Policies and Plans

1.0 Policy Statement

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment. 

We will follow the R-A-C-E acronym to safely evacuate residents/clients:

R - Rescue (remove persons in the most immediate danger first)

A - Alarm (ensure the alarm is sounding, or pull if you are first to see fire)

C - Contain (contain smoke to a smaller area by closing windows and doors)

E - Evacuate (continue to evacuate persons beyond the area of danger)

2.0 Purpose

The purpose of the Code Red policy and procedure is to define the process for response in case of fire, a fire alarm or smell of smoke.

3.0 Alarm Systems

A) Fire Panel:

• A fire panel is located on each home area in the communication centre.
• A master panel, for the entire home, is located by the main entrance of the building.
• A localized beeping sound at a panel indicates an interruption in the fire sytem. Examples of interruptions can include: low pressure in sprinkler, a system has been by-passed.

B) Stage 1 Alert (Code Red):

• Loud facility wide alarm
• Alert to notify staff there is a potential fire (opportunity for verification)

C) Stage 2 Alert (Code Green):

• Loud facility wide alarm that is the same tone, but a faster frequency than Stage 1.
• Alert to notify staff that an evacuation is required.

4.0 Initiating a Code Red

Any person can immediately initiate a Code Red by activating/pulling a fire alarm pull station.

Note: If alarm sounds (even if at change of shift), all staff must remain on premises until "all clear" is announced in order to assist with evacuation of residents/clients, if necessary.

5.0 Procedure (All Staff)

A. Discovery of Fire

• Remain calm and reassure resident/clients and visitors.

If you are in a room when the alarm sounds:

• Before opening the door; feel the bottom of the door for heat with the back of your hand (start low and move hand upwards).
• If the door is not warm, feel the door knob with the back of your hand.

If the door is not hot:

• Crouch low and brace yourself against the door and open slightly.
• If no fire or smoke is detected, evacuate room, close door and move to the dining room or location as designated by the registered staff/person in charge.

If the door of the room is hot or if hot air is felt when opening the door slightly:

• Close the door.
• Keep the door unlocked to allow for entry of fire fighters.
• Call RN or reception during business hours. They will notify the fire fighters.
• Seal all cracks where smoke can get in (e.g. use wet towels, clothing).
• Reception or RN to page overhead.

If you cannot leave the area you are in or have returned to it because of fire and/or heavy smoke:

• Go to a room with a door and a telephone (if possible).
• Close the door and remain in the room.
• Keep the door unlocked for entry of fire fighters.
• Call RN or reception during business hours. They will notify the fire fighters.
• Seal all cracks where smoke can get in.
• Reception or RN to page overhead.

B. Code Red Announced Specific to Resident Areas: Key Activities

Fire announced in your assigned area:

• Return to your work area to assist with ensuring safety of residents/clients, unless you are with a resident/client.
• Use stairs - not elevators. Use the access code to enter the stairs.
• Follow direction from the RN/RPN in charge and fire department upon their arrival.
• Use the R-A-C-E acronym to safely evacuate residents/clients.
• Ensure resident/client rooms and washrooms have been searched (behind doors, in closets and under beds).
• Evacuation alert signs are turned up if the room is empty. Leave evacuation alert signs down if resident/client remains in the room and report to RPN in charge immediately.
• Gather residents/clients to a safe common area outside the fire area (e.g. dining room, resident wings as directed) as directed by person in charge.
• Help RPN in charge as assigned:
  • Close windows and doors in areas outside the fire zone.
  • Clear all exits and corridors of obstacles.
  • Turn lights on.

Fire announced, but not in your assigned area:

• Listen for Code Red announcement for fire location.
• If working in a resident home area or CAP, remain with the residents/clients.
• If you are not on your home area at the time of the alarm return to your home areas immediately.
• If working in a non-resident home area/program, but have residents with you, remain with residents.
• If working in a resident home area or CAP, report to your area leader for direction.
• If you do not work in a resident home area or CAP, report to Control Centre for direction.
• Ensure safety of residents/clients.
• If on a non-home area with a resident (e.g. Hair Salon, Gift Shop, Chapel, Heritage Hall) stay with them and prepare a list of names for the person in charge of the Control Centre.
• Be prepared to evacuate if necessary.

Remember:

• Use stairs - not elevators.
• Remain calm and reassure clients and visitors.

Control Centre will be set up at reception, unless reception is the fire area, in which case the Control Centre will be set up in the Classroom (announced overhead).

C. Code Red Announced in Non-Resident/Client Area

• Follow the R-A-C-E acronym to safely evacuate residents/clients
• Follow direction from the RN/RPN in charge and Fire Department upon their arrival.
• Use stairs - not elevators.
• Remain calm and reassure clients and visitors.

Roles and Responsibilities: Role of the RN and RPN

Role of the RN in Charge of Fire Area

Note: Refer to Policy 12-86 for the role of Registered Staff in Supportive Housing.

Upon hearing Stage 1 fire alarm, the RN shall:

1. Check closest enunciator panel for location of fire.
2. (redacted)
3. Go to the fire area, using stairwells to provide direction. 
4. Check to determine if fire exists. If any indication of fire (smoke, heat, flames) is detected, escalate to second stage.
5. (redacted)
6. Page Code Green three times, indicating area of evacuation (if required). Note: Stairwell and exit doors unlock when Code Green is activated.
7. Call the Fire Department to update on status.
8. Provide direction and communicate with the RPN in charge of the area.
9. Communicate with the RN in charge of Control Centre.
10. Contact Manager on Standby.
11. In collaboration with the Manager on Standby and the Fire Department, determine if Voicenet or the emergency fan-out list should be implemented.
12. Call maintenance staff on call, if after hours.
13. Page Code Red (and Code Green, if applicable), All Clear, three times, when the situation is over, and all residents have been accounted for, or as directed by the fire department.
14. Complete fire drill (#12-60-A) report and forward to Coordinator, Staff Education and Quality Improvement and Risk Management.
15. Update communications and messaging if/when circumstances to the emergency change.

Role of the RPN in Charge of Fire Area

Upon hearing Stage 1 fire alarm, the RPN shall:

1. Wear vest to be easily identifiable.
2. Return to home area if not already there.
3. Take charge of the home area and remain in visible location.
4. Advise RN if a real fire exists (if determined prior to their arrival).
5. Coordinate the fire procedures by directing staff to prioritize the room/location of the first first, and then remainder of wing/area.
6. Remind staff how to safely check doors before opening, to enter a room to be checked (i.e. use back of hand, start at the bottom, check handle last if door is not hot, crouch down and open slowly if handle not hot).
7. Communicate with RN at Control Centre to send more staff, if needed.
8. Ensure resident rooms have been fully searched (behind doors, in closet, washroom, under beds) and evac-alert signs are turned up, if resident remains in room.
9. Remind staff not to cross in front of fire if the fire is not contained in a room where the door is closed.
10. Determine most appropriate place for staff to bring residents, ensuring they are moved beyond a fire door (ensure easy access and movement by Fire Department).
11. Report any issues to the RN (for example, residents who are unable to be evacuated from the fire area).
12. Take roll call of residents, using the census located in the emergency fire box and account for all residents on the home area.
13. If safe to do so, have staff re-check Evac alert signs to ensure evacuation complete.
14. If code green is called, coordinate evacuation of residents and prepare to move resident charts and medication cart.
15. If code green is called, assign staff members to watch exit doors to ensure residents do not leave the floor unattended.

Role of RN in Non-Fire Area

Upon hearing Stage 1 fire alarm the RN will:

1. Check closest enunciator panel for location of fire.
2. (redacted)
3. (redacted)
4. Ensure that CAP staff and Supportive Housing staff are kept informed of the situation.
5. Ask Security to unlock reception (if locked) and obtain the fire vest from emergency fire box.
6. Use the Control Centre Emergency Procedures Checklist (DOCS#288170), stored in the emergency fire box at reception to assign staff to emergency tasks. Complete the checklist.
7. Advise non-emergency callers to call back as we are having a fire alarm.
8. Assign staff/Security to meet fire department at the main entrance and escort them to the fire area to connect them with the RPN in charge of the fire area.
9. The staff person/Security will return to Control Centre to give report of fire situation to RN in charge of Control Centre.
10. Assign staff to check public areas and ensure safety of residents and visitors, as per checklist.
11. Assign staff to areas of the home as needed as per request from RPN in charge of fire area to assist in the fire area.
12. Maintain contact and take direction from RN/RPN in charge of fire area.
13. In maintenance is not yet on site, silence the panel when the all clear has been paged and on direction of the Fire Department. Do not reset the fire panel (maintenance will do so, on direction from the Fire Department).
14. Complete Control Centre Emergency Procedures Checklist (DOCS#288170) and forward to Coordinator, Staff Education.

Role of RPN in Non-Fire Areas

Upon hearing Stage 1 fire alarm the RPN will:

1. Remain in home area with residents, unless sent to assist in the fire area.
2. Assign staff members to watch exit doors until "all clear" is paged, to ensure residents do not leave the home area.
3. If night shift, send PSWs to assist in area of fire, and RPN to oversee both home areas.
4. Take roll call of residents to ensure all are accounted for.
5. Remain calm and reassure residents and staff.
6. Prepare to move medication and resident charts.

Role of Other Staff

• Community Alzheimer Program Staff
  • Follow the same procedures as in resident/client areas described above
• Laundry Staff
  • Turn off electric and gas-powered equipment if required
  • Exit the area and proceed to the Control Centre
• Housekeeping Staff
  • Turn off equipment and remove from corridors
  • Exit the area and proceed to the Control Centre
• Main Kitchen Staff
  • Turn off electric and gas-powered equipment
  • If the fire is in the kitchen, ensure activation of the hood suppression system
    • if fire suppression system for the exhaust hood is not automatically activated by the fire detectors, it can be manually activated in an emergency
    • to activate, go to the wall across from cart wash; locate the fire suppression switch; pull the manual release and leave the kitchen immediately
    • use only in case of fire in main cooking area
    • everyone must leave the area if the kitchen fire suppression system is activated
  • Exit the area and proceed to the Control Centre
• Maintenance Staff
  • If the fire is in mechanical room B-107 Franklin Building, one person from maintenance staff will proceed outside and turn off gas valve at the meter
  • At the sound of the fire alarm, a maintenance staff takes the nearest fire extinguisher and proceeds to the fire location to be assigned duties by the person in charge
  • If the fire is in the main kitchen or laundry area, a maintenance staff will shut off gas valves in the corridor outside the area
  • When emergency is over, re-set fire alarm system and the door security system as directed by the fire department/person in charge
  • Ensure discharged extinguishers are taken to maintenance supervisor/delegate for re-charging

6.0 Debrief

The Director/Administrator will lead of assign a delegate to lead the debrief.

The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident, as applicable.

Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff, residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety).

The debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence. 

References:

Code Green - Evacuation 6-10, Emergency Manual

Master Manual 1-10, Emergency Planning

Master Manual 5-100, Critical Incident Reporting

1.0 Policy Statement

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment.

2.0 Purpose of Code Green (Evacuation)

The purpose of CODE GREEN is to move residents from an area of danger to an area of safety. Situations that may require evacuation include, but are not limited to fire, structural damage, a chemical spill, a gas leak, flooding, or a bomb threat. The situation will determine what type of evacuation is ordered.

3.0 Evacuation Types

Evacuation types are provided in the below. Reference section 5.0 for triage and relocation options for offsite evacuation.

• Partial Evacuation of Building
  • Horizontal Description: The removal of people from the area of danger, to a safe area on the same floor.
  • Vertical Description: The removal of people from the area of danger using the stairwell to a lower level/ground level.
  • Why Partial or Complete Evacuation is Called: This is used when the concern or problem is only occurring in a home area or one part of the Home.
• Complete Evacuation of Building
  • Description: The removal of all people from a building to another location.
  • Why Partial or Complete Evacuation is Called: Only considered when staying in the Home causes a greater risk than leaving. Risk may be related to physical harm and/or exposure to a dangerous substance. Causes of risk may be due to events, such as a large scale fire or structural damage.

Note: If a room is designated for a new admission and the resident has not yet arrived; the admission will be put on hold and priority will be given to residents being relocated until the emergency is over.

See Appendix 1 for an illustration of Evacuation Flow.

Any staff can request a CODE GREEN by notifying the RN in charge. The RN in charge makes the decision if the evacuation will be horizontal or vertical in nature.

The decision to move to a partial or complete building evacuation, from the building, is made by the RN in Charge in consultation with Management and/or Emergency Services. 

If the Fire Department is onsite, they will determine whether a CODE GREEN is required and if the risk presented requires partial or complete building evacuation. 

Activating CODE GREEN will result in other workers coming to assist, including security and responding emergency services.

5.0 Options for Evacuated Residents

Relocation options available for residents who are displaced due to a building evacuation, include:

• Hospital
• Family/friends
• Other LTCs
• Hotels
• Reception Centre (municipal facility)

5.1 Reception Centre

Reception Centres are facilities designated by the Region of Waterloo and local municipalities for use as emergency evacuation sites. These sites are used as a place for residents to reside until a more permanent location can be found.

5.2 When to Use Reception Centre

Residents should only be moved to a reception centre (Municipal facility) if:

• There is no time to triage resident's needs beyond the first priority of immediately evacuating the building.
• All other relocation options have been exhausted or reached capacity.

See Appendix 2 for a summary table to support decisions for triaging residents.

5.3 Activating Emergency Reception Centres

The RN in Charge (in consultation with Management and/or Emergency Services) determines if an emergency reception centre needs to be activated.

Fire or Police Services will contact the Region's Community Emergency Management Coordinator (CEMC) to open the facility. If fire/police do not have time to contact CEMCs, they may open the community centre themselves.

The process, as described above, is guided by the Region's Emergency Social Services Plan (ESSP).

5.4 Roles and Responsibilities

The following roles and responsibilities exist for both partial and complete evacuations.

Staff who identify the incident:

• Ensure your safety and residents' safety first
• Isolate the area of concern and do not let others in
• Call RN in Charge to notify of the situation

RN in charge:

• The decision for a horizontal or vertical evacuation within the building is made by the RN in Charge or Emergency Services in consultation with the Standby Manager or Senior Management.
  • In the event that the Fire Department is onsite the decision to evacuate will be made by them.
• Call 911 and report incident, providing as much information as possible (i.e. location, type of incident, number of people affected).
• Use the pull station key on the RN keyring (insert and turn to right: 1/4 turn).
• Page overhead "CODE GREEN" three times. In your message include: area to be evacuated and location to evacuate to.
• Notify Security.
• Communicate with the RPN in charge of the area to be evacuated.
• The RN, in the area of evacuation, communicates with and updates the RN in charge of the Control Centre.
• The RN in Charge (in consultation with Management and/or Emergency Services) determines if an emergency reception centre needs to be activated.
• The RN in Charge or a Manager/Standby Manager, initiate the emergency call in procedure.

RN in Non-Evacuation Area Acting as: RN at Control Centre

• Responsible for establishing a Control Centre at reception or alternate area (if reception is unsafe).
• Follow the Control Centre emergency procedures Checklist (in the emergency box at reception).
• Maintain communication with the RN in Charge at location of evacuation.

RPN (Area of Evacuation)

• Takes direction from RN in Charge.
• Responsible to direct the evacuation of their unit.

Security

• Calls 911, if not already done
• Responds to initial incident and document details as possible
• Supports with evacuation as much as possible
• Calls security dispatch to inform them of the situation an provides updates

Manager, Resident Care/Alternate (Support from Manager of Business Operations and Social Work, as required)

• Manages staffing responsibilities and deploys staff, ensures residents are accounted for, safe, and monitored during evacuation.
• Ensures medications, necessary medical supplies, and resident charts and laptop computers are removed and sent to new locations with residents.
• Facilitates a list of all supplies and equipment taken offsite (e.g. wheelchairs, walkers, portable oxygen)
• Delegates record-keeping for destination of each resident.
• Facilitates collecting consent from residents for relocating them to evacuation destinations (if required).
• Collaborates with Home and Community Care Support Services (HCCSS) to create tracking document of all residents requiring evacuation (including all residents).
• Facilitates completion of the Evacuation Placement Form and Resident Information sheets and shares with HCCSS.
• Contacts Home and Community Care Services to request the following:
  • Dedicate Placement Coordinators, and necessary support staff, to facilitate emergency management activities. Support for placing residents based on current vacancies.
  • Obtain consents from Sunnyside (if able/appropriate), for resident admission authorization to homes where residents are placed (for residents currently receiving services). An expedited process for all residents at the time of the evacuation will be used should residents be transferred to a community location (LTCH, Care Partner's residence, Retirement Home).
  • Contact residents/families to review options.
  • As appropriate HCCSS will collaborate to share all required documents/information to support transfer of accountability and facilitate patient care.
  • Facilitate meetings with LTCs that will receive residents (i.e. case conferences to enable seamless transfer).
• Upon resident return to Sunnyside:
  • Notify Home and Community Care Services that residents that have been moved to other homes can safely return to Sunnyside. 
  • Designate a central control area for returning residents, staff and equipment.
  • Ensure checklists of residents and equipment are continually updated.

Manager, Business Operations/Alternate

• Notifies all staff (via Division wide email) about what happened and how they can help
• Notifies residents about what happened and what actions need to be taken (message confirmed with Manager of Care)
• Ensures families are notified via Everbridge about what happened and action to be taken (message confirmed by Director/Administrator/delegate)
• Ensures critical documents are gathered
• Ensures laptops with wifi capabilities are available

Facilities Management/Alternate

• Shuts down all equipment, as applicable
• Assigns person for traffic control of parking lot
• Turns off gas valves to prevent potential for explosion
• Upon resident return to Sunnyside:
  • Ensures all equipment is operational.
  • Ensures building is adequately ventilated.

Director/Delegate

• Notifies (and continue to provide updates) to Commissioner of Community Services.
• Liaises with Region of Waterloo Senior Management and Region of Waterloo Emergency Management.

Administrator/Delegate (Support from Manager of Care, Manager of Business Operations, as applicable)

• Collaborates with the Fire Department and police services.
• Notifies the Medical Director, Attending Physicians and Nurse Practitioner to indicate what happened, information about the plan and contact information for the Manager.
• Facilitates, as applicable, contractors and suppliers to inform of relevant changes to services or supplies.
• Provides corporate communications with relevant messaging for community if applicable.
• Provides Home's Communications Representative with key content to draft communication for residents, families and staff.
• Upon return to Sunnyside:
  • Ensure appropriate individuals or authorities have inspected and approved the area/home for residents to return.
  • Notify MLTC regarding return.
  • If required, submit Clearance documentation to the SAO. Clearance documentation may have been provided by Fire Department, Building Department, Public Health or any other authority involved in the emergency.
  • Ensure Managers are prepared to resume operations (e.g. staffing supplies, equipment, etc.)
  • Notify families about time and date of return , re-admission of residents who have been staying with families.
  • Ensure equipment is returned to the appropriate areas.
  • Lead or assign a delegate to lead the debrief.

Environmental Services/Alternate

• Assembles emergency supplies are necessary (e.g. blankets, sheets, etc.).
• Upon resident return to Sunnyside:
  • Ensures resumption of operations.

Manager Food and Environmental Services/Alternate

• Shuts down all equipment.
• Assemble and send emergency supplies as necessary:
  • Plastic plates, cups, and cutlery.
  • Draw on pandemic supplies, as applicable.
• Facilitate collection and shipment of non-perishable food supplies, including; but not limited to:
  • Bottled water.
  • Bread (peanut butter and jam).
  • Other (depending upon duration and need).
• Communicate special diets for residents (approx. 150) to care staff: consider triaging resident placement based on diet needs, as applicable and possible.
• Upon resident return to Sunnyside:
  • Arranges for a meal or snack for returning residents.

Admissions and Social Work/Alternate

• Assists in notifying families.
• Works with resident care team, as required.
• Upon resident return to Sunnyside:
  • Re-establishes routines as soon as possible.

Home and Community Care Services

• Dedicates Placement Coordinators, necessary support staff to facilitate emergency management as necessary.
• Sends communication to all LTCs in the area about the emergency and put all bed matches temporarily on hold.
• Supports placing residents from Sunnyside if required.
• Facilitates a meeting with all homes receiving residents to answer questions.
• Facilitate meetings with LTCs that will receive residents (i.e. case conferences to enable seamless transfer) and enables the waitlist process as needed.
• Contact residents/families to review placement options if needed.
• Obtain consents from Sunnyside (if able/appropriate), for resident admission authorization to homes where residents are placed (for residents currently receiving services). An expedited process for all residents at the time of the evacuation will be used should residents be transferred to a community location (LTCH, Care Partner's residence, Retirement Home).
• Employs the use of a tracking document to identify which residents have open files.
• Upon receipt of Evacuation Placement Form, from Sunnyside; HCCSS ensures completion of EPF. HCCSS to review, update systems and submit to MLTC.

Grand River Transit (GRT) (includes regular and Mobility +)

• Notified by Police/Fire on site, as required.
• Community Emergency Management Coordinator (EMC) may request: transportation from Sunnyside to alternate locations (including Mobility+ transportation for special needs as required)
• Consideration will be given to transporting staff, students, and volunteers as applicable/required.

Region of Waterloo Corporate Communications

• Work with Sunnyside Home on messaging to the public and media.

6.0 Communications

Remember to update communications and messaging if/when circumstances to the emergency change. See below for responsibilities, messaging and the audiences tat are communicated with.

• Senior Management Staff/Standby Manager notifies Director, Seniors' Services and Administrator. Messaging includes what has happened and action to be taken.
• Director/Alternate notifies Commissioner of Community Services and Senior Management and Region of Waterloo Emergency Management. Messaging includes what has happened and action to be taken.
• Administrator/Alternate notifies:
  • Staff - Messaging includes what has happened and how they can assist.
  • Residents - Messaging includes what has happened and actions to be taken.
  • Families (via Everbridge system) - Messaging includes what has happened and how they can assist.
  • Ministry of Long-Term Care - With support from Manager of Care, messaging includes what has happened, the type of emergency, and initial steps taken.
  • Home and Community Care Services - With support from Manager of Care, messaging includes a description of what has occurred, the type of emergency, initial steps taken and the initial plan, name and phone number of contact at Sunnyside Home for return call, and what is needed from Home and Community Care Services.
  • Attending Physicians, Medical Director, and Nurse Practitioner - With support from Manager of Care, messaging includes type of emergency, initial plan, and manager responsible for ongoing communication and placement decisions.
• Management Staff/Standby Manager notifies:
  • Ministry Service Area Office (SAO) Manager - Messaging includes alert of the emergency, maintain communication throughout the emergency, and submit Clearance documentation, if required.
  • Home and Community Care Services - Messaging includes notification that residents moved to other homes can return to Sunnyside.
• Corporate Communications notifies the media. Communication/message shared by Director of Seniors' Services and Administrator. Messaging as applicable and relevant based on need an inquiry.

7.0 Safety Procedures: Assistance to Evacuate Safely

Most residents will require assistance to evacuate safely.

The following are the procedures for evacuation of persons requiring assistance:

• Staff are to assist residents in the home areas as directed by the RPN/RN.
• Based on the degree of danger, staff will move residents to an area of safety (e.g. dining room) on the home area or off the home area.
• Whenever possible, people should be moved to the exit with their assistive devices (e.g. wheelchairs, crutches or scooters) as they will require these devices once outside the building.
• The device(s) should remain on the floor if too heavy or large to be transported.
• If a resident remains in their room, position room evacuation tag accordingly; and report to the RN in charge immediately.

8.0 Debrief

The Director/Administrator will lead or assign a delegate to lead the debrief. 

The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident, as applicable.

Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff, residents and substitute decision makers, volunteers, students, and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety).

The debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence.

9.0 Education

Education and testing of this policy is provided as per policy 1-10, Emergency Planning.

10.0 References

External Reference Documents:

• The Guide on Policy, Process, and Procedures during Emergency Evacuations, Ministry of Long-Term Care, 2021. Emergency Manual, DOC: 3773027.
• Lakeridge Health Code GREEN Policy.
• Ontario Hospital Association - Development Guidance Documents.
• Ontario FLTCA, 2021. Regulation 246/22.
• Government of Canada: Hazards and Emergencies (website): https://www.getprepared.gc.ca/cnt/rsrcs/pblctns/rthqks-wtd/index-en.aspx

Appendix 2: Triaging of Residents

First Triage Group

• Resident needs profile: High acuity (e.g. medical needs, palliative, elopement risk, responsive behaviours)
• Initial relocation option: Hospital
• Secondary relocation option: Other LTC
• Transportation option: Ambulance
• Approx. Percent of Residents: 60%

Second Triage Group

• Resident needs profile: Needs can be met by family safely at home
• Initial relocation option: Family caregiver's home. If no time permitted, evacuate to Stanley Park Community Centre
• Secondary relocation option: Family caregiver's home
• Transportation option: Private vehicle, Sunnyside van, Mobility Plus, other accessible transportation, GRT busing
• Approx. Percent of Residents: 10%

Third Triage Group

• Resident needs profile: Mobility issues requiring mechanical lift, cognitive impairment
• Initial relocation option: Reception Centre (Municipal Facility)
• Secondary relocation option: Other LTC
• Transportation option: Mobility Plus, other accessible transportation
• Approx. Percent of Residents: 25%

Fourth Triage Group

• Resident needs profile: Require minimal care and mobility assistance, with minimal to no cognitive impairment
• Initial relocation option: Reception Centre (Municipal facility)
• Secondary relocation option: Hotel with service/support setup, Reception Centre (Municipal facility)
• Transportation option: GRT busing, private bussing
• Approx. Percent of Residents: 5%

Note: To access the most recent resident profile.

1.0 Policy Statement

This policy outlines the response and related accountabilities in the event of an actual or possible Natural or Community Disaster/Extreme Weather event.

2.0 Natural or Community Disaster/Extreme Weather

A Natural or Community Disaster/Extreme Weather event, or alert, may take the form of one or more of the following occurrences: a flood, a tornado, a hurricane, a severe thunderstorm, extreme heat, or an earthquake.

3.0 Roles and Responsibilities

A. Initial Identification of Risk Event and Notifications

Staff who identify the incident

• Ensure your own and residents' safety first (see Appendix 1).
• Isolate the area of concern and do not let others in.
• Call RN in Chare or Member of Management Team/Standby Manager to notify of situation.

RN in Charge or Member of Management/Standby Manager

• Stay tuned to the local radio, television or weather website for related advisories.
• Page event details to inform organization of the event.
• Call 9-911 or pull the fire alarm:
  • Provide name and address of location.
  • Name of Most Responsible person: Management or Registered Nurse in Charge.
  • Provide essential details.
  • Call ambulances if required.
• Call Maintenance person on call after regular hours, or call Supervisor of Maintenance on call.

B. Respond to Event

Security

• Calls 911, if not already done.
• Responds to initial incident and document details as possible.
• Supports with management of event as much as possible.
• Calls security dispatch.

Manager, Resident Care/Alternate

• Manages staffing responsibilities and deploys staff as applicable.
• Ensures that resident charts and medications are accessible.
• Ensure that emergency first aid services are available and assigned to an agreed upon location(s).
• Contacts MLTC to share information about what happened, the type of emergency and initial steps taken, if applicable.
• Update communications and messaging if/when circumstances to the emergency change.

RN in Charge

• Completes census of residents/tenants/clients to ensure that persons are accounted for.
• Ensures that at least one staff remains on each house, on all home areas, (if safe and feasible to do), until ALL CLEAR is sounded over the P.A. system.
• Collaborates with the Fire Department and police services.
• Facilitate relevant action items, as per Appendix 1.

Manager, Business Operations/Alternate

• Notifies all staff about what happened and how they can help.
• Notifies residents about what happened and what actions need to be taken (message confirmed with Manager of Care)
• Ensures families are notified.
• Ensures critical documents are gathered.
• Ensures laptops with wifi capabilities are available.
• Update communications and messaging if/when circumstances to the emergency change.

Manager, Food and Environmental Services

• Secures perishables and initiates emergency plan for food services.
• Ensure that essential supplies, both perishables and non-perishables, are moved from storage rooms to a safe location to avoid damage/loss, as applicable.

Facilities Management/Alternate

• Reference policy, Maintenance Communications: System Failure/Organization Risk. The policy outlines key communication guidelines for Maintenance staff (and relevant stakeholders) in the event of an organizational system failure or issue that poses risk to the organization, residents, tenants, clients or staff.
• Key tasks include, but are not limited to:
  • Come on site to support.
  • Shuts down all equipment, as applicable.
  • Assigns person for traffic control of parking lot, if applicable.
  • Secure outside objects (e.g. chairs, windows), if applicable and safe to do so.
  • Facilitate receipt of necessary services and required goods.
  • Notifies, as applicable, contractors and suppliers to inform of relevant changes to services or supplies.
• Upon resident return to Sunnyside:
  • Ensures all equipment is operational.
  • Ensures building is adequately ventilated.

Director/Delegate

• Notifies (and continue to provide updates) to Commissioner of Community Services
• Liaises with Region of Waterloo Senior Management and Region of Waterloo Emergency Management

Administrator/Delegate (Support from Manager of Care)

• Collaborates with the Fire Department and police services
• Notifies the Medical Director, Attending Physicians and Nurse Practitioner provides information about the plan and contact information for the Manager.
• Provides corporate communications with relevant messaging for community, if applicable.
• Provides Home's Communication Representative with key content to draft communication for residents, families and staff. Updates must be shared at the beginning of the emergency, if there is a significant status of change and when the emergency is over.
• Update communications and messaging if/when circumstances to the emergency change.

4.0 Debrief

The Director/Administrator will lead or assign a delegate to facilitate the debrief.

The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident.

Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff, residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Health and Safety).

The debrief will serve to commence an evaluation of emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence.

Appendix 1. Considerations for action based on the event type and severity

Potential Action Items

• Flood:
  • Ensure all persons are indoors
  • Shut off all electrical, furnace, gas and water, and disconnect appliances
  • Move all persons to higher ground (top level of facility)
  • Move valuables/essential products from basement to upper floors
  • Raise large appliances up on wood or cement blocks
  • Tie down or bring in outdoor objects
  • Evacuate when instructed to do so by local authorities
• Tornado:
  • Ensure all persons are indoors
  • Move persons to lowest level possible
  • Avoid sheltering persons in a room with windows
  • Evacuate when instructed to do so by local authorities
• Hurricane:
  • Ensure all persons are indoors
  • Secure windows and doors
  • Move electronics and valuables away from windows
  • Close windows
  • Secure outdoor objects or bring them indoors
  • Close all blinds
  • Move persons away from windows
  • Move persons to interior sections of building (hallways) or to lowest level of building if possible
  • Evacuate when instructed to do so by local authorities
• Severe Thunderstorm:
  • Ensure all persons are indoors
  • Avoid using electronic devices connected to an electrical outlet
  • Avoid running water
  • Evacuate when instructed to do so by local authorities
  • If you need to use a phone, only use a cordless phone
  • Move persons away from windows and glass doors
• Earthquake:
  • Ensure all persons are indoors
  • Drop under heavy furniture such as a table, desk, bed or any solid furniture
  • Cover persons head and torso to prevent being hit by falling objects
  • If person can't get under something strong, or if you are in a hallway, flatten or crouch against an interior wall and protect your head and neck with arms
  • If you are in a wheelchair, lock the wheels and protect the back of your head and neck
• Extreme Heat:
  • Ensure all persons are indoors
  • Check for conditions of heat-induced illness including heat rash, heat syncope, heat cramps, heat exhaustion, and heat stroke
  • Ensure that external doors (including patio doors) are not propped open
  • Encourage use of lightweight clothing and discourage use of heavy blankets and coverings
  • Increase fluid consumption if tolerated
  • Reference Heath Related Illness and Prevention Management policy, 7-210

1.0 Policy Statement

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment.

2.0 Purpose

The Code Brown Policy provides guidelines in the event of an internal chemical spill or release. 

The policy outlines the two stages of chemical spills/release and procedures which will lead to safe containment, clean-up and disposal.

3.0 Chemical Spills/Release Stages and Procedures

Stage 1: Chemical Spill or Release (Response by Department/Home Area)

Some spills/releases can be handled by department/home area staff.

Examples of Stage 1 spills/releases include:

• small volume (less than 1 litre)
• identifiable substances
• do not pose threat of irritation to skin, eyes or lungs
• can be cleaned up with water and all purpose and/or disinfectant cleaner
• do not require personal protective equipment other than gloves and goggles
• do not require an evacuation

Stage 1: Procedure

Staff Finding Chemical Spill/Release

• Contact Housekeeping/Resident Home Assistant for assistance, as needed.

Housekeeping or Resident Home Assistant

• Initiate clean-up as per product instructions or Safety Data Sheets (SDS).

Stage 2: Code Brown (Response by Fire Department)

If after assessment the spill/release is deemed to be:

1. a health hazard
2. a fire hazard, or
3. an environmental hazard

Management or the RN in Charge is notified and the Fire Department is contacted to lead safe containment, clean-up and disposal.

Examples of Stage 2 spills/releases include:

• large volume (greater than 1 liter)
• hazardous or unidentifiable substance
• cause skin, eye or lung irritation
• require appropriate personal protective equipment to clean up
• release, or potential for release, to the outside environment
• cannot be cleaned-up with water and all-purpose and/or disinfectant cleaner or require special clean-up procedures or materials not available in the department
• may require evacuation of the immediate spill/release area

Stage 2: Procedure

Staff Finding Chemical Spill/Release

• Contact Management or RN in Charge and provide as much information as possible (i.e. location, details of chemical spill/release and any injury, if applicable)
• Under direction of Management or the RN in Charge:
  • Secure area and safely evacuate/direct all persons from the immediate vicinity
  • Prevent the spread of vapours/fumes by closing door(s) and interior window(s)
  • Leave all electrical equipment alone, do not turn anything on or off (including the light switches)

Maintenance

• See policy, Maintenance Communications: System Failure/Organization Risk
• This policy outlines key communication guidelines for Maintenance staff (and relevant stakeholders) in the event of an organizational system failure or issue that poses risk to the organization, residents, tenants, clients or staff.

4.0 Follow-Up and Documentation: Post Code Brown (Stage 2)

Once the Fire Department indicates Code Brown is all clear, Management or the RN in Charge/delegate will facilitate the following actions:

• Page "Code Brown All Clear"
• Notify Director and Administrator
• Ensure all relevant documentation is completed (i.e. Risk Report, HR 18s)

5.0 Debrief

If the incident was a Stage 2 chemical spill/release the following actions should be followed specific to a debrief.

• The Director/Administrator will lead or assign a delegate to facilitate the debrief.
• The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident.
• Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff, residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety).

The debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use of information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence.

1.0 Policy Statement

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment.

2.0 Purpose

This procedure outlines actions to be taken in the event of a natural gas leak (Code Brown). The procedure outlines the accountabilities of Staff, Management, the Registered Nurse in Charge, and Maintenance.

3.0 Procedures: Gas leak or fumes

Staff Finding Gas Leak or Fumes

• Contact Management or RN in Charge and provide as much information as possible (i.e. location, details of gas leak or fumes and any injury, if applicable). 
• Under direction of Management or the RN in Charge will:
  • Secure area and safely evacuate/direct all persons from the immediate vicinity.
  • Prevent the spread of vapours/fumes by closing door(s) and interior window(s). Exception: Do not close doors to the immediate area. Closing doors to the area could lead to a spark that causes an explosion.
  • Leave all electrical equipment alone. Do not turn anything on or off (including the light switches).

Management or RN in Charge/Delegate

Management or RN in Charge to lead or facilitate the following:

• Dial 9-911 for response by Fire Department Page "Code Brown".
• Notify Director and Administrator.
• Notify Maintenance.
• Direct staff to stay away from location of Code Brown and to assist with procedural items below:
  • Secure area and safely evacuate/direct all persons from the immediate vicinity.
  • Prevent the spread of vapours/fumes by closing door(s) to rest of building and interior window(s).
  • Leave all electrical equipment alone, do not turn anything on or off (including the light switches).
  • Remind all persons not to smoke in area as there is a potential for explosion.
• After front line emergency response procedures are notified and underway (9-1-1, Sunnyside staff engaged in response); notify the Community Emergency Management Coordinator (CEMC) of the incident and current situation. The CEMC will assess broader notification and available resource options.
• Notifies corporate Community Emergency.
• Ensures support for persons who experience distress post emergency is offered. This may take the form of a debrief/follow-up call or meeting, or referral to the Region of Waterloo's Employee Assistance Program.
• Facilities return to normal operations.
• Update communications and messaging if/when circumstances to the emergency change.
• See section 5.0 for accountabilities once Code Brown is confirmed all clear.

Maintenance

• Notifies City of Kitchener Emergency Gas Service.
• Shut off all electrical and gas equipment if possible in kitchen, laundry, boiler rooms, etc.
• See policy, Maintenance Communications: System Failure/Organization Risk. This policy outlines key communication guidelines for Maintenance staff (and relevant stakeholders) in the event of an organizational system failure or issue that poses risk to the organization, residents, tenants, clients or staff.

5.0 Post Code Brown: All Clear

Once the Fire Department indicates Code Brown is all clear, Management or the RN in Charge/delegate will facilitate the following actions:

• Page "Code Brown All Clear"
• Notify Director and Administrator

6.0 Debrief

The Director/Administrator will lead or assign a delegate to facilitate the debrief.

The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident. 

Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff, residents, and substitute decision makers, volunteers, students, and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety).

The debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use of information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence.

1.0 Policy Statement

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment.

2.0 Purpose

This procedure is used to restrict entry of contaminated external air into the building - i.e. fumes from a toxic gas release. The procedure is normally implemented if there is insufficient time to evacuate the facility.

This procedure does not apply if contaminates are heavier than air, e.g. explosive gas may enter from underground (sewers, natural gas leaks, etc.). In this case, the building should be ventilated and building evacuation procedures would apply.

3.0 Procedures: Discovery or suspicion of contaminated external air

Facilities or Management onsite or the RN in Charge in consultation with Standby Manager (depending on time of notification)

• Performs a quick assessment of the situation
• Will immediately call:
  • Police at 9-911
  • Fire Department at 9-911, and
  • Page - Code Grey

Management or RN in Charge

• Notify Director and Administrator
• Facilitates/calls on staff to help with:
  • Shut all windows and exterior doors
  • Disable all automatic doors on the manual switch on the door frames
  • Place wet blankets at openings where air could leak into occlude fumes
  • Post staff at doors to minimize potential of entry of contaminated air
  • Ensures support for persons who experience distress post emergency is offered. This may take the form of a debrief/follow-up call or meeting, or referral to the Region of Waterloo's Employee Assistance Program.
  • Facilitates return to normal operations
• Note: remember to update communications and messaging if/when circumstances to the emergency change. 
• Facilitates the following actions once the code grey is over:
  • Pages "Code Grey All Clear" three times
  • Notify Director and Administrator

Maintenance Staff/Maintenance on Call

• Promptly shut down all ventilation equipment from the Building Automation System, located in the maintenance office lower level of the Kenneth Building.
• Please reference policy, Maintenance Communications: System Failure/Organization Risk. This policy outlines key communication guidelines for Maintenance staff (and relevant stakeholders) in the event of an organizational system failure or issue that poses risk to the organization, residents, tenants, clients or staff.

All Staff

• Shut all windows and exterior doors
• Disable all automatic doors on the manual switch on the door frames
• Place wet blankets at openings where air could leak into occlude fumes
• Post staff at doors to minimize potential of entry of contaminated air

4.0 Debrief

The Director/Administrator will lead or assign a delegate to facilitate the debrief. 

The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident.

Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety).

The debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence. 

Code White: Violent/Behavioural Threat (Inside/Outside the Building) (Policy# 3-100)

1.0 Policy Statement

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment.

2.0 Code White Definition and Purpose

A Code White response is used by staff to respond to situations where a person (e.g. resident/client/tenant/visitor/volunteer/staff) behaves in a way that threatens the safety of others.

Activating a Code White provides:

• A standard response for staff to manage potentially violent persons
• Necessary support to maintain or regain control of the situation
• The means to minimize risk of injury 
• Structure for notifying other staff
• Assistance to the potentially violent person to regain control of their behaviour

Staff are encouraged to call a Code White when they feel threatened and de-escalation strategies have been ineffective.

3.0 Activation and Procedure for Code White

A. Who Calls a Code White: Any/All Staff

All staff can activate the Code White response. 

B. Who Responds to a Code White (by location)

The Code White alert is sent to the phones or heard on the overhead paging system. If paged overhead, the message will be heard within the LTC Home, but not in Supportive Housing.

Location of the Code White and Who Responds:

• Kenneth and Franklin Buildings
  • Security
  • RN
  • Staff in the home area
  • RPN from opposite house
  • BSO Team
• Supportive Housing
  • Security
  • Community Alzheimer Program RPN
  • Supportive Living Assistants
  • RN
• Community Alzheimer Program
  • Security
  • Community Alzheimer Program staff
  • RN

C. Roles of Responders During Code White

In a Code White situation, it is important to:

• Always remain calm and speak in a calm, soothing voice
• Stay at least a leg length away from a violent person
• Ensure that person does not get in between you and the exit door
• Never try to confront or control a violent person

Any/All Staff

• Activate the Code White
• If safe, redirect/distract (if the person is a resident)
• Help others to safety
• Wait in safe location for help
• Participate in debrief

Code White Lead: RN/RPN

• The Code White Lead will be the RN/RPN of the area where the Code White is called
• Contact police, if required
• Remove hazards and others from harm
• Determine level of response by Security
• Monitor/direct people responding
• Assign the Code White Negotiator
• Bring any medications required to the scene
• Note: Remember to update communications and messaging if/when circumstances to the emergency change.

Code White Negotiator: RN/RPN/BSO/Delegate

• The person communicating directly with the escalated person. This is the person who has the best rapport with the person
• Employ a Gentle Persuasion Approach, or Non-violent Crisis intervention techniques (if the person is a resident/client)
• Wait in safe location for help
• Participate in debrief

Code White Responders:

• Check that you can safely leave the residents/clients/tenants in your area
• Go to the Code White location
• Take direction from the Code White Lead
• Participate in debrief

Security Guard

• Go to the Code White location
• Take direction from the Code White Lead
• Participate in debrief

Management/Supervisor

• Provide support to staff as needed
• Ensures support for persons who experience distress post emergency is offered. This may take the form of a debrief/follow-up call or meeting, or referral to the Region of Waterloo's Employee Assistance Program
• Support those involved in the incident to take some "time out" to regain personal composure before returning to work, if necessary
• Water for signs of stress amongst staff and remind to contact the Employee Assistance Program for assistance, as needed
• Facilitate completion of HR 18s, if applicable
• Participate in debrief, if possible
• Ensure Responsive Behaviour Program Policy (R-40) is followed, if applicable

4.0 Code White Debrief and Follow-up: Facilitated by Code White Lead

• Lead debrief and complete the electronic Code White report immediately following the incident, detailing key information of the incident (form found on the desktops of all computers at Sunnyside)
• The Code White debrief will address the following:
  • Apparent or perceived triggers
  • Identification of any/all system issues that impacted either the response or resolve of the Code White (e.g. technology and staff response)
  • Identification of actions (both immediate and planned) to address the incident
• Ensure the person in crisis is appropriately assessed
• Initiate observation, documentation and reports as appropriate to the situation
• Phone call to resident/client/tenant's physician, or on call physician, as appropriate. If unable to reach an on call physician, contact the Medical Director
• Notify the person's family of the situation as soon as possible, if applicable
• Notify the Assistant Manager of Care/Supervisor or Standby Manager
• Complete Risk Report, if applicable
• Incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident
• Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff, residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety)
• Debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over
• As relevant, use of information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence

Appendix A: Code White Pendants: Technology and Activation

Sunnyside utilizes technology in the form of Code White pendants in the event of a known risk to self and others. The pendent system provides coverage in the Franklin and Kenneth building, including the Community Alzheimer Programs (CAP - Kitchener site, in Heritage Hall and Overnight Stay), but not in Supportive Housing.

The pendants are to be worn around the neck, using only the supplied lanyards that have an anti-choking break away feature. Pendants are equipped with a red light that illuminates when the button is pressed on the pendant.

The pendants are kept in each home area's Communication Centre, at Reception, at the Trust Clerk's desk in the main office, in CAP (in medication cart), in Cafe, and in Social Work Office (room 2151, affixed to bottom of phone) on the main floor.

Additional pendants are available to be signed out a Reception They can be accessed 24 hours and must be signed out and signed back in upon return, via Reception staff or Security.

Where Code White Pendants are utilized, the RN/Supervisor will: assess the need for Code White pendants and if applicable, distribute the pendants to staff responsible for the resident's/client's care.

The Code White pendant may also be used for employee health and safety as part of the Workplace Violence Protection Program.

Appendix B: Equipment Testing and Preventative Maintenance

Equipment Testing

All pendants are independently checked on a monthly basis to ensure that they are working. This test is conducted by Quality and Risk Management, and includes: activating pendants and checking to ensure that proper phone readouts occur (i.e. location of pendant).

Preventative Maintenance

Maintenance tests the batteries in the Code White pendants annually (and also replace when necessary, per monthly testing or notification from staff). If pendants are deemed defective, a new pendant is put in circulation via the office of Quality and Risk Management.

1.0 Policy Statement

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment. 

2.0 Purpose of Code Purple (Intruder/Hosting Taking)

Code Purple is a planned response to minimize harm when there is an intruder or hostage taking.

3.0 Initiating a Code Purple

Any person can immediately initiate a Code Purple by calling 911 when they observe or are told of a hostage taking situation.

4.0 Roles and Responsibilities

Staff who Identified the Threat

• Ensure your safety first
• If able, call 911 and report incident, provide as much information as possible (i.e. location, # of hostages, details of the intruder)
• If safe, isolate the area (evaluate and do not let others in)
• Protect yourself and others; follow the procedure in Section 5.0

RN at Control Centre

• Ensure all documentation is complete, as needed (Risk Report, HR 18's, Critical Incident Report, etc.): to occur post incident resolution
• Ensure all staff and residents/clients are accounted for
• Offer support to residents/clients and staff
• Protect yourself and others; follow procedure in Section 5.0

5.0 Safety Procedures

If you are taken hostage or in the location of the incident:

• Remain calm, courteous and cooperate
• Speak when spoken to
• Establish eye contact, but do not stare
• Sit rather than stand, if possible
• Avoid making suggestions/promises
• Attempt to escape only if safe
• Observe and gather information
• When police arrive, take direction from police

All other locations:

• Stay calm
• Avoid the area of the code
• Got to a safe location and remain in place until all clear

6.0 Debrief 

The Director/Administrator will lead or assign a delegate to facilitate the debrief. 

The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident.

Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff, residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department Region of Waterloo Emergency Management, Region of Waterloo Health and Safety).

The debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use of information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence.

7.0 Education

Education and testing of this policy will be conducted as per policy 1-10, Emergency Planning.

1.0 Policy Statement

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment. 

2.0 Purpose of Code Silver (Active Shooter/Assailant)

Code Silver is a planned response to ensure the safety of all persons when an individual is in the possession of a "weapon" (anything that can harm, i.e. knife, gun, etc.). Code Silver should be called if there is a threat, attempt, or active use of a weapon to cause harm, regardless of the type of weapon.

3.0 Initiating a Code Silver

Any person can initiate a Code Silver by calling 911 when they observe or are told of a person who is attempting to harm/injure people with a weapon, or carrying a weapon.

4.0 Roles and Responsibilities

Staff who identified the threat:

• Ensure your safety first
• If able, call 911 and report incident, provide as much information as possible (i.e. location, # of hostages, details of the intruder)
• If safe, isolate the area (evacuate and do not let others in)

RN at Control Centre:

• Ensure all documentation is complete, as needed (Risk Report, HR 18s, critical incident report, etc.)
• Ensure all staff and residents/clients are accounted for
• Offer support to residents/clients and staff
• Protect yourself and others; follow procedure in Section 5.0

5.0 Safety Procedures

6.0 Debrief

The Director/Administrator will lead or assign a delegate to facilitate the debrief.

The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident. 

Consideration should be given to including the following stakeholders as part of the debrief, as applicable; staff, residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety).

The debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence.

7.0 Education

Education and testing of this policy is provided as per policy 1-10. Emergency Planning.

1.0 Policy Statement

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment.

2.0 Purpose of Code Black

The purpose of Code Black is to provide a direction to persons involved in a bomb threat situation to minimize injury/harm or to resolved the crisis.

3.0 Initiating a Code Black

Any person can immediately initiate a Code Black by calling 911 when they observe or are told of a bomb threat.

4.0 Person Receiving Threat - Roles and Responsibilities

1. Suspicious Phone Call

2. Suspicious Letter/Email/Social Media

3. Suspicious Object Identified or Found

4. Verbal Threat

5.0 All Responders - Roles and Responsibilities

All Staff

• Follow the direction of the emergency crews/police, RN and Security

RN in Charge

• Once emergency is over, provide support to staff and residents

Security

• Follow the instructions of the emergency crews/police (if applicable)

Manager/Standby Manager

• Ensures support for persons who experience distress post emergency is offered. This may take the form of a debrief/follow-up call or meeting, or referral to the Region of Waterloo's Employee Assistance Program

6.0 Conducting a Search (Response to Threat)

7.0 Evacuating the Building

8.0 Code Black Box

9.0 Debrief

The Director/Administrator will lead or assign a delegate to facilitate the debrief. 

The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident. 

Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff, residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety).

The debrief will serve to commence an evaluation of emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence.

10.0 Education

Education and testing of this policy will be conducted as per policy 1-10, Emergency Planning.

1.0 Policy

Seniors' Services staff will be prepared to respond to medical emergencies on campus. Code Blue includes: cardiac arrest, choking, hemorrhage, head injury, and/or any other medical emergency.  

2.0 Procedure

2.1 Initial Response to Event

Any/All Staff

• Makes call or facilities paging Code Blue overhead: announce "Code Blue" and the location, calmly. Repeat three times
• If the Code Blue Team attending the scene needs further assistance, they will call additional registered staff
• Stays with person until help arrives

Code Blue Team: Comprised of the RN carrying phone 6355, RN carrying phone 6373, and RPN Greenfield carrying phone 6214.

• Both RNs and the RPN will respond immediately to the scene upon hearing overhead page
• Assess the situation and initiate the most appropriate emergency response
• The RNs will determine if it is necessary to contact EMS for transport to hospital

Security

• Respond to all Code Blue events
• Provide support as requested by registered staff
• Completes necessary/relevant documentation

Physicians (in building)

• Attend and support Code response, if onsite, and requested to help

2.2 Post Event: Once Code is All Clear

Registered Staff (Event Responders)

• Call or facilitates having All Clear called via overhead paging system
• Contact physician and families and update as appropriate

RPN (Greenfield)

• Lead or facilitate completion of Code Blue Flowsheet and Debrief event/report
• Return and replenish the Code Blue Cart (from Central Stores supplies) when the code is completed

Charge Nurse

• Complete Ministry Critical Incident report, if applicable
• Notifies the Manager of Care and Administrator of the event
• Call Manager-on-Call if the incident occurred after business hours
• Complete E-Risk form, if applicable
• Fills out paper copy of Code Blue Flowsheet and Debrief Report: to be transcribed/added to by RPN completing electronic Code Blue Flowsheet and Debrief Report
• Note: remember to update communications and messaging if/when circumstances to the emergency change

Management/Supervisor

• Provide support to staff as needed
• Support those involved in the incident to take some "time out" to regain personal composure before returning to work, if necessary
• Watch for signs of stress amongst staff and remind to contact the Employee Assistance Program for assistance, as needed
• Facilitate completion of HR 18s, if applicable

3.0 Code Debrief and Follow-up: Facilitated by RPN (Greenfield) or Delegate

• Lead debrief and complete the electronic Code Blue Flowsheet and Debrief report immediately following the event: form found on the desktops of all computers at Sunnyside
• The incident debrief should be attended by both persons where were impacted by the incident (if applicable), and persons who were involved in supporting the resolution of the incident
• Consideration could be given to including the following stakeholders as part of the debrief, as applicable: staff, residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety)
• The debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over
• As relevant, use information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence

Appendix: A: Medical Supplies in Code Blue Cart

The Code Blue Cart will contain the following:

• First Aid Kit
• Gloves 1 box
• Masks 1 box
• Gowns, disposable x5
• Hand sanitizer
• Periwipes 1 pack
• Sterile dressing tray
• Suction machine
  • Suction tubing x2
  • Yonker x2
  • Suction catheter x2
• CPR board
• Extension cord
• Oxygen tank
  • Mask x2
  • Tubing x2
• BP cuff and stethoscope
• Pocket Mask
• Defibrillator
• Ambubag
• Flashlight
• Blanket and Pillow
• Code Blue Flowsheet and Debrief Report x5 copies
• The Coordinator, Infection Control/delegate is responsible to complete the Code Blue Cart Monthly Checklist and replenish nursing supplies
• The contracted Respiratory Therapy provider is responsible to complete the Code Blue Cart Monthly Checklist and replenish oxygen supplies

1.0 Policy

The Yellow Code is intended for situations when a person is missing and their location is unknown. The Code Yellow policy supports and facilitates resident/client safety by:

1. Supporting early identification of a missing resident/client, and;
2. Facilitating a quick search response

2.0 Definitions

Elopement refers to a resident/client (herein referred to as resident) who leaves a secure home area unattended and without notice, who leaves the building, but it noticed by someone immediately and brought back. An elopement can demonstrate risk and identifies a 'near miss' that has the potential to become a Code Yellow.

Code Yellow refers to a situation where a resident is discovered to be missing, or has been off the home area/out of the building undetected for a period of time. In the event of a missing resident, the following Code Yellow procedural steps are followed.

3.0 Procedure

The RN in Charge will act as the leader during the procedures noted below.

3.1 Searching for a Resident

Stage 1) Initial Search (approximately 5-6 minutes)

• The person who noticed the resident missing will check if he/she has been signed out and notify the RPN in charge of the home area to organize a search of the home area.
• Staff on the home area will make an immediate and thorough search. Search storage areas, waiting areas, washrooms, showers, stairwells, resident rooms, beds, etc.
• If not found, the RPN will notify the RN in charge.
• As soon as it is determined that the resident is missing, the RN will assess the level of risk. Key areas of inquiry include, but are not limited to:
  • Is this a resident who is physically healthy and known to wander?
  • Is the resident vulnerable or at risk of getting lost?
  • Is the resident someone who threatens to leave or do harm?
  • Is the resident on roam alert due to risks of elopement?
• If the resident is determined to be "high risk" (to oneself and/or others), the RN will notify the police immediately by calling 9-1-1 before proceeding with the code yellow steps below.

Stage 2) Enhanced Search (approximately 10-15 minutes)

• RN will delegate a staff member to fill out the Description of the Missing Person form and make copies of the resident's photo
• RN will delegate staff to search the home area again, other program areas (e.g. hairdressing, Heritage Hall) and to call other places offsite that are known to be frequented by the resident
• RN will contact family, friends or POA to identify if they are aware of their whereabouts
• RN will contact security to assist in a search of the property and cameras. If the resident is found on the cameras to have left the building and not return, the RN will notify the policy immediately by calling 9-1-1

Stage 3) Activating the Code Yellow and Home Wide Search

• RN will page a "Code Yellow", giving the name of the house, name of the resident/client and the location of the Control Centre. Page three times
• RN will call Supportive Housing to advise them of the Code Yellow
• RN will verify if there is documentation that the resident is part of the Vulnerable Person's Registry
• Staff in other areas, upon hearing a Code Yellow, will make an immediate and thorough search of their home area/area
• RN will divide searchers into groups and assign them an area to search and ensure that each group has a staff member with a master key. The search should include:
  • All home areas and program areas
  • All washrooms, lounge areas, cafe, stairwells, locked and unlocked rooms, mechanical rooms, storage areas, elevators, etc.
• Note: remember to update communications and messaging to all relevant stakeholders if/when circumstances to the emergency change

Stage 4) Call Police and Second Home Wide Search

• If the internal search fails to locate the resident (and the police were not contacted earlier), the RN will call police immediately at 9-1-1. Let them know the resident is missing (note, if he/she is registered with the Vulnerable Persons Registry)
• RN will notify the SDM of the situation
• RN will notify the Administrator LTC or Manager, Resident Care (or delegate) during business hours, or the Manager on Standby after hours
• RN will assign staff to do a second complete indoor and outdoor search

If the resident is found see Section F, if not found the situation will remain in the hands of the Police and staff will assist as requested.

3.2 Resident Found (Follow-up)

• Once found, the RN will page "Code Yellow All Clear", three times
• RN will notify the SDM, police department (if not on premises), Manager of Resident Care and the Administrator LTC or designate during business hours, or the Manager On Standby after hours
• RN will assess resident for signs of possible injury and implement emergency care procedures as required
• RN will contact attending physician (or physician on call) of incident and condition of resident/client
• RN will implement safety plan (update care plan and communicate to staff) to prevent further elopements/Code Yellow
• RN will complete Code Yellow electronic debrief form (located on the desktop under forms). This form will automatically send to the Administrator and Manager of Resident Care
• RN will complete Risk Management and Document
• RN will complete an Unusual Occurrence Report
• RN will provide/offer support to any persons (i.e. resident, staff, etc.) who may be experiencing distress from this experience. This may include such things as inquiring on their well-being, offer to take a break, referring to Employee Family Assistance Program, leaving early etc.

4.0 Required Reporting and Documentation - CIS

If a resident is missing for any length of time, it is reportable to the MLTC. Refer to the Critical Incident Reporting Policy for more information as well as these guidelines:

Immediate Report:

• If resident is missing for three or more hours;
• Any missing resident who returns to the Home with an injury or change of condition, regardless of the time they were gone

Next Day Report:

• A resident who is missing for three or less hours and returns to the Home with no injuries or change in status

5.0 Code Yellow Debrief

The RN in Charge will complete/facilitate completion of:

• A debrief and documentation of the event using the Code Yellow Debrief E-form (must be completed for all Code Yellow events)
• The debrief should be attended by all persons who were impacted by the incident, and any persons involved in the resolution. Consideration could be given to including the following stakeholders: staff, residents and substitute decision makers, volunteers, students and external responders (e.g. Police, Fire Department)
• The debrief serves as an evaluation of the emergency plan. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over
• The Coordinator, Quality Improvement and Risk Management or delegate will: As relevant, use information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence

Elopement Log - To Be Completed by the Nurse in Charge

Stage 1: Initial Search - Resident is Noticed Missing and Reported to Charge Nurse (5-10 minutes)

• Ensure a complete check is completed in the immediate and alternate home area: Search storage areas, waiting areas, washrooms, showers, stairwells, resident rooms, beds, etc.
• Sign out binders and communication books
• Resident's progress notes for possible LOA that did not get communicated
• Contact family to inquire of whereabouts
• Recreation re: Activity Outing
• Ask Security to check cameras to determine if, when and where resident left the building and type and colour of clothing resident was wearing
• Assess level of risk, if resident is determined to be missing contact police immediately

Stage 2: Enhanced Search (10-15 minutes)

• Delegate a staff member to fill out the Description of Missing Person form and make copies of the resident's photo (in the chart or on PCC)
• Delegate staff to search the home area again, other program areas (e.g. hairdressing, Heritage Hall) and to call other places offsite that are known to be frequented by the resident/client
• RN will contact family, friends or POA to identify if they are aware of their whereabouts
• RN will contact security

Stage 3: Activate Code Yellow and Home-Wide Search (20 minutes)

• The RN will page a "Code Yellow giving the name of the house, name of the resident/client and the location of the Control Centre". Page three times
• The RN will call Supportive Housing to advise them of the Code Yellow. Ask them to search the building. Provide a copy of the resident's photo
• Verify if there is documentation that the resident is part of the Vulnerable Person's Registry
• Staff assigned to non-resident care areas - search basement, kitchen, laundry, and maintenance areas
• A team of at least two staff should check the exterior of the building starting through the front doors, conducting a thorough search of the exterior of the building and parking lots. In the parking lots, all cars must be looked into and under as well as around

Stage 4: Call Police and Second Home Wide Search

• If the internal search fails to locate the resident/client (and the police were not contacted earlier) call police immediately at 9-1-1. Let them know the resident is missing (note if they are registered with the Vulnerable Persons Registry)
• Notify the SDM of the situation
• Notify the Administrator LTC during business hours, or the Manager On Standby after hours
• Assign staff to do a second complete indoor and outdoor search
• Remind staff that they are expected to remain at the Home/continue with search until further notice is received from the police or the resident is located

When the Resident is Located

• Once found, page "Code Yellow All Clear"
• Notify the SDM, police department (if not on premises), Manager of Resident Care and the Administrator LTC or designate during business hours, or the Manager On Standby after hours
• Assess resident for signs of possible injury and implement emergency care procedures as required
• Contact attending physician (or physician on call) of incident and condition of resident/client
• Implement safety plan (update care plan and communicate to staff) to prevent further elopements/Code Yellow
• Complete Code Yellow Debrief Form
• Complete Unusual Occurrence Report

1.0 Policy Statement

This policy identifies key policies and contingency plans that may need to be followed in the event of the loss of or one or more essential services on campus.

2.0 Potential Causes for Loss of Essential Services

Loss of one or more essential services may result from, but is not limited to: mechanical failure, network failure, power outage, and loss of water.

3.0 Policies and Contingency Plans Related to Loss of Essential Service(s)

Technology and Related Equipment

• EMAR Failure-Contingency Plan
• Vital Hub-Contingency Plan
• System/Equipment Failures: Telephones, Nurse Call, Security
• Technology Software-Contingency Plan
• Contingency Procedure for Extended Disabled Server/Software/Power Outage

Fire Safety Systems

• System, Fire Alarm and Building Security
• Fire Alarm System in Distress or Announcing an Alarm

Mechanical

• Contacting Contractor and Suppliers in an Emergency
• Elevator(s) Not Working
• Person Trapped in Elevator
• No Water at Facility-Contingency Plan
• Water Failure
• Heat Related Illness and Prevention Management
• Electrical Failures-Emergency Generator
• Natural Gas Interrupted Service
• Systems/Equipment Failure
• Food Services and Laundry-Contingency Plan

Staffing

• Essential Staffing During an Emergency
• Staff Emergency Call-in
• Business Continuity Plan

Supplies/Food/Water

• Emergency Supplies
• Emergency Menus
• Boil Water Advisory

Communications and Reporting

• Management Standby Policy
• Reporting and Managing Risk Events (for LTCH)
• Critical Incident Reporting
• Maintenance on Call Service-Guidelines for Use
• Maintenance Communication: System Failure/Organizational Risk

Policy

Sunnyside Home will be prepared to respond in the event of an outbreak, epidemic, and/or pandemic, including outbreaks of a communicable disease and outbreaks of a disease of public health significance. 

It is noted that in the event of a pandemic, information and requirements may change rapidly as the situation evolves. Provincial mandates will supersede local practice as the highest authority where applicable.

Definitions

• Outbreak: An outbreak is a sudden rise in the number of cases of a disease and it carries the same definition of epidemic, but is often for a more limited geographic area.
• Endemic: The usual incidence of a given disease within a geographical area during a specified time period.
• Epidemic: An excess over the expected incidence of disease within a given geographical area during a specified time period. If the expected number of cases of a disease in a province is eight per year, and 16 occur in one year, this indicates an epidemic. It should be noted that an epidemic is not defined on the absolute number of cases but on the number of cases in comparison to what is expected.
• Pandemic: An epidemic spread over a wide geographical area, across countries or continents, usually affecting a large number of people. It differs from an outbreak or epidemic because it:
  • affects a wider geographical area, often worldwide
  • is often caused by a new virus or strain of virus that has not circulated among people for a long time. Humans usually have little to no immunity against it. The virus spreads quickly from person-to-person worldwide
  • causes much higher numbers of deaths than epidemics
  • often creates social disruption, economic loss, and general hardship

Procedure

The Manager, Resident Care or designate will:

1. Reference the Infection Prevention and Control manual for detailed outbreak preparation and response requirements.
2. Ensure an area(s) of the location is identified to be used for isolating residents as required.
3. Ensure a process is in place to divide both teams members and residents into cohorts as required.
4. Ensure staffing contingency plans are in place and kept current.

The Infection Prevention and Control Lead or designate will:

1. Ensure annual practice/testing of outbreak and pandemic preparedness, inclusive of any arrangements with external entities who may be involved in or provide emergency services in the area where the care community/residence is located (including, without being limited to, health service providers, partner facilities and resources that will be involved in responding to the emergency).
2. Involve the Medical Director (as applicable) and Public Health Unit in development and annual review of the location's emergency plans as related to outbreaks of a communicable disease, outbreaks of disease of public health significance, epidemics and pandemics.
3. Ensure process in place for inspection of outbreak/epidemic/pandemic supplies for functionality, expired dates, and restocking as needed.

The Coordinator, Education or designate will ensure that all staff are trained on PPE procedures.

 As part of Sunnyside's Emergency Management Program, the Management Team will develop and maintain Emergency Contingency Plans and related Policies to address the Emergencies as listed in the table below.

The policy details how Sunnyside will track/record:

• Consultations with stakeholders involved in emergency responses and pre-emptive emergency planning efforts (e.g. ensure contact information and arrangements are kept current)
• Changes to emergency plans based on testing results and policy updates

Note: Tracking and reporting, as described above, will be maintained by the Quality and Risk Management Office.

Note: An Annual Planning Template for Setting the Testing Cycle for Emergency Policies and Codes, is included in Appendix A.

Codes and Emergency Plans, Educating/Testing Cycle and Most Responsible

1. Fire Emergencies
   • Related policies and contingency plan: Code Red (DOC# 1907662)
   • Education/testing cycle: Annual
   • Most responsible person(s): Coordinator, Staff Education
2. Evacuation of Residents
   • Related policies and contingency plan: Code Green (DOC# 292234)
   • Education/testing cycle: Every three years
   • Most responsible person(s): Coordinator, Q&R Management
3. Violent/Behavioural Threat
   • Related policies and contingency plan: Code White (DOC# 292181)
   • Education/testing cycle: Annual
   • Most responsible person(s): Coordinator, Q&R Management
4. Missing Resident/Client
   • Related policies and contingency plan: Code Yellow (DOC# 279337)
   • Education/testing cycle: Annual
   • Most responsible person(s): Coordinator, Staff Education
5. Medical Emergency
   • Related policies and contingency plan: Code Blue (DOC# 897891)
   • Education/testing cycle: Annual
   • Most responsible person(s): Coordinator, Infection Control
6. Chemical Spill/Release (internal) and Natural Gas Leak
   • Related policies and contingency plan: Code Brown (DOC# 292191, 292192)
   • Education/testing cycle: Annual
   • Most responsible person(s): Coordinator, Q&R Management
7. Hostage Taking
   • Related policies and contingency plan: Code Purple (DOC# 292173)
   • Education/testing cycle: Every three years
   • Most responsible person(s): Coordinator, Q&R Management
8. Outdoor Air Exclusion
   • Related policies and contingency plan: Code Grey (DOC# 292196)
   • Education/testing cycle: Every three years
   • Most responsible person(s): Coordinator, Q&R Management
9. Natural Disasters/Extreme Weather and Community Disasters
   • Related policies and contingency plan: Code Orange (DOC# 4048155)
   • Education/testing cycle: Annual
   • Most responsible person(s): Coordinator, Q&R Management
10. Bomb Threat
    • Related policies and contingency plan: Code Black (DOC# 292157)
    • Education/testing cycle: Every three years
    • Most responsible person(s): Coordinator, Q&R Management
11. Active Shooter/Assailant
    • Related policies and contingency plan: Code Silver (DOC# 2885384)
    • Education/testing cycle: Every three years
    • Most responsible person(s): Coordinator, Q&R Management

Other Related Emergency Policies

1. Boil Water Advisory
   • Related policies and contingency plan: DOC# 4004438
   • Education/testing cycle: Annual
   • Most responsible person(s): Manager, Food and Environmental Services
2. Loss of One or More Essential Services
   • Related policies and contingency plan: DOC# 4069519
   • Education/testing cycle: Annual
   • Most responsible person(s): Manager, Food and Environmental Services
3. Infectious Diseases/Outbreaks, Epidemics and Pandemics
   • Related policies and contingency plan: DOC# 278882, DOC# 278902
   • Education/testing cycle: Annual
   • Most responsible person(s): Infection Prevention and Control Team

The Home will:

• Ensure that the emergency plans/policies for the home are evaluated and updated at least annually, including the updating of all emergency contact information as applicable.
• If an actual emergency occurs, in which any of the policies above are activated, the incident itself will count towards the requirement for annual or every three year testing, as long as a formal debrief of the emergency is completed.
• Ensure that if an emergency plan is activated (actual incident), the emergency plan will be evaluated and updated (if changes are required) within 30 days of the emergency being declared.
• Try, to the greatest extent possible when testing emergency plans, to include community agencies, partner facilities and resources that will be involved in responding to an emergency.
  • Consultation with external partners, with regards to emergency plan updates and incident debriefs, will be tracked.
• A written recording of the testing for the emergency plans and changes made to improve plans will be maintained. Key areas reported on will include: date of test, notable changes to policies and/or related emergency plans
  • To record testing and related changes
• Policies as referenced herein will be developed with local and municipal emergency planning groups, as possible.
• The testing schedule for all policies, as referenced herein, will be updated on an annual basis, by the Coordinator of Quality and Risk the Coordinator of Staff Education. Reference Appendix A. Annual Planning, Template for Setting the Testing Cycle for Emergency Policies and Codes.

Reference: Fixing Long Term Care Act, Emergency Management Sections of O. Reg 246/22.

Appendix A: Annual Planning Template for Setting the Testing Cycle for Emergency Policies and Codes.

Emergency Code Testing Schedule: Specify Year

A. Annual Testing Required

• Fire - Code Red
• Missing Resident/Client - Code Yellow
• Medical Emergency - Code Blue
• Boil Water Advisory
• Loss of One or More Essential Services
• Infectious Disease/Outbreaks, Epidemics and Pandemics

B. Every Three Years Testing Required

• Evacuation of Residents - Code Green
• