Lost, Found, and Abandoned Property Policy (v.1)
Lost and found property that has been deposited with AU Medical Center (AUMC) for safekeeping is managed in a reasonable and organized manner, to include appropriate documentation and release of the lost/found property only to the patient or their personal representative when possible. The management of a patient’s home medications is outside the scope of this policy. Approved: 4/3/2018
Transfer of Patient via AUMC Transfer Center Policy (v.1)
This policy applies to all transfer requests managed by the AUMC Transfer Center or Emergency Communications Center (ECC). The policy states that all requests from outlying hospitals for transfers of patients to AU Medical Center (AUMC) are managed in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C., Section 1395, all applicable Federal regulations and interpretive guidelines promulgated thereafter, and the tenets of this policy. Process & Procedures address emergency department to emergency department transfer, emergency department to In-patient unit transfer, and inpatient unit to inpatient unit transfer. Also addressed in the policy is the transfer center escalation process and denials in each transfer scenario. Approved: 4/6/2018
Blood Administration Policy (v.4)
This is an AU Medical Center policy governing the obtaining of informed consent and administration of blood and blood components. Approved: 4/6/2018
Diversion of Patient Transfer/Transport Policy (v.3)
AU Medical Center (AUMC) is committed to assuring that adequate resources are available to provide appropriate care to those who seek health care services at this institution. In order to assure safe care for those most in need of AUMC’s resources, certain transfer requests from other external organizations may be redirected for a limited time. Moreover, in the event that specific resources cannot be made available to provide adequate, safe care for additional critically ill or injured patients who may be transported through the EMS System, there will be a procedure to notify Regional EMS and other appropriate parties to accomplish the temporary diversion of patients to other facilities. This policy applies to all patient care units that admit within AUMC and CHOG. Approved: 4/6/2018
Adult Patient Elopement Policy (v3)
AU Medical Center is committed to the safety of all patients. Therefore, formal policies and procedures have been established to ensure an effective response in the event of a patient elopement. The purpose of this policy is for AU Medical Center to enact the proper and appropriate procedures for maintaining the safety of patients, staff and others at all times. The medical center shall take responsibility for individuals placed in its inpatients facilities for treatment regardless of voluntary or involuntary status.
Fire Watch Policy (v3)
The purpose of this policy is to supplement the existing fire detection and response systems and to provide additional compensatory activity to assure the safety of patients, visitors and staff in adjacent areas. The fire watch is intended to identify and report hazards, for correction action, and to document findings.
Infection Prevention and Control Annual Risk Assessment and Plan (v5)
Annually, AU Medical Center documents a risk assessment which describes the infection risks unique to its’ hospitals and clinics used to determine the Annual Infection Prevention and Control Plan.
Medical Gas Policy (v3)
To provide a policy for the installation, performance, maintenance, monitoring and testing of medical piped gas systems for AU Medical Center. Medical Gases are maintained and monitored by Facilities Support Services to ensure safe and uninterrupted operation for the purpose of patient care.
Moderate Sedation (Conscious Sedation) Policy (v2)
Establishes specific recommendations for the safe care of patients undergoing moderate sedation and/or analgesia administered during diagnostic, therapeutic, or invasive procedures performed by non-anesthesiologists for out of operating room areas throughout AU Medical Center. Applies only to the care of patients undergoing moderate sedation level only.
Monitored Anesthesia Care/Deep Sedation Policy (v2)
Establishes specific recommendations for the safe care of patients undergoing deep sedation and/or analgesia administered during diagnostic, therapeutic, or invasive procedures performed by non-anesthesiologists for out of operating room areas throughout AU Medical Center. Applies only to the care of patients undergoing deep sedation.
No Information Patients Policy (v2)
To define the procedure for AU Health workforce members in ensuring that the appropriate steps are taken to use or disclose protected health information (PHI) for its Facility Directory and protect the confidentiality of “no-information” patients admitted to AU Health.
Paint Policy (v2)
To provide a uniform policy and procedure to identify painting needs and painting process for AU Medical Center through Facilities Support Services. This policy applies to all building structures for AU Medical Center.
Personal Appearance Policy (v4)
AU Medical Center employees are expected to maintain a high standard of neatness and personal hygiene. Personal appearance must meet safety and cleanliness standards to ensure patient and staff protection. If an employee is uncertain about dress requirements in his/her department, the employee should consult with his/her immediate supervisor.
Pneumatic Tube System Policy (v2)
Establishes procedures and guidelines for the operation of the pneumatic tube system. Defines materials that are suitable for and/or prohibited from transport within the system.
Rules of Conduct Policy (v3)
AU Medical Center is committed to providing and maintaining a productive, professional work environment. AU Medical Center expects and requires every employee to meet certain behavioral standards and observe basic rules of conduct. Rules of conduct are necessary to protect the health and safety of employees, patients, and visitors, maintain the quality of services provided, and ensure a high level of professional behavior is maintained by employees.
Staff Rights and Responsibilities Policy (v3)
AU Medical Center has the responsibility to care for and treat patients by providing Patient-and-Family Centered Care. It also has a responsibility to its employees. However, when the rights of employees conflict with the needs of patients, such conflicts should be handled in a manner consistent with legal and professional standards of practice. This policy provides clear guidelines to assure uninterrupted patient care should a conflict over employee assignments, instructions and duties occur.
Volunteer Services Policy (v2)
AU Medical Center is committed to the development and implementation of volunteer engagement and utilization by all areas of the organization. Volunteers are not compensated and perform services without promise, expectation or receipt of compensation, future employment or any other tangible benefit. Volunteers servicing AU Medical Center are not to provide direct patient care.