Nursing Policy & Procedures Manual

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Table of Contents: Administrative Section: -1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Preface Nursing Services Organizational Chart Behavioral System Overview Change of Shift Procedure Verification of Licenses Individual/Individual and Family Teaching Code of Ethics for Nursing Services Nursing Services Records, Meeting Minutes Nursing Policy and Procedures Nursing Services Duties: Responsibilities Confidentiality of Individual Information Nursing Services Quality Improvement Program North American Nursing Diagnosis (NANDA) Taxonomy Nursing Services Mission and Organizational Structure Nursing Students Wellness & Recovery Treatment Teams (Nursing) Psychiatric Classification/Acuity Calculation and Report Psychiatric Mental Health Nursing Nursing Process Overview Spiritual Needs of Individuals Storage and Handling of Sporks Staffing Scope of Activity for Volunteers Unit Resource Reference Material for Nursing Services Staff

Section 1 - Admission and Discharge Procedures: 100 101 102 103 104 105 106 107 Admission Process Court Visit Process Death Procedure and Documentation Discharge to the Community Discharge Planning Nursing Discharge Planning/Summary Preparing Individuals for Transfer & Transfer Note Unit Process & Acceptance Note for Receiving

Section 2 - Abbreviations: 200 Unacceptable Abbreviations and Symbols

Section 3 - Nursing Care and Documentation: 300 301 302 303 304 305 Age specific nursing care Basic Bed making/Cleaning Bath tub use (medical unit) Care of the Individual with self-induced water intoxication Constipation monitoring Daily care flow sheet

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306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 334

End of life care Escorting Individuals off unit Fall prevention Feeding of individuals Legal requirements for nursing documentation Mouth care Nail care Nursing assessment: Initial, annual, and update Nursing care plans Nursing Discharge Summary Nursing progress notes Pain management Individual transfer, acceptance and/or discharge note Protective mechanical support devices Safety, security and supervision of individuals, visitors Special Incident Report Vital Signs Weight Monitoring Dysphagia

Section 4 - Treatments and Procedures: 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 425 428 429 430 431 432 433 438 Sponge bath for reducing temperature Retention catheter (foley) insertion and care Catheterization and the care of a catheterized male Individual Bed bath Dressing change Evening care of bed Individual Ear irrigation Compress for the eye hot and cold Eye irrigation Warm foot soaks Tube feeding (nasogastric) Peg Feeding/Gastrostomy Treatment of Pediculosis (lice) and scabies Cold pack treatment Oxygen Therapy Oxygen Concentrator Enemas Cast and Leg immobilizer application and care Tracheostomy care: Cleaning of inner cannula Tracheostomy suctioning Pressure soar treatment Care and use of the nebulizer Care of the Incontinent Individual Stoma Care CPAP: care, use and cleaning Central vascular access devices Giving or removing a bedpan or urinal Wounds Irrigation Bladder Irrigation Nasogastric Tube Insertion Gastric Lavage Adaptive Devices

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Tube Feeding

Section 5 - Medications: 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 Administration of medication and treatments: General Rules Administration of oral medication Topical Applications Suppositories Administration of Parenteral Medications Administration of Nose Drops/Nasal Spray Administration of hand-held inhalant medications Installation of eye medications Installation of ear medications Nursing protocol for Administration of Propanolol Care of the Individual receiving clozapine Care of the Individual receiving olanzapine Oxygen therapy Administration of insulin Noting physicians orders Control drugs (scheduled drugs) Medication related events Medication administration orientation / competency validation Intravenous procedures and certification Intravenous solutions and admixture I.V. solutions Inserting a male adaptor plug heparin lock saline lock Intravenous blood withdrawal by registered nurse Immunizations Self-Administration of medication 24 Hour night shift medication and treatment audit Medication Related Event Form

Section 6 - Diagnostic Procedures: 600 601 602 603 604 605 606 608 609 610 611 613 615 620 Clinic Procedures Laboratory Procedures Radiology Procedures Clean Catch (Midstream) Urine Collection Collection Of 24-Hour Urine Specimen Obtaining Stool Specimens For Laboratory Analysis DNA Specimen Procedure Blood Glucose Testing Competency Validation Blood Glucose Monitoring Collecting Specimens: Feces, Cultures And Urine Pulse Oximetry Holter Monitor Referrals Referring Individuals To Central Medical Clinic Computerized Laboratory Requisitions

Section 7 - Emergency Procedures: 700 701 702 703 Medical Emergency Management of a foreign body airway obstruction Cardiopulmonary Resuscitation (CPR) Seizures

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704 705 706 707 708 709 710 711 712 713 714 715 716 717 718

Emergency care of Burns Emergency care of wounds Heat related conditions Emergency care of shock Emergency treatment of head injury Emergency care of eye injuries Emergency care of fractures Emergency care of epistaxis Emergency care of poisoning Anaphylactic Reaction (shock) Emergency Medical Equipment Emergency care of Hemorrhage Monitor/Defibrillator Neuroleptic Malignant Syndrome Pepper Spray

Section 8 - Infection Control: 800 801 805 810 815 820 825 830 835 840 845 850 855 860 870 875 880 885 Infection control program Vernacare v2020 disposal unit/macerator Isolation and precautions for infectious/communicable disease Cleaning of electronic medical equipment used on the units Storage/handling of toothbrushes & toothpaste Dispensing individuals liquid soap/bar soap Clearing of residual instruments Safe storage and disposal of syringes and needles Safe storage and handling of shavers Use of personal protective equipment (PPE) Cleaning procedure for isolation rooms Cleaning of individuals Individual areas Hand hygiene Biohazardous waste Cleaning of water pitcher on units Disinfection of commonly shared grooming supplies Handling and storage of ice on the units Cleaning of leather restrains on the unit

Section 9 - Clothing and Linen: 900 Handling clean, infectious, or soiled linen and clothing

Section 10 - Central Supply: 1000 1001 Central Supply Medical Equipment Teaching

Section 11 - Orientation and Education: 1100 1101 1102 1103 Hospital wide orientation of nursing services staff Program Orientation HSS/NOD Orientation of new RNs to the program Orientation of staff to units not usually assigned to a unit

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Section 12 - Inside and Outside Facility Consultation: 1200 1201 1202 1203 1204 1205 1206 Staff escort of individuals to outside medical facilities Central Medical Clinic Dental Services Referring individuals to outside physician or facility EEG-ECG referrals Physical therapy services Referring special needs individuals for nursing consultation

Section 13 - Psychiatric Nursing Interventions: 1300 1301 1302 1303 1304 1305 1306 1307 1308 1309 1310 1311 1312 1313 1314 Withdrawn behavior Altered nutritional status: The Individual who is not eating Delusions Schizophrenia Bipolar disorders Continuous supervision of individuals Suicide prevention and intervention Expectorant shield Emergency use of behavioral restraint or seclusion Approaches for passive-aggressive or manipulative behavior Approaching the hostile individual Grief reaction Conversion disorder Psychosomatic disorder Hypochondriacal behavior

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Administrative Section

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative PREFACE Effective Date: August 31, 2006

PREFACEThe Nursing Policy and Procedure Manual of Coalinga State Hospital has been developed in concert with other health care professionals and clinically pertinent committees. The Committee members are representative of the Health Services Specialists, RN and PT Professional Practice Groups, Unit Supervisors, Training Center, Public Health Nurses, Nursing Performance Improvement, and staff from programs and other interested service providers. All nursing personnel shall have ready access to this manual at all times. Procedures are reviewed or updated at least every two years or as necessary to maintain quality nursing care. All clinically pertinent procedures are reviewed and approved by the appropriate committee responsible for maintaining specific protocol, e.g. Infection Control Committee, Emergency Care Committee, Pharmacy and Therapeutics Committee, Health Information Management Committee. All policies are under the direction of the Coordinator of Nursing Services. The CSH Nursing Policy and Procedure Manual can be located in CSH Intranet in PDF format. This allows for electronic access to all Nursing Policies and Procedures by staff having intranet access. Revisions of existing policies and procedures shall follow the Administrative Directives regarding Intranet access. Changes or addition of a new policy and procedure will be entered on the Intranet when the Nursing Policy and Procedure Committee make changes the week following the committees recommendations. The Manual is intended to provide nursing services personnel with guidelines, expectations, and requirements for providing quality nursing care. All individuals to whom the manuals are issued shall be responsible for maintenance and insertion of all current material provided by the CNS office.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 2 Effective Date: August 31, 2006 SUBJECT: BEHAVIORAL SYSTEM OVERVIEW 1. PURPOSE: The Behavioral Systems Model is utilized by nursing services at CSH as the framework for providing care to the forensic, psychiatric Individual in a biopsychosocial, holistic manner. The Behavioral Systems Model, which is based on Systems Theory, is evident throughout all phases of the nursing process including the CSH Individual Classification System for developing the Acuity Level specific for each Individual. There are several advantages to this model. It allows for: 1. 2. 3. 4. Allocation of staffing resources based on the degree of Individual illness; Monitoring of classification data for cost accounting purposes; Tracking changes and assisting in budget determination; Integrating classification data into utilization review and quality assessment and improvement. 5. Measuring Individual behavioral progress and intervention level. This model delineates nursing services distinct contribution to Individual care and it identifies universal patterns of behavior applicable to all individuals regardless of age, cultural differences, psychiatric, or medical diagnosis. The purpose of the Individual classification system is to determine the degree of each Individuals behavioral effectiveness and Nursings role in maintaining, supporting, and enhancing Individual behavioral effectiveness. The allocation of staffing resources is based on this dynamic relationship. The effectiveness of this classification system requires the utilization of the Behavioral Systems Model as the basis for professional nursing practice. 2. POLICY: The Behavioral Systems Model shall be used to measure Individual behavioral and intervention levels.

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3. DEFINITIONS: Behavior- The way in which one reacts to the environment. Environment - Composed of regulatory elements that impact on the behavioral system. There are both internal and external regulators in the environment. System - A whole that functions as a whole by virtue of the interdependence of its parts. Subsystem - The parts of the system that are organized around specialized tasks. Although the subsystems are mini-systems with their own particular goal and function, they are interdependent with the other subsystems that make up the larger system or whole. Systems Theory - Is an approach that considers the individual as a whole as opposed to his or her parts. The individual is considered an open system that is constantly interacting with the environment. 4. HISTORY: The behavioral systems theory springs from Florence Nightingales belief that Nursings goal is to help individuals prevent or recover from disease or injury. In addition, she maintained that the science and art of nursing should focus on theIndividual as an individual and not on the specific disease entity. Dorothy Johnson, a Nursing Theorist, using the work of behavioral scientists in psychology, sociology, and ethnology relied heavily on systems theory to develop a behavioral system approach for care of the psychiatric Individual. Later, Dr.s Jeanie Auger and Vivian Dee of the UCLA Neuropsychiatric Hospital expanded that theory to develop the Neuropsychiatric Individual Classification System to address the relationship between Individual behaviors and corresponding nursing care requirements. Today it is used at each of the California DMH State hospitals for: 1. Establishing the Individuals acuity level in order to determine levels of nursing care specific to the special care needs of the Individual. 2. A clinical measure of Individual progress. 3. To establish nursing services role in maintaining, supporting, and enhancing the Individuals behavioral effectiveness.

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5. GENERAL INFORMATION: Essential Principles of the Behavioral Systems Model: A. The Individual is viewed as an open, living system in constant interaction with the environment. B. The Individual is described as a behavioral system using 8 subsystems developed for the purpose of carrying out specific system tasks. C. The Individual, however, is viewed and functions as a whole by virtue of the interdependence of the parts. D. The Individual as a behavioral system strives for a balance. E. Balance is represented by a more or less equal distribution of energy among the 8 subsystems and is a reflection of the on-going relationship between the behavioral system and the environment. F. Environment is composed of all regulatory elements external to the behavioral system. The environment includes internal regulators such as physiological state as well as external regulators such as the family. G. Nursing Services assists the Individual to achieve system balance by creating an environment that protects, nurtures, and stimulates the behavioral subsystems. 6. THE NURSING PROCESS: When the Behavioral Systems Model is combined with the nursing process, a unique approach to Individual care emerges: Assessment - is organized around the behavioral subsystems and their interaction with regulators in the environment. Nursing Diagnoses - are labels that are formed, based on demonstration of ineffective behavior within one or more subsystems, and the relationship of these behaviors to the regulators. Outcome Identification - is based on goals for behavioral responses to more effectively achieve subsystem health and overall system balance. Planning - involves the creation of a Individual care environment of interventions.

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Nursing Interventions - are delivered, thereby enabling the Individual to initiate behavioral responses that more effectively meet the goals of the subsystems. Evaluation - is accomplished by reassessment of the subsystems and the regulators to determine if a more effective behavior is evident. 7. BEHAVIORAL SUBSYSTEMS: Ingestive - The ingestive subsystem is associated with food and fluid intake, and has to do with when, how, what, how much, and under what conditions we eat and drink. These responses are associated with social and psychological as well as biological considerations. Eliminative - The eliminative subsystem is associated with patterns of elimination, and like the ingestive subsystem, is associated with social, psychological, and biological considerations. Dependency - In the broadest sense, the dependency subsystem promotes helping behavior that calls for a nurturing response. Its consequences are approval, attention or recognition, and physical assistance. Developmentally, dependency behavior evolves from almost total dependence on others, to a greater degree of dependence on self. A certain amount of interdependence is essential for survival of social groups. Affiliative - Affiliative subsystem is probably the most critical, because it forms the basis for all social organization. On a general level, it provides survival and security. Its consequences are social inclusion, intimacy, and formation and maintenance of a strong social bond. Aggressive/Protective - The aggressive/protective subsystems function is protection and preservation from perceived or real harm. This is a basic drive, but these behaviors also derive from social learning. Society demands that limits be placed on modes of self-protection and that people and their property be respected and protected. Sexual - The sexual subsystem has the dual functions of procreation and gratification. This includes, but is not limited to, courting and mating. This response system begins with the development of gender role identity and includes the broad range of sex role behaviors. Achievement - The achievement subsystem attempts to manipulate the environment. Its function is control or mastery of an aspect of self or environment to some standard of excellence. Areas of achievement behavior include intellectual, physical, creative, mechanical, and social skills.

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Restorative - The restorative subsystem is associated with sleep, rest, recreation, and the sick role. Restoring equilibrium is a key concept in Nursings specific goal. It is defined as a stabilized but more or less transitory, resting state in which the individual is in harmony with himself or herself and with their environment. It implies that biological and psychological forces are in balance with each other and with impinging social forces. It is not synonymous with a state of health, since it may be found either in health or illness. 8. ENVIRONMENTAL REGULATORS: The concept of environment consists of external and internal factors which impact on, and are regulators of, behavior. 1. The internal regulators originate from within the individual and include: A. Developmental factors B. Bio-physical factors C. Psychological factors 2. The external regulators are comprised of the forces in the external environment which impact on the individual, including: D. Social and cultural factors E. Familial factors F. Physical environment All of these regulators have the ability to influence each of the behavioral subsystems, and the inter-relationships between subsystems. In addition, the subsystems and the behavioral system as a whole act on and influence the environment. This relationship is open, dynamic, and ongoing. The behavioral system as a whole is dependent upon the integrated performance of the eight subsystems. The integrity and balance of the system is maintained when: 1. The conditions in the environment remain orderly and predictable, 2. The functional requirements of the subsystems are met for the purpose of restoring, maintaining and attaining the highest possible level of functioning through the individuals own efforts or through an external regulatory force. 9. ASSESSMENT: The concept of behavior is basic to the model. Behavior may range from effective to ineffective. Behavioral data is gathered to determine the

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effectiveness of each subsystem. Based on the behavioral data, each subsystem is assigned a behavioral category score ranging from 1 to 5. 1 = effective 2 = inconsistently effective 3 = ineffective 4 = seriously ineffective 5 = critically ineffective In addition, data is gathered to determine the degree to which the internal and external environments protect, nurture, and/or stimulate the behavioral subsystems. Effective behaviors enable the Individual to meet the goals of the various behavioral subsystems resulting in overall system stability. Ineffective behaviors do not enable the Individual to meet the goals of the various subsystems resulting in behavioral system instability and unpredictability. 10. DIAGNOSIS: The Behavioral Systems Model defines 5 levels of effectiveness/ineffectiveness that depict behaviors on a continuum that denote a range of diagnoses from health to critical illness. The Diagnostic Process is based on the degree of effectiveness or ineffectiveness of each behavioral subsystem. Priorities are established and nursing diagnoses are formulated for those subsystems which pose the greatest threat to the overall behavioral system. The NANDA Taxonomy is used by the RN to develop the nursing diagnosis at CSH. This diagnosis provides the basis for selection of interventions for delivering Individual care to achieve outcomes for which the nurse is accountable.

