Annual Regulatory Requirements, Current Practice

(JCR staff, 2024a)

Information about both clients and staff must be kept secure and confidential. Specific staff should be designated to ensure this, and any staff member working with client information must know how to maintain and secure protected information. This is not the job of medical records staff; it is everyone’s duty.

(Chambers, 2023; OSHA, 2023a)

Let’s face it; you cannot discuss patient rights without serving up a side of HIPAA. The Joint Commission, CMS, and many state and federal agencies require all healthcare staff, from pathologists to plumbers, to be regularly versed on relevant aspects of the Health Insurance Portability and Accountability Act (HIPAA).

The HIPAA privacy rule is a federal regulation designed to address public concerns about managed care, insurance availability, and insurance affordability. However, this course only addresses the legislation's privacy, confidentiality, and security aspects.

The rule sets standards for patient privacy and confidentiality. It also sets severe civil and criminal penalties for people who violate a patient’s privacy. To comply with HIPAA, protected patient information must only be shared with people directly involved in that patient’s care. This is especially important when talking in public areas (elevators, restrooms, hallways, cafeterias, etc.). Charts or documents should not be left out where unauthorized persons might see them; computer screens should not be angled in such a way as to allow unwanted viewing. It is vitally important to observe surroundings when discussing patient care.

The privacy rule standards address the use and disclosure of individuals’ health information called “protected health information.” All facilities must limit access to protected health information only to those who need to know. A nurse seeking information about a patient not under their care violates the HIPAA rules. Protected health information can only be used for health purposes. Employers cannot use health history information to screen candidates for hire or promotion. Financial institutions may not use it to determine lending practices. Only the individual can explicitly authorize employers, banks, and individuals to have access to their medical information.

(CaseText Staff, 2023)

HIPAA also established the “minimum necessary rule,” which stipulates that only the minimum necessary information may be shared, even with the patient's authorization. A classic example would involve treatment for a case of child or domestic abuse; the professional would, rather than providing an entire medical record, share the pertinent data furnished in the form of an abstract outlining the information that is necessary to provide treatment and protect the victim. The abstracted information could be provided to legal and law enforcement entities.

Health professionals directly involved in treating patients are not subject to the minimum necessary rule and can have full access to all information needed to provide care. Health information that has implications for public health and safety can be shared without consent. There are several situations where medical information can be shared:

• Emergency 911 situations
• When infectious diseases are involved
• When law enforcement agencies participate
• If national defense or security is a factor

The public health department is deemed a legitimate recipient of certain personal health information, and professionals may occasionally report certain findings to the proper public health agency. Included are the cause of death even when the patient dies at home, reportable communicable diseases, child abuse, reporting an adverse drug reaction to the Federal Drug Administration, the occurrence of cancer in a state with a cancer registry, meningitis, and immunizations for children.

(Alder, 2023; HHS, 2023a)

HIPAA privacy regulations also mandate specific patient rights that include the following:

• Right to privacy notice requires disclosure and reasonable effort to ensure that the patient understands the agency’s policy concerning privacy of information.
• Right to request restrictions - patients may specify health information that cannot be released and may restrict to whom information can be released.
• Right to access personal health information - patients must be allowed to inspect and copy information in the agency’s record.
• Right to know what disclosures have been made - the agency must track all information released and be able to provide documentation to the patient.
• Right to amend personal health information - while patients may request amendments and the agency must allow amendments, the agency may deny some requests.

Electronically generated, stored, or transferred information also falls under HIPAA privacy rules. Both individuals and facilities are responsible for defending electronic protected health information (ePHI).

(Alder, 2023)

Protected information that is shared, either by accident or with purpose, must immediately be reported using the facility's established procedures. Depending on the extent of the information breach, the federal agency overseeing HIPAA accountability and local media may need to be notified.

(Ting, 2023)

Clients have the right to participate in decisions about their care and to set the course of their treatment. This means that they must be given accurate information. They have the right to know their diagnosis, prognosis, and treatment options. Healthcare providers must discuss all treatment options with their clients, which includes the option of no treatment. Further, they must know each treatment option's risks, benefits, and potential medical consequences.

Discussing clinical information with a client is part of informed consent. Informed consent is an ongoing communication process between a healthcare provider and the client. It allows the person to make intelligent decisions about a proposed course of treatment. Remember, information is useful to clients only if they can understand it. When discussing diagnosis and treatment options with the client, avoid the use of medical jargon and terminology, seek the services of a translator or interpreter if necessary, and assist the patient in obtaining a second opinion if requested.

After receiving all pertinent information, a client may consent to or refuse treatment. Signing as a witness on the informed consent document is witnessing that the client signed the document. It does not mean that the witness participated in providing informed consent.

Except in an emergency, a client must give informed consent before starting any procedure or treatment. Informed consent or the reason for a client’s inability to provide informed consent must be documented in the medical record. The informed consent document must:

• Be worded in simple terms without abbreviations.
• Indicate the specific procedure to be performed.
• Include a list of complications.
• Be written as stated in physician orders.
• Be signed by the client before receiving pre-op meds that induce sedation or amnesia or reduce anxiety.
• Contain the client’s dated signature if the client is of age and competent.
• Contain the signature of the physician performing the procedure.
• Ensure that the consent has a date and time.
• Include a witness’ signature affirming the client's signature.

Please note that two witnesses are required for the following:

• A person signing for an incompetent patient.
• Telephone consent.
• Signature of “X” if the client cannot write.
• When there is a clause for photographs and blood transfusion if applicable.

If the client cannot consent, laws vary from state to state, and policy varies from facility to facility. The following are accepted practices. The legal guardian must sign the consent if the client is a minor. An emancipated minor can sign consent. An emancipated minor is usually recognized as one who is not subject to parental control, as in the following situations:

• Married minor.
• In military service.
• College students are under legal age but are living away from home.
• Minor who has a child.
• Court-ordered emancipated minor.

