two weeks. Employee Handbook Emphasize

that the employee is responsible for reading and becoming familiar with the Employee Handbook. Encourage employee to ask questions in areas of uncertainty. 19 NEW EMPLOYEE ORIENTATION TO DEPARTMENT 30. Use of Personal Vehicles Explain that all employees authorized to drive their vehicles on organization business will be reimbursed on a per-mile basis, but they must have a valid drivers license and must carry liability insurance for bodily injury and property damage in the amounts required by State Law. In requesting reimbursement for mileage, employees will be required to certify that they are in compliance with the policy. Reimbursement for mileage is clocked through the time and attendance system. 31. Outside Employment Explain that employees engaged in employment outside the organization are required to complete an Outside Employment form as outlined in the Human Resources Policy, and that approval from their Supervisor/Manager is also necessary. Provide employee with form and ensure completion. 32. Conflict of Interest

Review the Corporate Policy with all management personnel and purchasing agents. Have the employee complete the attached disclosure statements, sign and have it signed by their immediate supervisor/manager. Return the completed, signed disclosure statement to Human Resources. 33. Job Description Review job description and performance expectations with the employee to ensure they are informed about their responsibilities and how to fulfill them within the organization and department. 34. Questions Encourage employee to come to you at any time with questions regarding organization/department policies and/or their job. 20 DIALYSIS DEPARTMENT Physical Address Fresno CRMC -1W Dialysis Unit Tel # 459-2722; fax# 459-2583 Fresno Outpatient Clinic & Home Program 215 N. Fresno St., Suite 150, Fresno, CA 93701; Tel #: 459-3901; Fax #: 459-2579 Clovis Outpatient - 685 N Medical Center Drive # 105, Clovis 93611 Tel #: 324-4030; Fax #: 324-3748 21 Administration Tree Director: Terri Bramer

Manager: Todd Whorton Tel #: 459-2638; Cell #: 281-7798 Inpatient Supervisor: Patti Magee RN Tel #: 459-2706; Cell # 250-3816 Viki Mohayaee RN Tel#: 459-2616; Cell # 250-0565 Charge RN: Kathleen Magnanao RN/Suman Kaur RN Fresno Outpatient Supervisor: Karen Echavez RN Tel #: 459-2608; Cell # 259-5744 Charge Nurses: Laura Hill RN/Zarah Abejo RN Clovis Outpatient & Home Program Supervisor: Elizabeth Samoylenko RN Tel #: 324-4707; Cell # 259-2395 Charge Nurse: Gina Rodriguez RN Technical Supervisor: Monica Fierro CHT/CCHT Tel #: 459-2560; Cell #: 248-6363 Educator: Edith Martinez RN Tel # 459-2736; Cell # 259-9750 Vascular Access RN: Elwina Yazon RN Tel # 324-4758; Cell #: 250-8297 22 Schedules 2015 S J uly 26th August 22nd 26 Supervisor on call M T W $T F 27 28 29 30 31

MF S S M T W T F 1 2 3 4 5 6 7 MF MF S S M T W $T

F 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 KE KE S S M T W T F KE KE S KE RN's Laura (Charge) ML ML ML ML ML ML Zarah (Charge) Sahida (vascular access)

Melissa 7 X X R R Elwina J un 7 C X X C C 7 7 7 7 7 R J arnail (Charge) 7

7 Eleanor Paras C C Eleanor( Part time) R C Gurpreet C 7 7 ML ML ML ML ML ML 7 7 C R X X X X R

R R C 7 R 7 7 7 C C R C C C C C C ML ML ML ML ML ML R R X X C 7

7 R C R 7 7 7 C C C C 7 7 R R C C 7 7 C C 7

7 C R R R X X C 7 7 7 R 7 C R R R X X R R R

7 7 R C ML ML ML ML ML R R C C 7 C 7 7 7 R 7 R 7 C C 7

7 ch7 7 7 C C C C R X C 7 ED R R C C 7 C ED C C Tony Fe C C

RNs Openers 2 2 2 2 2 2 2 1 2 3 2 2 2 2 2 2 2 2 2

2 2 2 2 2 RNs Closers 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 3 2 2 Denis 7 7 7 7 7 7 7 7 7 DR

7 7 7 7 7 7 7 7 7 7 J ustin 7 7 7 7B 7 7 7 7 7B 7

7 7 7 7B 7 7 7 7 7B 7 Shawn 7 7 7 7 7 7 7 7 7 7 7 7

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

7 7 7 7 7 7 7 Senior Techs Stock Clerk Rico 23 Time & Attendance Absence (ABS) ABS during Probationar y (Introductory) Period 2 Tardys (TARS) Failure to Report to Work / 4 occurrences Verbal Warning 5 occurrences Written Warning

