Leadership exam 3

Infection Control Must

• Prevents cross-contamination

• Critical to patient & staff safety

Infection Control: Nurse's Responsibilities

• Educate staff on infection prevention/control

• Ensure proper equipment is available

• Ensure isolation procedures are followed

Infection Control: Policies and Types

• Follow protocols for infection control

• Use as a resource (e.g., HIV blood testing procedures)

• Standard

• Airborne

• Droplet

• Contact

Precautions for Everyone

Most Important: HAND HYGIENE

• Always apply

• Use latex-free gloves (nitrile/vinyl) if latex allergy is present

• Perform before/after client contact

• After removing gloves

• Before aseptic tasks

Infection Control: Linens and needles, etc

• Use moisture-resistant bags

• Tie in a knot

• Do not double-bag unless visibly contaminated

• Use retractable/needleless systems

• Avoid recapping needles

• Report needlesticks (incident report required)Clean after each client use

• Includes BP cuffs, thermometers, pulse oximeters

Hazardous Materials Guidelines

employees have the right to refuse to work in hazardous working conditions if there is a clear threat to their health; OSHA guidelines:

- provide each employee a work environment that won't cause death or serious physical harm

- make protective gear accessible (antineoplastic meds, sterilization chemicals)

- provide measurement devices and keep record of an employees exposure over time to hazardous materials (radiation from x-rays)

- provide education and recertification opportunities to each employee regarding these rules & regulations (handling of hazardous materials)

- safety data sheets (SDS) should be available to all employees

- designate HAZMAT response team that responds to hazardous events

- standard precautions at all time

Components of a SDS

- level of toxicity
- handling and storage guidelines
- first aid and containment measures to take in case of accidental release of toxic, radioactive, or other dangerous materials

Nurse's Responsibility Related to Equipment Safety

- learning how to use equipment (disconnect equipment prior to cleaning)
- checking that equipment is functioning properly at the beginning and during each shift (O2, NG suction)
- electrical equipment should be grounded (3-pronged plug and grounded outlet) to decrease the risk for electrical shock
- ensuring that outlet covers are used in environments w/ individuals at risk for sticking items into them
- unplug using the plug not cord, to prevent risk for electrical shock
- ensuring that life-support equipment is plugged into outlets designated to be powered by a backup generator during power outages
- ensuring that all IV pumps (general and PCA) have free-flow protection to prevent an overdose of fluids or meds
- don't overcrowd outlets and only use extension cords when absolutely necessary (if they must be used in an open area, tape the cords to the floor)
- regularly inspect equipment = faulty equipment (frayed cords, disrepair) = fire/electrical shock and should be removed from use and reported immediately

Risk Factors for Falls

- physiological changes associated with AGING (decreased strength, impaired mobility and balance, endurance limitations, decreased sensory perception)
- decreased visual acuity, generalized weakness, orthopedic problems (diabetic neuropathy), urinary frequency, gait & balance problems (Parkinson's, osteoporosis, arthritis), cognitive dysfunction
- medications effects (ortho hypo, drowsiness)
- greater risk w multiple risk factors, or having fallen previously

Formula used to compare fall rates and evaluate incidence of falls

(# of client falls / # of client days) x 1000 = fall rate per 1000 client days

How to Prevent Falls

- Ensure pt understands how to use assistive devices & can locate items·
- Place clients at risk for falls near the nurse's station
- Ensure tables, phone, water, call light are within pt reach
- Maintain bed in low position, lock wheels, use bed alarms to
alert staff for clients at risk for getting up unattended
- Keep bed rails up for pt's who are sedated or unconscious and partly up for other clients
- Nonskid footwear
- Keep room clutter free: no scatter rugs, cords, furniture, & provide adequate lighting

Seizure Precautions

- assign pt in room close to the nurses station
- rescue equipment available at bedside: oxygen, and an oral airway & suction equipment
- a saline lock can be placed for IV access if pt is high risk
- instruct pt to use precautions: avoiding triggers when out of bed

Guidelines for Seclusion & Restraint: Use

- prescribed for shortest duration possible & only after less restrictive methods have proved insufficient: attempt early release if client is calm

- explain the purpose of the restraint and that the restraint is only temporary (may feel embarrassed)

- PRN prescriptions for restraints are NOT allowed

- must be prescribed by the provider based on a FACE-TO-FACE assessment of the client; in emergencies: place the client in restraints but obtain a prescription ASAP (w/in 1 hr)

- 8 hrs max for adults, 2 hr max for ages 9-17, 1 hr max if younger than 9; violent/self-destructive pts should be 4 hr; prescriptions are renewable for a max of 24 hours

Guidelines for Seclusion & Restraint: Prescriptions

- the reason, location, and type of the restraint

- how long the restraint can be used

- type of behaviors demonstrated by the client that warrant use of the restraint

Legal Considerations for the Use of Seclusion and Restraints

- nurses should understand agency policies as well as federal ands state laws that govern the use
- false imprisonment = the confinement of a person without their consent
- improper use of restraints can subject the nurse to charges of false imprisonment

Nursing Responsibilities for Seclusion and Restraints

- obtain prescription from provider, even in emergency situations

- neuro checks q 2 hrs (circulation, sensation, mobility)

- hygiene & elimination means; offer foods & fluids Q2

- assess client q 15 min

- get signed consent from the client or guardian

- remove or replace restraints frequently; D/C if not needed

- pad bony prominences

- secure restraints to a moveable part of the bed frame; use a quick-release knot: DO NOT secure restraints to the siderails of the bed

- ensure the restraint is loose enough for ROM and can fit 2 fingers

- never leave the client unattended w/o the restraint

- DOCUMENT

RACE

R = RESCUE & move pt to safer location, horizontal movement preferred, clients who are ambulatory can walk independently to a safe location

A = ACTIVATE the alarm system and report the fire's details and location

C = CONFINE/CONTAIN fire by closing doors & windows, turn off oxygen sources & electrical devices, ventilate those on life support with bag valve mask

E = EXTINGUISH the fire if possible

PASS

P = PULL the pin
A = AIM at the base of the fire
S = SQUEEZE the handle
S = SWEEP the extinguisher from side to side, covering the area of the fire

Priorities for Fire Safety

- staff must know the location of exits, alarms, fire extinguishers, and oxygen turnoff valves
- make sure equipment does not block fire doors
- know the evacuation plan for the unit and the facility
- change smoke alarm batter twice a year
- smoke filled area: exit holding damp cloth to mouth and as close to floor as possible

Working with the IP Team to Assess the Home

Nurses must collaborate w/ the client, family, and members of the IP teams to promote client safety.

When the client demonstrates factors that increases the risk for injury, a home hazard evaluation should be conducted by a nurse, PT, and/or OT. The client is made aware of the environmental factors that can pose a risk to safety and suggested modifications to be made.

To initiate a plan of care, the nurse must identify risk factors using a risk assessment tool and complete a nursing history, physical exam, and home hazard appraisal.

Risks for Infants & Toddlers

at risk for injury due putting objects in their mouth while exploring their environment

Aspiration: keep small objects out of reach, cut food, no supine position when eating, no hard candy/popcorn, pacifier 1 piece

Water safety: never leave unattended in water, teach how to swim

Suffocation: no balloons or latex bags, learn CPR/Heimlich, back when sleep, snug fit mattress, crib slats < 2 3/8 in apart

Poisoning: keep houseplants and cleaning agents away, remove lead sources, dispose meds properly

Falls: discontinue use of high chairs, swings, etc when the child outgrows size limits, rails up, gates on stairs

Motor vehicle injury: rear-facing car set in the back w five-point harness, middle seat

Burns: test temp., cover electrical outlets, matches/lighters out of reach

Risks for Preschoolers and School-Age Children

often face injury from limited or underdeveloped motor coordination

Drowning:

Motor vehicle injury; teach safety rules of the road, never run after toy in road, children < 12 in back seat, boosters seats if < 4'9 and < 40lb

Firearms: teach to never touch a gun or stay at a friend's house where there's a gun, store bullets away from gun and locked and unloaded

Play injury: ensure equipment is appropriate size for the child, teach to play in safe areas & to avoid strangers, NO running w candy in mouth

Burns: water heater < 120 degrees, no fireworks, proper microwave use

Poison: keep dangerous substances out of reach(alc/cigs/drugs), call poison control & keep the number accessible

Risks for Adolescents

stems from increased desire to make independent decisions, and relying on peers for guidance rather than family

Motor vehicle Accident: driver's ed, # people in car, seat belt, uber if impaired

Water Safety: Check water depth before diving

Burns: sunscreen and wear protective clothing, sunbathing and tanning beds

Other risks: suicide, smoking/alcohol, unprotected sex, social media and the internet, reinforce safety for sports/hobbies, firearms

