Assignments

Chapter 12

Plant and Environmental Services

What You Will Learn

•  Plant and environmental services include maintenance, housekeeping, laundry, security, waste management, and environmental safety. Various factors govern the organization and staffing for these functions.

•  Maintenance operations must plan for urgent service calls, routine repairs, preventive maintenance, and different types of contract work.

•  Housekeeping practices require daily routine cleaning, weekly heavy-duty attention, and periodic reconditioning. Certain sanitizing and infection control practices specifically apply to housekeeping.

•  Laundry operations require microbicidal washing, standard precautions, and prevention of cross-contamination. To ensure an adequate linen supply, the administrator should institute par levels and inventory control systems.

•  A security audit should be part of the physical security operation. Procedural security systems are implemented to control supplies, capital assets, and access to various areas of the building.

•  All associates must be trained in fire protection steps represented by the acronym RACE. The facility must have designated areas of refuge during a fire or disaster emergency. Updated plans must outline all procedures, including partial and total evacuation.

•  General waste disposal should be in a covered dumpster. Disposal of hazardous waste requires special handling.

•  Various environmental safety procedures and monitoring of hot water are necessary to prevent accidents.

Introduction

Plant and environmental services are organized to accomplish three main objectives: (1) to perform regular building maintenenace and upkeep tasks that ensure a clean, comfortable, and safe environment, (2) to undertake timely maintenance and repairs of all equipment so that all services can be provided efficiently and with the least interruption possible, and (3) to protect the residents, associates, and visitors against various types of hazards. Plant and environmental services should help optimize clinical care as well as the residents’ quality of life.

Griffith (1995) suggested that the environmental support system provides all the services of a hotel but with narrower tolerances for temperature and humidity controls, air quality, cleanliness, waste removal, and environmental safety. Security operations and fire and disaster planning and training are also part of environmental services. In addition, environmental services should support the aesthetic appeal of the facility’s exterior.

Organization of Environmental Services

The organization of the various environmental functions varies according to the size of the facility and the skill levels of the supervisory personnel responsible for environmental services. Some large nursing homes have a position of facilities manager responsible for all plant and environmental services. Other facilities have working supervisors responsible for the various services.

Maintenance Department

In most facilities, maintenance is a separate department, even though it may be staffed by just one or two people. An average-size facility of 100 beds needs one full-time person responsible for all maintenance and repairs. A half-time person may be added for each additional 50 to 60 beds. Staffing for maintenance will vary according to how much of the routine work, such as groundskeeping, is contracted out. For the winter season, snow removal is generally contracted out, especially if the facility has large parking areas and walkways. Many facilities add temporary staff during summer to do their own groundskeeping, whereas others outsource this service. Large facilities may find it cost effective to have a painter on staff. As a rule of thumb, every patient room and private bathroom should be completely repainted once every 2 to 3 years. Some areas of the building may require more frequent painting than others. Touch-up painting to keep walls free of scuff marks is an ongoing function.

In a typical nursing home, the maintenance department is headed by a maintenance mechanic (usually called “maintenance man”), although the position is formally referred to as maintenance supervisor. This individual must be multi-talented to handle simple plumbing, heating, ventilation, air conditioning, and electrical problems. Apart from handling routine repair jobs, the maintenance supervisor is responsible for an ongoing preventive maintenance program. Other than minor troubleshooting and repairs, mechanical system breakdowns are restored by calling outside service contractors (Magee, 1988). By working alongside these external tradesmen, over time the maintenance supervisor can develop substantial technical skills in handling more than just basic problems.

Housekeeping and Laundry Departments

Housekeeping and laundry are considered two separate departments. However, depending on the size of the facility, the two departments may be headed by one supervisor or two separate supervisors, who are often working supervisors. For example, the supervisor may take on routine cleaning assignments for certain sections of the building or may perform specific tasks such as floor polishing. A position strictly confined to supervisory duties may be necessary only when the number of beds exceeds 150, provided that the facility operates its own in-house laundry.

The facility should determine the number of housekeepers needed according to the square footage, the layout of the facility, and the number of resident rooms. Adequate weekend coverage is also essential, and a skeleton crew should cover the evenings to finish cleanup chores after dinner and attend to any other sanitation needs in the facility. Most facilities also require janitorial staff for routine floor and carpet maintenance and for handling other heavy work such as window washing and moving furniture.

The laundry requires personnel in two categories: sorting and washing soiled laundry, and drying and folding clean laundry. Separating these two functions is essential to prevent cross-contamination.