If the client is incompetent or incapacitated, permission can be sought from a patient representative, usually a family member or Power of Attorney. An incompetent client is any client who is mentally or physically incapacitated, as determined by physicians, such that the client cannot communicate treatment preferences. The client does not have to be found incompetent by a court of law to consent to a procedure. Facility policy usually dictates the process and how many physicians must be involved in the decision.

In an emergency where the physician feels that delaying a procedure would be an immediate threat to the client’s life or limb, and the client cannot consent, the physician may proceed with the procedure without consent. This process requires extensive documentation and often a consultation with other physicians. Check your facilities policy.

Clients have the right to refuse treatment. Even after giving informed consent, the client may change their mind anytime. If the client decides to withdraw consent, the treatment must be stopped. Clients who refuse treatment have the right to know what will happen. They should receive information on medical and other consequences of refusing treatment. Parents, guardians, family members, or others designated as the client's representative must be provided with the same information if he cannot make their own decisions.

The Patient Self Determination Act became effective in December 1991 (GovTrack.us, 2024). This federal law requires that all hospitals receiving Medicare or Medicaid funding provide information to all adult clients upon admission about advanced directives and to ask whether they have an advanced directive. By federal and state regulations, clients should receive information regarding advanced directives if they do not present it upon admission. Advanced directives can be used from admission to admission; however, they should be reviewed with the client at each admission to verify accuracy. The Joint Commission and CMS require ongoing training by healthcare professionals on advanced directives and resuscitation.

The surrogate or proxy should provide information if the client is incompetent at admission. If the client is temporarily incapacitated, the information should be provided when decisional capacity returns. A client’s right to make decisions about their care is true even after they can no longer communicate those decisions directly. Advance directives can protect people who may be unable to communicate due to a condition such as irreversible brain damage or brain disease that affects the ability to think as well as communicate.

Advanced directives can limit life-prolonging measures when there is little or no chance of recovery. For example, advanced directives may enable clients to make their feelings known about cardiopulmonary resuscitation (CPR), intravenous (IV) therapy, feeding tubes, ventilators, respirators, and dialysis. Advanced directives can address pain relief, either requesting or refusing it.

(CFR, 2024; CMS, 2023a; JCR Staff, 2024c)

An advanced directive is a legal document allowing clients to participate in future healthcare decisions. There are two forms of advanced directives:

• Living Will: a client documents their wishes for future treatment in the event of a terminal illness. A living will takes effect when a client develops a terminal condition that makes it impossible to communicate healthcare decisions directly. They are called living wills because they take effect while a client is alive.
• Durable Power of Attorney for Healthcare: the client appoints a representative to make healthcare decisions in this document. The power of attorney goes into effect when the client loses the ability to communicate their own decisions. The client names a person called a surrogate or proxy to make decisions.

An additional tool for participating in future healthcare decisions is the do-not-resuscitate (DNR) order. A DNR order states that a client does not want CPR if they go into cardiac or respiratory arrest. A client may request a DNR order; however, only a physician can approve and give the order.

To be clear, an advanced directive takes effect only after the client can no longer communicate directly. Until then, the client’s direct communication was the only thing that mattered. A competent client may change their advanced directive at any time. If a client wishes to change a directive, the healthcare professional must make it possible. Care must never be based on whether the client has an advanced directive and the decisions in the directive. All clients must be treated fairly and equally, regardless of advanced directives.

Power of attorney, drafted by a licensed attorney, is when one person authorizes another person to act on one’s behalf. Some important points regarding a power of attorney include signatures of the principal party, two adult witnesses, and the notary public. It may be used immediately. A power of attorney does not need to be filed in court except for real estate transactions. A power of attorney is in effect until revoked by the principal, participant’s death, or revoked by the court. A power of attorney may have more than one agent. If so, all agents must concur when making decisions. There are several types of power of attorney.

• General: an agent acts on behalf of the person in a variety of situations
• Limited: limited to a specific transaction
• Healthcare: to make decisions when incapacitated
• Springing: in effect at some future time – illness, disability of the principal
• Durable: all the above can be made “durable” by adding text – that enables the agent to act when the principal is incompetent and physically unable to make decisions

A healthcare surrogate is any competent adult expressly designated in writing by a client to make healthcare decisions on their behalf when incapacitated. This surrogate has no authority to act until the primary care physician determines that the principal cannot make informed healthcare decisions. A proxy is a competent adult who has not been expressly designated to make healthcare decisions for a particular incapacitated individual but who, nevertheless, is authorized to make healthcare decisions. A healthcare proxy is appointed by the hospital when there is no power of attorney or surrogate and healthcare decisions need to be made. Potential representatives for an incapacitated patient may include:

• Guardian
• Adult child
• Domestic partner
• Sibling
• Close friend

When clients often lose the ability to communicate directly, they do not have an advanced directive. The hierarchy of healthcare decision-makers for a client without an advance directive depends upon state law.

Clients have the right to be part of research studies or educational activities. If a client refuses experimental treatment, this should not affect their regular care. If the client wants to be part of a research study, they must sign a written consent explaining that the proposed treatment is experimental. The consent form for experimental treatment must include the nature of the experimental treatment, procedures involved, risks and benefits, other available options, and confirmation of any interruption in client care.

(CMS, 2023a)

Clients have the right to choose organ donation. They must give informed consent if they want to donate their organs. The organ procurement agency affiliated with the facility must be notified, as described in the facility's policy. The organ procurement agency will determine if the potential donor is medically suitable.

(JCR Staff, 2024d)

Consumers of health services have the right to question, complain about, file grievances, or appeal decisions made concerning their health care. CMS, TJC, and many state and federal agencies request and require healthcare professionals to be trained on this subject annually.