ACUITY BEHAVIORAL CATEGORY: 1. Effective Behavior 2. Inconsistently Effective Behavior Deviation 3. Ineffective Behavior 4. Seriously Ineffective Behavior 5. Critically Ineffective Behavior

INDIVIDUAL HEALTH: 1. Health 2. Potential for Health 3. Illness 4. Serious Illness 5. Critical Illness

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11. PLANNING, INTERVENTION AND EVALUATION: There is a dynamic relationship between the Individual behavioral category and the levels of nursing intervention required. The numbers 1 to 5 represent these behavioral categories, and also the level of nursing intervention required. 1. Effective: The goal of nursing is to provide a nurturing and stimulating environment within the general unit milieu. Inconsistently Effective: The primary goal is the same as level 1; however, this is an alert to monitor for the potential for system imbalance and health deviation. There may be a need for a nursing care plan. Ineffective: In addition to the goal of level 1, the nurse must address the system imbalance and illness by providing frequent supervision, a nursing care plan, and special care needs. Seriously Ineffective: The Individual demonstrates serious system imbalance and illness. He is no longer able to function in the unit milieu without a restriction being placed on him. He requires a nursing care plan and intensive nursing supervision. Critically Ineffective: The Individual demonstrates critical system imbalance or illness and is no longer able to function in the unit milieu without a staff being with him at all times. Therefore, he requires a nursing care plan and constant intensive supervision with a 1:1.

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Planning - is based on mutual goal setting between the Individual and the nurse in conjunction with the focus of the WARMS in order to determine the methods for increasing behavioral effectiveness. Intervention - is based on mutual goal setting, behavioral activities, and internal/external environmental changes that protect and/or stimulate the behavioral subsystems. Evaluation - involves measurement of the Individuals response to the interventions and the progress made toward the expected outcomes (short term goals) to determine if increased behavioral effectiveness was achieved.

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12. COMPETENCY/TRAINING: All nursing staff will initially receive training during New Employee Orientation, and all nursing employees will receive an overview of the Behavioral Systems Model and application.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 3 Effective Date: August 31, 2006 SUBJECT: CHANGE OF SHIFT PROCEDURE 1. PURPOSE: This Nursing Policy will provide the minimum requirements and the necessary guidelines for nursing staff to provide a meaningful change of shift report for each oncoming shift.

2. POLICY: It is the policy of Coalinga State Hospital that there will be a change of shift meeting conducted by nursing services at each shift change at 0630, 1430, and 2245. Off-going nursing staff shall remain on duty until completion of the change of shift process and until minimum staffing is present to cover the oncoming shift. As part of the change of shift procedure, the on-coming and off-going Shift Lead or designee together shall conduct environmental rounds. This shall consist of a physical walk-through of the unit including the courtyard, a counting of the individuals charts (a.k.a. medical records), sharps, tool, alarm pens and devices, shavers, individuals I.D. badges, and emergency equipment check, and a physical check of all individuals on high risk suicide observation, individuals in seclusion, and in all forms of restraint. Verification will be documented each shift in the Daybook. The Off-Going Shift Lead/designee, Registered Nurse, and Medication Room Staff, shall communicate all pertinent information about the individuals on the unit to the On-Coming Shift Lead/designee, Registered Nurse, and Medication Room Staff, which shall be documented on the unit Day Book, the unit Medication Room Log, and/or other appropriate communication tools. This information shall include but not be limited to: Containment Risks, High/Low Risk for Suicide, Assault, Seclusion, Restraint, 1:1 status, etc.

All nursing staff is responsible for providing a safe environment for individuals and reporting any and all safety hazards or safety concerns. All individuals medical records are to be accounted for at the beginning of each shift by the oncoming Shift Lead/designee and signed off in the Daybook Log with the -1N.P.P. No. 3

number of charts recorded prior to each change of shift. All charts must be accounted for and/or its location identified. 3. GENERAL INFORMATION: 1. The Unit Supervisor is responsible to ensure that each Shift Lead or designee together with the RN(s) conducts change of shift report and rounds at all shift changes. In order to assure that there is continuity of care and treatment for all individuals, there will be a formal change of shift meeting implemented and attended by: -Shift Lead or designee. -RN(s). -Employees assigned to medication/treatment room (on-coming and going) to join report after medication count/key exchange procedure. -All other employees scheduled for duty from the oncoming shift and off going not assigned to a change of shift task.

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Other discipline members are encouraged to attend and participate as appropriate. 2. During the change of shift procedure, the off-going Shift Lead/designee will assign one of their staff to maintain 1:1 observations and Supervise activities of the general population as required. 3. Off-going staff assigned to specific change of shift tasks is not required to attend the change of shift report. 4. Staff floated from other units will receive a report from the Shift Lead/designee advising of the individuals on specific ALERTS, 1:1s, High/Low Risk Observations, pertinent acute medical or behavior issues, individuals on containment risk, and a formal orientation to the unit physical environment including new equipment specific for that unit. 5. All staff will communicate pertinent nursing concerns to the Shift Lead and the RN(s) throughout the shift. In addition, notations on a designated form or flow sheet may be utilized and helpful.

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PROCEDURES: At 0630, 1430, and 2245 hours, each shift will conduct a formal change of shift t assure pertinent information is reported to the on-coming shift. The off-going Shift Lead/designee shall be responsible for the change of shift report with appropriate clinical input from the RN(s), medication room staff, and other relevant treatment staff. Off-going and on-coming Medication/Treatment Room staff will conduct a separate change of shift review including an accounting of controlled medications; syringe -2N.P.P. No. 3

count, key exchange, oxygen tank, emergency drug box, etc. then join report after this procedure to recount the shift events at the change of shift report. Individual care need and acuity will be reviewed and updated as clinically indicated. The Shift Lead will consult with the RN(s), and make assignments based on RN assessed clinical needs to address nursing concerns of each individual, giving special attention to the following areas as applicable. Change of Shift Report: The number of charts present on the unit and an accountability of the location of each chart. All individuals with an acuity level of 4 or 5 requiring an individual care assignment, or individuals with an acuity level of 3 needing a special care assignment or nursing intervention(s) Alerts (suicide behavior, assaultive behavior, fire setting, blood and body fluids precautions, medical-physical precautions related to behavioral intervention {e.g. containment risks}, etc.) Seclusion, restraints, special incidents. Individual Care assignments. Psychosocial Factors, subjective and objective observations (self-abusive behavior, delusional depression, manic behavior, impulsiveness, psychomotor agitation or retardation, social withdrawal, etc.) Significant information regarding PRN medication, treatments, physical and psychological profiles, conferences (including Staffing), and behavior unusual to specific individuals. Vital signs, special Diagnostic procedures and Consults. Behavior during the previous shift, sleep patterns and activity level (sleeping, wandering about dorm, smoking habits, incontinence, frequent trips to the rest room, etc.) Personal hygiene and general ADL care needs (appraisal of individuals ability for self-care including ability to shower, shampoo, care for dental, nail, skin, and foot care needs) Eating habits (compliance and non-compliance with restricted diets, diet intake, water intake) New physician orders and monthly medication reviews. Preps for lab work, x-ray, EEG/EKG, etc. Individuals scheduled for court visit, discharge, off grounds or on grounds clinic appointments. Specific documentation and/or follow-up needed. Other pertinent information related to individuals care. The off-going shift is responsible to leave the unit in an acceptable condition. If the condition of the unit is unsatisfactory to the on-coming Shift Lead or an individuals medical record cannot be accounted for, the Unit Supervisor or Program Management shall be notified of the appropriate action. -3N.P.P. No. 3

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 4 Effective Date: August 31, 2006 SUBJECT: VERIFICATION OF LICENSES 1. PURPOSE: To outline the requirements of the Central Nursing Services office to ensure each nursing services employee maintains a current and valid license (RN, PT, LVN) or CNA certificate (for PTA) as a condition of employment at Coalinga State Hospital. 2. POLICY: 1. Verification of Licensure or certification will be done prior to employment and annually thereafter during the Annual Performance appraisal process to assure compliance with current licensure and certification requirements. 2. It is the direct responsibility of the individual nursing employee to: 3. Maintain a current valid license or certificate as a condition of employment at Coalinga State Hospital. 4. Have the license or certificate in your possession at all times while on duty. 5. Present your new license or certificate on or before the expiration date shown on the license or certificate to the Central Nursing Services office or to authorized management personnel for verification. Authorized management personnel are defined as Program Management or your Unit Supervisor. The verification process by authorized management personnel consists of the following: A. Verify the license or certificate renewal by confirming the expiration date and confirming the licensees signature is present on the new license. B. Make a photocopy of the renewed license or certificate and compare the copy with the actual license or certificate. C. Authorized management personnel will then write on the photocopy, Verified By: and provide their full signature, title, and date indicating confirmed verification