Security and Safety Functions

In many locations, security has become a growing concern for facilities. Except for some very large retirement living and nursing care complexes, a typical nursing facility does not have a security department. In fact, most facilities do not employ any security personnel. In the absence of a designated person being in charge of security, the responsibility for security falls on the administrator’s shoulders.

Safety specifically means fire and disaster preparation and accident prevention. Some aspects of safety and physical security (discussed later) can be delegated to the maintenance supervisor. Accident prevention, on the other hand, requires leadership from the administrator but is the responsibility of everyone working in the facility.

Maintenance Operation

The main operations in the maintenance department can be classified into four areas: urgent service calls, routine repairs, preventive maintenance, and contract work.

Urgent Service Calls

Because emergencies arise without warning, an unexpected breakdown of critical mechanical systems, components, or equipment can severely disrupt vital services, compromise patient safety, or result in loss of property. For example, a breakdown of the heating system in the middle of winter will severely disrupt patient care and threaten the safety of patients. Failure of the food storage freezer can result in the loss of hundreds or even thousands of dollars worth of food. Such breakdowns or a failure of the facility’s emergency systems, such as fire alarms, fire suppression system, or emergency power generator, must be attended to immediately.

Along with the administrator, the director of nursing (DON), and the maintenance supervisor are on call 24/7. If by chance the maintenance supervisor is not available during an emergency, the administrator should be notified so that an outside firm can be called to deal with the situation. Similar authority should be given to the DON and also to the dietary manager for occasional unforeseen breakdowns of dietary equipment.

Routine Repairs

Routine repair work is organized by instituting a system in which all routine requests for repairs are submitted on a work order. Each department and each nursing station keeps a box where their work orders are placed. Many facilities have a computerized work order system. The work orders are prioritized to plan the day’s work. Other routine tasks such as lawn care should be included in a weekly schedule. Local trips to purchase needed supplies and parts should also be planned to minimize the number of trips away from the facility. With proper planning, no more than one to two trips should be necessary each week.

A work order system generally works well for reporting problems that hinder staff members’ ability to do their jobs or addressing complaints from residents and family members. However, this system misses many other problems that go unreported. To address unreported concerns, the facility needs a preventive maintenance program.

Preventive Maintenance

Preventive maintenance is the term used for routine inspections and performance of certain tasks that are planned in advance and are carried out to prevent unexpected equipment failures (Niebel, 1985). Over the long run, a good preventive maintenance program is cost effective because it prevents costly breakdowns, delays the need to replace equipment that may otherwise wear out prematurely, and minimizes disruption of vital services. Appropriate training is needed to set up and manage a well-designed preventive maintenance program. All equipment must be periodically checked for smooth operation. Equipment coils and motors require periodic cleaning. In accordance with the manufacturer’s recommendations, equipment may also require periodic lubrication, filter changes, or inspection and replacement of components that show signs of wear and tear. If the maintenance supervisor does not possess the necessary training and skills to perform this maintenance, the administrator may outsource preventive maintenance work to a private independent firm. At the very least, however, the facility must have a basic preventive maintenance program that includes three main preventive functions: routine checks, revolving inspections, and ongoing upkeep.

Routine Checks

Routine checks and tests are necessary to ensure that all emergency systems are operating. A written or electronic log of these tests must be maintained. Emergency systems include the fire alarms, automatic fire doors, smoke detectors, and emergency power generators. The Life Safety Code® requires testing the fire alarm system quarterly, but many facilities do this check more frequently.

Revolving Inspections

A plan must be instituted by the facility to ensure that every day, in accordance with a rotating schedule, a different specified section of the building interior and exterior is closely inspected. The goal should be to conduct a revolving inspection so that all patient rooms, bathrooms, utility rooms, kitchen, laundry, mechanical rooms, and all other areas receive a close inspection once every 4 to 6 weeks. The administrator can monitor this schedule by requiring that the maintenance department keep a written or electronic log and provide a report to the administrator as inspections are completed in each area of the building. Such inspections often reveal irregularities that may not get reported through the routine work order system. Examples include leaky faucets; leaks at the bottom of toilet bowls; windows that do not properly close or lock; doors that do not completely shut; missing ceiling tiles; ventilation or exhaust problems in bathrooms, kitchen, laundry, or utility areas; scuffed walls in need of painting or repair to the wall covering; and curtains and window coverings in disrepair. The administrator should do periodic spot checks to see whether a revolving inspection program is being followed.