6 occurrences Final Written Warning 7 occurrences Termination 2 occurrences Termination 1 ABS occurence 1st occurrence Final Written Warning 2nd occurrence Termination 2 consecutive occurrences Termination No Call - No Show 24 Request for TIME OFF I hereby request paid time offfrom my position in the length of time and for reason indicated below: NAME: Department Dialysis Facility: CRMC I request Click here to enter text. working hours of paid leave from Click here to enter a date. through Click here to enter a date., inclusive.

Reason for Absence SICK LEAVE: Illness EXPLANATION: Click here to enter text. Employee Signature: Click here to enter text. Date: Click here to enter a date. Doctor appointment Approve PAID TIME OFF / PAID ANNUAL LEAVE OTHER PAID LEAVE: Denied ded Approved as modified from ___________ through ___________ Supervisor/Manager Signature ________________________________ Date ________________ Bereavement Jury Duty Court appearance Click here to enter text. All requests for paid time off/paid annual leave should be originated by the requesting employee. The terms and conditions of all leaves are governed by the appropriate Community Medical Centers policies; please refer to the Human Resources policies on The Forum. 25 Dress Code standard 1.Employees may be divided into

various classifications which have different dress requirements: 1. Clinical employees - with direct patient care responsibilities (e.g., RN, Patient Care Assistant, Physical Therapist and Respiratory Therapist) - scrub type apparel is preferred. 2. Clinical Support employees - provide services that assist the direct patient care personnel (e.g., Materials Management, Dietary, Laboratory) - uniforms are preferred to provide distinction between clinical and non-clinical employees. 1.Earpiece devices - Wearing earpiece devices for music/entertainment within patient care and/or public service areas is not appropriate. Any exceptions must be made by management. 2.Style of clothing must be professional and appropriate to a hospital setting and must fit properly. 26 Dress Code standard 1.Scrubs/Uniform - Coordinating knit tops (non-T-shirt) are acceptable. Scrub design

should be professional and appropriate for the area. 2.Scrub jacket/lab coat/sweater, white or of a coordinating color, may be worn with scrubs. 1.Pants - must be business-like in style, fabric and fit and should project a professional image. No denim clothing may be worn (i.e., pants, skirts, dresses and vests) during work time. 2.Collared shirts and slacks are considered appropriate attire for all male employees. 27 Dress Code standard 1.Slacks, pantsuits, mid-calf dress pants or dresses/skirts are considered appropriate attire for female employees as long as they maintain a professional appearance. 1.Shoes - must be appropriate to the workplace and

coordinated to the manner of dress. Shoes must be polished and well maintained. If tennis shoes are worn, they must be primarily white in color. Beach footwear is not appropriate. A dress sandal appropriate for the work place is allowed. For safety reasons, employees who push equipment or transport patients may not wear open-toed shoes. 28 Dress Code standard 1.Holiday Dress - dress code guidelines must be adhered to, but seasonal attire is permitted as appropriate. 2.Business Casual Days - are only allowed for specially designated corporate events, and Corporate logo items are allowed on Fridays. Unacceptable Dress - shorts, T-shirts, knit stretch pants, leggings, mini skirts, bare midriff, spaghetti strap tops or dresses, sweatshirts, denim or denim appearing clothing (includes casual days), "all black" scrubs, fatigue motif scrubs, sheer or see-through apparel, hats or caps (except nursing or surgical). Exceptions: employees who change from

street clothes into scrubs on arrival to their unit may wear jeans, T-shirts, shorts (of tasteful length) and sweatshirts. 29 Dress Code standard 1.Unit-specific dress standards must adhere to general guidelines unless contradicted for patient care. 2.Cultural and/or religious diversity - consult with Human Resources. 30 Dress Code Risk Areas - Employees who work in areas that are at high risk when special procedures are performed or who care for specific patient diagnoses must use personal protective equipment when there is a possibility of contact with blood or body fluids. Staff are provided with equipment such as disposable gowns, gloves, masks, goggles, and face shields. Such equipment is made available on each unit. Examples: Med/Surg, Critical Care, Dialysis, Endoscopy, Radiology, Respiratory Therapy, Physical Therapy, and Emergency Services. 31 Standards of Conduct Background Community Medical Centers (CMC) prides itself in promoting patient and employee safety, creating a professional work environment, and providing excellent service

