Infection Control/Employee Health

Infection Control/Employee Health

Infection Control/Employee Health Annual Update Section 3 EMPLOYEE HEALTH SERVICES X-3401 Include: Pre-employment physicals, initial TB mask fit-testing, annual health checks, injury and exposure care and follow-up, flu shots, immunizations and updates, referrals, and education for prevention and promotion of wellness. To report a work injury: Report the injury to the unit Manager or if after hours to the Nursing Supervisor after hours. Complete A Report of Occupational Injury or Illness. Supervisor will complete their portion of the report. Report to Workers Comp with the report. X-3247 If treatment is not desired, paperwork must still be completed and submitted.

U.S. Healthworks, a Dignity Health member, now manages all occupational injuries and other Employee Health services going forward. MEDICAL EMERGENCY EMPLOYEE INJURIES Report all injuries to your immediate supervisor. Complete an INJURY REPORT at time of the injury. Report the injury to Workmens Comp office, X-3247. During off shift hours, report to the Nursing supervisor who will provide the necessary direction. US Healthworks will manage all Occupational injuries for SBMC. NON-EMPLOYEE INJURY or ACCIDENT Visitors, volunteers, contract employees, students or faculty. Complete an Event Report (IVOS). Immediately call 5000 to report the location and severity of the injury. If the incident occurs inside the building, offer victim the option to be treated in our ER,. First Aid should be rendered if necessary. Outside the building, call 911 if necessary. Be sure to complete an Event Report (IVOS). INFECTION CONTROL PREVENTION

HANDWASHING Single most important procedure for preventing the spread of infection Done appropriately, it can prevent 90% of Nosocomial Infections 6 required elements of good hand washing are: 1. Time: 20-30 seconds 2. Warm running water: works with soap to lift and rinse organisms down the drain 3. Soap: lifts bacteria from skin creases 4. Friction: all hand and nail surfaces including wrists 5. Rinse: from wrists down to fingertips 6. Dry: Thorough drying prevents excessive loss of skin moisture through evaporation Hand hygiene refers to hand cleaning with soap and water, the use of alcohol-based hand rubs or the surgical scrub to

decontaminate hands. Handwashing Cont. Improved adherence to hand hygiene has been shown to reduce the transmission of pathogens, antimicrobial resistant organisms and the overall infection rate.

Wet hands transmit larger numbers of microorganisms than do hands that are thoroughly dried. Fingernails harbor high concentrations of bacteria. Artificial nails harbor an even higher number of bacteria than do natural nails. Artificial nails are not permissible at SBMC. Gloves DO NOT provide COMPLETE protection against contamination. Hands should be washed after glove removal. Gloves should not be washed or reused Studies show that skin underneath rings is more heavily colonized. When hands are visibly dirty, they should be washed with soap and water; not alcohol based rubs. Alcohol does not kill spore forming bacteria. Soap and water, hand hygiene and gloves are required when caring for patients with diarrhea. You can contaminate your hands even during clean activities such as taking a pulse or using a phone. Gel-in-Gel-outIn addition to soap-and-water hand washing, remember to use alcohol hand gel every time you enter a patient room and when you leave the patient room Hand washing is the single most effective way to protect yourself and your patients from acquiring or transmitting infection Respiratory Etiquette Serious respiratory illnesses like influenza, RSV, whooping cough & SARS are

spread by the following: coughing or sneezing unclean hands To help stop the spread of germs: Cover your mouth & nose with a tissue every time you cough or sneeze If you dont have a tissue, cough or sneeze into your upper sleeve, not your hands Put used tissue in the waste basket Always clean hands after coughing or sneezing with soap & water or Purell. Nurses should make a point of teaching respiratory etiquette to their patients and visitors. Teaching should always be documented in the patients chart. Waste Management including Sharps Control

Red Bag Waste "Dripping" Blood and Body Fluids Pieces and parts from Surgery/Pathology Sharps/Pharmaceutical Sharps/syringes must be placed in puncture-proof blue& white combined sharps/pharmaceutical bio-hazardous waste containers. Employees/Physicians must use devices with Engineered Sharps Safety when available ISOLATION PRECAUTIONS used for patients with known and/or suspected contagious diseases-require special cleaning requirements by EVS Airborne Precautions: requires patient isolation in a designated (airborne)

isolation room with negative air flow. Droplet Precautions: full PPE within six feet (intimate) contact with the patient, including face shield or eye protection (goggles). Contact Precautions: for diseases where transmission occurs through touch or contact with infected materials. Antibiotic Resistant Microorganisms (ARM) Precautions MDROs): requires PPE every time you enter the room. The patient is not allowed to leave the room without specific written MD order. IMPORTANT: Activate isolation Alert into Cerner Terminal cleaning of a room after isolation requires all surfaces be wiped, then wiped with cleaning solution, with proper dwell time and curtains to be changed. Remember Nothing on Top

Bloodborne Pathogens Exposure Control Plan (BBP ECP) The purpose of St. Bernardine Medical Center's BBP ECP is to reduce occupational exposure to Hepatitis B virus (HBV), Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV) and bloodborne pathogens" employees may come in contact with. Employees can become infected with the Bloodborne pathogens listed when infected body fluids penetrate the skin and get into the bloodstream through needlesticks and lacerations, through wounds, cuts, or damaged skin, or through contact with the mucous membranes (eyes, nose, or mouth). BBP ECP cont. Employees have an important role in the BBP ECP compliance program and preventing the transmission of blood borne pathogen infections. Employee compliance ensures minimum exposure to Blood borne Pathogens for themselves, co-workers, patients and visitors.

Employee responsibilities for compliance include: Know what tasks they perform that have occupational exposure. Read blood borne pathogens information completely in Annual Update. Develop good personal hygiene habits. Bloodborne Pathogen Standard A copy of the Bloodborne Pathogen Standard from OSHA is found in the Infection Control Manual and is part of the St. Bernardine Medical Center BBP ECP. Our BBP ECP uses the following categories to identify potential risk for employees: CATEGORY I: Tasks that involve exposure to blood, body fluids, or tissues. All procedures or other jobrelated tasks that involve an inherent potential for membrane or skin contact with blood, body fluids, or tissues, or a potential for spills or splashes of them are Category I tasks. Use of appropriate protective measures is required for every employee engaged in Category I tasks. CATEGORY II: Tasks that involve no exposure to blood, body fluids, or tissues, but employment may require performing unplanned Category I tasks. The normal work routine involves no exposure to blood, body fluids, or tissues, but exposure or potential exposure may be required as a condition of employment. Appropriate protective measures should be readily available to every employee engaged in Category II tasks.

CATEGORY III: Tasks that involve no exposure to blood, body fluids, or tissues, and Category I tasks are not a condition of employment. The normal work routine involves no exposure to blood, body fluids, or tissues (although situations can be imagined under which anyone, anywhere, might encounter potential exposure to body fluids.) Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid to be potentially exposed in some other way. Tasks that involve handling of implements or utensils, use of public or shared bathroom facilities or telephones, and personal contacts such as handshaking are Category III tasks. Samples of Tasks/Procedures by exposure categories as well as a list of the employee job classifications by exposure category can be found in the BBP ECP. Standard Precautions All employees are required to practice Standard Precautions. Use precautions with all patients regardless of their diagnosis and when working with all contaminated equipment and materials. All blood and body fluids are to be treated as if infected with HBV, HCV, HIV, or other blood borne pathogens.

Wear personal protective equipment (PPE) when working with blood and body fluids. Wash hands immediately if they become contaminated with blood or body fluids. Wear gloves when your hands are likely to be in contact with blood or body fluids. Wear personal protective equipment whenever exposure to blood and body fluids can be anticipated. Blood spill kits are available on all PAR Central Service carts or in designated areas in your department for cleaning up blood spills that are <500cc. Use standard precaution and PPE as needed. Remember to dispose of anything treated with a chemical solidifier (Isolyzer) in Pathology waste. Work Practice Controls HANDWASHING Before and after patient contact After removal of gloves or other personal protective equipment (PPE) Following contact with any potentially infectious materials. OTHER REQUIRED WORK PRACTICE CONTROLS

Needle-less systems and devices with engineered sharps injury protection is to be used preferentially for: 1. Withdrawal of body fluids after venous or arterial access 2. Administration of meds or fluids 3. Any other procedure with potential for exposure Contaminated needles are not to be bent, sheared, broken or re-capped unless there is no alternative, the action is required for a medical procedure, or if required capping will be done with the use of a medical device or using a one-handed technique. Contaminated sharps are to be disposed of at the immediate point of origin. Combined Sharps/Pharmaceutical containers are not to be over-filled. When full, sharps containers are to be disposed of. NEVER reach into combined sharps/pharmaceutical containers. Disposable combined sharps/pharmaceutical are not to be re-used. NO eating, drinking, applying cosmetics or lip balm, or handling contact lenses in patient care areas.

Mouth pipetting/suctioning of blood or other infectious material is prohibited. Minimize splash, spraying when performing tasks involving blood and body fluids. Specimens of blood and body fluids are to be placed in designated leak-proof containers, appropriately labeled, for handling and storage. If outside contamination of primary specimen container occurs, place that container in a second leakproof container appropriately labeled. Appropriate biohazard warning label is to be attached to any equipment contaminated with blood and body fluids prior to transport. 2015-2016 Flu Vaccine According to the Centers for Disease Control, The 2015-2016 flu vaccine will protect against the four (4) influenza viruses that research indicates will be most common during the season. This includes influenza A (H1N1) virus, influenza A (H3N2) virus and an influenza B virus. Vaccines are the best preventive measure to help fight the spread of flu. Your Annual Flu vaccination will protect YOU, your families, friends, and your PATIENTS! Spread the word VACCINATE, not the flu!!

Per the Public Health Officer for the County of San Bernardino mandatory flu vaccine is required for all healthcare workers (this includes all employees working in the hospital regardless of patient contact). Those not taking the flu vaccine must wear a mask while in the facility (except in cafeteria or other areas where no contact is made with patient care workers) through flu season (March 31, 2016). Policy IC.500.130 Personal Protective Equipment (PPE) PPE is the employee's "last line of defense" against blood borne pathogens. This equipment includes, but is not limited to: gloves, gowns, face shields/masks, safety glasses, goggles, mouthpieces, resuscitation bags, pocket masks, hoods, and shoe covers. PPE can be found on the Central Supply carts in all the clinical areas as well as on the Isolation carts when ordered from Central Supply for patient use. SBMC practices Universal Standard Precautions and treats all trash and linen as if infectious; therefore, upon task completion, gloves, masks, goggles and disposable gowns are to be disposed of in regular trash. DO NOT RE-USE disposable PPE

Eye Protection Employees will wear masks in combination with eye protective devices such as splash glasses with solid side pieces, fluid resistant goggles, or face shields, whenever splashes, spray, spatter, or droplets of blood or body fluids may be generated and eye, nose and mouth contamination can be anticipated. Procedures where light mist or small volume splashes of blood or body fluids require eye protection devices such as fluid shield masks, safety glasses and a mask or full face shield. Examples of these procedures are: IV care, Oral care, Wound care, Trach suctioning, Foley care, Illieostomy care, Colostomy care, and sputum inductions. Procedures where larger volumes of blood or body fluids may be generated require maximum eye protection consisting of fluid resistant goggles and a fluid shield mask. Examples of these procedures are: Colonoscopy procedures, Endoscopy procedures, central line insertions, irrigation procedures, sigmoidoscopy procedures, ER trauma, OR procedures, labor and delivery, bronchoscopies, intubations. Hepatitis B Vaccination

To protect our employees from the possibility of HBV infection after exposure to blood and body fluids, our facility has implemented a vaccination program. This is free to employees who have exposure to bloodborne pathogens and will be offered after training and within 10 days of assignment. If HBV vaccination has been declined by the employee, it may be obtained at any future time. Post Exposure Eval and FU If one of our employees is exposed to bloodborne pathogens, the employee will receive medical consultation and treatment as required, and the exposure incident will be investigated. An exposed employee may decline evaluation and follow-up through this facility. When consent is refused, a confidential medical evaluation and follow-up from another healthcare professional will be offered. This process will occur within 15 days of the exposure incident or as required by current regulations. To report a blood and body fluid exposure incident: Wash the site with soap and water. (Flush eyes, mucous membranes with copious amounts of water.) Report the incident to your immediate Supervisor. Fill out the Employee Injury Report Form.

Report IMMEDIATELY (within 2 hours of the exposure) to Employee Health, Occupational Health, or the Emergency Dept. Upon being seen, you will be evaluated for the degree of exposure to HIV, Hepatitis C, and Hepatitis B, and offered the appropriate prophylaxis using current guidelines. All Sharps injuries are posted on the Sharps Injury Log which is kept and maintained by the Employee Health Nurse. All employee bloodborne pathogen exposure follow-up, counseling, and treatment will be provided by SBMC unless otherwise requested by the employee. Hepatitis B Hepatitis B is a serious liver disease caused by the Hepatitis B virus. The disease causes liver cell damage and can lead to scarring of the liver and increased liver cancer in some patients.

Approximately 90-95% of adults will recover within six months and not contract HBV again. About 2-5% become chronically infected with HBV and become "carriers." Many people with HBV have NO symptoms at all or may have very mild flu-like symptoms including loss of appetite, nausea, fatigue, muscle aches and mild fever. Some patients may notice dark urine, yellowing of the skin and eyes, or light-colored stools. A few patients have a more severe course of illness and may die of overwhelming hepatic failure within a short period of time after getting sick. Transmission of HBV occurs through contact with body fluids containing HBV such as blood, semen and vaginal secretions. It is most commonly passed from person to person through sexual contact. It can also be transmitted through exposure to sharp instruments contaminated with HBV such as tattooing, body piercing and acupuncture needles, sharing of razors, nail files, or toothbrushes with an infected person. The virus can survive outside the body for at least 7 days on a dry surface and is 100 times more contagious than HIV. There are safe and effective vaccines for HBV. After a series of three injections, if there is immune system response with positive antibody formation, a person will be protected for at least 12 years and possibly a lifetime from HBV. It will not "cure" a person who is already infected. Hepatitis C Hepatitis C is one of a number of viruses that can cause hepatitis (literally, inflammation of the liver), but this virus is known to become chronic and cannot be cleared from the system. The virus is constantly present and causes cirrhosis or hepatocellular carcinoma many years after the initial infection. Initially, patients

are asymptomatic. The modes of transmission of HCV are not completely known, but the most commonly identified means of spread are through transfer of or contact with contaminated blood (or blood products). This virus may also be sexually transmitted and possibly vertically transmitted (from mother to infant). There is currently no widely-accepted treatment for HCV and no vaccine available for prevention of infection. AIDS AIDS stands for Acquired Immune Deficiency Syndrome. It is a disease caused by a virus HIV - Human Immunodeficiency Virus. HIV attacks the immune system - the part of our bodies that protects us against infections and illnesses. People with AIDS become very ill and die because their bodies can't fight off diseases.

Symptoms of HIV/AIDS are similar to those of many other diseases. Only a medical doctor can diagnose AIDS. Common symptoms include fatigue, chills, night sweats, swollen glands, pink to purple spots on skin, white spots and sores in mouth, persistent diarrhea, weight loss of 10 pounds or more, a dry heavy cough, shortness of breath, and repeated serious vaginal yeast infections in women. The HIV virus is relatively fastidious and cannot survive for long periods of time outside of the human body. It can be transmitted as free virus in secretions or as cell-associated virus by transmission of live cells (e.g., in blood products, breast milk, or semen). Transmission requires parenteral, non-intact skin or mucous membrane contact with contaminated blood and/or body fluids. Combination therapy may achieve more complete viral suppression, limit emergence of drug-resistant virus when viral replication is on-going, and treat established drugresistant quasi-species. Therapy with at least three agents has become standard. The goal of therapy is to suppress replication to undetectable levels. TUBERCULOSIS EXPOSURE CONTROL PLAN (TB ECP)

M. tuberculosis is a bacteria that is carried in airborne particles, or droplet nuclei, that can be generated when persons who have pulmonary or laryngeal TB sneeze, cough, speak, or sing. Infection occurs when a susceptible person inhales tiny droplet nuclei containing M. tuberculosis, and these bacteria reach the alveoli of the lungs. During the first two years after exposure (converted to PPD positive), approximately 5% of those infected will develop active disease. Another 5% will develop active disease during their lifetimes. Those people who have been exposed to TB but do not develop active disease are known to be TB infected but not currently transmitting the disease. Both persons with TB infection and known active TB will be PPD positive for the rest of their lives. The purpose of the TB ECP is to protect all individuals from exposure to tuberculosis in the healthcare setting. Contained in the plan is information about how SBMC: Defines employees who are at risk of occupational TB exposure Identifies suspect or confirmed TB cases Isolates, or controls, exposures when a suspect or confirmed infectious TB patient is identified Minimizes employee exposure Alerts employees to hazards Screens employees for TB

All employees are responsible for complying with all elements of the TB ECP including attending education sessions, obtaining required screening, using respirators when indicated, using safe work practices, reporting all TB exposures. A copy of the TB ECP can be found in the Infection Control Manual. DEFINITION OF A SUSPECT OR CONFIRMED TB PATIENT Is known, or with reasonable diligence should be known, to be infected with TB and have signs and symptoms of pulmonary TB. Has had a positive acid-fast bacilli (AFB) smear. Has a positive CXR which was ordered for the purpose of diagnosis pulmonary or laryngeal TB. Has a persistent cough lasting 3 or more weeks. Has one of the following which are known to increase risk of TB: HIV Positive Close contacts of TB cases Foreign-born persons from Asia, Africa, Latin America

Homeless Alcoholism or IV drug use Current or former resident of a correctional facility Known PPD positive DEFINITION OF A SUSPECT OR CONFIRMED TB PATIENT continued Patients with known or suspected TB will wear a mask until placed into a negative pressure isolation room. A TB patient is to be preferentially placed in negative pressure isolation rooms. These patients must remain isolated until 3 consecutive sputum specimens (at least 24 hours apart) are negative for AFB and discharge approval has been obtained from the TB Control Officer at San Bernardino County Public Health. Demystifier (Scavenger) Units are HEPA filter units which enhance the air flow and filtration within negative pressure isolation rooms. These units must be running in all negative pressure isolation rooms and are patient

chargeable through Central Supply. Negative pressure rooms require a closed door. YOU MUST NEVER TURN DOWN A HEPAFILTER DUE TO NOISE AS IT WILL PLACE EMPLOYEES AT RISK FOR EXPOSURE EMPLOYEE TB SCREENING All employees, physicians, and volunteers who have potential for exposure to M. tuberculosis, will be screened for TB at hire, and at least annually thereafter. If suspected or active M. tuberculosis is identified in any of the above individuals, that person will not return to work until the diagnosis of active disease has been ruled out or: 3 consecutive negative AFB sputum smears (each at least 24 hours apart) Has completed 2 weeks of multi-drug anti-tuberculous therapy if every sputum smear positive, or 4 days of multi-drug anti-tuberculous therapy if always sputum smear negative and Clinical improvement is seen and Continued medical supervision is followed.

Reading PPD Skin Tests All PPD tests must be administered, read and interpreted in accordance with current CDC guidelines. SBMC policy mandates that any licensed nurse (RN) who has completed an annual competency assessment may read and interpret SBMC employee PPD results. The skin test is to read between 48 & 72 hours after the test. Note: You must date and note time when PPD is placed and read. Reading a PPD result before 48 hours will not produce an accurate result for interpretation. Any employee who does not have a PPD result read within 72 hours must be rescheduled for another skin test. The test is read and measured in millimeters of the INDURATION. An induration is a palpable, raised, hardened area The reader should NOT measure any erythema (redness), only the induration (raised area). An induration of 5 or more millimeters is considered positive in a recent contact of a person with TB disease. An induration of 10 or more millimeters is considered positive in employees of high-risk settings,This such is the

as health care workers. 10mm line the edge is An induration of 15 or more millimeters is considered positive in any person. The measurement in millimeters should be documented on the employees skin test record. over Measuring Induration To measure induration (NEVER REDNESS) take a ballpoint pen, draw a line in at 4 points to where you feel the induration. Measure between the points. If greater than 10mm see employee health Employee Exposure Incidents "Exposure" to M. tuberculosis is defined as a prolonged contact or an occurrence of direct contact

with a patient who has confirmed infectious tuberculosis or to air containing aerosolized M. tuberculosis without the benefit of all applicable exposure control measures. All exposure incidents are to be reported immediately to the Employee Health Nurse and/or the Infection Control Nurse. Respiratory Protection After passing appropriate N-95 respirator mask fit testing, facility employees are required to wear NIOSH-certified N-95 respirators, which have been approved for protection against TB when: In the presence of a suspected or confirmed case of active TB. Entering a room which has been occupied by an unmasked suspect or confirmed active TB patient. Transporting or accompanying a suspect or known infectious TB patient in an enclosed vehicle. When changing filters in HEPA air filtration machines or ventilation ducts.

Our facility guidelines state no re-use of N-95 masks in isolation. PAPRs will be required during high-risk sputum producing procedures Any patient care worker who cannot wear an N-95 mask must wear a PAPR when providing patient care in airborne isolation Employees are fitted for N-95 mask which requires no facial hair to be present when the employee is being tested or while in an area where an N-95 mask would be required. Scabies Prevention All patients should have a skin assessment upon admission and throughout the hospital stay. If the RN determines that the patient has a rash that is suspicious for scabies, the patient should be placed into contact isolation and the physician should be notified. Perform a skin scraping. Document skin assessments and actions in the EHR. Clostridium Difficile

All patients with diarrhea should be assessed for risk for clostridium difficile infection. If c. diff is suspected, the RN should place the patient in contact isolation and inform the physician. Remember only soap & water hand washing while caring for these patients. Alcohol (Purell) does not kill C. diff spores. EVS cleans all contact isolation rooms with a bleach disinfectant. Remember we now have C-diff Protocol Resistant Organisms

Resistant organisms are difficult to treat and care should be taken to prevent transmission to other patients, family or staff. MRSA: All admitted patients are screened at time of admission and, if negative, again at discharge. VRE: Vancomycin resistant enterococcus ESBL: extended spectrum beta-lactamase Gram -: E. Coli, Klebsiella Pseudomonas Gram +: MRSA, VRE overuse of antibiotics can cause bacteria to become resistant. strict isolation precautions minimally wear gown & gloves every time you enter the room. NO HARM CAMPAIGN: CLABSI PREVENTION BUNDLE Central Line Associated Blood Stream Infections Prevention CLABSI Prevention Bundle

Daily line assessment Insertion site check Stabilization device Occlusive dressing 96 hour tubing changes Routine dressing change Document need criteria in medical record GET-IT-OUT! Strict adherence to evidence based practice to reduce the potential for CLABSI:

Hand Hygiene Chlorhexidine gluconate skin prep Skin prep is dry before insertion Maximum sterile barriers, (gloves gown, cap, mask, and large sterile drape) Optimal site selection (avoidance of the femoral vein) Daily review of line necessity NO HARM CAMPAIGN: CLABSI PREVENTION BUNDLE CUROS PORT PROTECTOR CAPS TECHNOLOGY (LITTLE GREEN CAPS) IV port protector for All Ports, All patients, All the time. Scrub hub with 10 twists when cap has not been in place for at least 3 minutes prior to entry. Every port has a bright green cap (70% alcohol) Caps are single use (replaced after each injection) When administrating multiple medication, scrub hub with 10 twists between administrations

NO HARM CAMPAIGN: Indwelling Catheter Urinary retention Urinary obstruction Strict intake & output Surgery of genitourinary tract Surgical patient (d/c by post-op day 2) Acute genitalia wounds Stage 3 or 4 pressure ulcers (cant be kept dry otherwise)

End of life comfort care If patient doesnt meet the above, then LEAVE OUT (catheter) ! If patient no longer meets the above, then GET IT (catheter) OUT! NO HARM CAMPAIGN: Indwelling Catheter Interventions: Document the time of insertion and discontinuation Insert indwelling catheters using aseptically approved hospital protocol Always anchor indwelling catheter with a stabilization device without tension on tubing Place collection bag lower than bladder and prevent backflow of urine into the bladder Daily peri-care required using bath in a bag to include 4 inches along catheter from insertion site Ventilator Associated Pneumonia (VAP)

Prevention Sedation vacation Elevate HOB 30 degrees Turn every 2 hours Routine oral care (Chlorhexidine) Daily Chlorhexidine bath

Ulcer prevention DVT prevention Surgical Site Infection (SSI) Prevention SCIP Bundle Prophylactic antibiotic with in one hour of surgical incision Prophylactic antibiotic discontinued with in 23 hours after surgery end time Glucose control for Cardiac surgery patient Appropriate hair removal Urinary catheter removed on POD 1 or POD 2 with day of surgery as day zero. Temp management Beta blocker received during periop period VTE prophylaxis

Attendance & Tardy The following policies are related to clocking, attendance and tardy rules. These policies can be read in their entirety in the policy and procedures housed under Human Resources using the indicated policy number. Please read the policies as questions will be asked regarding these policies. HR05026 Electronic Time Keeping Altering, falsifying, and/or tampering with time records, swiping in or out for another employee or falsifying time for another employee may result in disciplinary action for all parties involved, up to and including termination of employment. It is understandable that on occasion an employee may forget to record their time by swiping the Ceridian time clock. However, employees who consistently fail to record their hours worked via the time clock may be subject to disciplinary action, up to and including termination.

PLEASE READ THE ENTIRE POLICY HR03005 Hours of Work/Rest & Lunch Breaks/Shift Differential Your department supervisor will assign your work hours and shift based upon the work load of the department. For regularly scheduled full and part time employees, a schedule of work hours will be provided in advance according to department protocol. Schedules may vary depending on workload and staffing needs. SBMC provides paid rest periods and unpaid meal periods as

required by law. Hospital work requires 24 hour operation. Shifts other than the day shift are seen as inconvenient to employees' personal lives and are therefore compensated by providing a shift differential payment. The Medical Center reserves the right in its absolute and sole discretion to vary the number of hours worked based upon our needs Cont. HR03005 Employees are permitted a 10 minute rest break for each 4 hours of their shift. Employees may not combine break times with the meal period or use the break time to leave hospital premises. Lounge areas are provided to enable employees to take breaks away from the work area. The rest breaks are paid time. Employees whose shift lasts longer than 5 hours receive a 30 minute unpaid meal period. Non-exempt employees are required to document the time spent away from the job on the meal period by using the clocking system. Employees are permitted to leave the hospital premises during the meal period but must advise their supervisor of their intention to leave the hospital. PLEASE READ THE ENTIRE POLICY

HR05005 Attendance & Punctuality While it is recognized that periodically employees may not be able to fulfill their scheduled shift for unforeseen reasons, excessive or repeated absences or tardiness is unacceptable and grounds for counseling and disciplinary action, up to and including termination. Record period - Tardy and absence occurrences for each employee will be accounted for in one 12-month period beginning on July 1 and ending on June 30. Occurrences from one record period will not be carried over. Cont. HR05005 Punctuality Occurrence - Employees are considered tardy when they badge in at their designated time clock more that

7 minutes after the scheduled start of shift. Attendance Occurrence - Defined as any number of days or part of a day that an employee is scheduled to report to work but does not report or remain at work whether avoidable or unavoidable, voluntary or involuntary and whether or not at the fault of the employee. An employee will incur one absence occurrence for any day, part of a day or number of days that is not separated by a return to work. Exceptions to an absence occurrence are defined below. Cont. HR05005 NORMAL DISCIPLINARY PROCEDURE PLEASE READ THE ENTIRE POLICY ATTENDANCE OCCURRENCES 4th occurrence = informal, nondisciplinary, counseling by supervisor.

5th occurrence = Formal verbal counseling by supervisor. (To be documented) 6th occurrence = Formal written disciplinary warning with goals. 7th occurrence = Formal Last Chance Written Warning. 8th occurrence = subject to termination from employment.

PUNCTUALITY/TARDINESS OCCURRENCES 4th occurrence = informal, nondisciplinary, counseling by supervisor. 5th occurrence = Formal verbal counseling by supervisor. (To be documented) 6th occurrence = Formal written disciplinary warning with goals. 7th occurrence = Formal Last Chance Written Warning.

8th occurrence = subject to status change or termination from employment.

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