(CMS, 2023a; JCR Staff, 2024c)

Every client has the right to a fair, fast, and objective review of any complaint that they have concerning the health plan, doctors, hospital, or other healthcare personnel. This includes complaints about waiting times, operating hours, healthcare personnel's conduct, and healthcare facilities' adequacy. Many facilities have a client care representative to deal with complaints or grievances. Many client complaints can be addressed quickly. For example, if a client complains about getting the wrong items on her lunch tray, make sure she gets the right items next time. The sooner the issue is resolved at the lowest level possible, the better client compliance and satisfaction with the healthcare provider. The client may need access to the ethics committee for issues regarding their care. They should expect that issues related to end-of-life care be treated with respect and sensitivity. The client should be able to examine and receive an explanation of their bill regardless of the payment source.

More than 50% of the clients who sue do so because of miscommunications, anger, and lack of information between physicians, hospital staff, and clients/families. Grievance management is everyone’s responsibility. Handling grievances effectively from the start benefits everyone involved, helps keep minor grievances from becoming big ones, and reduces the risk of liability. When complaints cannot be resolved quickly and easily, clients have the right to file a grievance. A grievance is a formal, written, or verbal complaint. If a client wants to file a grievance, the healthcare professional must:

• Explain the grievance process at the facility. This includes the name of the staff person the client should contact for assistance resolving their grievance.
• Explain that grievances may be filed with state agencies. This is true whether the client has already used the facility’s internal grievance process.
• Give the client the phone number and address to file a grievance with the state.

Healthcare facilities must review, investigate, and resolve all grievances within a reasonable period. If the grievance has to do with the client’s safety, it should be reviewed immediately. Examples include grievances about abuse or neglect. The facility must give the client a written report to complete the grievance process. This report should explain how the facility investigated the grievance and the facility’s decision about the grievance.

On a related note to HIPAA and grievances, clients can question their bills. They have the right to request and receive a detailed explanation of every item on a bill.  Training on this subject is expected separately or as a component of client rights training.

In past years, the Joint Commission has differentiated between physical and chemical restraints used for safety in medical settings and physical or chemical restraints used in mental health or behavioral treatment settings. That separation still exists yet is diminishing.

Behavioral use of restraints is a last-used option and should be considered only when a client is imminently at risk of harming themselves or others with their behaviors. Less intrusive methods of regaining safety must be attempted before restraint is applied.

Medication to control behavior should be used only as part of a therapeutic plan after appropriate assessment by professionals. Chemical restraint is a term used to describe using medications for purposes unrelated to the client’s medical condition. An example is the use of a sedating psychotropic drug to manage or control behavior.

It is the intended use of a device that classifies the device or method as a restraint. For instance, IV arm-boards, postural support devices, orthopedic appliances, and protective devices like helmets are not restraints when used to promote healing or protect an easily injured tissue or surgical site.

(TJC, 2022)

Restraints or seclusion are to be used as a last resort after all alternatives have proven unsuccessful. Restraints should not cause harm or be used as a form of punishment. Examples of other options for restraints include but are not limited to.

• Interaction on a 1:1 basis with staff.
• Redirection.
• PRN medication with client consent.
• Staff or client-initiated time out in a quiet room with the door unlocked. It should be presented as a way for a client to regain control, not as a threat.
• Staff presentation of limits where consequences are presented for the client to choose from.
• Removal of stimuli from the client or vice versa. Remember that moving a client close to a busy nurses' station so you can keep a close eye on them could overstimulate and worsen symptoms.
• Relaxation exercises.
• Calming music.
• Distraction tactics.

If lesser interventions are unsuccessful, and you must apply physical restraint as a last resort, use the least restrictive device possible. For example, a lap buddy is a soft vinyl device that attaches to the wheelchair rather than the client. Although the client can remove it when they are oriented, it serves as a reminder that they should not get up without assistance and protects them if they become confused again. Another alternative is a geriatric chair set in a reclining position or with a lapboard. This is less restrictive than a safety belt or roll belt. A roll belt, in turn, is less restrictive than a vest restraint. Mitts are more suitable than wrist restraints because they are less restrictive and allow clients to move their arms freely. Another option is elbow restraints, which keep the arm straight but allow free movement.

A licensed, independent practitioner must order the restraint or seclusion; however, the facility may authorize qualified staff members, usually registered nurses, to initiate the use of restraints when needed before an order is obtained. The independent practitioner must evaluate the need for restraint or seclusion and assess the client within 1 hour.

The authorized staff member can discontinue restraints or seclusion when the assessment reveals that restraints or seclusion are no longer necessary. Restraints for acute medical or surgical purposes must be reviewed and renewed if needed by the licensed, independent practitioner at least every 24 hours. The use of restraints for behavioral healthcare purposes in long-term care must be reviewed and renewed if needed by the licensed, independent practitioner at least every 30 days.

Procedures for checking and documenting while a client is in restraints are rigorous. Each facility will have a restraint or seclusion documentation tool that must be completed, including the following.

(JCR Staff, 2024c)

The written order in the chart must include the justification for restraint or seclusion, the type of restraint used, and the time limit for use. Some facilities will have a template for the physician’s order. The documentation of restraints and seclusion needs to include the circumstances that led to seclusion or restraint, consideration or failure of non-physical interventions, rationale for intervention used, notification of family if appropriate, criteria for discontinuation as well as informing the client of the behavior criteria, each evaluation, any assistance provided to the client, continuous monitoring, debriefing of client with staff and any injuries that are sustained and treatment received.

Physical restraints should always be fastened for easy release in an emergency. The restraint should be attached to a fixed part of the furniture, like the bed frame. Fixing it to a movable part, like a side rail, could inadvertently tighten the restraint, causing client injury, or could loosen the restraint, causing it to be ineffective.

A high fall risk is not an acceptable reason to use restraints. The following are suggestions to reduce fall risk:

• Check the client at least every hour.
• Remind the client to call for assistance if they want to visit the bathroom.
• Use low beds or put the mattress on the floor for high-risk clients who will not call for assistance to get up.
• Arrange furniture so that it does not block the walkways.
• Use nightlights and keep debris and liquids off the floor.
• Always keep the client's personal items, water pitchers, and call light within reach.
• Make sure the client wears their eyeglasses, hearing aids, or other assistive devices.
• Ask family or friends to stay with them at night or when they will likely try climbing out of bed.

(TJC, 2024a)

Let us face it: something about the healthcare environment brings out the best and the worst in people and their behaviors. Sexual harassment is not acceptable and can lead to civil prosecution and disciplinary action up to termination. Sexual harassment includes unwelcome:

• Sexual advances.
• Request for sexual favors.
• Verbal, visual, or physical behavior of a sexual nature.

State laws and requirements control the mandate for training concerning preventing sexual harassment in the workplace. Be assured that training will be required for ALL employees on a frequency specific to your state laws. National oversight of sexual harassment policies and complaints is provided by the U.S. Office of Civil Rights (OCR), and they are proactive in exerting authority when incidents are reported (OPA, 2024).

Sexual harassment becomes unlawful when it becomes a condition of employment or advancement, unreasonably interferes with work performance, or creates an intimidating, hostile, or offensive work environment.

(Krofcheck, 2023)

Work environments vary, and people have varying levels of sensitivity. The worker is responsible for informing the people involved to stop because they are offended or feel sexually harassed. If the behavior continues, report it to your supervisor or the human resources department. Do not mistakenly think it will go away on its own. Like a lingering foul stench, harassment requires positive action to have it cease.

If you are injured or exposed to a dangerous substance on the job, stop what you are doing; report the injury or exposure to your supervisor; seek medical attention if needed; and complete an employee accident report.

(N.C. Department of Labor, 2022)

Accident hazards such as wet floors, stairway obstructions, and faulty ladders make the environment of care dangerous; eliminate them. Wet-floor hazards can be reduced by proper housekeeping procedures such as marking wet areas, cleaning up spills immediately, cleaning only one side of a passageway at a time, keeping halls and stairways clear, and providing good lighting for all halls and stairwells. Stairway hazards can be minimized by using the handrail on stairs, avoiding undue speed, and maintaining an unobstructed view of the stairs ahead, even if that means requesting help to manage a bulky load.

Back injury prevention, safe lifting, and safe movements fall under ergonomics. Ergonomics is a science that designs equipment and work tasks to fit the worker. The goal is to prevent worker injury. If you have pain, tingling, or numbness associated with a specific activity, reevaluate how you perform the task to ensure you do it correctly. Consult your supervisor or employee health provider for an ergonomic evaluation of your work. There may be equipment and methods available to reduce the risk of injury.

(OSHA, 2023b)

Injuries and illnesses that affect muscles, nerves, tendons, ligaments, joints, or spinal discs are known as musculoskeletal disorders (MSDs). Injuries can result from cumulative trauma and repetitive strain, where small injuries, over time, build up until one more injury triggers a debilitating MSD. The following tasks have a substantial risk of cumulative trauma and repetitive strain:

• Repetitive activity (typing).
• Contact stress (hammering).
• Twisting while lifting or carrying.
• Pulling or dragging.
• Sitting or standing in one position for a long time.
• Reaching above your shoulder.
• Lifting.
• While stooping low.
• Heavy objects.
• Unwieldy objects.
• Reaching for or using an object positioned far from your body.
• Frequent lifting without rest between lifts.

The primary approach to preventing back injury involves reducing manual lifting and other load-handling tasks that are biomechanically stressful. The secondary approach is to train workers to perform stressful tasks while minimizing the biomechanical forces on their backs, maintaining flexibility, and strengthening the back and abdominal muscles. To prevent back injury, workers should:

• Use tools to avoid lifting when possible.
• Lifting devices.
• Slide boards.
• Shower chairs.
• Gait belts.
• Use proper lifting techniques.
• Keep your back in its normal upright position when lifting.
• Keep your head and shoulders up and tighten your abdominal muscles when lifting.
• Bend at the knees, not at the waist.
• Get a good grip and slightly bend your elbows.
• Lift with your legs in a smooth, even motion, not with your back.
• Bear the weight with your arms and legs, not your back.
• Bear the weight as close to your body as possible.
• Pivot on your feet to change direction; do not twist.
• Lower an object by widening your stance and bending your knees.
• Do not reach higher than your shoulders to lift.
• Limit the number of lifts per day.
• Request help. When in doubt about whether a task may strain the back, a worker should request help rather than take a chance.
• Back exercises can strengthen the back muscles and help prevent back injuries. A physician or physical therapist should be consulted.
• The benefit of using back belts is undetermined. The belt may lead to a false sense of security and a failure to use proper lifting techniques. This can lead to injuries.

Client transfers are particularly hazardous for healthcare professionals. The following special points should be emphasized to prevent back injuries during transfers (Atwell, 2023).

• Obtain lifting equipment as applicable.
• Do not do a manual transfer alone.
• Position equipment and furniture effectively (for example, move a wheelchair beside the bed) and remove obstacles.
• Communicate the action plan to the client and other workers to ensure the transfer is smooth without sudden, unexpected moves.
• Use a wide, balanced stance.
• Ensure sound footing for the client if applicable (clients should wear slippers that provide good traction).
• Maintain eye contact and communication with the client. Be alert for trouble signs.
• Record any problems on the client’s chart so that other workers will know how to cope with difficult transfers. Note the need for any special equipment, such as a lift.

All healthcare facilities are required to have detailed information about the chemicals at the worksite. This information is in a standard Safety Data Sheet (SDS) format. OSHA requires annual training for all staff on access and use of Safety Data Sheets. A Safety Data Sheet (SDS) is an updated form of the material safety data sheet (MSDS). The transition from MSDS to SDS should have been completed by December 2015. The reason for this transition is the mishmash of different MSDS styles and formats in the United States, which was unwelcome news and confusion for all end users. The new rules require a standardized format of 16 sections in strict ordering.

