EMERGENCY OPERATIONS PLAN 2015-2016 - in.gov Emergency Operations Plan 2015.pdf · The Logansport State Hospital Emergency Operations Plan is designed to outline the basic infrastructure

LOGANSPORT STATE HOSPITAL

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EMERGENCY OPERATIONS

PLAN

2015-2016

Prepared for Logansport State Hospital

By: Environment of Care Committee


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EMERGENCY OPERATIONS PLAN

TABLE OF CONTENTS

ACTIVATION OF PLAN Page 4

DUTIES OF THE COMMAND CENTER Page 5

STAFF RESPONSIBILITIES Page 6

COMMUNICATION Page 10

EMERGENCY CODES Page 12

MANAGEMENT OF RESOURCES Page 13

EVACUATION OF AREAS Page 14

HAZARDOUS MATERIALS EXPOSURE Page 22

WINTER WEATHER PROCEDURES Page 24

SEVERE WEATHER - STORM/WIND/TORNADO Page 27

UTILITY FAILURE/HEATING/COOLING Page 28

HOSTAGE/ACTIVE SHOOTER/WORKPLACE VIOLENCE Page 29

BOMB THREATS Page 30

ELOPEMENT Page 32


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EMERGENCY OPERATIONS PLAN INTRODUCTION

The Logansport State Hospital Emergency Operations Plan is designed to outline the basic

infrastructure and operating procedures utilized to mitigate, prepare for, respond to, and recover from

emergency situations that tax the routine operating capabilities of the Hospital. The Plan describes a

comprehensive approach to emergency management that can be adapted to respond to a variety of

emergencies. The plan covers all areas of the hospital and its comprehensive implementation is the

responsibility of all hospital personnel. The plan is written by the Environment of Care Committee

and reviewed/approved by Senior Leadership.

The Plan is designed to assure appropriate, effective responses to a wide variety of emergency

situations that could affect the safety of patients, staff and visitors or the integrity of the environment

of LSH. The plan describes a comprehensive command structure for coordinating the six critical

areas: communications, managing resources and assets, safety and security, staff responsibilities,

utilities, and clinical activities.

OBJECTIVES

The Emergency Operations Plan objectives are to:

1. Prevent or lessen the impact that an emergency may have on the institution and the community.

(mitigation)

2. Identify resources essential to disaster response and recovery and facilitate their access and

utilization. (preparedness)

3. Prepare staff to respond effectively to an emergency or disaster situation that affects the

environment of care (response) and to test response mechanisms.

4. Plan processes for re-establishing operations after the incident. (recovery)

PLANNING ACTIVITIES

HAZARD VULNERABILITY ANALYSIS

Recognizing that certain emergency situations are more likely to occur or to have an adverse

impact on the hospital and as a part of its mitigation, and preparedness activities, LSH has established

a Hazard Vulnerability Analysis, designed to:

Identify emergency situations that could occur in this environment

Assess their potential impact on the institution and the community

Assess the hospital’s preparedness to respond to and recover from them.

If a disaster situation warrants, the Incident Command System will be activated and a Command

Center will be established to coordinate and sustain Disaster response efforts. LSH has developed

appropriate specific emergency response plans based on priorities established as part of the HVA.

As appropriate, specific mitigation, preparation, response, and recovery procedures have been

developed for those hazards that have been prioritized as areas of concern.


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ACTIVATION OF THE PLAN

The hospital has adopted the Incident Command System model. The command structure of this model

is the same used by the community emergency response agencies. The primary responsibility of the

command structure is to coordinate management of the six (6) critical areas: Communication,

Resources and Assets, Safety and Security, Staff Responsibilities, Utilities Management and Patient

and Clinical Support activities during an emergency. The Incident Command System is an emergency

management system comprised of key positions. Each position has a specific list of responsibilities

and actions to take in an emergency situation. The Incident Command System is designed to be

flexible and when additional help is needed can fit into escalation to the community, state, and/or

National Response Systems. Only those positions or functions which are needed will be activated.

The Incident Command System plan allows for the addition of needed positions, as well as the

deactivating of positions at any time. The Incident Command System may be fully activated for a

large extended emergency, or only partially activated for smaller or more localized emergencies.

Activation of the Incident Command System- DISASTER

A disaster is a type of emergency that due to its complexity, scope, or duration, threatens the

hospital’s capabilities to sustain patient care, safety or security functions and cannot be controlled

under normal operating procedures. During emergencies, staff assignments supersede normal roles

and responsibilities.

In an emergency or disaster situation, staff in the affected area should call Communication Center

(3190/3290/2702) with details of the event.

Following evaluation of information concerning the emergency (type and scope of incident), the

leaders below and in this order are responsible for initiating and coordinating the response:

1) Superintendent

2) Assistant Superintendent

3) Medical Director

4) Senior Supervising Nurse (DON/ADON/Nursing Supervisor)

The above staff should report immediately to the Command Center (IRTC Communication Center). If

the IRTC Communication Center is damaged beyond use, the Maintenance Building will be the

alternate Command Center location. Keys to the maintenance building are on all medication rings and

in a lock box at IRTC. The Superintendent and Assistant Superintendent also have keys.

A Command Center Checklist and an Incident Commander Checklist are provided to assist in making

sure all necessary actions are taken during the disaster response. In addition, a checklist is provided

for the IRTC Communication Center staff/Special Attendant Supervisor to assure all necessary actions

are taken during the disaster response.


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Duties at the Command Center

The first to report to the IRTC Communication Center (Alternate site- Maintenance Building)

will evaluate and declare the disaster and coordinate the response from the Command Center. (Superintendent, Assistant Superintendent, Medical Director, or Senior Supervising Nurse) This

person will be designated the Command Center Manager.

The Command Center Manager will: (Use Command Center Checklist)

1. Instruct Communication Center staff to:

o Communicate a DISASTER via pagers, phone system and LSH email (unit staff will

take all patients to their red alert areas with their emergency box, kardex and radio)

o Notify Steam Plan regarding RED ALERT/Disaster (Steam plant will sound siren for 3

continuous minutes)

o Contact these staff if they have not yet reported to Communication Center:

MOD/Medical Director, Special Attendant Supervisor, DON/ADON/Nurse Supervisor,

Safety Director, Physical Plant Director

o Contact staff in cottages via phone, runners, or security

o Contact Logansport Juvenile Detention Facility

o Use Command Center Checklist

2. Appoint an Incident Commander and send them to the site with a radio to coordinate

efforts at the disaster site.

3. Appoint the Medical Director or physician designee to report to the disaster site with a 2-

way radio. He/She becomes the Medical Commander and will assume medical command

(determine injuries, triage, supplies needed, etc) at the on-site area (Command Post).

The Medical Commander will communicate with the Command Center via radio.

4. Instruct Special Attendant Supervisor(s) to:

a. Receive patient head counts from units and outlying areas

b. Assure vehicles are available for emergency transport

c. Notify off-duty staff to report for duty if necessary.

d. Notify other departments, housekeeping, dietary, etc. if needed

e. Contact outside agencies (911) for assistance if necessary

f. Arrange for “runners” if necessary.

g. Monitor weather if applicable using internet, radio, weather radio.

h. Take direction from and provide assistance to the Command Center Manager.

i. Use the Special Attendant Supervisor Checklist

5. Communicate via radio with the Incident Commander at the disaster site and respond with

needed supplies and personnel.

6. Appoint a recorder to document actions taken. A sign-in sheet will be available at the

Communication Center to note what staff is available to assist at the incident site.

7. Provide notifications to the Division of Mental Health and Addictions and other agencies.


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Incident Commander (Use Incident Commander Checklist)

o The Command Center Manager will assign an Incident Commander to take a radio to the

disaster site and report the status of the disaster. Vests identifying the Incident Commander and

Medical Commander are located in the Safety Office and will be brought to the site by

assigned staff. The Incident Commander will coordinate the response efforts at the disaster

site, communicate all necessary information to the Command Center, and direct assistance to

the disaster site in a safe and organized manner.

o The Incident Commander will also establish a Command Post at the disaster site. The

Command Post will be a safe area near the disaster site where needed supplies and personnel

report to assist.

o The Incident Commander will also work with the Medical Commander of the site to determine

the best location for a triage site if needed.

STAFF RESPONSIBILITIES

Senior Supervising Nurse

Report to the Command Center in IRTC Communication Center.

If first to report (Superintendent, Assistant Superintendent, Medical

Director, Senior Supervising Nurse) will initiate duties of the Command

Center Manager.

Assign jobs and direct other personnel to report to needed locations

Appoint a nurse to assume nursing responsibility for the nursing duties

of the on-site team and send nurse to the disaster site with a radio

All Available Nursing (not assigned to a unit) and Medical Personnel

Report to the IRTC Lobby for assignments as needed.

Steam Plant Operator

Sounds the appropriate siren for three minutes of continuous blasts.

Maintenance Emergency Assessment Team

The Maintenance Emergency Assessment Team (PPD, Maintenance

Supervisor and Maintenance Foremen) shall be dispatched by the

Physical Plant Director or Designee to the disaster scene to assess

the damage done, and identify equipment and personnel needed.

The Maintenance Emergency Assessment Team shall report all

findings to the Physical Plant Director or his designee, who shall

report directly to the Incident Commander at the Command Post.

Safety Director will initially report to the IRTC Communication

Center. Safety Director may be assigned as Incident Commander by

the Command Center Manager.


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Staff on Units Follow instructions from Communication Center

Gather emergency box, kardex, and radio

Escort patients to Red Alert Area (unless otherwise instructed)

If evacuation from the building is necessary, evacuate ambulatory

patients first.

Call or radio patient count to Communication Center

All Support Personnel listed below will remain in their area (non-unit personnel) to assist with

patient care on the units and await further direction from Command Center personnel.

Chaplain

Allied Health Staff

Environmental Services

Rehabilitation Department

Material Management

Pharmacy Department

Psychology Department

Social Services Department

Health Information Services Department

Driver

Other departments

Other Emergency Trained Staff

Any staff with specific emergency medical training such as First

Responder, EMT, Paramedic, or CPR Instructor should report to the

Command Center for assignment.

Triage

Triage is a process and not a location. It is defined as a screening

and a classification of the sick and injured. It establishes an order of

care based on needs. Its use is essential to maximize saving of the

most lives.

Usual classifications are:

1. Immediate- e.g. Arterial bleeding and airway problems

2. Minimal- e.g. Minor cuts/abrasions (if short on help may be

useful to use them to assist medical personnel.

3. Delayed- e.g. Closed fractures without bleeding

Triage is a continual process since the classification can change at

any time during care. (A fractured rib may puncture a lung and

become immediate)

Triage Teams

Triage teams may provide emergency care at the disaster site. The

triage area will be the closest available safe location, dictated

according to area damaged, weather, and/or number of casualties.

The triage area will be designated by the Incident Commander with

assistance by the Medical Commander. Individuals requiring acute


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care in the hospital will be evacuated as soon as possible after being

stabilized.

Medical On-Site Team

The Medical Director or designee assigned to be the Medical

Commander will be the head of the On-Site Team. The Senior

Nurse at the Command Center will appoint a nurse to assist the

Medical Commander and direct nursing and non-nursing personnel

providing care at the scene. The On-Site Team will assess and treat

at the site of the disaster as soon as possible, evacuating injured

persons as needed. The On-Site Team will assess and label the

patients (using triage tags) as to their treatment needs. The LSH

disaster supply box located in the Safety Office will be delivered to

the site. The disaster supply box contains various medical supplies

(no medications) and vests to be worn by the Incident Commander

and Medical Commander.

Media Relations

Release of any information to the press will be handled by the

Superintendent or Assistant Superintendent following FSSA/DMHA

guidelines.

Managers

Department Heads/Service Line Managers/Supervisors are

responsible for ensuring that each employee in their area is aware of

the Emergency Operations Plan and their role.

Managers are to ensure that applicable emergency checklists are

available.

Security Security staff will report to the Communication Center in the

security vehicle for assignments.

Patients

Different emergency situations or types of disasters require different

patient management strategies. The Superintendent will work with

the Medical Director and Service Line Managers to tailor the patient

management strategies to the particular emergency situation at hand.

No patients will be admitted, discharged or transferred during an

Emergency Operation.

Psychology/Pastoral Care

Provisions for trauma counseling for patients and/or staff will be the

responsibility of the Psychology Department, as determined by the

Incident Commander and/ or Medical Commander. Trauma

counseling for victims, families and staff will be conducted at a

place designated by the Incident Commander.


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Volunteers-Disaster Privileges

Disaster privileges for volunteer LIPs may be granted by the Medical

Director/designee. The volunteer LIP will provide a valid,

government-issued photo ID. As soon as disaster is under control,

the verification process for credentials will begin (See Medical Staff

By-Laws).

Traffic Control

Security Officers shall report to the Communication Center and may

be assigned, along with other available staff, to secure hospital

entrances.

Transportation

The hospital has one vehicle which is used by the Concourse

Nursing Service Office to transport patients. This vehicle would be

available and utilized in a disaster situation. Safety Director,

Maintenance staff and driver will be instructed to transport patients,

staff or supplies as needed during a disaster.

Emergency Equipment

A staff member from the Concourse Nursing Office will be

dispatched to obtain additional supplies and take to the on-site

disaster area. With the disaster supply box are vests to be worn by

the Incident Commander and Medical Commander.

A disaster supply box is kept and maintained by the Safety Director.

The disaster supply box will be taken to the on-site disaster area. It

is inventoried monthly by the Safety Director. The disaster Supply

Box includes:

Note Pad 1

Ink Pen 1

Pen light/flashlight 1

Pocket mask 1

Gloves (medium) 1 Box

Gloves (large) 1 Box

Face shields with eye guard 7

Disaster/triage tags 50

Ambu bag 1

Airways 1 package

Blood Pressure Cuff 1

Stethoscope 1

Medical scissors 1pair

Medical tape (assorted sizes) 2 rolls

4x4 gauze 1 sleeve

ABD pads 2


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Ace wrap (assorted sizes) 9 rolls

Splints (full arm, half arm,

hand/wrist, full leg, half leg,

foot/ankle)

6 (one of each)

Alcohol pads 10

Ice packs 2

Stiff neck collars (assorted sizes) 5

Emergency Medication Boxes

Emergency medication boxes from each ward, if not needed on the

ward area for emergency treatment, will be brought by a member of

the unit staff to the on-site area if requested.