Risks for Young and Middle-Age Adults

- MVA: leading cause of death & injury to adults

- Occupational injuries contribute to the injury & death rate

- High consumption of alcohol & suicide are also major concerns (monitor for depression)

Risks for Older Adults

prevention is key cause they can have longer recovery times from injuries and are at an increased risk for complications from injuries

Risks:

- physical, cognitive, and sensory changes

- musculoskeletal and neuro changes

- impaired vision and/or hearing

- ambulating frequently at night because of nocturia and incontinence

Mods for Home Safety:

- remove throw rugs/loose carpet

- nonskid mat in shower & shower chair/bedside commode if needed

- tape down electrical cords

Categories of Conflict

IntrApersonal
IntErpersonal
Intergroup

IntrAPersonal Conflict

occurs within the person and can involve internal struggle related to contradictory values or wants

EX: a nurse wants to move up on the career ladder, but not if finding that time w/ their family would be compromised

IntERpersonal Conflict

occurs between two or more people with differing values, goals, or beliefs
- involves disagreements among nurses, clients, family members, and w/in a healthcare team; bullying and incivility are examples
- contributes to burnout and work-related stress
EX: a new nurse is given a client assignment that is heavier than those of other nurses, and when the new nurse asks for help, it is denied

Intergroup Conflict

occurs between two or more groups of individuals, departments, or organizations and can be caused by a new policy or procedure, a change in leadership, or a change in organizational structure

EX: there is confusion if it is the responsibility of the nursing unit or dietary department to pass meal trays to clients

Stages of Conflict

1. Latent Conflict
2. Perceived Conflict
3. Felt Conflict
4. Manifest Conflict
5. Conflict Aftermath

Stage 1: Latent Conflict

actual conflict has not yet developed however factors are present that have a high likelihood of causing conflict to occur.. UNAWARE and no emotional response

EX: a new scheduling policy is implemented within the org. the nurse manager should recognize that change is a common cause of conflict

Stage 2: Perceived Conflict

a party perceives that a problem is present though an actual conflict might not actually exist.. AWARE, but no emotional response

EX: a nurse perceives that a nurse manager is unfair with scheduling --> the nurse might not be aware that it is only because the nurse manager misunderstood the nurse's scheduling request

Stage 3: Felt Conflict

those involved begin to feel an emotional response to the conflict
EX: a nurse feels anger towards the nurse manager after finding out that they were scheduled to work two holidays in a row

Stage 4: Manifest Conflict

the parties involved are aware of the conflict and action is taken.
- actions can be positive and strive towards conflict resolution or they can be negative and include debating, competing, or withdrawal
EX: the nurse manager and nurses on a unit agree that the current scheduling system is causing conflict and agree to work together to come up with a solution

Stage 5: Conflict Aftermath

the completion of the conflict process and can be positive or negative
EX: the nurse manager and nurses on a unit are satisfied with the newly revised scheduling system & feel valued for being included in the conflict resolution process

Actions nurses can take to promote open communication and de-escalate conflicts

- use "I" statements, and focus on the problem, not on personal differences
- listen carefully, and try to understand others perspectives
- move an escalating conflict to a private location or postpone the discussion until a later time to give everyone a chance to regain control of their emotions
- share ground rules with participants.

EX: treat everyone w/ respect, only 1 person speaks at a time, everyone should get to speak, etc

Steps of the Problem-Solving Process

1. identify the problem
- state it in objective terms, minimizing emotional overlay
2. discuss possible solutions
- brainstorm solutions as a group
3. analyze identified solutions
- discuss pros and cons of each to narrow down solutions
4. select a solution
5. implement the selected solution
- create a procedure and timeline for implementation
6. evaluate the solution's ability to resolve the original problem
- if unsuccessful, redo the process

Negotiation

a process by which interested parties resolve ongoing conflicts, agree on steps to take, bargain to protect interests, and pursue outcomes that benefit mutual interests; may be used on a daily basis

the focus is on a win-win solution or a win/lose-win/lose solution in which both parties win and lose a portion of their original objectives.