to our patients, physicians, volunteers, and staff. Our Target 100 Standards of Service Excellence Policy in the Administrative Policy Manual explains CMCs expectations in terms of customer service, teamwork, and overall approach to working at CMC while performing respective job responsibilities and ethical employee conduct. Objective The objective of this policy is to ensure all CMC employees adhere to all policies, procedures, and professional standards of conduct and to promote CMCs commitment to its Corporate Ethics and Compliance Program by including compliance as an element of the expected standards of conduct. Policy Detail Employees are required to comply with all CMC policies, procedures, and professional standards of conduct. Failure to do so may be grounds for disciplinary action, up to and including termination of employment. In cases where an employee has previously violated the same or other rules, or is not performing at an acceptable level, the employee may be subject to immediate termination of employment. CMC employees are encouraged to report workplace problems and concerns, and are required to report potential violations of the law. It is the responsibility of each employee who has knowledge of a suspected or confirmed violation of the Standards of Conduct Policy to report it to an appropriate member of management and/or Human Resources. Termination

of an employee for any severe breach of conduct does not preclude CMC from taking and/or seeking civil or criminal action against the employee. 32 Standards of Conduct While it is not intended to be an Theft and/or Vandalism exhaustive list, the types of misconduct that may lead to disciplinary action, up to and including termination of employment include, but are not limited to, the following: Insubordination Violating Safety/Health Rules or Actual or Threatened Physical Violence Sleeping or Loafing While on Duty Inappropriate Verbal Communication Engaging in Intimidating and/or Practices Unsatisfactory Job Performance and/or Violation of any CMC Policy Disruptive Behaviors Falsifying Documentation/Records 33

Licenses & Certificates (RN, CHT/CCHT, BLS) Summary The purpose of this policy is to establish accountability for maintaining current licensure for all employees in positions that require a state license or certificate. Any employee who fails to keep his/her required licensure/certification(s) current will be immediately removed from the schedule, receive a written warning, and will be placed on unpaid suspension. If the employee does not have a current license/certification after 5 calendar days, termination will result. 34 EPIC DOCUMENTATION Flowsheets LDAs Progress Notes Order Entry 35 Hemodialysis Flowsheets Antibiotics eradicate good bacteria and leave room for

other bacteria (i.e. C.diff) to overgrow and produce toxins. 36 Hemodialysis Flowsheets 37 Hemodialysis Flowsheets 38 Post Hemodialysis Assessment Flowsheet 39 Dialysis Vitals 40 LDA documentation for Hemodialysis 41 Inpatient Hemodialysis Progress Notes Duration: Net 180 minutes (3 hours) Ultrafiltration/ Fluid removed: 2800 mL= 2.8 L Vascular Access: Vital LFA AVF Signs: stable - see doc flow sheet Comments:

AVF LFA, bruit and thrill present. Pressure dressing applied-dry, intact & clean, no prolonged bleeding noted. Patient tolerated hemodialysis treatment. Discharged in stable condition. Seen by Dr.___ Report given to: _________________Primary RN Or: Vascular Access: Left Tunneled Catheter Comments: Left CVC dry & intact; no redness; no discharge. Dressing changed with new Biopatch; labeled with date & initials. New Tego connector applied. Or Comments: Left CVC dry; no redness; dressing intact. 42 Outpatient Hemodialysis Progress Notes New opdt smartphrase 43 Forum 44 Policies & Procedures 45 Education -HLC 46

Education HLC Online Learning How to Log in 47 Employee Portal 48 2828 Fresno Street, Suite 203, Fresno, CA 93721 (559)459-6416. Fax (559)459-2494 EMPLOYEES OCCUPATIONAL INJURY/ILLNESS REPORT This form must be submitted to Employee Health Services (EHS) within 24 hours of incident. EHS fax number: 52494 or 459-2494. If bloodborne pathogen exposure (BBP), call House Supervisor, report to EHS within 2 hours (Emergency Department after hours). If injury is serious, life threatening, requires hospitalization, or if multiple employees are injured, notify Employee Safety at 56480. TO BE COMPLETED BY THE INJURED EMPLOYEE: (PLEASE PRINT CLEARLY) Name: Date of Birth: Address: Employee ID: City: State: Zip Code: Cost Center #: Job Title: Cell Phone #: Home Department: Facility: Home Phone #: Work Phone/Ext.: Managers Name: Date of incident: Time of incident: a.m. p.m. Time shift began: a.m. p.m. Specific place of incident (i.e., cafeteria, surgery, etc.): Describe the injury or illness and body part(s) affected: How did the incident occur?