During the detailed inspections, the maintenance supervisor should look for safety problems such as missing fire extinguishers, torn or buckled carpeting, nonfunctional patient call systems, missing floor tiles, and burned-out light bulbs. Sanitation problems may be noticed near the garbage dumpster, which can attract vermin and other scavengers. Broken screens or missing exterior screen doors may allow flies and other insects to enter food preparation areas. Signs of pest activity, such as droppings, may be noticed in the kitchen, food storage areas, or patient rooms. Outside the building, lights may be missing, the parking lot may be in need of cleaning, cracks in pavement may require sealing, or shrubs may require trimming.

Ongoing Upkeep

Ongoing maintenance of a facility’s internal and external appearance is also an important part of preventive maintenance. Damage to walls caused by wheelchairs and other equipment is a common occurrence. However, effectively managed facilities set themselves apart from others by instituting a daily touch-up painting program. When undertaken on a daily basis, touch-up painting only requires a fraction of the time it would take to paint large sections of the building that have been left unattended. Wall coverings should be cleaned and repaired periodically and replaced when they are heavily worn or faded. The parking lot also needs daily attention to pick up loose trash and cigarette butts. Effectively managed facilities maintain attractive lawns, have some basic landscaping, and plant seasonal flowers to present an inviting appearance.

Contract Work

The need for contracting is unavoidable, but the maintenance supervisor should oversee the work of outside contractors to ensure that the agreed-upon work is completed satisfactorily. Professional completion of work includes any cleanup and removal of debris after a job is finished.

Some contracts for services that are performed on a regular basis, called  routine contracts , are generally executed annually. Routine contracts cover pest control, waste removal, snow removal, lawn care, annual inspection of emergency equipment, inspection and maintenance of elevators, and expert preventive maintenance. Routine contracting is undertaken by the administrator, in consultation with the maintenance supervisor. As a matter of policy, no contract should exceed 1 year. This limit allows the administrator to review each year, the quality of services performed, and to compare prices.

Nonroutine contracts include open-call contracts and job-unit contracts.  Open-call contracts  are established with preferred contractors to provide services on an as-needed basis. Contracts for heating and cooling, plumbing, and electrical work are the most common types of open-call contracts. This type of contracting eliminates the time and administrative effort required in setting up a separate contract each time the need for services arises (Heintzelman, 1987). By making a commitment to use the same contractor on an open-call basis, the facility can receive priority service and often negotiate discounted fees.

A second type of nonroutine arrangement is a  job-unit contract , which is established each time a need arises for infrequent major jobs (Heintzelman, 1987). The contract automatically terminates when the specified work has been completed and paid for. Job-unit contracting is appropriate for jobs that are occasionally needed, are planned ahead of time, and generally involve substantial capital outlays. Examples include renovation projects, roof repair or replacement, installation of major equipment, and major landscaping.

Housekeeping Operations

The housekeeping department is responsible for maintaining a sanitary, pleasant, and safe environment in the facility. The department must have policies and procedures for cleaning, sanitizing, infection control, and safety. Unlike hotels and motels, the housekeeping staff in nursing facilities must not handle either clean or soiled linens. The tasks of bed making, replacing clean linens in patient rooms, and removing soiled linens are assigned to nursing assistants.

Cleaning, Reconditioning, and Floor Care

Housekeeping jobs can be classified as daily cleaning, weekly cleaning, reconditioning, and floor care. Daily cleaning consists of routine procedures for cleaning, sweeping, mopping, and vacuuming all patient care and public areas in the facility. Weekly cleaning tasks include dusting furniture and fixtures, cleaning baseboards, paying attention to floor edges and corners, polishing bathroom fixtures, cleaning draperies and cubicle curtains, and other heavy-duty tasks. The housekeeping supervisor should develop a rotating schedule so that all areas of the building receive weekly heavy-duty cleaning. To accomplish this goal, certain sections of the building are included in the daily cleaning schedules to receive the weekly heavy-duty attention. On weekends, many facilities have reduced staffing to perform the daily tasks; in that case, weekly tasks are covered using a five-day rotating schedule.

Reconditioning  involves thorough cleaning of certain areas, particularly patient rooms. Reconditioning is always performed after a patient has been discharged and involves tasks such as cleaning and sanitizing the bed and mattress. All patient rooms should receive reconditioning attention on a rotating basis every 5 to 6 weeks. Floor care is generally assigned to custodians, who are responsible for stripping, waxing, and polishing floors and for shampooing carpets.

Sanitizing

The term  sanitizing  describes a process that results in a reduction of microbes to relatively safe levels (Belkin, 2003). Sanitizing requires the appropriate use of disinfectants approved by the U.S. Environmental Protection Agency (EPA), which oversees the registration of antimicrobial products. A list of registered antimicrobials is available at the EPA’s website (see For Further Learning). The listed categories include sterilants, tuberculocides, anti-HIV products, anti-HBV (hepatitis B virus) products, anti-HCV (hepatitis C virus) products, and products that are effective against methicillin-resistant Staphylococcus aureus (MRSA). A fresh solution of diluted household bleach (1 part bleach to 10 parts water) made up every 24 hours is also an effective disinfectant. Contact time for bleach solution is the time it takes the product to air dry; afterward, rinsing is necessary.

The housekeeping supervisor should periodically determine whether the housekeeping procedures are effective on a microbiological level. Such an evaluation is done by taking periodic cultures from various surfaces for bacterial colony counts.

Infection Control

The housekeeping staff plays a vital role in controlling infections in the facility by following sanitary practices that can prevent the spread of microorganisms. Disease-causing pathogens can spread through dust particles, air particles, and surface contact. Proper cleaning and sanitizing of floors and other surfaces is a means of infection control. But housekeeping practices employed while performing daily tasks are equally important. For instance, a housekeeper who gives a quick shake to a dust rag after having used it to dust furniture is spreading germs through the air. Hence, plain dry sweeping and dusting have no place in health care housekeeping practices; chemically treated disposable dry mops and dust cloths should be used. Vacuum cleaners used for carpeted areas should have microbial filters to avoid disseminating bacteria from the vacuum exhaust. Wet-mopping should employ a double-bucket technique, with one bucket for cleaning with a disinfectant solution and the other for rinsing the mop (Vesley & Greene, 1973). Frequently changing the mop water is also necessary for minimizing the spread of microorganisms along the floors. Hand-washing is critical when contact is made with clean surfaces after touching soiled objects or surfaces.

Laundry Operations

The laundry department is responsible for the processing, distribution, and storage of washable linens, garments, and other such items (Goldberg & Buttaro, 1990). An alternative to operating an on-site laundry is to have a contract with a commercial laundry service. For small facilities in particular, it may not be cost effective to operate an on-site laundry.

The basic laundry tasks include sorting, washing, drying, folding, storing, and delivering. Soiled linens are brought to the laundry by nursing assistants, or bags of soiled laundry are conveyed down a laundry chute in multistory buildings. Clean linen is delivered to the patient care areas by the laundry staff. Clean linens must be transported through the facility using covered carts to prevent cross-contamination. Nursing home laundries generally do not do ironing and mending. Widespread use of no-iron linens has eliminated the need for ironing.

Microbicidal Washing

The  microbicidal  (killing of microbes) action of the normal laundering process is affected by several physical and chemical factors. Soaps or detergents loosen soil and also have some microbicidal properties. Hot water provides an effective means of destroying microorganisms. A temperature of at least 160° F (71° C) for a minimum of 25 minutes is commonly recommended for hot-water washing of laundry. Chlorine bleach in the wash provides an extra margin of safety. The final action performed during the washing process is to add a mild acid to neutralize any alkalinity in the water supply, soap, or detergent. Detergents that can reduce microbial contamination at lower water temperatures are also available. Instead of the microbicidal action of hot water, low-temperature laundry cycles rely heavily on the presence of bleach to reduce levels of microbial contamination.

Standard Precautions

Nursing facilities must follow standard precautions when handling all soiled laundry. Standard precautions must be used by all personnel when handling items that may contain blood, body fluids, secretions, and excretions, regardless of the patient’s diagnosis. Laundry workers should use gloves, gowns, and masks when sorting and washing linens. Laundry should be handled as little as possible and with minimal agitation. To avoid punctures from improperly discarded syringes, personnel should hold laundry bags and linens away from the body and avoid squeezing them. Using normal washing cycles in accordance with the laundry detergent manufacturer’s recommendations should be quite sufficient for thorough washing. However, patient linens (bed sheets, towels, washcloths, etc.) should be washed separately from kitchen laundry and patients’ personal clothing.

As mentioned earlier, soiled-laundry sorting and clean-linen processing must be separated. A separate room, equipped with  negative-pressure ventilation , is best for the sorting process. The negative pressure allows air to move from a clean to a soiled area, and not vice versa, and is designed to prevent movement of airborne particles from the soiled area to the clean linen processing area (Vesley, 1973).