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D. Document the Program, Unit, Shift, and Cycle of the employee on the photocopy E. This photocopy may then be hand carried to the CNS office or routed through the Coalinga State Hospital mailing system. During the renewal process, if you have not yet received your current license from the Board, "Acceptable Evidence of renewal may be accepted until the actual license is received. Acceptable Evidence shall include the following: Money Order receipt and return receipt from Certified Delivery indicating license renewal; or, copy of canceled personal check; or, current/valid license, registration, or certificate and confirmation of renewal from the respective Boards by the CNS Office. The photocopy of the license or certificate will remain on file in the Central Nursing Services office for term of the license. A condition of employment is that you possess a valid current license or certificate. It is your responsibility to maintain your license. If you have not renewed your license or certificate by the expiration date you will not be able to work. Employees without a current license or certificate do not meet minimum qualifications for employment, therefore the employee. 3. GENERAL INFORMATION: The CNS Office maintains two systems for license or certification verification: -Binders with hardcopies of the actual license with employee names listed I in alphabetical order. -A computer database with all nursing staff information regarding licensure that is continually updated. Renewal of licenses should be done immediately upon notification by the Licensing Board. You must have a current license or certificate in order to work. It may take 6 to 8 weeks for the Board of Registered Nurses, Board of Vocational Nurse and Psychiatric Technicians, or the Department of Health Services (CNA certification for PTA) to process your license or certificate for renewal. To avoid disruptions in your employment, renew your license or certificate early. It is strongly recommended that you renew as soon as you get notice that your license is due. If you do not get this notice you must contact the Board and pay your renewal fee. Make sure you include a list of your Continuing Education Units (CEU) with their designated Nursing Provider

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Number and sign the form in each location requesting a signature (this may be both the front and back of the form). If the renewal form is unsigned, the CEUs not listed, or any other discrepancy is on the form, your license renewal process may be delayed. The Board expects the licensee to retain their course completion certificates for a period of 4 years. 4. DEFINITIONS: Active license - A license is considered active when payment of the renewal fee and submission of proof of 30 hours of CE are submitted prior to the expiration of the license. Inactive license - A license is considered inactive when payment of the renewal fee is made but proof of completion of 30 hours of CE is not submitted. Delinquent license - A license is considered delinquent when payment of the renewal fee and/or proof of completion of 30 hours of CE have not been received by the Board within 30 days following the expiration date printed on the license. To make inquiries about your license:

Board of Registered Nurses: Tele # 916-322-3350 Email address: www.rn.ca.gov

Tele # 800-838-6828

Board of Vocational Nurse and Psychiatric Technicians: Tele # 916-263-7800 FAX # 916-263-7855 Email address: www.bvnpt.ca.gov Department Of Health Services: Tele # 916-327-2445

FAX # 916-327-4320

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 5 Effective Date: August 31, 2006 SUBJECT: INDIVIDUAL AND FAMILY TEACHING 1. PURPOSE: Health education is an essential component of nursing care and is directed toward promotion, maintenance, and restoration of health and toward adaptation to the residual effects of illness. The objective of this policy is to assist the Individual to strive toward achieving their maximum health potential by development of an Wellness and Recovery approach to Individual/family teaching and through effective health teaching practices. 2. POLICY: 1. The teaching-learning process is an integral part of the nursing process. With a focus on learning and with regard for the principles, variables, techniques, and strategies of teaching and learning the steps of the nursing process. Assessing, planning, implementing, and evaluating are used for the purpose of meeting the teaching and learning needs of the Individual and his or her family. Individual and family teaching shall be an essential part of nursing care for each Individual. This teaching shall begin at the Individual's admission and continue through discharge. The family shall be included when available and appropriate. On admission, the RN/Case coordinator will begin to identify the physical and mental health learning needs of the Individual and incorporate those needs into the Individual care plan. By applying the nursing process to a learning/teaching situation, the RN will utilize a systematic approach to include the following steps: A. Identify the Individuals learning capabilities (assessment); B. Identify the Individuals learning needs (nursing diagnoses); C. Develop learning goals and behavioral objectives designed to meet those goals (planning); D. Select the appropriate teaching strategy (intervention); E. Evaluating the Individuals progress and the effectiveness of the overall teaching plan (evaluation).

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Utilizing the Wellness and Recovery Individual/Family Health Education Record, each Individual will be assessed to determine their learning needs, abilities, learning preferences and readiness to learn. This assessment will consider cultural and religious practices, emotional barriers, desire and motivation to learn, physical and cognitive limitations, language barriers, and the financial implications of care choices. The Wellness and Recovery Individual/Family Health Education Record will be initiated on all Individuals. The RN/Case coordinator shall be responsible for insuring this record is present for each Individual they case manage. The Wellness and Recovery Individual/Family Health Education Record will be included in the Admission packet and shall be filed in the Education section of the Individuals chart. The Wellness and Recovery Individual/Family Health Education Record shall be completed as follows: A. Part I (Readiness to Learn and Specific Barriers to Learning) this assessment section shall be completed by the Registered Nurse on the Admission Unit prior to the Individual 7 Day Master Treatment Plan Conference. It shall be reviewed and updated by the RN as needed when the Individual is transferred or returns from a discharge of more than seven days. If changes are made, the RN shall initial and date the changes. B. Part II (Referrals section) shall be completed when referrals related to education needs or identified barriers are sent out (e.g. ADEP, Easy Street, inability to read or write). C. Part III is a complete list of codes to be used in the recording of the teaching/education provided identified in Part IV. D. Part IV is the ongoing flow of Individual teaching done by all disciplines. This section documents what, who, and how the Individual was taught and their response to the education. After completion, the providers signature is entered.

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The Education Record is meant to consolidate Individual information regarding teaching being provided by the Individuals Wellness and Recovery Team members. Education recorded on the Wellness and Recovery Individual/Family Health Education Record does not need to be

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recorded in the Wellness and Recovery Notes. Pertinent information not addressed on the Record shall be addressed in the IDN. 11. The Wellness and Recovery Individual/Family Health Education Record shall not be thinned from the chart. Individual teaching shall include but not be limited to the following: A. All Individuals shall be taught basic hygiene for infection control purposes (e.g. Hand hygiene; personal grooming; discouragement of the sharing of utensils, cups, toothbrushes cigarettes, hats, clothes, avoid sleeping in socks); B. Measures to avoid blood borne pathogens (e.g. process for obtaining and the effective use of condoms; discouraging the sharing of razors, ear piercing, tattooing; safe sex); C. All Individuals shall be taught the importance of their medication, purposes of use, expected beneficial effects, and food-drug interactions. Teaching shall include potential side effects on individual medications and self monitoring for recognition of adverse response; D. All Individuals will be provided counseling on nutrition and modified diets; E. All Individuals shall be taught in the areas of communication, interpersonal relations, social skills, behavioral self-control, and coping skills; F. The rationale for the treatment program; G. The Unit Milieu (e.g. Orientation to the unit and Treatment Team members, rules of the unit, PST activities, How to make a request from the team, How to tell staff when feeling sick or in need of medical attention); H. The underlying pathology causing the disease symptoms; I. The nature of diagnostic tests and studies, the preparation for those tests, and the meaning of the test results. 3. GENERAL INFORMATION: The Wellness and Recovery Individual/Family Health Education Record designed to be utilized by all disciplines to provide an on-going record of the progress of the Individual and family education, their response to the

12.

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education provided, and areas for teaching still needed for the Individual and/or family. It serves to provide information about the Individuals individual teaching needs and their potential barriers to the education process. When assessing the Individuals Readiness to Learn the Individual is given a rating of (P= Poor, A = Average, G = Good) for their ability to understand verbal instructions, ability to understand written instructions, and their knowledge of their educational needs and Treatment Plan. When assessing the Specific Barriers to Learning and Special Considerations determine the presence or absence of barriers associated with physical, sensory (visual or auditory impairment), cultural, religious, reading, language, motivation, cognitive, age related issues, emotional, or financial concerns. Family, Other is defined as the Individuals family, spouse, significant other, conservator, legal guardian, or accepting facility that will oversee the Individuals care and treatment.

Principles of teaching and learning:The teaching-learning process requires the active involvement of both the nursing staff member and the Individual. The desired outcome of the teaching-learning process is a change in the Individuals behavior. The nursing staff member serves as a facilitator of learning. Learning facilitated by progressing from the simple to the complex and from the known to the unknown. Learning is facilitated when the Individual is aware of his/her progress toward the learning goals.