How could the accident have been prevented? Who witnessed the incident? I have contacted my manager/supervisor and informed him/her of this injury. Yes No If yes, and the contact was made with the manager listed above, please check here: If you contacted another manager or supervisor, please list his/her name: and contact number: If no, you must contact your manager or supervisor now. Did you seek medical treatment? Yes No If yes, where? Employee Health Emergency Department Other I refuse treatment at this time (employee initials) I DECLARE UNDER PENALTY OF LAW, THAT THE ABOVE STATEMENTS ARE TRUE. I AM AWARE THAT FALSIFICATION OF THE INFORMATION PROVIDED MAY RESULT IN CORRECTIVE ACTION UP TO, AND INCLUDING TERMINATION. Employee Signature Date 49 Policies & Procedures Administration of Heparin - Dialysis Central Line Site Care with ChloraPrep Central Venous Lines for Hemodialysis Initiating and Terminating Dialysis with Central L Consent for Dialysis Fresenius K Cleaning, Post Treatment Machine Take Down and Cleaning Disinfecting Procedure Medication Administration Monitoring the Patient During Treatment Patient Assessment Post Hemodialysis pHoenix Meter Calibration and Use Priming the Fresenius K Hemodialysis Machine Termination of Hemodialysis with Fresenius K Machines 50 Policies & Procedures Administration of Antibiotics during

Hemodialysis Administration of Normal Saline Bolus Method Altering Calcium Chloride Content in the Dialysis Bath Altering Potassium Chloride Content in the Dialysis Bath Chloramine Testing Daily Water Testing Dialyzing Patients with Suspected Hepatitis B or C Hepatitis B Immunizations for Adult Dialysis Patients Initiating Hemodialysis Treatment with Fresenius K Machines Needle Insertion ButtonHole Constant-Site Cannulation Technique for AV Fistulas Patient Assessment Pre-Dialysis Tego Connector Use For Dialysis Capped Catheters Change in Mental Status- Guidelines Changing a Clotted System Dialyzer Dialysis Services in an Emergency Disaster Use of Thrombolytic Agents in Hemodialysis Central Venous Access 51 Policies & Procedures Emergency Evacuation Emergency Take Off Procedure Excessive or Prolonged Bleeding after Air Quality Monitoring Anaphylactic Reaction to Hemodialysis

Patient Orientation and Education to Hemodialysis Patient Emergencies Patient Emergency Complications Air Embolus Patient Emergency Complications Clotted Dialyzer Patient Emergency Complications Dialyzer Blood Leak Patient Emergency Complications Hemolysis Pyrogenic Reaction Plan of Care - Dialysis Power Failure Staff Training and Education TB Screening for Patients Receiving Hemodialysis Visitors in the Hemodialysis Unit Water Failure Medication - Outpatient Central Line Site Care with ExSept Chemical Spill in Dialysis Dialyzer & Hemoperfusion Characteristics Disinfecting and Rinse-Out of Water System - Inpatient Area CAPD Manual Exchange 52 Priming the Fresenius K and Fresenius T Hemodialysis Machine Policy # 11396 PROCEDURE Press the POWER key. Insert the acid (red) concentrate connector into the acid concentrate source.

Select the DIALYSIS button In the CONFIRM CONCENTRATE SCREEN, verify the correct concentrate. If the concentrate must be changed to match the prescription, select the CONC button, enter the concentrate type using the Up or Down arrow then confirm. Select the base sodium and base bicarbonate. Press CONFIRM (acid and bicarb pumps start when CONFIRM is pressed). Plug the bicarb (blue) concentrate connector into bicarbonate concentrate source. Make sure the jug contains enough acid for the entire treatment if using jugs. Stringing Bloodlines Put arterial drip chamber into holder, clamp med port, transducer line, and Heparin line. Put patient end of arterial bloodline into prime bucket. Do not allow the ends to touch the fluid in the bucket to prevent contamination. Open the blood pump door, insert pump segment, press and hold the START/STOP key to load. Close blood pump door. Follow color coded arterial line guides and connect dialyzer end of arterial bloodline to the arterial port of the dialyzer. Roll the venous drip chamber into holder with filter below sensor heads; close and latch door. Clamp med port and transducer line. Connect the dialyzer end of the venous line to the venous port of the dialyzer. !!! Do Not Put Venous Line into the Optical Detector and Venous Line Clamp at this time!!! 53 Priming the Fresenius K and Fresenius T Hemodialysis Machine Policy # 11396 Priming Bloodlines and

Dialyzer Attach saline administration set to saline port, aseptically spike saline bag and gravity prime the arterial line prior to the arterial drip chamber (from saline line to drain bucket). Clamp arterial line. If the heparin pump is to be used: connect heparin syringe, prime heparin line and load heparin syringe into heparin pump. If heparin pump is not used, clamp the heparin line. Fill arterial drip chamber by unclamping the transducer line. Fill drip chamber about 3/4 full. Press PRIME, press START/STOP to start blood pump. Adjust the flow rate by pressing the up or down keys. Set blood speed to 150 ml/min. Blood pump will stop when PRIME mode is complete. (to complete 300 mls of prime). When pump stops, put venous line into optical detector and venous line clamp. Press the PRIME to fill venous drip chamber. Blood pump will stop when fluid rises. Aseptically connect the patient ends of arterial and venous lines together and unclamp both lines. Set the blood pump rate to 350-400 mls/min. Ensure that the extracorporeal circuit is free of air bubbles. TESTS (Can be performed after termination of treatment or prior to the first treatment of the day 54 Dialysis Permanent Access Management and Needle Insertion Dialysis

Policy # 11029 POLICY Dialysis access is considered the patient's "lifeline" and will not be used for blood draws, IV access, or blood pressure sites. Exception: Emergency IV access only per order of Nephrologist, Vascular Surgeon, or Emergency Physician. Inspection of the AVF or AVG access will include the following: Presence/absence of thrill and/or bruit Physical location of the access including depth and direction of flow Condition of incision(s) especially newly placed access or revised access Presence of swelling or edema Sign and symptoms of infection, including temperature, redness , pain, swelling, drainage

Bruising and/or bleeding Aneurysms and/or psuedoaneurysms Condition of previous cannulation sites Erosion of skin over access site Stenosis as manifested by high pitched bruit upon auscultation Inspection of the entire access extremity including hands or feet, with comparison to opposite extremity, includes the following: Edema/swelling Temperature Peripheral pulses Pain Numbness Discoloration Inspection of the access and access extremity should be performed each dialysis pre, during and post treatment. Patients are encouraged to wash access extremity with soap and water upon arrival for dialysis if able. If patient is unable, patient care staff will clean access extremity with skin cleansing agent and pat dry 55 Dialysis Permanent Access Management and Needle Insertion Dialysis Policy # 11029 New fistulas and new AV grafts will be cannulated by experienced staff members only. Prior to cannulation, direction of access flow will be determined. Fistula requires a tourniquet for cannulation (some patients may prefer to manually simulate a "tourniquet" with their non access hand). A tourniquet should not be left on the access extremity during hemodialysis except, in rare occasions, with a physician's order. If the tourniquet is in place, it must be between the arterial and venous needles and documentation must include checks of the access flow above

and below the lightly placed tourniquet. Needle insertion sites will be rotated to prolong the life of the access (Exception: AV Fistulas with "Buttonhole"). Maximum number of attempts to cannulate an AV access will be limited to 2 (two) sticks per arterial and 2 (two) sticks per venous end of the access. PROCEDURE Prepare supplies Wash hands and put on glove and protective barrier gown, don mask and face shield. Apply mask to patient. Visually inspect access for sign of infection (redness, swelling, crusting at previous needle site). Place underpad under access. Clean access with alcohol prep followed by chloraprep scrub using friction. DO NOT touch site with non-sterile item i.e. gloves, non-sterile gauze. If access site was touched, use alcohol swab to disinfect prior to cannulation. Apply tourniquet to AV fistulas 56 Dialysis Permanent Access Management and Needle Insertion Dialysis Policy # 11029 New fistulas and new AV grafts will be cannulated by experienced staff members only. Prior to cannulation, direction of access flow will be determined. Fistula requires a tourniquet for cannulation (some patients may prefer to manually simulate a "tourniquet" with their non access hand). A tourniquet should not be left on the access

extremity during hemodialysis except, in rare occasions, with a physician's order. If the tourniquet is in place, it must be between the arterial and venous needles and documentation must include checks of the access flow above and below the lightly placed tourniquet. Needle insertion sites will be rotated to prolong the life of the access (Exception: AV Fistulas with "Buttonhole"). Maximum number of attempts to cannulate an AV access will be limited to 2 (two) sticks per arterial and 2 (two) sticks per venous end of the access. PROCEDURE Prepare supplies Wash hands and put on glove and protective barrier gown, don mask and face shield. Apply mask to patient. Visually inspect access for sign of infection (redness, swelling, crusting at previous needle site). Place underpad under access. Clean access with alcohol prep followed by chloraprep scrub using friction. DO NOT touch site with non-sterile item i.e. gloves, non-sterile gauze. If access site was touched, use alcohol swab to disinfect prior to cannulation. Apply tourniquet to AV fistulas 57 Dialysis Permanent Access Management and Needle Insertion Dialysis Policy # 11029 Inject local anesthetic intradermal to form a small wheal per MD order. Close plastic needle clamp and remove protective

needle cover. Holding the needle by the butterfly wings, bevel up, insert the needle into the chosen arterial site at a 45 degree for AV grafts, and at 25-30 degree angle for AV fistulas until you feel it enter the vessel. A "flash" of blood will indicate entrance into the vessel. Level off the angle and thread the needle into the vessel up to the hub. Release the tourniquet. Place 1 inch tape over the fistula wings to secure the needle. Tape wings in chevron style then apply Band-Aid over needle insertion site. Place a final tape to the lower edge of the band-aid to further secure the fistula needle wings. Repeat steps K through L for venous needle placement. IF USING VENOUS NEEDLE DEVICE ALARM: Apply the sensor patch directly over the needle insertion site of the vascular access followed by the Band-Aid. See attachment for Redsense 58 Release plastic clamp and slowly loosen protective cap from end of the line to allow the tubing to fill with blood. Tighten cap and replace clamp. Blood work may be drawn at this point. Needles should be placed at least twofingerbreadths apart to prevent recirculation. Heparin bolus may be given into venous needle. Loosely loop the bloodlines to allow movement of the patient but prevent the bloodlines from pulling on the needles. Ensure the patients access site is uncovered throughout treatment so it is be readily visible to staff. Note: Use 2 Lidocaine syringes for each cannulation site.

59 Initiating Hemodialysis Treatment with Fresenius K and Fresenius T Machines PROCEDURE Correctly identify the patient. Verify machine is ready for dialysis: Conductivity and pH have been checked. Machine pressures and Alarms test have passed. Normal Saline is recirculating in bloodlines. Obtain and document pre-dialysis vital signs. Set target hours and weight loss desired. Establish access per procedure (refer to policy Dialysis Permanent Access Management and Needle Insertion) and administer heparin loading dose per nephrologist/AHP order. Wait a minimum of 3 minutes following administration of heparin loading dose prior to actual start of the hemodialysis treatment. Verify Bicarbonate setting and dialysate flow rate. Perform hand hygiene and change gloves. Stop blood pump and clamp venous bloodline. Aseptically discard 50 mils of recirculated saline from the arterial bloodline then clamp. Unclamp the venous bloodline, turn on the blood pump and discard 250 mils of recirculated saline then clamp. Clamp normal saline. Using aseptic technique, connect arterial bloodline to arterial end of access. Connect venous bloodline to venous end of access. Unclamp bloodlines. Start blood pump at 200 ml/min. 60 Initiation of Dialysis. (Refer to Tego Connector policy for Tego capped catheters when changing Tego connectors)

Assemble supplies. Have patient put on mask. Wash hands. Don clean gloves, face shield and protective gown. Place Chux under lines. Remove Curos cap from the catheter. Swab Tego fwith Alcohol. Place a 5 ml syringe on Tego, unclamp then withdraw and discard 5 mls of blood, re-clamp. Swab Tego with Alcohol. Place a 10 ml syringe of normal saline on Tego, unclamp and flush, reclamp. Repeat steps 5-9 for other port. Termination of Dialysis Assemble supplies. Wash hands; don clean gloves, face shield & protective gown. Have patient put on mask. Place Chux under lines. Stop blood pump - clamp catheter and arterial bloodline. Disconnect arterial bloodline. lcoholego connector for arterial port with Alcohol for Place 12 ml saline syringe onto arterial port. Flush with 10 ml N/S. Connect arterial bloodline to IV tubing via white connector and return the blood. Disconnect venous bloodline. Swab Tego connector for venous port. Flush with 10 ml N/S. 61 Termination of Hemodialysis with Fresenius K and Fresenius T Machines Place folded 4X4 gauze over adhesive bandage, remove needle, engage