Emergency Medication boxes are checked monthly by Pharmacy

staff and items are replaced as necessary.

Other Equipment and Supplies Pharmacy will be directed by the Command Center as to which

supplies are needed and a vehicle will be dispatched to pick these

supplies up and deliver them to the area needing them.

Litters: A staff member will be dispatched from the Command

Center to collect litters from each Service Line.

Each Treatment Center: Litters/Gurneys, Oxygen, Ambu bag,

Emergency Box, S-Tube, Bulb Syringe Suction

Allied Health: AED, Oxygen, suction machine, ice packs, first aid

supplied

Fogel Activity Building: AED, Oxygen, and Ambu Bag

Flashlights and additional PPE may be obtained from Material

Management.

Wheelchairs are located at the IRTC, Employee Health Clinic, Fogel

Auditorium and Larson Treatment Center.

COMMUNICATIONS

The Communication Center will communicate a disaster via pagers, phones, radios and LSH

email.

In the event of a disaster ALL radio traffic should stop, except for that related to the disaster.

Phones and/or runners should be used for non-emergency communication.

Units/outlying areas will report patient head count to Command Center.

Communications between the Command Center and the Command Post, Incident Commander

will be maintained by LSH 2-Way radios.


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If for some reason the telephone system is not operating, Gordon-Kapes (red) phones, cell

phones, radios and pagers will be used for communication. If all electronic systems are

impaired, communication coordinators will be assigned to run the messages to all hospital units

and departments. The communications coordinators can be any available employee.

Emergency Phone (Gordon-Kapes) location and numbers are listed below.

DN BUILDING ROOM LOCATION AREA DISPLAY NAME

3950 ISAAC RAY 806 IRTC Communications Center CommCtr GK

3951 LARSON E1015 Telephone Switchboard Operator GK

3952 ADMINISTRATION

Administration Secretary Admin GK

3953 CONCOURSE C103 Nursing Services Office Nursing GK

3954 LARSON E1029 Medical Services Secretary MedSvcs GK

3956 ISAAC RAY 1005 Telephone/Computer Room MDF GK

3957 ISAAC RAY 114 I1W Chartroom/Nursing Office I1W GK

3958 ISAAC RAY 514 I2E Chartroom/Nursing Office I2E GK

3959 ISAAC RAY 414 I1E Chartroom/Nursing Office I1E GK



3962 ISAAC RAY 828 Isaac Ray Administration Suite IRTC Admin GK

3963 ISAAC RAY 902 Allied Health Clinic Receptionist AHC GK

3964 LARSON E1093 Larson 1 Nursing Office L1N/L1S GK

3965 LARSON E2093 Larson 2 Nursing Office L2N/L2S GK

3967 LARSON E2015 Larson Administration Secretary LTC Admin GK

3968 LARSON E1141 L1E Clinical Administrative Area Clinical Adm GK

3969 MAINTENANCE

Maintenance Security Office Security GK

3970 ISAAC RAY 1010 Pharmacy Director’s Office Pharmacy GK

3971 ADMINISTRATION

Information Management Office Info Mgmt GK

3972 COTTAGE #18

MOD Cottage #18 MOD GK

Departments will accept responsibility for notifying needed persons within their own

department.

Each department will maintain a list of emergency telephone and pager numbers.

If established communication channels are unavailable, the Command Center will establish a

runner system.

All appropriate external authorities will be notified when the Incident Command System is

initiated. Communication outside the facility will utilize

o Alpha-numeric or digital pagers


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o Email, if the infrastructure is working

o Two-way radios

o Runners

o State and local Police/Fire will be contacted

Non-disaster calls will not be accepted during the disaster situation. In-hospital telephone

communication will be used for emergency calls and will be kept brief to keep lines open.

Telephones will be operable under emergency power. The Command Center, Switchboard,

and all Treatment Center buildings have emergency power from emergency generators should

electrical power be lost. Additionally, there are two incoming lines which operate if the

emergency generators fail to operate. A TDD line is located in the IRTC Communication

Center and a FAX line is in the Concourse Nursing Office. Cell phones are available in the

IRTC Communication Center, the Concourse Nursing Office and the Rehabilitation Director’s

Office.

Since some emergencies could last longer than one or two shifts, and sometimes days,

Logansport State Hospital will make every attempt to assist staff members who may be

required to remain on campus, to communicate with family and friends to ensure that

dependents in their care are provided for. The hospital will also work to help staff members

learn the extent of conditions outside the hospital if the emergency extends out into the

community. Transportation will be provided, when possible, between work and home.

TWO-WAY RADIO PROCEDURE

Two-way radios are used for a back-up system to the phone and pager system. The two-way radios

are located on each patient unit and are to be taken along with the emergency box and kardex for all

fire and weather drills and actual emergencies for communication. The radio system is checked

monthly for proper functioning.

EMERGENCY CODES

Logansport State Hospital has designated a CODE SYSTEM to alert staff regarding specific

situations. Information concerning a specific code will be communicated to all staff by the IRTC

Communication Center via e-mail, pagers system, radios and telephone broadcast message. An

EMERGENCY code may not rise to the level of a disaster. Staff must listen to the information

relayed and act accordingly.

CODE BLUE –call 2911. Assistance is needed as soon as possible. Nursing and medical staff

will be advised where to report

YELLOW ALERT- safety conditions (weather, DOC breach) are such that patients must

return to the unit or have staff supervision.

RED ALERT- severe safety conditions based on the type of event. Communication Center

will instruct staff and patients. For Example,

o GO TO NEAREST RED ALERT AREA (due to tornado, earthquake, or

explosion).


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o SHELTER IN PLACE (due to bomb threat, workplace violence, and

hazardous material incident) Staff and patients will take shelter in the building

where they are located when the emergency occurs. (i.e.; if staff and patients are

in the Fogel building, they will remain there until all clear).

o For any type of RED ALERT, staff will call or radio patient count to

Communication Center.

CODE E- a patient has eloped.

Dr. GREEN- (IRTC only) Serious help needed on a specific unit

FIRE EMERGENCY- call 2222

COMMUNITY INVOLVEMENT

The Safety Director participates in meetings with the local EMA personnel. Planned emergency drills

can include participation by community entities such as the police and fire departments. The hospital

will work with the Cass County Health Department and the Cass County EMA to assist in responding

to disaster at the facility. The LSH Pandemic Plan can be initiated as applicable.

CLINICAL ACTIVITIES

Different emergency situations or types of disasters require different patient management strategies.

The Medical Director/DON/Service Line Managers will tailor the patient management strategies to the

particular emergency situation at hand. Clinical activities will be addressed based on the emergency

situation.