Linen Inventory

A system of linen inventory is essential for control purposes. This system requires a secured linen storage room to which only authorized personnel have access. The main institutional linens include bed sheets, towels, and washcloths. After washing, drying, and folding, linens are temporarily stored. Patients’ personal clothes are delivered to their individual rooms. The nursing facility must have enough quantities of linens so that after washing all linens get a chance to “rest” for at least 24 hours before being put into service again. Adequate linen quantities are also necessary to meet all patient care needs over the weekend when the laundry operation is generally shut down. Goldberg and Buttaro (1990) proposed a stratified inventory system that assumes that for every piece of linen in use, four others are being processed or are in storage. Under such a system, the linen inventory should consist of the number of items used daily multiplied by five. The resulting number is called the  par level . It refers to the minimum number of units of an item the facility should maintain in the inventory, including items in circulation and storage.

A certain amount of linen loss is to be expected. Such losses can result from wear and tear as well as pilferage. An inventory control system is used to find out the extent of loss and to determine the quantities of linen that should be purchased to replenish the stock to par levels. A running linen inventory record includes the following entries:

The facility should take a physical inventory of linens once every 3 or 4 months to compare the actual linen count to the closing inventory. The difference shows how much linen is being lost that must be replenished to maintain the par levels.

Security Operations

Rowland and Rowland (1984) pointed to two basic facets of security: physical and procedural.

Physical Security

Physical security encompasses three main areas: (1) protecting people against bodily harm by intruders from the outside, (2) protecting residents from wandering out and getting injured, and (3) protecting the property of both residents and the facility against theft. Physical security requires integrating a variety of protective measures, including control of the facility’s parameter, intrusion alarms, lock-up procedures, and electronic surveillance. Installing and maintaining security systems and hiring security personnel can be quite expensive. However, some minimal equipment installed in strategic locations is generally necessary. Undertaking risk assessment and cost–benefit evaluation are essential before a large investment is committed for security. Potential costs to the facility include restitution to the party harmed, legal action against the facility, and loss to the facility’s image if a resident or associate is harmed and the injury is attributed to lack of security. The probability of such losses should be taken into account in doing a cost–benefit evaluation.

The administrator should work with the local law enforcement authorities to evaluate security needs. Following their recommendations, the administrator can then work with two or three reputable security firms to obtain bids for appropriate security technology. At a minimum, the facility must ensure that all parking areas and the building’s exterior are adequately lit. The administrator should also arrange with local law enforcement to have the facility on routine police patrol. A high-visibility patrol is one of the best deterrents against crime (Sells, 2000).

All facilities must have policies specifying who is responsible for locking up designated entrances after specified hours in the evening and for locking up the remaining entrances for the night. Self-locking timer devices can be installed to minimize human error. Security policies may also specify that after certain hours no employee can go outside the building unaccompanied.

Many facilities provide employee lockers for safeguarding personal effects such as purses. Most facilities also have resident policies that discourage keeping valuables, such as expensive jewelry, or more than minimal amounts of cash on one’s person or in the room.

A variety of monitoring systems are available to prevent unnoticed wandering by residents who may be particularly vulnerable because of dementia or confusion. In many locations, local or state codes allow installation of a delayed opening system on fire exit doors. With these devices the doors will not open for a set time, usually 15 seconds, when someone tries to open a fire exit door. During the delay period an alarm sounds to alert the staff on duty (Sells, 2000). This short delay, along with the sound of the alarm, may be sufficient to dissuade a patient who may be attempting to exit unnoticed.

Security Audit

Periodically, the administrator should undertake a  security audit . In this audit, all physical security measures and potential lapses should be closely examined. A comprehensive audit must be undertaken any time a significant security incident occurs or a problem that could have resulted in an incident is reported. A security audit would be undertaken in addition to a thorough investigation and documentation of any actual incidents. The purpose of an audit is to prevent recurrence of an incident or prevent the occurrence of a nonrelated incident. All security audits and corrective actions resulting from such audits should be documented.

Procedural Security

Procedural security involves control systems to prevent internal theft and pilferage of supplies and materials. Four different systems are needed to protect the facility’s assets:

•  A system for ordering, receiving, storing, and controlling the inventory for all supplies and materials

•  A tagging and inventory system for all movable capital assets

•  A key control system that restricts access to various storage and office areas

•  Security of electronic data

Supplies and Materials

In addition to the control systems for food and dietary supplies, the facility must have a central system for ordering, receiving, storing, and controlling the inventory for all supplies and materials. Other than food, supplies and materials that may be vulnerable to theft include linens, cleaning chemicals, maintenance tools and equipment, and medical supplies. Large facilities may have a central storeroom with a stock clerk responsible for all items other than food. In most facilities, however, each department head has the responsibility for ordering and maintaining supplies used by the department. In this case, each department manager must exercise adequate controls over the supplies and materials by using inventory systems to minimize theft.