Variables that affect learning readiness:1. Physical readiness: A. Physical distress that absorbs the Individuals attention prevents effective learning. B. Readiness to learn can be promoted by alleviating or at least minimizing as much as possible the Individuals physical or emotional distress. 2. Emotional readiness: Motivation learning depends upon: A. Acceptance of the illness or acceptance of the fact that

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illness is a threat. B. Recognition of the need to learn. C. A therapeutic regimen compatible with the Individuals life style or altered lifestyle. 3. Motivation to learn can be promoted by: A. Creating a warm, accepting, positive atmosphere B. Encouraging the Individual to participate in the establishment of acceptable, realistic, attainable learning goals. C. Providing feedback about progress, that is, positive reinforcement, when the Individual is successful and constructive criticism when he or she is unsuccessful. 4. Teaching Strategies: Selecting teaching techniques and methods that are most appropriate to meet the Individuals needs facilitates learning. A. Lecture - is the most useful in teaching groups of Individuals who share the same learning needs. The Lecture format should always be accompanied by discussion, which allows the Individual to express their feelings, and concerns, ask questions, and clarify information. B. Group discussion - is most useful for Individuals who relate well in groups. It allows Individuals to experience security through being a member of a group of Individuals with similar problems or learning needs. It also provides Individuals with the opportunity to gain support, assistance, and encouragement from group members. be C. Demonstration and practice - is most useful when skills are to learned. Ample opportunity must be provided for practice sessions. Equipment should be the same as that which the Individual will use after leaving the hospital. D. Teaching Aids - are useful to supplement the resources of the nurse in helping the Individual to learn. It includes books, pamphlets, pictures, films, slides, tapes, and models. The teaching aids must be reviewed prior to presentation to ensure that they are appropriate for meeting the Individuals individual learning needs.

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E. Reinforcement and follow-up - allow ample time for the Individual to learn and to have his/her learning reinforced. Follow-up sessions promote the Individuals confidence in their ability to retain their newly learned behaviors. Evaluate the Individuals progress, which is imperative and plan additional teaching sessions as necessary.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 6 Effective Date: August 31, 2006 SUBJECT: CODE OF ETHICS FOR NURSING SERVICES 1. PURPOSE: The code (adapted from the American Nurses Association Code of Ethics for Nurses) provides guidelines with respect to the care of individuals and for accountability to individuals, to the profession, and to society. The objectives and expectations for nursing staff at Coalinga State Hospital follow this code. 2. POLICY: Nursing Services staff shall interact in professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. Nursing Services staff safeguards the individual's right to privacy by judiciously protecting information of a confidential nature. Nursing Services staff promotes, advocates for, and strives to protect the health, safety, and rights of the individual. Nursing Services staffs are responsible and accountable for individual nursing practice and determine the appropriate delegation of tasks consistent with the nurses obligation to provide optimum individual care. Nursing Services staff assumes responsibility and accountability for individual nursing judgments and actions. Nursing Services staffs have a responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. Nursing Services staff exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating activities to others.

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Nursing Services staff participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. Nursing Services staff participates in the professions efforts to establish and maintain conditions conducive to high quality care. Nursing Services staff collaborates with other health professionals and the public in promoting community, national, and international efforts to meet heath needs. The profession of the Nursing Services staff, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

3. OBJECTIVES: 1. To provide care and treatment with respect and dignity with the desired outcome of improving the quality of life for the individuals committed to our facility. 2. To administer nursing care in accordance with the Hospitals Mission and Vision statement delineates the philosophy, goals, and policies of Coalinga State Hospital. 3. To review existing policies and procedures on an annual basis and verify that they include current theory and reflect national standards. 4. To formulate new policies and procedures that reflects changes created by advances in the health field. 5. To provide an environment in which Nursing personnel work effectively with others. 6. To provide a climate for the encouragement of individual and group participation in professional Nursing organizations. 7. To establish and maintain a relationship of mutual respect and collaboration with other disciplines throughout the hospital. 8. To develop clinical management skills by promoting staff development programs.

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9. To maintain a systematic approach in monitoring and improving Nursing Care. 10. To recruit and select qualified Nursing personnel who meet the specific job criteria.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 7 Effective Date: August 31, 2006 SUBJECT: NURSING SERVICES RECORDS, MEETING MINUTES, QUALITY IMPROVEMENT DATA AND REPORTS 1. PURPOSE: To identify timeframes for retention of Nursing Service records, meeting minutes, Quality Assessment/Improvement data collection, and reports according to State and Federal requirements. 2. POLICY: Central Nursing Services shall retain the following records as identified below: -CNS Department Quality Improvement, Meeting Unit (QIMU) Minutes/Projects for 3 Years. -HSS Staff Meeting Minutes for 3 Years. -Nursing Quality Improvement Committee Meeting Minutes for 3 Years. -Nursing Quality Improvement Committee and HSS Quality Assessment/Improvement Indicators and Monitors for 3 Years. -Nursing Policy and Procedures for 1 Year/after update. -HSS 24 Hour Reports for 3 Years. -Nursing 0800 Report for 3 Years. -Nursing Staffing Compliance Worksheets for 3 Years. -Search and Seizure Records for 2 Years. -Professional Practice Groups Meeting Minutes for 1 Year. -License Verifications for; Registered Nurse, Psychiatric Technician, Licensed Vocation Nurse and Psychiatric Technician Assistant (CNA) for 2 Years.

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Program Nursing Coordinator Office shall retain the following records as identified below: -Drug Regimen and Medication Reviews for 1 Year -NPPM New/Revised Nursing Policy Sign Sheet (Indicating each unit employee from each shift has read the updated policy) for 1 Year -Unit QIMU Meeting Minutes and Projects for 3 Years -Program Auditor data collection and reports for nursing personnel for 3 Years -Staff Competency Training, employee orientation to program/unit, update continuously.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 8 Effective Date: August 31, 2006 SUBJECT: NURSING POLICY AND PROCEDURES 1. PURPOSE: 1. To provide a guide for nursing care that reflects optimal standard nursing practice. 2. Define and describe the scope and conduct of individual client care provided by staff. 2. POLICY: 1. The Coordinator of Nursing Services ensures that nursing standards of individuals care and standards of nursing practice are consistent with current nursing research findings and nationally recognized professional standards. 2. The Coordinator of Nursing Services implements the findings of current research from nursing and other literature into the policies and procedures governing the provision of nursing care. 3. Nursing policies and procedures, nursing standards of individual client care, and standards of nursing practice are approved by the nurse executive (Coordinator of Nursing Services) or a designee(s). 4. Development of nursing policy and/or procedures shall be the responsibility of the Chair of the Nursing Policy and Procedure Committee working in collaboration with the Nursing Policy and Procedure Committee and appropriate staff and pertinent departments associated with the subject matter of the policy. 5. Program Management shall be responsible to ensure nursing staff reviews all new and/or revised Nursing Policies. 6. Program management shall be responsible to assign and supervise participation of their program representative to the Nursing Policy and Procedure Committee.

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3. GENERAL INFORMATION: The nurse executive (Coordinator of Nursing Services) is responsible for ensuring that policies, procedures, and standards describe and guide how the nursing staff provides the nursing care required for all individuals and client populations served by the hospital and as defined in the hospitals plan(s) for providing nursing care. All nursing policies, procedures, and standards are defined, documented, and accessible to the nursing staff in written or electronic format. Regardless of how it is documented, the nurse executive (CNS), or designee(s) approves each element, before it is implemented. 4. DEFINITIONS: Policies and Procedures - The formal, approved description of how a governance, management, or clinical care process is defined, organized, and carried out. Practice Guidelines - Descriptive tools or standardized specification for care of the typical individual in the typical situation, developed through a formal process that incorporates the best scientific evidence of effectiveness with expert opinion. Synonyms include clinical criteria, parameter (or practice parameter), protocol, algorithm, review criteria, preferred practice pattern, and guideline. 5. ONGOING POLICY REVIEW SCHEDULE: The Nursing Policy & Procedure Manual will be reviewed on an ongoing basis, utilizing the following schedule: MONTH January February February March April May June July August September October November December SECTION Administrative Section Section I Admission & Discharge, Section II Abbreviations & Terms Section III Basic Nursing Care Section IV Treatment Procedures Section V - Medication Section VI Diagnostic Procedures Section VII Emergency Procedures Section VIII Psychiatric Nursing Section IX Clothing & Linen, Section X Central Supply Section XI Orientation & Education Section XII Infection Control Holiday Month / Make-up Month (Appendix)

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6. PROCEDURE: 1. Chairperson:

The Chairperson of the NPPM Committee is an ACNS (Assistant to the Coordinator of Nursing Services) 2. Committee: A. The committee meets one times monthly or on call of chairperson B. The committee membership is composed of interested staff and: -H.S.S. representative(s) -Training Center representative(s) -Public Health Nurse -Representative from the Unit Supervisor Group -Representative from each Program (RN or Psychiatric Technician) -Standards Compliance Coordinator Representative -Chairpersons of the RN and PT Professional Practice Groups. - (After activated and these positions are in operations) 3. Committee Process: A. Always and makes recommendations on nursing procedures and policies every two years or more frequently as necessary. B. Develops drafts of Nursing Policy and Procedures. C. Assures Nursing Policy and Procedures reflect current levels of clinical practices D. Distributes drafts of the policy for review and input from appropriate staff and pertinent departments associated with the subject matter of the policy. 4. Review Process Guidelines: Effort will be made to review sections of the policies according to the Ongoing Policy Review Schedule (see page xii.1). Section 2 is reviewed and approved by the medical staff via the (MHDS) Medical Records Committee (February). Section 5 is reviewed the 5th month (May) with selected policies reviewed by the Pharmacy and Therapeutics Committee and the Med Room Group.