(N.C. Department of Labor, 2022)

If no relevant information is found for any given subheading within one of the numbered sections, the SDS must indicate that no applicable information is available. Sections 12-15 of the new SDS are not currently mandatory, while sections of the SDS 1-11 and section 16 are. SDS sections contain the following:

1. Product identification.
2. Hazard(s) identification.
3. Composition/ information on ingredients.
4. First-aid measures.
5. Fire-fighting measures.
6. Accidental release measures.
7. Handling and storage.
8. Exposure controls/personal protection.
9. Physical and chemical properties.
10. Stability and reactivity.
11. Toxicological information.
12. Ecological impact information (Non-mandatory).
13. Disposal considerations (Non-mandatory).
14. Transport information (Non-mandatory).
15. Regulatory information (Non-mandatory).
16. Other information, including the date of preparation or last revision of the SDS or the last change to it.

Chemicals may exert either acute or chronic effects on workers. The effects depend on the following:

• Extent (concentration and duration) of exposure.
• Route of exposure.
• Physical and chemical properties of the substance.

Did you know that all the hazard pictograms used in the United States have already been replaced with international symbols? That was a nationwide training mandate for 2013, and you had better be on guard for questions related to the new SDS and hazard symbols during surveys.

The new worldwide visual warning system is part of the Globally Harmonized System of Classification and Labeling of Chemicals (GHS) and uses two sets of warning pictograms. One set is for transporting chemicals, and the second is for workplace use and storage.

Let us look at a new pair of warning symbols that have replaced the retired poison pictogram commonly found in medical closets and work areas.

GHS Chemical Hazard Symbol

Health Hazard	Skull and Crossbones
Carcinogen Mutagenicity Reproductive Toxicity Respiratory Sensitizer Target Organ Toxicity Aspiration Toxicity	Acute Toxicity (Fatal or Toxic)

Effects exerted by a substance may also be influenced by other chemicals and physical agents or by an individual’s use of tobacco, alcohol, or drugs. The exposure dose is the amount of a substance that enters the body during exposure. The substance continues to be present in the body until it is metabolized or eliminated. Although some chemicals are rapidly metabolized, others are not and may be excreted unchanged or stored in the fatty tissues (solvents), lungs (dust and fibers), bone (lead and radium), or blood (soluble gases).

(N.C. Department of Labor, 2022)

Toxic substances can enter the body through several routes, including intact skin, the respiratory system (inhalation), the mouth (inhalation and ingestion), the eyes, and by accidental needle punctures. Inhalation and skin exposure are the most likely. Some substances can also damage the skin or eyes directly without being absorbed. Not all substances can enter the body through all routes. Inorganic lead, for example, can be inhaled or swallowed, but it does not penetrate the skin. Exposure routes for antineoplastic and other hazardous drugs are inhalation, skin absorption, ingestion, and injection.

Not every toxic substance’s annual training requirement should be on your individual training list. It would be best if you were not handling asbestos, for instance. However, someone in the hospital or at the care site does, as many buildings used for offices, clinics, and hospitals fall into the period during which asbestos was used in flooring, ceiling products, building insulation, and many other practical products. Take the time to find out which specific substances are used and managed in your work setting and whether you need any of the annual training concerning them.

Training in fire safety is not only required by the major regulatory agencies; it is common sense. Any health professional who has lived through a fire in a care setting knows and has night terrors about the complexity of moving ill clients out of harm’s way in an emergency.

OSHA, the Occupational Safety and Health Administration, and NFPA, the National Fire Protection Association, both have strong guidance on healthcare facility safety. Point of trivia: when CMS surveyors investigate an organization’s physical safety and disaster planning, they pull out the NFPA guidelines and go by them. To satisfy CMS, know, follow, and exceed NFPA guidelines.

(JCR Staff, 2024h; N.C. Department of Labor, 2022)

In healthcare, we are all expected to render assistance during situations that place our clients at risk. We, therefore, all require a working understanding of fire response, small fire suppression, and tactics to slow the spread of larger fires. As found in OSHA regulations, a fire brigade designation does not pertain to every health worker but to those who have received additional fire suppression and rescue instruction. If you have the floor or unit staff designated as “safety officers” or “fire wardens,” please review the OSHA Fire Brigade definitions to ensure they receive correct training before an inspection or cross your fingers before you are called to perform in an emergency.

(JCR Staff, 2024e; NFPA, n.d.)

For all of us, when you enter a new work area, look around and find fire alarms, fire extinguishers, exit signs, and oxygen cut-off valves. One way to remember fire safety is the acronym RACE.

• R: rescue
• A: alarm
• C: contain the fire (if possible)
• E: extinguish or evacuate

Never hesitate to sound the alarm with any suspicion of fire, yet never “fire.” Yelling “fire” creates panic. Instead, call out the facility's verbal code for fire. Call the switchboard to report the fire and pull the fire alarm. When you call the switchboard, please stay on the phone long enough to ensure they have received the correct information, such as where you are!

If a fire is small and confined, you may be able to extinguish it. If a client’s garments are on fire, wrap them tightly in a large blanket to extinguish the flames. If a piece of equipment catches fire, pull the plug or cut the electricity as soon as possible.

OSHA is clear if you place hand-held portable fire extinguishers for staff to use in emergencies, you must train every staff member annually on how to use them. Portable fire extinguishers come in different classes for use on fires of diverse sources. The extinguisher has small pictures on the label that help you identify the type of fire source material they should be used on. Class A puts out fires involving ordinary combustibles. Class B extinguishers smother fires involving flammable liquids or gases. Class C extinguishers put out fires in or near electrical equipment. Type ABC extinguishers can be used to fight all three types of fires.

To use an extinguisher, remember PASS:

• Pull the pin
• Aim the nozzle at the base of the fire
• Squeeze the trigger while making
• Sweeping strokes with the extinguisher plume

If a fire cannot be extinguished and smoke, fumes, or flames threaten client safety, you may need to evacuate. Evacuate ambulatory clients first. Stay calm and give clear directions. Evacuate horizontally for as long as you can. Then, evaluate vertically down to a lower level. Never use an elevator to escape during a fire. A sudden loss of power could leave you and your client trapped inside the elevator.

Healthcare units are required to be separated by heavy fire doors that close automatically when the alarm is sounded to keep the fire from spreading. To confine a fire, close the doors, windows, and all vertical openings like the laundry chute. Stuff wet towels under the doors to keep smoke out. Shut off oxygen supplies if directed to do so. Usually, facility policy designates someone in supervision to decide when to turn off oxygen supplies.

When rescuing anyone in immediate danger, remember to stay low. Smoke rises to the ceiling, forming a heavy, dense cloud that slowly descends. This cloud is deadly because it contains toxic gases.

Staff responsible for inspecting, maintaining, or repairing fixed fire extinguishing equipment such as sprinklers or fire hose reels must be trained annually concerning these essential safety items.

Katrina, Joplin, Missouri, the Twin Towers; the list of disasters affecting hospitals, all of us in the health professions, is limitless since emergencies come to us, either physically or by proxy, in the form of waves of injured.

(CIHQ, 2024; CMS, 2023b; JCR Staff, 2024g; N.C. Department of Labor, 2022; NFPA, n.d.) 

Joint Commission requests and requires annual training for emergency responses specific to healthcare facilities, including twice-yearly live emergency scenarios (e.g., bomb threat, hostage situation, facility fire, plane crash into the building, etc.). At least one of these annual training must involve the community around the organization, such as the fire department, search and rescue, police, etc. Be aware that TJC requires an assigned survey member at these exercises to monitor performance and document deficiencies, with staff training following up to correct anything found lacking. Do not be tempted to take emergency response training lightly; not only will regulatory agencies grade it, but it could also save the lives of those precious to you.

Supervisors must know how to initiate the disaster plan and designate worker tasks.

Each worker must be trained to:

• Locate the disaster plan on each unit where they work.
• Know the alarm codes for each type of disaster.
• Know the exit routes.
• Know how to use any evacuation equipment.

As of January 1, 2016, the Joint Commission began expecting ongoing training on the purpose and correct operation of medical device alarm systems. This is now an expectation for every healthcare professional using any device with alarms.

(JCR Staff, 2024f)

Every medical device possesses an audible or visual alarm these days, and the wild cacophony that is heard and often ignored in health settings is a cause of “alarm fatigue” to both the public and regulatory agencies. Knowing when to set the alarm, how to set it, and how to respond promptly requires proper training and accountability.

As health systems move further into the age of electronic health records and systems, expect digital monitoring of essential medical equipment. In other words, should equipment alarms sound consistent without being addressed, the marvelous mechanism of the Joint Commission Tracer System is likely to stumble upon and take notice. So, train appropriately, staff accordingly, work intelligently, or practice how to respond to accreditation surveyor queries.

Under the current Centers for Disease Control (CDC) handwashing guidelines, washing hands with soap and water is to be done whenever the hands are visibly dirty. If not visibly soiled, rubbing hands with an alcohol hand rub is the primary means of hand hygiene for routinely decontaminating the hands during routine client care. Alcohol-based hand rubs increase compliance with hand hygiene because hand rubbing requires less time, results in less skin irritation, and does not require proximity to a sink. Hand hygiene is indicated before (CDC, n.d.a).

• Client contact.
• Donning gloves when inserting a central venous catheter (CVC).
• Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that do not require surgery.

Hand hygiene is also indicated after:

• Contact with a client’s intact skin.
• Contact with body fluids, excretions, non-intact skin, or wound dressings.
• After removing gloves.

Efficacy of Hand Hygiene Material

Standard precautions are strategies for protecting healthcare workers from the occupational transmission of organisms. The premise is that all pre-existing client infections cannot be identified; therefore, barrier precautions should be used routinely to protect from all sources of potential infection. Standard precautions apply to blood and all body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood, non-intact skin, and mucous membranes. Additional precautions are based on highly transmissible or epidemiologically important pathogens. Transmission Based Precautions (isolation) are airborne, droplet, and contact.

(CMS Staff 2023a; JCR Staff, 2024i)

Appropriately using personal protective equipment (PPE) is an important element of standard infection prevention precautions. Gloves provide a protective barrier between the client and the healthcare worker and prevent gross contamination of the hands. Gloves do not replace the need for handwashing because gloves may have small defects, may be torn during use, and hands may become contaminated during glove removal.

(Safety Culture Contact Team, 2024)

Masks, goggles, or face shields should be used to protect the mucous membranes of the eyes, nose, and mouth when there is a likelihood of splashes or sprays. Healthcare workers wear surgical masks to protect against large-particle droplets during close client contact. When tuberculosis is known or suspected, healthcare workers should wear an N95 respirator, a high-efficiency particulate air (HEPA) filter respirator, or a powered air-purifying respirator (PAPR).

Gowns are worn to prevent clothing contamination and protect the healthcare worker’s skin from exposure to blood and body fluids. Impermeable gowns, leg coverings, boots, or shoe covers provide more protection when copious quantities of blood or body fluids may be splashed. Gowns are also worn as a part of some transmission-based precautions. Mouthpieces, resuscitation bags, or other ventilation devices should be used instead of mouth-to-mouth resuscitation.

Needles should never be recapped, bent, broken, or removed from contaminated syringes. Sharps should be disposed of in a puncture-proof container and transported to a reprocessing area. Improved engineering controls are among the most effective approaches to reducing occupational hazards and, therefore, are a principal element for a needlestick prevention program. Such controls include eliminating unnecessary needles and implementing devices with safety features. Most injuries from hollow bore needles can be prevented with the use of safer sharps devices, and several sources have identified the desirable characteristics of such safety devices. These characteristics include the following:

• The device has no needle.
• Safety features are an integral part of the device.
• The device preferably works passively (i.e., it requires no activation by the user). If the user action is necessary, the safety feature should be engaged with a single-handed technique, allowing the worker's hands to remain behind the exposed sharp.
• The user can easily tell whether the safety feature is activated.
• The safety feature cannot be deactivated and remains protective through disposal.
• The device performs reliably.
• The device is easy to use and practical.
• The device is safe and effective for client care.

Although these characteristics are desirable, some are not feasible, applicable, or available for certain healthcare situations. For example, needles will always be necessary where alternatives for skin penetration are not available. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its merit and ability to reduce workplace injuries. The desirable characteristics listed here should serve only as a guide for device design and selection (OSHA, n.d.)

Transmission-based precautions and protective environment (PE) are terms used to describe protective measures that need to be employed by specific groups of clients. An older term for this was isolation. Clients requiring transmission-based precautions require a private room. Clients infected with the same organism can share a room. This is referred to as cohorting (CDC, n.d.).

Contact precautions are used for clients with known or suspected infections or who are colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact (CDC, n.d.b). Examples include:

• Presence of stool incontinence (may include norovirus, rotavirus, or Clostridium difficile), draining wounds, uncontrolled secretions, pressure ulcers, or presence of ostomy tubes and bags draining body fluids.
• Presence of generalized rash.

For contact precautions, clients should be in a private room. Standard precautions should be used, and a gown should be worn if direct contact with the client or environmental surfaces is likely.

Airborne precautions are implemented for diseases transmitted by microorganisms in airborne droplet nuclei (CDC, n.d.b). Droplet nuclei are tiny particle residues left when droplets evaporate. Droplet nuclei remain suspended in the air and can be widely dispersed by air currents. Early identification and triage of suspected cases of airborne transmitted diseases should be made, and infectious clients should be separated from others and asked to wear a surgical mask.

Airborne precautions require a specially ventilated room with at least six air changes per hour, negative air pressure relative to the hallway, and outside exhaust or HEPA-filtered recirculation. The door to the room must be kept closed. The negative air pressure should be monitored. An N-95 mask, or a powered air-purifying respirator (PAPR), is used by health workers in airborne precaution settings:

• These masks and respirators should be labeled and stored in a paper bag between uses.
• These masks and respirators should be discarded if soiled or no longer maintain their structural or functional integrity.
• The N-95 mask should also be discarded at the end of each work shift.
• The disposable respirator should be discarded at the end of 2 weeks.

Each employee who may work in an airborne precautions setting must be fit tested to ensure that the N-95 mask or PAPR fits the employee’s face so that droplet nuclei cannot get in gaps between the mask and the face. Be aware employees with beards will not pass fit testing.

When a client in airborne precautions needs to be moved or transported, they should wear a surgical mask from when they leave the isolation room until they return.

Tuberculosis (TB) is a current high-interest topic for training due to nearly (according to WHO, the World Health Organization) 10 million new TB cases every year (CDC, 2024). Estimates that two billion people, one-fourth of the world’s population, may be infected with TB. TB symptoms are cough lasting for more than two weeks, loss of appetite, weight loss, night sweats, hemoptysis, and fever. Clients presenting with these symptoms should be asked to wear a surgical mask until a physician can determine whether to use airborne precautions. If an acid-fast bacillus (AFB) test is ordered, TB is suspected, and airborne precautions should be implemented.

Droplet precautions are used for clients known or suspected to be infected with microorganisms transmitted by droplets generated during coughing, sneezing, talking, or performing procedures (CDC, n.d.b). These microorganisms include, yet are not limited to:

• Respiratory viruses (e.g., influenza, parainfluenza, adenovirus, respiratory syncytial, human metapneumovirus).
• Bordetella pertussis.
• For the first 24 hours of therapy: Neisseria meningitides and group A streptococcus.

Droplet precautions require a private room, but no special ventilation is necessary, and the door may remain open. Masks should be donned upon entering the room, especially if working within three feet of the client. The client should be masked if transported.

Neutropenic precautions (reverse isolation) are implemented to protect immunocompromised clients. Neutropenia is a condition that causes low neutrophils in the blood. Neutrophils are a type of white blood cell made in the bone marrow that aids the body in fighting infection. Examples of conditions that might warrant neutropenic precautions include:

• Acquired immunodeficiency syndrome.
• Agranulocytosis.
• Burns, extensive noninfected type.
• Dermatitis, noninfected vesicular, bullous, or eczematous disease (when severe and extensive).
• Immunosuppressive therapy until the patient’s immunity is adequate.
• Lymphomas and leukemia, especially late stages of Hodgkin’s disease or acute leukemia.

Neutropenic precautions require a private room with positive air pressure relative to the air pressure in the hall. Other precautions may range from standard precautions and traffic limitations to extensive precautions using gloves, gowns, and masks. This varies depending on the reason for the precautions and the degree of the client’s immunosuppression.

Central Line-Associated Bloodstream Infection (CLABSI) and Surgical Site Infection (SSI) prevention are critical areas of concern. Annual training is a focus for any healthcare staff whose job duties place them in contact with central venous catheters (CVCs) or surgical wounds and dressings. CVCs play a vital role in supporting the client, administering intravenous fluids, medications, blood products, and parenteral nutrition, and providing hemodialysis access and hemodynamic monitoring. CVCs have also been identified as one of the most frequent causes of healthcare-related bloodstream infections. SSIs are estimated to account for 20% of all Hospital Acquired Infections (HAIs), leading to longer hospital stays (Canada & Daitch, 2023). It is estimated that this is due to the lack of accurate, voluntary hospital reporting on SSIs. This trend has not gone unnoticed and will inevitably lead to more regulations and oversight should healthcare organizations not be willingly forthcoming concerning important public safety issues.