Movable Capital Assets

A tagging and inventory system is used to identify and control all movable capital assets, such as television sets, cameras, computers, office equipment, and medical equipment. Permanent, nondetachable metal tags with the facility’s name and a tag number should be affixed to all movable assets. A record, which can be easily computerized, should identify each item, its tag number, location, date of acquisition, and cost. This record should also bear the date of retirement after an item has been retired from service. An annual or biannual inventory should verify that each item still in service is actually present in the facility.

Access Control

Access to various parts of the building is controlled by establishing a centralized system to regulate distribution of keys to authorized personnel only. This function is best controlled by the administrator or assistant administrator. Working with a master locksmith, the facility should plan and implement a hierarchical system of grand master keys, master keys, submaster keys, and individual keys. The system allows authorized personnel to have access to more than one locked area, using no more than two keys. For instance, the administrator and the assistant administrator can have access to all secured areas using the one grand master key. A submaster key may allow the DON to have access to all secured areas except food storage and maintenance areas.

Records must be kept to account for every key issued. Keys must be retrieved and accounted for as personnel leave their positions. Appropriately maintained key inventory records can help track missing keys. When keys are missing, a decision can be made whether to rekey or change the locks in certain areas of the building. Establishing a key control system initially requires rekeying all locks in the building, something that can be quite expensive. First, a cost–benefit evaluation of a key control system should be done. Second, if a decision is made to implement the key control system, the system must be maintained. A facility can quickly lose most of the benefits of such a system and its investment in it if the system is allowed to break down. “Do not duplicate” should be engraved on all keys as a deterrent against unauthorized duplication. Mechanical and electronic keyless lock systems are gradually replacing physical keys.

Security of Electronic Data

Security breaches of electronic data have been on the rise. The matter takes on added seriousness when patient information is compromised. First, all computers and networks must be adequately secured. Second, password protection is not enough; data must be encrypted using encryption technology. Scam artists can also try to steal patients’ billing information for financial gain. They may call a facility posing as physicians, pharmacists, or insurance representatives. Such calls must be authenticated.

Fire and Disaster Planning

All facilities must have written fire safety, disaster, and evacuation plans. These plans must outline duties and responsibilities of various staff positions and the steps to be taken during emergencies such as a tornado, hurricane, earthquake, flood, or snow blizzard. These plans are best developed and rehearsed in conjunction with the local fire department and other civil defense agencies. The plans must address the individual characteristics of the particular facility and take into account the availability of local resources and the response time of emergency services to deal with events in which the safety of residents is paramount. Copies of the emergency plan must be available to all supervisory personnel, and all associates must be periodically trained and kept informed with respect to their duties under the plan.

Fire Safety Plan and Steps

The Life Safety Code® requires a written fire safety plan to include the following: use of alarms, transmission of alarms to fire department, emergency phone call to fire department, response to alarms, isolation of fire, evacuation of immediate area, evacuation of smoke compartment, preparation of floors and building for evacuation, and extinguishment of fire.

All associates must receive training in the sequential fire-protection steps represented by the acronym RACE (Kavaler & Spiegel, 1997):

R—Rescue and remove anyone in immediate danger.

A—Activate the nearest fire alarm.

C—Confine and contain the fire and smoke by closing all doors and windows.

E—Extinguish the fire with portable extinguishers, wet sheets, and blankets.

The most critical step in fire protection is to activate the fire alarm. This step is vital because the fire department must be notified immediately when fire is suspected. The Life Safety Code® requires that the fire alarm system be connected to an outside agency, such as a fire security company, that will transmit the alarm to the nearest fire department. Pulling the fire alarm is the quickest way to summon the fire brigade to the facility. When the alarm box is activated, a fire alarm goes off within the facility, and all fire doors close automatically.

The facility’s fire safety protocols should also include a preestablished code phrase, such as “Doctor Red” or “Code 99.” The code is used to alert all associates in case of an actual fire, during fire drills conducted between 9:00 p.m. and 6:00 a.m., or during a malfunction of the building fire alarm system. The code phrase is generally announced over the intercom system.