MANAGEMENT OF RESOURCES AND ASSETS

Inventory of Assets and Resources

The Resource Inventory Sheet will be maintained by the Safety Director. During an emergency the

Safety Director or Incident Commander will monitor usage of resources and will take necessary steps

to replenish supplies as needed. The inventory will be updated as often as necessary for the duration of

the emergency and the updated inventory communicated to the Command Center. The Command

Center will determine if continued operations area viable. Options can include curtailing operations or

relocating patients to a serviceable facility. The Resource Inventory is reviewed and updated by

appropriate managers.


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Food Service

ARAMARK is contracted to provide food services to Logansport State Hospital. They keep a

revolving 14 day minimum food inventory on site. The Safety Director and Superintendent (or

designee) will coordinate with ARAMARK to provide meals for patients and staff during any

disaster/emergency situation.

EVACUATION OF AREAS, BUILDINGS, AND THE FACILITY

Evacuation will be to the nearest safe area as determined by the Incident Commander and/or

Safety/Security Director.

The following alternate emergency buildings have been designated. In case of fire or disaster, all

patients and personnel will, upon orders of the Authority having jurisdiction, move to the Alternate

Building as quickly as possible and remain in this area until further advised:

BUILDING ALTERNATE BUILDING

#105 Dodds (Administration staff) #106 QM/Staff Development/HIS

#109 Isaac Ray Treatment Center #8 Fogel Building

#106 QM/Staff Development/HIS #107 Larson Treatment Center

#107 Larson Treatment Center #106 QM/Staff Development/HIS

SUPPLIES HOW MUCH ON HANDHOW LONG

WILL THIS LAST

Response Procedures

(if past 96 hrs)

EM.02.01.01 EP2

Personal Protective Equipment

Water - Potable

Water - Non-Potable

Fuel

- Transportation (Underground tanks)

- Fuel Oil

- HVAC

- Generators (Diesel / Natural Gas)

Medical Supplies

- Oxygen

- Suction machines

- IV Equipment

Medication

Food Services (Cold storage)

Linen

Housekeeping

Laundry

Material Management

The Resource Inventory Sheet will be maintained by the Safety Director.

During an emergency the Safety Director or Incident Commander will monitor usage of resources and will take the necessary steps to replenish supplies as needed.


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LEVELS OF EVACUATION

Immediate Evacuation

Should immediate evacuation of any building or a portion of any building be necessary to avoid risk to

patients, staff, and visitors, the decision must be made and implemented by the Command Center

according to evacuation routes available and alternate buildings available.

1. Patient Care Staff will follow the evacuation routes (posted or directed) and gather at their

designated area of hospital grounds.

2. Safety Director will gather state vehicles and contact Cass County Emergency Management

Agency for further transportation needs.

3. The Senior Supervising Nurse will triage patients to determine which patients will be first

transported. It is recommended that infirmary patients, those in restraints, or at risk of AWOL,

be selected first for transportation.

4. The Superintendent, Physical Plant Director, and Safety Director will determine, along with

local authorities whether the building is safe for return.

Partial Evacuation

Should a portion of any building be damaged leaving patient units uninhabitable, the Command Center

may select an alternative building as a temporary shelter until damage is assessed and if necessary, the

short-term or long-term evacuation arrangements can be implemented.

1. Damage to a hospital building will be assessed by Superintendent, Safety Director, and

Physical Plant Director.

2. Superintendent, Safety Director, and/or Physical Plant Director will notify the IRTC

Communication Center to inform direct care personnel that a move to another building is

necessary.

3. Direct Care Staff will escort patients to alternative site. Service Line Managers will be

responsible for transfer to alternative site:

Patient charts

Medications

First aid kits

Universal precautions kit

4. Environmental Services will:

Provide all available linens, pillows

Stock and maintain nearby restrooms

Beds, if directed by Director of Nursing

Waste receptacles

Hazardous waste receptacles

Tables and chairs for nursing area


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Chairs for patients

5. The Superintendent, Physical Plant Director, Senior Supervising Nurse, and Safety Director

will determine if an alternative site will be necessary overnight. If so, the Senior Supervising

Nurse will notify the IRTC Communication Center, Direct Care Staff, and Environmental

Services.

Complete Evacuation Short Term

Should the hospital be deemed completely uninhabitable for a period expected to last no more than

five days, patients will be transported to sites designated by the Cass County Red Cross.

1. As soon as the event occurs, the Superintendent, Physical Plant Director, and/or Safety

Director will evaluate the need for short-term evacuation. The Superintendent will contact

DMHA to notify of need for transfer to the Red Cross designated locations.

2. Superintendent will contact DMHA to coordinate notification of patient’s families.

3. Immediately the Safety Director will assemble State vehicles and call Cass County Emergency

Management Agency for further transportation to be provided by the Logansport School

Corporation.

4. The Senior Supervising Nurse will inform Service Line Managers of plan to transfer.

5. The Senior Supervising Nurse along with the Human Resources Director will pool staffing

necessary for:

A. Transportation of patients and direct care staff

B. Staff to remain with patients for direct care while at alternative staff pool facility

C. Transportation of necessary belongings and supplies.

The Unit Nurses will triage patients to determine which patients will be first transported. It is

recommended that infirmary patients, those in restraints or at risk of AWOL be selected first for

transportation.

Patients chosen for immediate transportation will be transported by one driver and a direct care staff to

the appropriate facility. Any necessary items, clothing, patients' charts and medications will be

transported along with the patients.

6. Direct Care Staff will escort patients to alternative site. Service Line Managers will be

responsible for transfer to alternative site:

Patient charts

Medications

First aid kit



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7. Pharmacy will be responsible for packaging medications for patients as ordered by the

physician. Nursing staff will courier orders to pharmacy as needed and return medications to

appropriate alternative site.

Complete Evacuation Long Term

Should the hospital be deemed completely uninhabitable for a period expected to exceed more than

five days, patients will be transported to Richmond State Hospital, LaRue Carter State Hospital,

Madison State Hospital, and/or Evansville State Hospital per the Mutual Aid Agreement on file in

Quality Management.

1. The Superintendent, Physical Plant Director and Safety Director have deemed the building

uninhabitable, and evacuation begins.

* Superintendent will collaborate with DMHA to notify patient’s families.

2. Immediately the Safety Director will begin assembling State vehicles and call Cass County

Emergency Management Agency for further transportation.

3. The Command Center will notify Richmond State Hospital, LaRue Carter State Hospital, Madison

State Hospital, and/or Evansville State Hospital that transfer of patients will soon begin. Also

requested from the SOF’s will be the maximum number of patients each hospital can accept.

4. The Senior Supervising Nurse will divide patients according to their newly designated location.

An attempt will be made to keep service line patients and staff together to maintain continuity of

care.

5. The Senior Supervising Nurse along with Director of Human Resources will pool staffing

necessary for:

A. transportation of patients all direct care staff

B. staff to remain with patients for direct care while at alternative facility

C. transportation of necessary belonging and supplies

6. The Unit Nurses will triage patients to determine which patients will be first transported. It is

recommended that patients in restraints or at risk of AWOL be selected first for transportation.