In healthcare, everyone is responsible for properly disposing of biohazardous material. One negligent act can result in biohazardous exposure. Biohazard materials include blood and body fluids. If you are in doubt, use a biohazard container to dispose of the material. All biohazardous containers should be red and have the following biohazard symbol.

Biohazard sharps containers are to be red and come in varied sizes. All sharps must be placed in biohazard sharps containers, not just needles. Biohazardous sharps containers are made to store small glass objects and anything capable of piercing or puncturing the skin, whether it is contaminated or not. This includes sharps with protective devices like retractable sheaths. Even if a sharp object is not contaminated, if it is put in regular garbage, someone may be stuck with that sharp object and not know if it was contaminated. Typical examples are needles, sutures, scalpels, disposable instruments, and lancets. Replace sharps containers when they are three-quarters full. Failure to do so may result in someone being contaminated because sharps near the top of the closure device do not swing freely.

Biohazardous bags are red and are to be used for biohazardous material that is not sharp and may be contaminated with blood or body fluid. These bags are also used to dispose of chemotherapy drugs and chemicals, even though they are not infectious.

Biohazard Symbol

Biohazard Sharps Container

General waste bags are used for general trash and some body fluids and equipment if there is no visible blood: urine, feces, disposable pads or chux, PPE, used gloves, respiratory care items, and suction canisters. However, if in doubt, use a biohazardous bag.

Healthcare worker vaccination is a hot-button topic, so anticipate frequent training focused on this topic for years to come.

(JCR Staff, 2024i)

The CDC’s perspective is that health professionals are always at risk for exposure to serious and sometimes deadly diseases. We each work directly with clients or handle material that could spread infection. Due to these factors, each of us should be appropriately vaccinated to reduce the chance of catching or spreading vaccine-preventable diseases. The CDC hot list of healthcare worker vaccinations includes:

(Correll, 2023)

OSHA possesses a comprehensive bloodborne pathogen standard for workers in areas of risk, including healthcare, housekeeping, and emergency responders, to name a few. As a healthcare professional, be careful to take this topic seriously, as in the U.S. alone, some 600,000 hospital-based healthcare workers experience occupational, percutaneous injuries annually (King & Strony, 2023). Infectious organisms present in the blood that can cause serious or life-threatening diseases in humans include hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

An exposure control plan is essential in a healthcare setting, and as a healthcare professional, you must know your facility's policies. The exposure control plan must describe how an employer will use a combination of engineering and work practice controls, ensure the use of personal protective clothing and equipment, and provide training, medical surveillance, hepatitis B vaccinations, and signs/labels. Engineering controls are the primary means of eliminating or minimizing employee exposure, and safer medical devices, such as needleless devices, shielded needle devices, and plastic capillary tubes, are used.

Should a needlestick or exposure to blood occur, Provide immediate care to the exposure site.

• Wash wounds and skin with soap and water.
• Flush mucous membranes with water.
• Irrigate eyes with clean water, saline, or sterile wash.

Please note that no scientific evidence has shown that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.

A comprehensive exposure prevention plan and strategies significantly decrease the risk of infection from bloodborne pathogens. The risks of exposure with appropriate precautions are low, yet they are real. Understanding how exposure occurs and the risk of exposure is imperative for both the occupational health clinician and the healthcare worker. After occupational exposure to a bloodborne pathogen, the risk of infection depends on several factors, including:

• Type of body substance involved.
• Route of exposure.
• Volume of blood or body fluid involved.
• Severity of exposure.
• Pathogen suspected.
• Degree of viremia (e.g., viral count or quantity of virus in the blood).
• Immune status of the healthcare worker at the time of exposure.
• Was appropriate post-exposure prophylaxis (PEP) used?

Basic pain assessment is simple, must be performed regularly, and action is planned based on client reports. It makes no difference whether the client is in the hospital, a long-term care facility, a behavioral health facility, an outpatient clinic, or being cared for by a home care agency. No matter where the client is, the intensity of pain should be assessed and documented:

1. During the initial evaluation of the client
2. After any known pain-producing procedure
3. With each new report of pain
4. At regular intervals when vital signs are taken
5. At suitable intervals after pharmacologic intervention (60 minutes after oral; 30 minutes after parenteral) or nonpharmacologic intervention to evaluate the current pain treatment plan.

The most widely used measure to assess intensity is the Numerical Rating Scale (NRS), where the client is asked to rate their pain from 0 to 10, with 0 equaling no pain and 10 equaling the worst possible pain they can imagine. Since we have no instrument to objectively measure pain intensity like a sphygmomanometer measures blood pressure, the only valid measure of pain is the client’s self-report (a subjective measure). Sometimes, healthcare professionals may believe they are the best judges of a person’s pain; however, many studies demonstrate that healthcare professionals either overestimate or underestimate a client’s pain.

Face Pain Scale

The Faces Pain Scale (FPS) for adults and children can be used for clients who cannot respond verbally and rate their pain numerically. This scale consists of images of faces with various expressions (e.g., smiling, frowning, grimacing). The client selects the face that is consistent with their current pain level.

If a client has cognitive/expressive deficits, observation of nonverbal expression and behavior or report of a family member or significant other needs to be considered when assessing pain intensity.

Each healthcare institution should use a pain intensity rating that will elicit a full assessment. Besides intensity, the complete pain assessment includes the following:

• Location of pain.
• Character or Quality (throbbing, shooting, sharp, cramping, aching, burning, etc.).
• Onset, duration, variations, rhythms (is the pain better or worse at certain times, certain hours?).
• Alleviating factors - what makes the pain better?
• Aggravating factors - what makes the pain worse.
• Effects of pain (impact on daily life, function, sleep, appetite, relationships with others, mood, emotions, concentration, etc.).