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The Emergency Care Committee reviews section 7 policies. The Infection Control Committee reviews section 12 policies. Recommendations for changes may be made by any employee via: A. Formal process: The program representative will bring the recommendations and input they obtain from the program to committee. B. Informal process: Written memos or telephone calls can be made to the Chairperson who will bring to committee for discussion as the policy comes up for review. The Chairperson will send drafts on new policies to appropriate staff for input. Policy and Procedures related to infection control are reviewed and approved by the Infection Control Committee. Policies and Procedures related to emergency care are reviewed and approved by the Emergency Care Committee. The Pharmacy and Therapeutics Committee reviews medication related policies. Dependants on the policy, pertinent staff or departments associated with specific policies are consulted for input and review of the policy. Final drafts are then prepared and submitted to the Coordinator of Nursing Services and the Chief of Medical Staff for review, approval, and signature. 5. Distribution: Policy and Procedures are sent by the Chair of the Nursing Policy and Procedure Manual Committee to all Department holders of the manual via the hospital LEGEND "E" distribution list. Policies for manuals on nursing units are sent as packets to the Nursing Coordinators of each Program. The packets consist of the following: 1. A cover letter addressed to the Nursing Coordinator (NC) of the identified Program describing the policies(s) being distributed and any additional instructions that may be needed. The NC packet also includes a copy of the policy for the Program Management Manual. 2. Within the NC packets are individual packets addressed to each Unit Supervisor of the Program. Each Unit Supervisors packet consists of two copies of each procedure including a NPPM Signature Sheet. The Signature Sheet is to be used as a management and

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supervision tool for the Unit Supervisor. Unit staffs are to read the policy and show evidence of this requirement by signing the NPPM Signature Sheet. 3. One copy of the procedure shall be placed in the Nursing Policy and Procedure Manual by the unit supervisor. One copy shall be posted with the Signature Sheet for the unit staff to read. 4. The Unit Supervisor/designee shall date and post the NPPM Signature Sheet (see ATTACHMENT A). Unit Staff of all three shifts are expected to review the posted new and/or revised policies. The Unit Supervisor and/or the Shift Leads of all three shifts are to ensure that their staff review and sign the Signature Sheet. When completed, and after review by the Unit Supervisor, the Signature Sheet will be forwarded to the Nursing Coordinator to be retained in the Program Office for 1 year. 5. The Unit Supervisor/Shift Leads of all three shifts are encouraged to assist staff with methods to alert staff of the new changes (e.g. provide an in-service at the Change of Shift, request training assistance from the Staff Development Center, etc.).

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 9 Effective Date: August 31, 2006 SUBJECT: NURSING SERVICE: DUTIES AND RESPONSIBILITIES

1. GENERAL: The Nursing Services is an important member of the Wellness and Recovery Model System who is frequently in closest contact with the Individual and can observe and impact the day-to-day adjustment and behavior of the Individual. The relationship between the Individual and his staffs is a fundamental aspect of his care and treatment. All Individuals will be assigned to licensed nursing service staffs, which may include one staffs each from the a.m. and p.m. shifts. I. INTRAHOSPITAL TRANSFER - ORIENTATION (Admission to the hospital Receiving Unit Protocols.) A. Interview the Individual as soon as possible after admission to the unit in order to supply the Individual with needed support and guidance, to assess the Individual's adjustment to the hospital and unit environments, and to identify immediate problem areas. B. Explain unit rules and expectations, e.g. attendance at groups, therapeutic community meetings, Individual Access System (PAS) rules, unit visiting rules, etc. C. Introduce the Individual to other Individuals, particularly unit government officers. They will be helpful in explaining unit routines and in further orienting the new Individual. D. Direct the Individual to the Individuals Rights bulletin board. Review his rights with him and point out the phone numbers of Individuals Rights officers posted. Chart his response in the I.D. Notes per - Individuals Rights Advocacy Program. II. ESTABLISHING NURSING GOALS AND OBJECTIVES A. Upon receiving the Individual on the unit, a Registered Nurse will update that Individual's Nursing Assessment

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B. Nursing Staff members will meet with the Individual to develop a Nursing Care Plan to present to the Wellness and Recovery Model System. The nursing goals and objectives for each Individual are the result of collaboration between the Psychiatric Technician and the Registered Nurse assigned to his care. C. The staffs will provide input to other members of the Wellness and Recovery Model System to assist in establishing and/or revising priorities in treating identified problems at each scheduled Team meeting. It is the staffs responsibility to act as the Individuals advocate in issues brought before the ID Team. III. OBSERVING AND COMMUNICATING A. Staff has the responsibility of frequent observation of the Individuals assigned to them and for relaying pertinent information about their behavior to other members of the treatment staff. Staffs shall have at least weekly contact with their assigned Individuals to evaluate and to assist their progress toward attaining their individual goals. B. All pertinent observations are to be entered in the Intergraded Assessment Notes C. Special problems of the Individual (mental and physical) will be verbally reported during the change of shift report and referred to the unit physician if needed. D. Any Individual observation that requires the special attention of staff shall be entered into the unit communication log. For example: "See IDN (5/25 at 1300) on J. Smith, assaultive, depressed, etc." E. Staffs are responsible for routinely reviewing and updating Rand Card information on each of their assigned Individuals. IV. DAY-TO-DAY NEEDS OF THE INDIVIDUAL Individuals rely on their staffs for many of their day-to-day needs. A. The staffs initiates requests for and receives the Individual's property from storage (CDS) and the Trust Office. B. The staffs advocates for referrals to treatment-oriented work assignment, occupational therapy shop, clubs, therapy groups, etc. C. The staffs, as a member of the Wellness and Recovery Model System, has a responsibility to assist the Individual on a daily basis to implement his Nursing Care Plan. D. The staffs will conduct nursing group activities as assigned by the Unit Supervisor. E. The Staffs will work 1:1 with his or her assigned Individuals to assist them to meet their nursing care objectives. -2N.P.P. No. 9

V. STAFFS GROUPS A. All Individuals will be assigned to a staffs group. B. The staffs group will create an accepting atmosphere for the Individual. C. The staffs offers encouragement and support as needed in order to develop trust toward his therapeutic milieu. D. The staffs evaluates each Individual's ability to participate in group. The staffs will meet on a 1:1 basis with Individuals that require individual remedial attention before they are able to function in a group setting. E. The purpose of the staffs group is to: 1. Assist the Individual to resolve personal issues that arise from living in an in-Individual setting; 2. Assist the Individual to increase his problem-solving abilities; 3. Provide information; 4. Assist the Individual to improve interpersonal interaction skills; 5. Provide support; 6. Assist Individual in meeting treatment goals related to his dispositional setting. VI. MEETING WITH OTHER MEMBERS OF THE WELLNESS AND RECOVERY MODEL SYSTEM Staffs will meet regularly with the primary clinician, other members of the unit staff, and the Wellness and Recovery Model System to evaluate the Individual's progress, to evaluate the effectiveness of the Individual's treatment plan, and to make recommendations regarding the Individual's needs. Nursing Care Plans are reviewed as needed in the I.D. Team. The Registered Nurse and / Psychiatric Technician will be responsible for bringing dietary information, nutritional assessment updates to the Wellness and Recovery Model System Conferences. VII. CHARTING The staffs is responsible for documenting in the Integrated Assessment Notes the Individual's progress or lack of progress in meeting the Nursing Care Plan objectives. Weekly staffs summaries must address any pertinent Individual care issues, changes in the overall acuity rating, temporary conditions, and the Individuals progress toward meeting the specific objectives identified in psychiatric nursing care plans and acute physical problems. The Staffs will also ensure that pertinent behavior, participation in activities, response to treatment, PAS status, and overall progress toward release from the hospital is recorded. When there is a nutritional problem open on the Individual's Physical Profile, the staffs will review the nutritional assessment and will incorporate the plans the dietitian has recommended that requires nursing service staff -3N.P.P. No. 9

interventions into the Individuals treatment. The staffs will also monitor and document compliance in weekly Integrated Assessment Notes and Document all teaching on the Individual Family Education Record.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 10 Effective Date: August 31, 2006 SUBJECT: CONFIDENTIALITY OF INDIVIDUAL INFORMATION 1. PURPOSE: Confidentiality applies to any and all information obtained in the course of providing nursing services to the Individual. The following expectations are provided to ensure that all Individual information is maintained in a confidential manner according to clinical and legal requirements. 2. POLICY: Nursing personnel shall keep all Individual information confidential in accordance with relevant CA, W&I Code Section 5328. All phone calls to the units requesting information shall be referred to the unit Physician, unit Social Worker, or Program Director. When in public areas, either on CSH grounds or off, nursing personnel is expected to comply with confidentiality statutes and not refer to Individuals by name or discuss confidential information outside of the workplace. Confidentiality does not apply within the treatment team. Pertinent information shall be shared with all members of the treatment team and the Individual should be so advised prior to giving confidential information to one member of the team. All nursing personnel are responsible for maintaining confidentiality of any and all portions of the Individuals medical record and for safeguarding its informational content against loss, defacement, tampering and from use by unauthorized individuals. Disposition of all materials containing Individual information shall be done in such a manner as to ensure confidentiality. All employees are required to observe for and report breaches in the maintaining of confidentiality to supervisors. Nursing personnel shall immediately report to the physician or Program Director any threat to person or property made by a Individual.