The real danger from a fire is usually not the flames, but smoke that can travel quickly to areas far from the fire. Smoke inhalation is the major cause of death during a fire. Hence, closing doors and windows and using wet towels to cover any open spaces between the doors and the floor must be given top priority after patients in immediate danger have been evacuated and the fire alarm has been activated. The associates should start closing doors and windows throughout the facility as soon as the alarm is sounded. In all emergency situations, the staff must remain calm and reassure patients and visitors that appropriate procedures are being followed.

Fire safety procedures should clearly designate the person who takes charge when a fire or suspected fire is discovered. For example, an unusual odor may create suspicion of fire, in which case the administrator, the DON (in the administrator’s absence), or a charge nurse (on the night shift) will ascertain whether smoke or fire is present anywhere in the facility. Once the presence of fire is confirmed, a phone call should also be made to the local fire department to confirm that there is a fire. An associate should be posted at the front entrance of the facility to direct the fire department personnel to the location of the fire in the building, while the person in charge of fire safety directs associates to secure all patients and follow the RACE steps.

On the other hand, when no smoke or fire is detected, notice of a false alarm should be relayed to the fire department by telephone to confirm that there is no fire, because an alarm would have been previously relayed if a fire alarm had been activated. In most instances, however, the fire brigade is already on its way by the time the person in charge of fire safety has confirmed the state of “all clear.” In this case, the individual should meet the fire brigade at the front entrance and explain the situation. Some fire personnel may still want to go through the building and ensure complete safety before leaving the premises.

Emergency Evacuation

Evacuation  is the removal of patients and vital equipment from an unsafe area to a safe area during a fire or other emergency situation (Tweedy, 1997). It does not necessarily refer to evacuation of the building.

Evacuation plans should cover both partial and total evacuation of patients. When a fire alarm is activated, automatic closure of fire doors segregates the point of origin of the fire from other areas on the same floor. Because fire doors provide a barrier against smoke and flames, a safety zone is created beyond the fire doors away from the point of origin of the fire ( Figure 12–1 ). Such a space becomes an area of refuge, which the Life Safety Code® defines as either (1) “a story in a building where the building is protected throughout by an approved, supervised automatic sprinkler system and has not less than two accessible rooms or spaces separated from each other by smoke-resisting partitions,” or (2) “a space located in a path of travel leading to a public way that is protected from the effects of fire, either by means of separation from other spaces in the same building or by virtue of location, thereby permitting a delay in egress travel from any level.” In simple terms, an  area of refuge  is a zone of safety within a building that is protected from the effects of fire and smoke, and provides direct access to an exit.

Figure 12–1  Partial Evacuation to an Area of Refuge or Total Evacuation During a Fire Emergency

A partial evacuation consists of moving patients from the area of fire to a neighboring area of refuge. Total evacuation consists of removing patients and vital equipment from an entire wing or floor or evacuating the entire building. Bed-bound patients should be removed on stretchers because rolling beds into the hallways can quickly clog vital evacuation routes. Nonambulatory patients who are not bed bound can be rolled out in wheelchairs. Ambulatory patients should be led as a group, holding each other’s hands. An associate should lead such a human chain, with another associate following the chain. After patients have been moved to an area of refuge, they must remain under staff supervision.

For the purpose of total evacuation, the facility must make prior arrangements for temporary shelter of residents in a local school, hospital, or Red Cross center. Evacuation plans should include transfer of patients; protecting and transferring medical records; continuing critical medical care services; and maintaining vital functions such as providing food, water, and clean linens.

Simulation Drills

The facility must conduct regular fire drills on all shifts. The Life Safety Code® requires that the facility conduct an unannounced fire drill on each shift once a quarter. Because of staff turnover, however, more frequent fire drills are recommended. The facility’s associates are not expected to function as firefighters, but they must know how to operate a portable fire extinguisher. The staff members’ main role is to contain any immediate danger and minimize the spread of fire till the fire brigade gets to the scene, at which point the firefighters will take over. A disaster simulation drill is necessary once a year to rehearse the response of the associates and the response of the local civil defense teams. All fire drills and disaster simulation drills must be documented, and training should follow to address areas of weak response. Simulation drills are also used to educate associates about the importance of remaining calm and thinking clearly during unexpected emergencies.

Waste Management

General Waste

As much as 90% or more of the waste produced by nursing care facilities is regarded as “nonrisk” general waste, which is comparable to domestic garbage and can be safely disposed of by contracting with a reputable waste removal company. A dumpster of sufficient size is essential so that trash does not overflow at any time. The dumpster must be a covered container, and it must remain covered after each use. All garbage and waste must be appropriately bagged; no loose trash should be thrown into the container. The ground around the dumpster should be kept clean at all times. This function is generally the responsibility of the maintenance department.

Hazardous Waste

The facility must have policies and procedures in effect for the safe handling, removal, and disposal of all wastes regarded as hazardous. The most common types of hazardous waste can be classified as infectious wastes, pathological wastes, and sharps.  Infectious waste  can pose health risks from communicable infectious agents. Such waste can come from patients who have been isolated for infections, dressings from infected wounds, human excreta, or laboratory cultures.  Pathological waste  is human waste that may contain human tissue, blood, or body fluids. It includes stoma bags, incontinence pads, and protective gloves and masks used by associates.  Sharps  can be any objects that can cut or puncture, such as needles, blades, broken glass, and nails.

Hazardous waste must not be deposited in the regular dumpster used for general waste. Safe handling requires precautions to avoid injury from sharps and to prevent cross-contamination from infectious and pathological waste. Special puncture-proof containers are used for all sharps. Infectious and pathological waste is bagged in clearly marked or color-coded heavy-duty plastic bags that are also leak proof. The plastic bags are placed in rigid leak-proof containers, never on the floor. Unlike most hospitals, nursing facilities generally do not have on-site disposal or incineration facilities because of the costs involved. Contracts must therefore be established with qualified waste carriers for the regular removal and disposal of all hazardous wastes. Any storage of waste before collection for off-site disposal should be in a secure location designated for the purpose (Prüss, Giroult, & Rushbrook, 1999).

Environmental Safety

Safety is one of the primary elements to be incorporated in the various environmental policies and procedures discussed in this chapter. Personnel working in a facility’s environmental services departments need specific training in safe work habits and in monitoring the environment for safety. For instance, monitoring hot water in patient rooms and bathrooms is a critical aspect of safety that prevents scalding. As a general rule, hot water temperature in these areas should not exceed 110° F (43° C). Hot water supply to patient areas and public areas is equipped with thermostatically controlled mixing valves to keep the water temperature from rising above the specified limits. The maintenance supervisor must pay particular attention to this area and record daily temperature readings to ensure safety. On the other hand, adequate supply of water that is hot enough for washing and sanitizing in the kitchen and laundry is equally important. Because the hot water temperatures required for patient care areas and for sanitizing functions differ substantially, a common practice is to have separate hot water systems and booster heaters that are locally mounted on sanitizing equipment to achieve the desired temperatures.

Maintenance and housekeeping personnel must pay close attention to their equipment. If equipment is left unattended, it presents a hazard. Floor cleaning and polishing chemicals should be nonskid. Safety signs must be used while mopping floors. Mopping the hallways lengthwise, doing one half of the hallway at a time, leaves the other half for safe passage.

Furniture and equipment must be kept away from traffic paths and exits. Various electrical gadgets are operated with long cords, which should be kept along the baseboards and not across the hallway. Heavy housekeeping trucks, food transportation carts, and linen carts can cause serious injury. They often block the operator’s view and require caution, especially when turning blind corners. Strategically placed mirrors can help associates using these carts to see people around the corner and use caution to prevent injuries.

Terminology for Review

area of refuge

evacuation

infectious waste

job-unit contract

microbicidal

negative-pressure ventilation

open-call contracts

par level

pathological waste

reconditioning

routine contracts

sanitizing

security audit

sharps

For Further Thought

  1.  What would be some of the important clauses to include in (a) routine contracts, (b) open-call contracts, and (c) job-unit contracts?

  2.  What may be some of the reasons for not allowing the housekeeping staff in nursing facilities to handle either clean or soiled linens, unlike hotel and motel operations?

  3.  Discuss how certain environmental standards in the facility can be effectively used to convey value to potential clients.

FOR FURTHER LEARNING

U.S. Environmental Protection Agency: Provides information on registered antimicrobial products.

http://www.epa.gov/oppad001/chemregindex.htm

REFERENCES

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Kavaler, F., & Spiegel, A. D. (1997). Assuring safety and security in health care institutions. In F. Kavaler and A. D. Speigel (Eds.), Risk management in health care institutions: A strategic approach. Boston: Jones and Bartlett Publishers.

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Tweedy, J. T. (1997). Healthcare hazard control and safety management. Boca Raton, FL: Lewis Publishers.

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Vesley, D., & Greene, V. W. (1973). Sterilization, disinfection, and cleaning techniques. In R. G. Bond, G. S. Michaelsen, and R. L. Deroos (Eds.), Environmental health and safety in health-care facilities. New York: Macmillan Publishing.