safety device and immediately apply pressure. Continue to apply pressure over the site until bleeding stops being careful not to occlude the access. Upon cessation of active bleeding of vascular access needle site, apply adhesive bandage directly to patients needle stick sites. Apply gauze pressure dressings over adhesive bandage dressings, be sure to NOT wrap adhesive tape entirely around the patient's access limb. Upon completion of dressing application, date and time dressing for appropriate removal time for non-dialysis patient care staff in the inpatient areas. Time for removal of pressure dressings should be no longer than 2 hours. Document dialysis access report given to patient care staff on the dialysis treatment record. Note: Change pressure dressing gauze if soiled with blood before taping. Blood is an excellent source of bacterial growth. 62 Infection Control! Wash hands between patients! Hand hygiene after each glove removal! 63 FORMS Commonly used forms for the OPD Workflow 64 Patient Schedule DATE_____________ H&H Q W FOR EVERYONE M/W/F PATIENTS PLEASE REMEMBER VENOUS PRESSURES / ACCESS FLOW DOCUMENTATION 0430-0800 Patient, A ELISIO 25H AVF L 0830-1245 Patient, Al F250 Na Profile

0445-0815 3. Patient, A. F250 0845-1230 1330-1715 1400-1730 POD # 1 3. Patient, A. F250 0430-0830 4. Patient, A, L. 5. P atient, A, I AVF L 0915-1230 3. Patient, A. 0500-0830 6. Patient, A, John 0900-1200 4. Patient, A, L. F250 1330-1700 1230-1615 0445-0815 7. Patient, A, Ma (HC) 0845-1215 6. Patient, A, John 0430-0815 8. Patient, A, A.

0845-1215 6. Patient, A, John 1245-1630 7. Patient, A, Ma (HC) 0445-0815 9. Patient, A, T 0900-1230 7. Patient, A, Ma (HC) 1315-1645 8. Patient, A, A. 0515-0900 8. Patient, A, A. 0930-1345 8. Patient, A, A. 1415-1745 9. Patient, A, T 0500-0830 9. Patient, A, T 0915-1245 9. Patient, A, T 1315-1615 5. P atient, A, I AVF L 5. P atient, A, I AVF L 1245-1645 POD #2 10. Patient, A J

16 0430-0815 GA 3. Patient, A. 11. Patient, A 0430-0830 4. Patient, A, L. 12. Patient, A, L 0515-0815 13. Patient, A, A. F250 0845-1215 3. Patient, A. F250 1330-1715 0900-1230 4. Patient, A, L. 5. P atient, A, I AVF L 0900-1300 1300-1630 5. P atient, A, I AVF L 1345-1715 0445-0845 6. Patient, A, John

0915-1300 6. Patient, A, John 1330-1700 0500-0930 7. Patient, A, Ma (HC) 1000-1330 7. Patient, A, Ma (HC) 1415-1730 15. Torres, M (HC) 0445-0830 8. Patient, A, A. 0900-1330 8. Patient, A, A. 1400-1730 16. Figueroa Montano, S 0500-0815 9. Patient, A, T 0845-1215 9. Patient, A, T 1245-1545 14. Patient, A, J F250 L POD#3 3. Patient, A. F250 0445-0945 3. Patient, A. 4. Patient, A, L. 5. P atient, A, I AVF F250

0445-0945 1015-1330 3. Patient, A. 0430-0745 4. Patient, A, L. L 0430-0800 5. P atient, A, I AVF F250 0445-0945 1400-1730 0430-0745 0815-1130 4. Patient, A, L. L 0430-0800 0830-1245 5. P atient, A, I AVF 0430-0745 1200-1515 L 0430-0800 1315-1645 6. Patient, A, John 0500-0815 6. Patient, A, John 0500-0815 0900-1230 6. Patient, A, John 0500-0815 1315-1715

7. Patient, A, Ma (HC) 0445-0830 7. Patient, A, Ma (HC) 0445-0830 0900-1230 7. Patient, A, Ma (HC) 0445-0830 1330-1700 8. Patient, A, A. 0500-0900 8. Patient, A, A. 0500-0900 0930-1300 8. Patient, A, A. 0500-0900 1330-1700 9. Patient, A, T 0515-0900 9. Patient, A, T 0515-0900 0930-1315 9. Patient, A, T 0515-0900 1400-1745 *PLEASE REMEMBER VENOUS PRESSURES / ACCESS FLOWS* REMI NDER!! RI NSE BI CARB LOOP EVERY FRI DAY 65 66