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3. DEFINITION: Confidential Individual information is defined as any and all information obtained in the course of providing services to Individuals. This information includes, but is not limited to: Individual records, reports, photographs, fingerprints, correspondence, Addressograph plates, documents generated and discarded during a Individuals hospitalization, draft reports, and notes designed for disposal rather than filing in Individual records, etc. FAX COVER SHEET: The following is a recommended phrasing on the FAX Cover Sheet when faxing Individual information to other agencies or facilities:

This message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the intended Recipient or the Employee or Agent responsible to deliver it to the intended Recipient, you are hereby notified that any use, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received the facsimile in error, please immediately notify us by telephone and return the original message to us at the address on this cover sheet via the U.S. Postal Service. Thank You.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 11 Effective Date: August 31, 2006 SUBJECT: NURSING SERVICES QUALITY IMPROVEMENT PROGRAM 1. PURPOSE: 1. To monitor and evaluate the quality and appropriateness of care provided to Individuals. 2. Maintain high quality Individual care where it already exists. 3. Improvement of Individual care in identified areas of concern. 4. Compliance with Standards of Nursing Care adopted by Coalinga State Hospital. 5. Compliance with JCAHO, DHS, and Title 22 requirements.

2. POLICY: 1. The Coordinator of Nursing Services ensures that nursing standards of Individual care and standards of nursing practice are maintained. 2. To assess, monitor, and evaluate the effectiveness of Individual care and nursing practice, Central Nursing Services maintains a Quality Improvement Program consistent with the Quality Improvement goals of the hospital. 3. Under the guidance, direction, and approval of the CNS, development of Quality Improvement (QI) indicators shall be the responsibility of the Nursing Quality Improvement Coordinator in collaboration with the Nursing QI Committee and appropriate staff and pertinent departments associated with the subject matter being monitored. 4. Indicators are developed and designed based on the important aspects of Individual care utilizing the principles of high risk, risk management, high volume, and problem prone issues. 5. Data results, with recommendations for corrective actions, are reported on a monthly/quarterly basis or more frequently, if indicated, to CQIT or EQIT. -1N.P.P. No. 11

6. Program specific data compilations shall be submitted to the Program Directors or designees by the Health Services Specialist for corrective actions and follow up. Recommended corrective actions will be included when clinically appropriate. 7. Program Quality Improvement items involving clinical nursing issues will be referred to the CNS in writing. 3. COMMITTEE STRUCTURE AND FUNCTION: 1. Chairperson: The Chairperson of the Nursing Quality Improvement Committee is an RN/HSS (Health Service Specialist). 2. Committee: The Committee meets the second Wednesday of each month. The committee membership is composed of interested staff and: - 1 Health Services Specialist representative from each compound - Staff Development Center representative(s) - Chairpersons of the RN and PT Professional Practice Groups - Unit Supervisor(s) and/or representative from the Unit Supervisor Committee - Nursing staff representative from each Program (Program Auditor, RN, PT, or LVN Level of Care Nursing staff) 3. Committee Responsibility: -Determine important aspects of Individual care to be monitored and the frequency of evaluation. -Identify problems, criteria, data sources, and sample size for areas of Individual care being monitored. -Determine if care is appropriate according to Standards of Practice and policy. -Approval of methodologies to investigate problem causes. -Recommendation of appropriate problem solutions to CNS and Program Management for implementation. -Referral of Individual care concerns, not related to Nursing Services, to the appropriate discipline, department, or hospital Quality Improvement Program. 4. Committee Reporting -Annually, the Nursing Quality Improvement Coordinator will submit a

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summary of the important aspects of Individual care, review quality improvement plan and activities on ongoing basis, and the proposed activity schedule to the Coordinator of Nursing Services (CNS) and the Medical Director for final review an approval. 5. Committee Accountability: - The CNS is accountable for the monitoring and evaluation of Individual care to the Medical Director, the Executive Director, and ultimately to the Governing Body. The CNS is responsible for the integration of the activities through the CQIT and other pertinent hospital QI Programs. - The Health Service Specialists (HSS) are responsible to the CNS for the conducting of monitoring activities during their shift within their respective building and are responsible to the CNS for the proper and timely completion of its activities. 6. Communication: - The CNS provides the communication link between the NSQIC for CQIT & EQIT. - In the absence of the CNS, the Nursing Quality Improvement Coordinator assumes this duty of communicating the QI data, findings, and recommendations to the CQIT and/or other pertinent QI Programs or committees. - The HSSs assigned to each building will attend each Program Quality Improvement Committee meeting to review data findings and recommend corrective action to the Program for their implementation. - The HSSs may receive referrals from the Program Quality Improvement Committee that are appropriate for review by the Nursing Services Quality Improvement Committee. 7. Report Distribution: -Nursing QI Reports are sent to: Hospital-wide Performance Improvement Manager. CQIT for distribution to: -Chairperson of Physician Quality Improvement -Chief of Psychiatric Services -Chief of Medical Surgical Services -PNED for distribution to the Nursing Instructors. -Clinical Administrator for distribution to each Program Director

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-Nurse Executive Council members -Medical Records Committee -Pharmacy Director who will in turn prepare a report for the Pharmacy and -Therapeutics Committee -HSS staff -Med Room Group (Medication Error Audit findings) -Standard Compliance Coordinator

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 12 Effective Date: August 31, 2006 SUBJECT: NORTH AMERICAN NURSING DIAGNOSIS (NANDA TAXONOMY FOR DEVELOPING THE NURSING DIAGNOSIS) 1. PURPOSE: In 1982 the professional association, North American Nursing Diagnosis Association (NANDA), was established to develop, define, and promote taxonomy of nursing diagnostic terminology of general use for professional nurses. NANDAs intent is to provide a common language for the health problems nurses deal with. The nursing diagnosis serves as the vehicle to inform nurses about the nature of and care activities required for the specific health problem. The ANA has officially sanctioned NANDA as the organization to govern the development of a classification system of nursing diagnosis. 2. POLICY: The NANDA taxonomy is used by the RN to develop the nursing diagnosis. Nursing diagnoses provide the basis for selection of interventions for delivering Individual care to achieve outcomes for which the nurse is accountable. 3. GENERAL INFORMATION: Developing the diagnosis: The assessment component of the nursing process serves as the basis for identifying nursing diagnoses and collaborative problems. After completing the nursing assessment, the nurse organizes, analyzes, synthesizes, and summarizes the data collected and determines the Individuals need for nursing care. The nurse then proceeds to develop the nursing diagnosis, which is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. A nursing diagnosis is a statement that describes the Individuals actual or potential response health problem that the nurse is licensed and competent to treat.

to a

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When choosing the nursing diagnoses for a particular Individual, the nurse must first identify the commonalties among the assessment data collected. These common features lead to the categorization of related data that reveal the existence of a problem and the need for nursing intervention. The Individuals identified problems are then defined in the nursing diagnosis. It is important to remember that nursing diagnoses are not medical diagnoses; they are not medical treatments prescribed by the physician; they are not diagnostic studies; they are not the equipment used to supplement medical therapy; and they are not the problems that the nurse experiences while caring for the Individual. They are the Individuals actual or potential health problems that are amenable to solution by independent nursing actions. Nursing diagnoses that are succinctly stated in terms of the specific problems of the Individual will guide the nurse in the development of the nursing care plan. To give additional meaning to the diagnosis, the characteristics and the etiology of the problem must be defined and included as part of the diagnoses. The nursing diagnosis consists of three components: 1. The human response or problem 2. The related factor 3. The signs and symptoms Each of the three parts of the nursing diagnosis is written differently. The first part of an actual diagnosis, the human response or problem, comes from the NANDA list whenever possible. The NANDA taxonomy list contains qualifiers or adjectives that clarify the nursing diagnoses and precede the human response. The vast majority of human responses identified by the North American Nursing Diagnosis Association (NANDA) define problems that nurses are licensed to treat by virtue of their education. After gathering and analyzing assessment data, the nurse formulates the nursing diagnosis by selecting the human response from the list of accepted nursing diagnoses. If the nurse is unable to locate a human response on the NANDA list, he or she develops a statement that defines the Individuals problem. The second part of the nursing diagnosis is the related factor. It is linked to the human response with the words related to, abbreviated in the text as R/T. The words related to demonstrate that there is a relationship between the first two parts of the diagnosis; this implies that if one part changes, the other will also.