- each party agrees to give up something

- emphasis is on accommodating differences rather than similarities between parties

Avoiding/Withdrawing Strategy

- both parties know their is a conflict, but they refuse to face it or work toward a resolution

- can be appropriate for minor conflicts, when one party holds more power than the other party, or if the issue can work itself out over time

- conflict remains and can surface again at a later date and escalate over time

- lose-lose situation

Smoothing Strategy

- one party attempts to "smooth" another party by trying to satisfy the other party (compliments)

- often used to preserve or maintain a peaceful work environment

- the focus can be on what is agreed upon, leaving conflict largely unresolved

- lose-lose situation

Competing/Coercing Strategy

- one party pursues a desired solution at the expense of others

- managers use this when a quick or unpopular decision must be made

- party who loses something can experience anger and a desire for retribution

- win-lose situation

Cooperating/Accommodating Strategy

- one party sacrifices something, allowing the other party to get what it wants

- original problem might not actually be resolved

- can contribute to future conflict

- lose-win solution

Compromising/Negotiating Strategy

- each party give up something
- to consider this a win/lose-win/lose solution, both parties must give up something equally important. if one party gives up more than the other, it can become a win-lose solution

Collaborating Strategy

- both parties set aside their original individual goals and work together to achieve a new common goal
- requires mutual respect, positive communication, and shared decision-making between parties
- win-win solution

What is disciplinary action?

addressing deficiencies identified during a performance appraisal or reported by coworkers
- evidence regarding the deficiency must support such a claim
- written documentation by the manager is placed in the staff member's permanent file

First Infraction

- informal reprimand (casual way of addressing someone's behavior)

- manager and employee meet

- discuss the issue

- suggestions for improvement/correction

Second Infraction

- written warning

- manager meets w/ employee to distribute written warning

- review of specific rules/policy violations

- discussion of potential consequences

Third Infraction

employee placed on suspension with/without pay & gives the employee the opportunity to:

- examine issues

- consider alternatives

Fourth Infraction

employee termination

follows after multiple warnings have been given and employee continues to violate rules and policies

Role of the Preceptor

focus on providing one-on-one approach to mentor/assist newly licensed nurses, helping them learn their new role while also introducing them to the values/cultures of the team they'll be working with (socialization)
- they orient the new nurses to the unit and supervise their acquisition of skills for a limited amount of time

Steps in Providing Staff Education

1. Identify and respond
- determine the need for knowledge or skill proficiency
2. Analyze
- look for deficiencies, and develop learning objective to meet the need
3. Research
- resources available to address learning objectives based on EBP
4. Plan
- program to address objectives using available resources
5. Implement
- program(s) at a time conducive to staff availability; consider online learning modules
6. Evaluate
- use materials and observations to measure behavior changes secondary to learning objectives

What are benchmarks?

benchmarks: #1 = establish standard of care
- goals that are set to determine at what level the outcome indicators should be met (for example a specific percentage)

What are the different types of indicators?

Outcome (clinical) indicators: reflect desired client outcomes related to the standard under review
Structure indicators: reflect the setting in which care is provided and the available human and material resources
Process indicators: reflect how client care is provided and are established by policies and procedures (clinical practice guidelines)

Audits

produce valuable quantitative data(#'s)

Types of Audits

- process audits: review how care was provided and assume a relationship exists between nurses and the quality of care provided

- structure audits: evaluate the influence of elements that exist separate from or outside of the client-staff interaction

- outcome audits: determine what results, if any, occurred as a result of the nursing care provided

- some outcomes are influenced by aspects of care

- nursing-sensitive outcomes = directly affected by the quality of nursing care

Steps in the Quality Improvement Process (QI)

1. A standard is developed and approved by a facility committee

2. Standards are made available to employees

3. Quality issues are identified by staff, management

4. An inter-professional team reviews the issues

5. The current structure and process r/t issues are analyzed

6. Data collection methods are determined - quantitative data primarily used

7. Data is collected, analyzed, and compared with the established benchmark

8. If benchmark (goal) is not met, influencing factors determined. May use a root cause analysis (focuses on variables that surround the consequence of an action)

9. Potential solutions are analyzed and one solution is selected for implementation

10. Educational or corrective action implemented.

11. Issue reevaluated at a pre-established time to determine if benchmark met.

Nurse's Role in Quality Improvement (QI)

- Serve as unit rep. on committees developing policies & procedures
- Use reliable resources for information (CDC, journals, EBP research)
- Enhance knowledge & understanding of the facility's policies & procedures
- Document client care thoroughly
- Participate in the collection of info/data related to staff's adherence to selected policy or procedure
- Assist with analysis of the info/data
- Compare results with the established benchmark
- Make a judgement about performance
- Assist with provision of education or training necessary to improve staff performance
- Act as a role model
- Assist with the re-evaluation of staff performance by collection of info/data at a specified time

Cost-Effective Care

strategies that achieve optimal results in relation to the money spent to achieve those results. in other words, "get your money's worth"

Strategies for Cost-Effective Care

- providing clients with needed education to decrease future medical costs associated with future complications
- use of evidence-based care, resulting in improved client care outcomes
- promoting cost-effective resource management

How do nurses contribute to saving costs?