Staff Assignment Wednesday 5/25/16 Att. Nurses *******please **** Please clean Cleanmedroom Medroomfridge fridgetop top&&bottom bottom1st 1stof ofthe themonth********* month**** 1. Prepare/set up for 2nd & 3rd shift (am/pm) 13. Prep* charts and make heparin labels for next day 1st shift (pm) CHARGE NURSE Laura 7 Glucometer 2. Empty trash/biohazard 1st shift (am) 14.Prep* charts and make heparin labels for 2nd & 3rd shift (am) SPECIAL TREATMENT ROOM Frank ot (take break @ 0630) 8,22,18 3. Empty trash/biohazard 2nd shift (pm) 15. Check water hardness at night and rinse bicarb tank loop (pm) 4. Empty trash/biohazard 3rd shift (pm) 16. Clean bicarb and acid connectors (pm) 5. Draw heparin syringes 1st shift (am)

17. Bleach all Phoenix meters by 1500 (am/pm) unless there's a 4th shift 6. Draw heparin syringes 2nd shift (am/pm) 18. Make packs 7. Draw heparin syringes 3rd shift (pm) 19. Clean Water Room daily - wipe floor/wall surfaces 8. Break down boxes and discard (am/pm) 20. PM shift stock NS bags and clean heparin room counter 9. Bleach jugs on Wednesdays (am/pm) 21. Restock big supply cart in pod 2 when Rico is on vacation 10. Prep acid for 1st, 2nd, and 3rd shifts (pm) 11. Clean O2 concentrator filter every Monday 22. Make lab bags weekly and monthly. ****Special treatment room opening tech to help put on pts in Pod 1**** POD 1 RN Melissa 7 TECH 1 J ennifer ot 1, 2, 5, 6, 9, 12, 14, 21, 22, 25 TECH 2 Luis 7 3, 4, 7, 9, 10, 12, 15,16, 21, 23, 24, 25

Epo Count PM/ Eyewash check Q Monday/ Mix special bath POD 2 RN Erika C Stock Medroom Supplies/ Clean Medroom Counters PM/ Mix special bath TECH 1 Rico OT 1, 2, 5, 6, 9, 14, 21, 25 TECH 2 Roxanna 7 3, 4, 7, 9, 10, 13, 16, , 21, 23, 24, 25*** 23. ***Rinse machine buckets with bleach every night. 12. Restock oxygen (am/pm) POD 3 RN 1 Gurpreet C Emergency Cart/ Epo Count AM/ Mix Special Bath TECH 1 Pa C 1, 2, 5, 6, 9, 14, 19, 21, 25 Lupe 7 3, 4, 7, 9, 10, 13, 16, 20, 21, 23, 24, 25***

TECH 2 Dawn 7 - float Rico OT 24. Rinse drain lines daily at the end of day 25. Mon-Fri: Check emergency take off bag present and properly stocked ****BLEACH MACHINES EVERY MON AND FRI NIGHTS**** 67 Medication worksheet Wednesday 5/25/16 DAILY DIALYSIS MEDICATION LIST Patient Name EPO units Hectorol m cg HOLD 0.5 MWF M WF 4m cg vial used Hectorol m cg Wasted RN Signature POD 1 Venofer mg

Venofer mg Wasted RN Signature Vit C mg Other Meds 1st Shift Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name 2900 MWF 2 MWF HOLD 1 MWF 5500 M 3 MWF 1200 MWF 8 MWF HOLD 2000 MWF 50 50 50 Liquacel (P) 50 Liquacel (P) 2nd Shift

Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name 11,800 MWF 2.5 MWF HOLD 3400 M 1800 MF 1000 M 1000 MF HOLD 1100 M 5 MWF 3 MWF 11,200 MWF 3 MWF 9 MWF 50 50 50 5 MWF 50 50 50 3rd Shift

Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name Patient Name Liquacel (P) 4300 MWF 4 MWF 5400 MWF 1 MWF 5000 MWF HOLD 2 MWF 3400 M 1.5 MWF NO EPO 10 MWF 1000 M 2 MWF 3100 MF 3.5 MWF 50 50 50 50 Liquacel (P) 68 Against Medical Advice Educate patient on the risks of not completing

treatment. Ask patient to sign. Document in Epic. 69 Quarterly Patient Disaster Review Go over the procedure. Ask patient if he/she is able/unable to perform the procedure. Ask patient to sign. Document in Epic 70 INPATIENT 71 What else?? 1. Review P & Ps 2. Competency Checklists 3. HLCs 4. Unit Specific Inservices 5. Email 6. Staff Meetings 72 Questions?

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