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The third part of the statement consists of the pertinent defining characteristics, the signs and symptoms. They are linked to the second part with the words as evidenced by, abbreviated AEB in this text. The three-part actual nursing diagnosis has been referred to as the PES format: Problem (or human response), Etiology (related factors), and Signs and Symptoms (or defining characteristics). 4. NANDA TAXONOMY: Pattern 1: Exchanging Altered Nutrition: More Than Body Requirements Altered Nutrition: Less than Body Requirements Altered Nutrition: Risk for More Than Body Requirements Risk of Infection Risk for Altered Body Temperature Hypothermia Hyperthermia Ineffective Thermoregulation Dysreflexia Risk for Autonomic Dysreflexia Constipation Perceived Constipation Diarrhea Bowel Incontinence Risk for Constipation Altered Urinary Elimination Stress Incontinence Reflex Urinary Elimination Urge Incontinence Functional Urinary Incontinence Total Incontinence Risk for Urinary Urge Incontinence Urinary Retention Altered Tissue Perfusion (Specify Type: Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) Risk for Fluid Volume Imbalance Fluid Volume Excess Fluid Volume Deficit Risk for Fluid Volume Deficit Decreased Cardiac Output Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Inability to Sustain Spontaneous Ventilation Dysfunctional Ventilatory Weaning Response Risk for Injury Risk for Suffocation Risk for Poisoning Risk for Trauma Risk for Aspiration Risk for Disuse Syndrome Latex Allergy Response Risk for Latex Allergy Response Altered Protection Impaired Tissue Integrity Altered Oral Mucous Membrane Impaired Skin Integrity Risk for Impaired Skin Integrity Altered Dentition Decreased Adaptive Capacity: Intracranial Energy Field Disturbance

Pattern 2: Communicating Impaired Verbal Communication

Pattern 3: Relating Impaired Social Interaction Social Isolation Risk for Loneliness Altered Role Performance Altered Parenting Risk for Altered Parenting Risk for Altered Parent/Infant/ Child Attachment Sexual Dysfunction Altered Family Processes Caregiver Role Strain Risk for Caregiver Role Strain Altered Family Processes: Alcoholism Parental Role Conflict Altered Sexual Patterns

Pattern 4: Valuing Spiritual Distress (Distress of the Human Spirit)

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Risk for Spiritual Distress Potential for Enhanced Well-Being

Pattern 5: Choosing Ineffective Individual Coping Impaired Adjustment Defensive Coping Ineffective Denial Ineffective Family Coping: Disabling Ineffective Family Coping: Compromised Family Coping: Potential for Growth Potential for Enhanced Community Coping Ineffective Community Coping Ineffective Management of Therapeutic Regimen: Individuals Noncompliance (specify) Ineffective Management of Therapeutic Regimen: Families Ineffective Management of Therapeutic Regimen: Community Effective Management of Therapeutic Regimen: Individual Decisional Conflict (specify) Health Seeking Behaviors (specify)

Pattern 6: Moving Impaired Physical Mobility Risk for Peripheral Ne4urovascular Dysfunction Risk for Perioperative Positioning Injury Impaired Walking Impaired Wheelchair Mobility Impaired Transfer Ability Impaired Bed Mobility Activity Intolerance Fatigue Risk For Activity Intolerance Sleep Pattern Disturbance Sleep Deprivation Diversional Activity Deficit Impaired Home Maintenance Management Risk for Altered Growth Relocation Stress Syndrome Risk for Disorganized Infant Behavior Altered Health Maintenance Delayed Surgical Recovery Adult Failure to Thrive Feeding Self-Care Deficit Impaired Swallowing Ineffective Breastfeeding Interrupted Breastfeeding Effective Breastfeeding Ineffective Infant Feeding Pattern Bathing/Hygiene Self-Care Deficit Dressing/Grooming Self-Care Deficit Toileting Self-Care Deficit Altered Growth and Development Risk for Altered Development Disorganized Infant Behavior Potential for Enhanced Organized Infant Behavior

Pattern 7: Perceiving Body Image Disturbance Self-Esteem Disturbance Chronic Low Self-Esteem Situational Low Self-Esteem Personal Identity Disturbance Sensory/Perceptual Alterations (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory Unilateral Neglect Hopelessness Powerlessness

Pattern 8: Knowing Knowledge Deficit (Specify) Impaired Environmental Interpretation Syndrome Acute Confusion Chronic Confusion Altered Thought Processes Impaired Memory

Pattern 9: Feeling Pain Chronic Pain Nausea Dysfunctional Grieving Anticipatory Grieving Chronic Sorrow Risk fore Violence: Directed at Others Post-Trauma Syndrome Rape-Trauma Syndrome Rape-Trauma Syndrome: Compound Reaction Rape-Trauma Syndrome: Silent Reaction Risk for Post-Trauma Syndrome Anxiety Death Anxiety

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Risk for Self-Mutilation Risk for Violence Self-Directed

Fear

5. DEFINITIONS: Pattern 1: Exchanging Risk for injury - The state in which an individual is at increased risk for being invaded by pathogenic organisms. Pattern 2: Communicating Impaired verbal communication - A state in which an individual experiences a decreased or absent ability to use or understand language in human interaction. Pattern 3: Relating Altered family processes - The state in which a family that normally functions effectively experiences dysfunction. Altered parenting - The state in which the ability of nurturing figure(s) to create an environment that promotes the optimum growth and development of another human being is altered or at risk. Altered role performance - Disruption in the way one perceives one's performance. Social Isolation - Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatened state. Sexual Dysfunction - The state in which an individual experiences a change in sexual function that is viewed as unsatisfying, unrewarding, or inadequate. Altered patterns sexuality - The state in which an individual expresses concern regarding his or her sexuality. Pattern 4: Valuing Spiritual distress (distress of the human spirit) - Disruption in the life principle that pervades a person's entire being and that integrates and transcends the individual's biologic and psychosocial nature. Pattern 5: Choosing

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Impaired adjustment - The state in which the individual is unable to modify his or her lifestyle or behavior in a manner consistent with a change in health status. Family coping: potential for growth - Effective managing of adaptive tasks by family member involved with the client's health challenge who now exhibits desire and readiness for enhanced health and growth in regard to self and in relation to the client. Ineffective Family Coping: Compromised - Insufficient, ineffective, or compromised support, comfort, assistance, or encouragement usually by a supportive primary person (family member or close friend); client may need it to manage or master adaptive tasks related to his for her health challenge. Ineffective family coping: disabling - Behavior of significant person (family member or other primary person) that disables his or her own capacities and the client's capacities to effectively address tasks essential to either persons adaptation to the health challenge. Ineffective individual coping - Impairment of adaptive behaviors and problem-solving abilities of a person in meeting life's demands and roles. Noncompliance - A person's informed decision not to adhere to a therapeutic recommendation. Pattern 6: Moving Altered health maintenance - Inability to identify, manage, or seek out help to maintain health. Diversional activity deficit - The state in which an individual does not experience stimulation from or interest or engagement in recreational or leisure activities. Altered growth and development - The state in which an individual demonstrates deviations in norms from his or her age group. Impaired home maintenance management - Inability to independently maintain a safe, growth promoting immediate environment. Self-care deficit - A state in which the individual experiences an impaired ability to perform or complete bathing and hygiene, dressing and grooming, feeding, or toileting activities by self.

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Sleep pattern disturbance: - Disruption of sleep time causes discomfort or interferes with desired lifestyle. Pattern 7: Perceiving Hopelessness - A subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf. Powerlessness - Perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening. Body image disturbance - Disruption in the way one perceives one's body image. Personal identity disturbance - Inability to distinguish between self and non-self. Self-esteem disturbance - Disruption in the way one perceives one's selfesteem. Pattern 8: Knowing Knowledge deficit - A state in which specific information is lacking. Altered thought processes - A state in which an individual experiences a disruption in cognitive operations and activities. Pattern 9: Feeling Chronic pain - A state in which the individual experiences pain that continues for more than 6 months in duration. Anxiety - A vague, uneasy feeling, t