- teaching clients how to effectively manage their disease process, reducing risks for complications
- implementing the use of evidence-based techniques to reduce complications

What are things necessary to ensure costs are contained?

- using all levels of personnel to their fullest when making assignments. delegating effectively to members of the nursing care team
- providing necessary equipment and properly charging clients
- returning uncontaminated, unused equipment to the appropriate department for credit
- using equipment properly to prevent wastage
- providing training to staff unfamiliar with equipment
- returning equipment to the proper department as soon as it is no longer needed. this prevents further costs to clients

Examples when an Incident Report should be filed

- medication errors
- procedure/treatment errors
- equipment-related injuries/errors
- needlestick injuries
- client falls/injuries
- visitor/volunteer injuries
- threat made to client or staff
- loss of property (dentures, jewelry, personal wheelchair)

Nurse's Role in Incident Reports

the priority is to assess the individual for injuries and institute any immediate care measures necessary to decrease further injury

- if client-related, notify the provider and implement additional tests or treatment as prescribed

- report should be completed by the person who identifies the event and should be done as soon as possible - within 24 hrs of the incident

- do not share it w/ pt and do not put it in the EHR, just factually document what you saw

What should be included in the incident report?

- client's name and hospital number (or visitor's name & address if visitor injury), along w/ the date, time, and location of the incident
- factual description of the incident and injuries, avoiding assumptions
- names of witnesses to the incident and client/witness comments regarding the incident
- corrective actions that were taken, including notification of the provider and referrals
- name & dose of any meds or ID # of any equipment involved in incident

Emergency Operating Plan (EOP)

a requirement of facilities receiving CMS reimbursement
- facilities accredited by the Joint Commission must have an EOP and are mandated to test the plan at least twice a year: one has to be a full-scales exercise
- the nurse usually calls to activate the EOP, then the hospital administrator starts the activation

Internal emergencies

within a facility and include loss of electric power or potable (drinkable) water, and severe damage or casualties related to fire, weather (tornado, hurricane), explosion, or terrorist act
- readiness includes safety and hazardous materials protocols, and infection control policies and practices

External emergencies

affect a facility indirectly and include weather (tornado, hurricane), volcanic eruptions, earthquakes, pandemic flu, chemical plant explosions, industrial accidents, building collapses, major transportation accidents, and terrorist acts (including biological and chemical warfare)
- readiness includes a plan for participation in community-wide emergencies and disasters

Agencies that have a role in Disaster Response

- Federal Emergency Management Agency (FEMA)

- CDC

- U.S. Department of Homeland Security (DHS)

- American Red Cross

- Office of Emergency Management (OEM)

- Public Health System (PHS)

- State level: Department of Human Health & Services, Office of the Governor:

a state must request assistance from the MCI if needed

Emergency Response Plans

- a planning committee develops emergency preparedness plans. reviews information regarding potential emergencies then determines what resources are needed

- nurses and other members of the healthcare team should be involved in the development of an EOP.

- criteria for an EOP should be clear

- all roles should be outlined

- designated area should be established & a person to serve as the incident control manager

key roles in the EOP:

* medical command physician: provider to manage client numbers and resources

* triage officer: an individual to prioritize treatment

* community relations/public info officer: a media liaison

- the nurse should create an action plan for personal family needs

Hospital Incident Command System (HICS)

for disaster management
- offers a clear structure for disaster management at the facility level

Nurse's Role for Biological Incidents

- early detection is key: be alert to indications of possible bioterrorism attack

- be alert for the appearance of a disease that does not normally occur at a specific time or place, has atypical manifestations, or occurs in a specific community/people

- recognize whether the disease requires isolation, decontamination, and PPE

- use appropriate isolation measures (Ebola, plague, smallpox-airborne)

- transport or move pts only if needed for tx & care

- protect self and others

- recognize indications of infection/poisoning

Nurse's Role for Chemical Incidents

- looks for safety data sheet (SDS)

- take measures to protect self and avoid contact

- ABC, give first aid as needed

- decontaminate the pt outside the ED before caring for them, irrigate skin w/ running water

- brush off the agent if it is a dry chemical

- gather a specific history of the injury, if possible (name and concentration of the chemical, duration of exposure)

- know which facilities are open to exposed clients and which are open only to unexposed clients

- follow emergency response plans

Nurse's Role for Hazardous Material incidents

- approach scene with caution & take measures to protect self & avoid contact

- identify the hazardous material with available resources: emergency response book, poison control centers

- know where SDS manual is

- contain the material in one place prior to arrival of hazardous materials team

- decontaminate affected individuals as much as possible or as close to scene as possible

* don gloves, gown, mask, & shoe covers

* carefully remove contaminated clothing so it doesn't become airborne

* water is the universal antidote

* wash skin with LOTS of water & antibacterial soap if biological hazard

Nurse's Role for Radiological Incidents

- amount of exposure is r/t the duration of exposure, distance from source, & amount of shielding

- prevent contamination of treatment areas: floors, air vents, ducts should be covered

- wear water-resistant gowns, double glove, & fully cover body with caps, shoe covers, masks, goggles

- wear radiation dosimetry badge (monitors radiation exposure)

- survey pts with radiation meter to determine amount of contamination

- decontaminations with soap & water & disposable towels should occur prior to pt entering facility(water runoff will be contaminated and need to be contained)

- re-survey pt and continue irrigation until pt is free of contamination

Mass Casualty Triage

Part 1: Say, “If you can walk, come to the sound of my voice” – anyone walking is tagged green

Part 2:

1. Breathing

- RR > 30 = tag immediate (red)

- RR < 30 = move to step 2

- No respirations after 2 chin tilt attempts = black, deceased: turn pt to L side & move on

2. Circulation

- Cap refill > 2 sec = tag immediate (red)

- Cap refill < 2 sec = move to step 3

- Bleeding? Control with pressure bandages

3. Mental status

- Give “squeeze my hand” command

- No response = tag immediate (red)

- Follows commands but is unable to walk – tag delayed (yellow)

Red Tag

Highest priority: EMERGENT/IMMEDIATE; potential for fatal injury but also have a high possibility of survival

- Abnormal respirations (>30 in adult, >45 or <15 in peds)

- No radial pulse or cap refill > 2 sec

- Uncontrolled/severe bleeding

- Signs of shock

- Open chest/abdominal cramps

Yellow Tag

Second-highest priority (urgent/delayed) - pts with potential for serious injury & require tx within 30 min-1 hr

- Burns with no airway issues

- Major/multiple bone or joint injuries

- Back injuries without spinal cord injuries

Green Tag

Non-urgent/minimal:

- walking wounded pts with minor fractures or soft tissue injuries that are not life threatening and can wait hrs/days for tx

Black Tag

Lowest priority: expectant/unsalvageable: non-survival injury

- agonal breaths

- cardiac arrest

- no palpable pulse

- no respirations after opening airway or providing rescue breaths

comfort measures can be provided

Nurse's Role in Facility Security Plans

nurses should be prepared to take immediate action when breaches in security occur. time is of the essence in preventing a breach in security

Emergency Designations

- code red = fire
- code pink = newborn/infant/child abduction
- code orange = chemical spill
- code blue = medical emergency
- code gray = tornado
- code black = bomb threat

nurses should be familiar with procedures and policies that outline proper measures to take when one of these emergencies are called

Severe Thunderstorm/Tornado

- close all doors, draw shades, and close drapes to protect against shattering glass
- lower all beds to the lowest position, and move beds away from the windows
- place blankets over all clients who are confined to beds
- relocate ambulatory clients into the hallways (away from windows) or other secure location designated by the facility
- do not use elevators
- turn on the severe weather channel to monitor severe weather warnings

Bomb Threat

- do NOT touch it if it looks like a bomb; clear the area, and isolate the device
- notify the appropriate authorities (police, administrator, director of nursing)
- cooperate with police and others: assist to conduct search as needed, provide copies of floor plans, have master keys available, and watch for and isolate suspicious objects (packages and boxes)
- keep elevators available for authorities
- remain calm and alert, and try not to alarm clients

Bomb Threat: Phone Call

- extend the conversation as long as possible
- listen for background noises (music, voices, traffic, airplanes)
- note voice characteristics of the caller
- ask where and when the bomb is set to explode
- note whether the caller is familiar with arrangement of the facility

Active Shooter Situation

RUN: get out!!! leave everything behind!
HIDE: if you can't dip, be quiet and prevent noise in your hiding spot
FIGHT: beat that b***h up! or yell
- call 911 when safe, even if you can't talk; don't move wounded people until it's safe; remain calm and quiet; keep hands visible when the police show up and be cooperative
- protect patients and protect yourself