Patients chosen for immediate transportation will be transported by one driver and direct care staff

to the appropriate facility. Any necessary items, clothing, patients’ charts and medications will be

transported along with the patients.

7. Direct Care Staff will escort patients to alternative site. Service Line Managers will be responsible

for transfer to alternative site:

Patient charts

Medications

First aid kit


8. Pharmacy will be responsible for packaging medications for patients as ordered by physician.

Nursing staff will courier orders to pharmacy as needed and return medications to appropriate

alternate site.


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9. The assigned communication coordinators will continue as needed to courier messages,

information, etc. between alternative sites and the Command Center.

Direct Care Staff are required to report to the alternative site as their schedule dictates. Command

Center Staff are to report to Command Center as scheduled or directed by the Superintendent or

Director of Nursing. All other staff is required to report to the facility as scheduled or directed, unless

informed otherwise, to carry out the everyday operations of the facility or to be a member of the labor

pool.

Return to Facility

The patients and staff will remain in the alternate site until the Superintendent has instructed the return

to the facility.

When this is announced:

1. The Director of Nursing will coordinate the move of the patients back to the facility by

contacting the appropriate alternate site, Assistant Directors of Nursing, and Service Line

Managers.

2. The Safety Director will arrange for the State Hospital vehicles as well as vehicles through

Cass County Emergency Management Agency to return patients.

3. The Safety Director and Director of Nursing will pull from the labor pool to provide drivers to

transport staff, patients, belongings, medications, charts, equipment, etc., back to the hospital.

4. Directors of all departments will be responsible for coordinating supplies and rehabilitation of

their areas.

5. The Safety Director will compile data and present an After Event Report within thirty days

after the event.

6. The Environment of Care Committee will review the report and make recommendations as

appropriate.

7. The Directors of Psychology and Social Services will coordinate groups for debriefing and

support.

Through a Mutual Aid agreement with the other State Operated Facilities (SOF) we could be asked to

receive patients if another SOF would need to initiate a total evacuation of their facility. The Mutual

Aid Agreement is on file in the Quality Management Office. The Superintendent is the contact person

for the initiation of the Mutual Aid Agreement. The Assistant Superintendent will be the alternate

contact person.


19

SAFETY AND SECURITY

During an emergency situation, the Safety Director, working with the Incident Commander, will

implement contingency plans to secure the facility, areas within the facility and manage vehicular and

pedestrian traffic, based on the needs of the specific situation.

Direct care staff may be used to augment the security forces, if the situation warrants. When

appropriate, local, state law enforcement will assist if possible.

UTILITIES

Seven emergency generators are located on Logansport State Hospital grounds. Elevators are

not to be used during disasters. The maintenance department is responsible for

isolating/correcting safety issues in the emergency/disaster area.

Location of Generator Supplies Building(s)

Fogel Rehabilitation Building - Building #8 Fogel Rehabilitation Building

Power House (Steam Plant) – Building #1 Steam Plant

Dietary Building – Building #103 Dietary Building

“F” Building (#108) – Building #108 Residential Complex

Mechanical Room (Allied Health Bldg)-2 generators –

Bldg #109

Isaac Ray Treatment Center / Allied Health

Sewage Lift Station – Building #6 Sewage Lift Station

When emergency generator provides our only source of electrical service to a building, ward

refrigerators are in most cases all inoperative. In addition, forced ventilation is not provided;

therefore heating and air conditioning capabilities are minimized.

During an emergency, the organization will identify alternate means for providing essential

utility systems. These utility systems will be identified as well as alternate means for

providing services. The organization will assess the requirements needed to support these

systems such as fuel, water, and supplies for a period of time identified in the Resource

Inventory Sheet. This information will assist the hospital in identification of capabilities and

establishes response procedure for when the hospital cannot maintain adequate utilities.

Alternate means of providing essential building utility needs include:

Water: LSH has 600,000 gallons of potable in water tower.

Ventilation: No alternative other than opening windows and doors.

Fuel: LSH has 2- 2,000 gallon tanks of fuel (2,000 unleaded gasoline and 2,000 diesel)

Generators: LSH has 7 diesel- powered generators to supply power to the Fogel

building, dietary building, IRTC and the Residential Complex.

Medical Gas: N/A


20

EVALUATION/DRILLS

EVALUATION OF THE PLAN

LSH conducts exercises to assess the Plan’s appropriateness, adequacy, and effectiveness. As

an emergency response exercise, LSH conducts drills twice a year (6 months apart). The

exercises incorporate likely scenarios that will allow LSH to evaluate its handling of

communications, resources and assets, security, staff, utilities, and patients. If the plan is

activated in response to an actual disaster, that will count toward the twice yearly requirement.

The Safety Director is responsible for planning and implementing drills and for providing

ongoing emergency preparedness training.

During exercises and/or actual responses, designated individuals are assigned to monitor and

document all aspects of the exercise. A debriefing meeting will be held to evaluate staff

response to the drill/event. Identified deficiencies and opportunities for improvement will be

communicated to the EOC who will be responsible for ensuring implementation of

modifications/interim measures/training.

EVALUATION OF THE HAZARD VULNERABILITY ANALYSIS

Each identified event is given scores by the EOC Committee in three areas; probability of

occurrence, level of risk, and preparedness level of the hospital. These scores are totaled and

any event that scores an 8 or higher is evaluated quarterly. Events scoring 6 to 7 are evaluated

semi-annually and any event with a score of less than 6 is evaluated yearly. Changes in the

environment of the hospital grounds or area surrounding the hospital may result in events being

evaluated at other times than specified by their current HVA score.

ORIENTATION, TRAINING, EDUCATION

a. New Employee Orientation

All new employees receive training on emergency preparedness during their orientation.

b. Annual Training

Each disaster drill is evaluated by the Environment of Care Committee. Information is

provided to staff based on the results of those evaluations.

c. Each employee completes an annual disaster training refresher on-line.

PERFORMANCE MEASUREMENT

a. Performance evaluations of the Mock Disaster Drills each calendar year.

The Safety Director will collect, aggregate, analyze, and report data including conclusions and

recommendations regarding emergency preparedness to the Environment of Care Committee

after each mock disaster drill and as needed and to the Clinical Executive Committee on a

quarterly basis.

b. Specific indicators incorporated into the hospital-wide measurement design system are

completion of disaster drills, functioning of backup communication systems, and staff

knowledge

c. Annual Evaluation:

The Safety Director with the assistance of the Environment of Care Committee will complete a

written evaluation of the emergency preparedness plan’s objectives, scope, performance and

effectiveness on an annual basis. This information is disseminated to the Environment of Care

Committee and to Quality Management.


21

External Disaster

An external disaster is defined as any disaster not on hospital grounds and not affecting the normal

operations of the hospital (i.e., electric, gas, water, etc.).

Although Logansport State Hospital is not a receiving hospital and is not expected to participate in an

external disaster, the following instructions will be used by the Superintendent or his designee to make

a determination of whether we could offer any assistance to a requesting agency.

Any call from agencies requesting assistance for an External Disaster will be forwarded to the

Superintendent or his designee immediately. The Superintendent or his Designee will decide,

depending on the type of the disaster, what actions will be taken by Logansport State Hospital.

If it is a mass casualty disaster and the agencies wish to send injured personnel to Logansport State

Hospital, the Emergency Operations Plan should be followed. If it is determined that Agencies who

wish to send personnel to LSH for emergency housing, the following action should be taken:

1. The Cass County Emergency Management Director should be notified that personnel

would need to be sent to assist with all shelter and personnel areas.

2. Bedding, food and emergency clothing, or other items if needed, will be used for the

care of personnel.

3. Security will be sent to the main entrance and escort personnel to shelter areas, and give

access to buildings to Emergency Management personnel.

The following departments could provide the following:

1) Health Information Services – The HIS staff could help with clerical service.

2) Social Service - The Social Service Department could make available the services of Social

Service staff to assist in notifying family members of the disaster and enlisting their assistance,

also in finding community resources to meet the needs of victims of the disaster, such as

hospital beds, in another community, etc

3) Nursing - A list of off duty personnel can be obtained from the Nursing Department. On duty

staff above our minimum coverage can be loaned to the scene of the disaster.

4) Central Supply - Central Supply equipment (bandages, syringes, etc.) and emergency

equipment (Ambu bags, leaving one Ambu bag per unit) can be provided as they are available.

5) Patient transport vehicles are available. Some emergency boxes can be taken (leaving one

emergency box per unit). Some oxygen containers are available (leaving an oxygen container

per unit). Extra blankets/linens/pillows can be loaned. Some liters/gurneys would be

available.


22

Hazardous Materials Exposure (biological/chemical)

RED ALERT- SHELTER IN PLACE

If a biological or chemical release should occur near or on hospital grounds, the

Communication Center and Safety Director should be notified immediately for activation of

the response plan. If the Communication Center is in jeopardy, the Concourse Nursing Office

will serve as the command center.

Activate the Incident Command System

Notify Communication Center (3190/3290/2702) and Safety Director to activate the response

plan—Supt/Asst Supt/Senior Supervising Nurse/Medical Director will report to

communication center.

Staff and patients are to SHELTER IN PLACE and close all windows

Safety Director/PPD will be the liaison with responding community agencies (Cass County

Emergency Management, fire, police) to gather critical information: location, wind direction &

speed, amount of agent released. This information will be used to determine if staff/patients

will be evacuated or remain in place. The Safety Director/PPD will continuously update the

command center will pertinent information.

The Safety Director has the Department of Transportation Emergency Action Guidebook for

hazardous materials which can be used to identify material involved in the event and actions to

take.

Logansport State Hospital's safest buildings and areas to control air penetration are as follows:

A. Residential Complex (buildings 105, 106, 107)

B. Dietary Annex

C. Isaac Ray/Allied Health

The quickest way to shut down the air intake system for the above buildings is to pull a single fire

alarm in each building area. This will shut down the air intake system. The IRTC Communication

Center can silence the alarm remotely in this circumstance. In addition, the IRTC Communication

Center Staff and Safety Director have the capability of shutting down the air intake system all at once.

Communication Center

A. Make internal and external notifications per Command Center checklist as

appropriate for the situation

B. Relay instructions to staff regarding the actions to take based on

information received from the Safety Director’s ongoing assessment

C. Call the “All Clear” when advised by Safety Director

Safety Director (liaison with responding community agencies)

A. Direct safety issues

1. Communicate with Command Center regarding initial response and ongoing

assessment

2. Instruct staff in Fogel, Adm, Environmental Service, Dietary (Aramark)

whether to shelter in place or move to alternate location

Alternate locations for these individuals would be the Dietary

conference room and the multipurpose room in the main concourse


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3. Issue Health Care/Surgical Masks to Command Center staff

4. Issue Health Care/Surgical Masks to Physical Plant Director, Aramark

Director, and Environmental Services Director/designee for staff in their areas

5. Collaborate with Medical Director to determine if evacuation is necessary

6. Monitor and take air samples

7. Determine when event is no longer a threat and notify Command Center

Director of Nursing (ensure adequate nursing staff)

A. Ensure Health Care/Surgical Masks are issued to all staff and patients

B. Ensure any patient or staff using oxygen has ample supply

Physical Plant Director/Maintenance Staff (ensure all maintenance staff accounted for)

A. Ensure all outside air intake is shutdown

B. Ensure all ventilation, air handlers, vents are shutdown

C. Ensure all air conditioners are off (window units)

D. Ensure means are in place to check water if necessary

E. Restore air handlers and vents when all clear

Unit Staff

1. SHELTER IN PLACE

2. All windows and doors must be closed

3. Listen to LSH radio for instructions from Command Center

4. Remain inside

ARAMARK Supervisor

A. Ensure emergency food items are in place

1. Ensure items for wards on carts

2. Issue Health Care/Surgical Masks to remaining staff

Environmental Services Director

A. Ensure emergency items are in place

1. Be prepared to move items if necessary (towels, linens, patient clothing) to

residential complex or to evacuation site. Wait for instructions from Safety

Director.

2. Issue Health Care/Surgical Masks to remaining staff

Staff in ADM, Fogel, Maintenance, Environmental Service, Aramark

A. Close all windows and turn off air conditioners

B. Safety Director will relay instructions whether to shelter in place or evacuate to

alternate location. Alternate locations for these individuals would be the Dietary

conference room and the multipurpose room in the main concourse.


24

Winter Weather Procedures

Essential personnel to ensure the continued operation of the facility during severe inclement weather:

Direct Care Staff

Maintenance Staff

Environmental Services Staff

Medical Staff

Nursing Care Staff

Communication Center Staff

Winter weather procedures will be put into effect at LSH whenever snow accumulation, drifting, or

extreme ice conditions warrant such action. These procedures may also be activated when these

conditions are anticipated.

Notification of Winter Weather Procedures: Due to the type of facility and the need for 24 hour care

of LSH patients, any weather bulletins made by the Governor for State employees and/or the Mayor of

LSH, Cass County Commissioners, or other surrounding counties or area cities, may not apply to LSH.

LSH will negotiate authorization for travel for employees’ from home to work when a traffic

moratorium or curfew is declared by the Mayor of Logansport, Cass County Commissioners, or the

State of Indiana.

LSH Telephone Information Hotline

A telephone information hotline is available to assist in the dissemination of information regarding

events that may affect the operation of the hospital, such as a weather emergency. The Superintendent

or designee will provide updates concerning essential and nonessential staff, facility conditions, and

attendance expectations.

To access the LSH Information Hotline:

1) Dial 3911 from inside the hospital (from any hospital extension)

2) Dial 737-3911 from any local Logansport area number (outside the hospital)

3) Dial 574-737-3911 from any cell phone or from any landline phone that is long distance

from Logansport.

Current information pertaining to adverse weather conditions is available:

1) https://exchweb.in.gov/owa/ to access your State email from home

2) http://www.in.gov/dhs/traveladvisory/ for State and county travel advisories

3) http://casscountyonline.com/site/ for Cass County delays, closings and county travel

advisory.

4) LSH may be announced over the following radio stations:

WSL-1230 AM WHZR 103.7 FM WLHM 102 FM

https://exchweb.in.gov/owa/

http://www.in.gov/dhs/traveladvisory/

http://casscountyonline.com/site/


25

Direction during weather emergencies:

The IRTC Communication Center will be the command center whenever severe weather dictates. The

command center will be directed by a member of the LSH Senior Executive Board or Senior Nursing

Staff on duty and will be responsible for the coordination of all weather related activities including

assignments of staff, transportation, food, linen, and medical supplies and the removal of snow and ice

on the hospital grounds and parking areas.

Staffing Duties and Employee Responsibilities:

1. If an essential employee is off duty (regular time off or holiday), all employees are asked to

contact the concourse nursing office to find out if they are needed for special duty.

2. If an essential employee is scheduled to work, they should make every effort to come in. If

snowed in, telephone the command center, report your availability and receive instructions.

3. In emergency conditions, all staff residing on grounds are expected to report for regular duty or

to the IRTC Command Center for assigned duties.

4. Employees on duty or able to arrive when snow or inclement weather conditions develop may

be assigned duties out of their job classification to meet the needs throughout the hospital

campus. In the event of operational necessity, staff shall be required to work extra shifts.

5. Employees scheduled but unable to report to work due to weather conditions must use personal

leave to cover their absence, or may be granted vacation leave or authorized leave at the

discretion of the appointing authority.

Arranging Transportation for essential personnel:

The Senior Nursing Supervisor on duty will determine the need for providing transportation to

LSH from along designated top priority snow removal routes in Logansport. When in effect,

pick up times and locations will be arranged with the IRTC Communication Center as advised

by the employee’s availability.

Logansport State Hospital resources include:

The escort service through the nursing department will be able to provide emergency

transportation during inclement weather conditions.

Physical Plant Department/Maintenance will assist with transportation as well as snow removal

on hospital property and will assist with other duties as deemed necessary/essential.

All arrangements for transportation or assistance are to be made through the IRTC Communication

Center Senior Nursing Staff on duty.

Community Agencies: the Cass County Emergency Management Agency (Cass Co EMA) may assist

with transportation of personnel and may also assist with other duties as deemed

appropriate/necessary. The Safety Director (or designee) will be the liaison between LSH and the Cass

County Emergency Management Agency to plan and coordinate efforts during emergency weather

situations or conditions.


26

Government Agencies/Organizations:

1. The State Highway Department may assist with snow removal on and around hospital grounds.

2. Local and county Highway Department personnel may be contacted (if so needed) to check on

road conditions and assistance (for snow removal if time and conditions permit) in reaching

essential hospital personnel.

3. Other government agencies to contact include, but are not limited to the following:

- Logansport Police Department

- Cass County Sheriff’s Department

- Indiana State Police

- National Guard (Cass Co EMA will contact if necessary)

The above agencies have been noted for assisting medical facilities in emergency situations, if time,

conditions, other emergencies, and duties permit and may be contacted if the need arises.

Maintenance Functions - Related to Severe Cold/Snow Disaster

When inclement weather occurs, Security staff will contact the IRTC Communication Center.

Communication Center staff will call the Grounds Foreman.

The Grounds Foreman assures adequate staff coverage to remove snow from parking lots, sidewalks

and building entrances.

Pharmacy Snow Emergency Procedures

When a weather emergency is announced by the hospital, all pharmacy employees are to call the

Director of Pharmacy by 7:30 a.m. and describe their situation. Employees living near snow route

pick-up points are to make arrangements to be picked up if they are not able to get to work on their

own. A Pharmacist must be available. The Pharmacist On-Call phone number is (574) 601-5191.


27

Severe Weather – Storm, Wind, Tornado

RED ALERT-GO TO RED ALERT AREA

Communication Center staff monitors a weather radio. In the event of an Emergency Weather alert,

the Senior Supervising Nurse is contacted to determine declaration of appropriate alert.

1. Weather/Tornado – WATCH – (YELLOW ALERT)--Severe weather, hail, damaging winds,

weather conditions conducive to formation of a tornado

a. All areas notified by telephone, pagers, email, and two-way radio by Communication

Center staff.

b. Staff will be informed of changing weather conditions directions

c. Patients on leisure time activities will report to their unit.

2. Weather/Tornado – WARNING – (RED ALERT) GO TO NEAREST RED ALERT AREA

DANGER – Violent weather imminent. Local area weather conditions appropriate for a

tornado developing or tornado has been sighted in area.

a. Communication Center notifies all areas by telephone, pagers, email, and two-way

radio

b. Instruct staff to go to red alert areas with radio-or to side of the building opposite the

storm and behind a second wall. Interior hallways or interior rooms are safest. Protect

from injury and glass using any available items (furniture, mattress)

c. Communication Center notifies Safety Director and Steam Plant. LSH siren will blow

three waves or blasts at five–ten second intervals for about five minutes.

d. If out of the building, seek nearest shelter of brick construction (return to treatment

center if deemed safe).

e. Patients on assigned programs will be taken to the closest safe building and to basement

if possible.

f. Security will check grounds to make sure all patients have returned to their wards

immediately.

Safety Director is to observe sky conditions notifying IRTC Communication Center when conditions

might be threatening. IRTC Communication Center will keep staff informed with as much

information as possible.

3. When conditions are safe for return to normal operations, IRTC Communication Center will

notify all staff via telephone, pagers and radio.


28

Utility Failure/Heating/Cooling

Communication Center will:

Notify the Superintendent/Assistant Superintendent, the Safety Director and the Physical Plant

Director who should report to the Communication Center if necessary to direct the response.

Communicate with staff via email and phones regarding the status of the utility repair.

Staff on patient care units will take the following actions if applicable:

Non-clinical staff will assist nursing staff in obtaining blankets from the laundry to provide

comfort due to lack of heat, or in obtaining ice and fans in cases of extreme heat.

In cases of extreme heat, units will provide patients with extra ice/fluids throughout the day.

Obtain flashlights for use at night in patient rooms and to prepare medication. (Flashlights are

available from the IRTC Communication Center and from Material Management).

Store refrigerated medication on a unit with electricity or in Dietary.

Notify ARAMARK about food and liquids in refrigerators so it may be placed elsewhere. (If

outage is of short duration, care should be taken to only open refrigerator when absolutely

necessary). ARAMARK may also provide ice in insulated containers for cold water. (Security

has access to ARAMARK areas if their staff is not on site.)

Notify the Pharmacy in the Allied Health building so refrigerated items can be moved.

Oxygen machines and suction machines do not work unless plugged in the one outlet that has

emergency power.


29

Hostage/Active Shooter/Workplace Violence

RED ALERT--SHELTER IN PLACE

Upon the realization that a hostage/active shooter situation exists, staff shall call 3190/3290/2702

to notify Communication Center who will initiate the appropriate response.

1. Awareness--Be aware of what should be and what is happening in your work area. Be aware

of any persons in your work area who act suspiciously, someone recently discharged, someone

who doesn’t work there, or someone with a weapon. Knowledge of any potential event should

be given to the immediate supervisor who should inform senior leadership.

If the situation is actually occurring in your area, take action necessary to provide

immediate safety—evacuate, lock doors, hide, silence pagers and cell phones

2. Notify the Communication Center if there is someone acting suspiciously or someone with a

weapon in your area.

3. Communication Center:

Notify Superintendent, Assistant Superintendent, Senior Supervising Nurse, and

Medical Director who should report to Communication Center if possible.

Notify the Cass County Sheriff’s Office and the State Police.

Instruct staff via phones, pagers, email, radio—Red Alert/Shelter in Place.

Instruct Security to secure campus entrances.

Notify cottages and Logansport Juvenile Correctional Facility if applicable.

4. Superintendent, Asst Superintendent, Senior Supervising Nurse, Medical Director,

Safety Director:

Report to the Communication Center if possible.

Assist with notifications and assist with managing the response to the event.

5. Staff/Patients:

LISTEN for instructions from the Communication Center

All patients and staff should Shelter in Place (remain at their work site/indoors).

Close and lock all doors/windows.

Notify Communication Center with patient head count

If the situation actually is occurring in your area, take action necessary to provide

immediate safety, i.e. evacuate, hide, and silence pagers/cell phones.

6. Security should secure the campus entrances so that no one enters except for law enforcement.

7. Law enforcement will take control of the situation upon their arrival.

Refer to FSSA Policy Prevention of Workplace Violence

Refer to LSH Policy A-41 (Weapons Policy)


30

Bomb Threats

RED ALERT—SHELTER IN PLACE PROCEDURE:

1. When a bomb threat telephone call is received, the person receiving the call will remain calm, listen

carefully to what the caller says, take notes, and listen. If possible, the caller should be put on speaker

phone and get another staff person to listen. If an additional staff person is available to listen, he/she

will contact the Communication Center via landline phone or in person. Try to keep the caller on the

line and ask for information such as:

a. When is the bomb going to explode?

b. Where is the bomb right now?

c. What does it look like?

d. What kind of bomb is it?

e. What will cause it to explode?

f. Why did you place the bomb?

g. What is your address?

h. What is your name?

i. Note the following:

Caller’s identity: male/female, adult/juvenile

Caller’s voice: loud/soft, high-pitched/deep, intoxicated

Caller’s accent: local, foreign, region, description

Caller’s speech: fast/slow, stutter, slurred, nasal, distorted

Caller’s manner: calm/angry, rational/irrational, coherent/incoherent, laughing,

emotional

Background noises: machines, trains, animals, music, traffic, voices

2. IMMEDIATELY upon termination of the phone call, notify the Communication Center via

landline telephone (3190/3290/2702). Runners may also be used if necessary. The use of 2-way

radios, cell phones, pagers will be stopped until cleared for use.

The Communication Center will use only landline phones, email, and runners to:

Notify the Superintendent/Assistant Superintendent, Senior Supervising Nurse, Medical

Director and the Safety Director who should report to the Communication Center, if possible,

to direct the response.

Notify Cass County Sheriff’s Office and the State Police.

Notify the area involved in the threat to evacuate to a given location, if evacuation has not

already occurred.

Notify staff in the non-affected area of Red Alert—Shelter in Place (bomb threat)

Superintendent, Asst Superintendent, Senior Supervising Nurse, Medical Director, Safety

Director:

Report to the Communication Center if possible.

Assist with notifications and assist with managing the response to the event.

Will assist law enforcement and will determine when situation is safe.


31

Staff/Patients:

FOLLOW instructions from the Communication Center

All patients and staff should Shelter in Place wherever you are (remain at work site/indoors).

The affected area may be instructed to evacuate.

Notify Communication Center with patient head count via landline phone

3. Law enforcement will take control of the situation upon their arrival.

SEARCH PROCEDURE:

1. Search procedures will be directed by the Safety Director with assistance from State Police,

County Sheriff, and other personnel as needed.

2. Portable radios will be turned off during the search and there will be no radio transmissions

within 750 feet of the threat areas.

3. A systematic search will be quickly conducted, looking and listening for any suspicious device.

4. A visual search of each room starting at the floor level and working up. Each door will be

marked with tape, chalk, marker, etc. to indicate the room has been checked.

5. If a device is found, do not attempt to touch or remove it, as a State Police Explosive Device

Officer will be assigned. Report the find to the Safety Director or State Police officer.

ALL CLEAR:

Safety Director, Supt/Asst Supt, and/or State Police will make the decision as to when the

building/area is safe and can be occupied.

The all clear/ nothing found will be given by the search party to the Communication Center who will

then notify all persons involved that an ‘all clear’ has been called.

DOCUMENTATION: Documentation of the bomb threat events will be completed by Safety

Director and directed to the Superintendent.

BOMBING EVENT: In the event of a Bombing Event (damage occurred), the Incident Command

System (disaster) will be activated by the Superintendent.


32

Elopement

RED ALERT- SHELTER IN PLACE

Procedure

An elopement has occurred when a patient is not accounted for, has left grounds without permission,

fails to return from an off grounds pass, or leaves from an off ground activity.

1. When an elopement occurs, staff will contact the Communication Center immediately

(3190/3290/2702). An accurate description of the patient should be given including clothing

worn, place last seen and any known circumstances regarding the elopement.

2. Communication Center will:

Call CODE E and give instructions, “Staff and patients shelter in place and call in head

count”

Notify Security

Notify cottages

Notify Logansport Juvenile Correctional Facility

Notify INDOT

Cancel the Code E when it is safe to resume normal activities. (Notify all of the above)

3. DON/ADON/Nurse Supervisor will:

Report to the Communication Center to assist with managing the event

Contact Cass County Sheriff’s office and the Indiana State Police

Secure the scene: ensure that any clothing left at the sight is not touched

Notify Superintendant/Designee; DON; SLM of the unit involved

Collect staff statements, complete elopement form, notify family/guardian

Follow DMHA notification procedures

4. Staff will:

Remain with your patients wherever you are (shelter in place). You do not need to return

to the unit.

Call Communication Center with patient head count. Staff having patients with them in an

activity out of the building will call the Communication Center with their patient head

count from where they are located.

Staff with patients on the unit in activities will call the Communication Center with patient

head count.

5. Employees may only leave hospital grounds to purse the patient if within line of sight.

Patients who are within line of sight and apprehended on grounds will be returned to the

facility by security.

Employees are not to leave grounds to search for a patient not within the line of sight. If a

patient leaves an article of clothing, staff is not to touch it as it may interfere with the

investigation if a detection dog is used by law enforcement. One SA may remain at the

point patient was last seen until law enforcement arrives.

If the patient is located off grounds, law enforcement will transport the patient back to the

facility.

Documents

EMERGENCY OPERATIONS PLAN 2015-2016 - in.gov Emergency Operations Plan 2015.pdf · The Logansport State Hospital Emergency Operations Plan is designed to outline the basic infrastructure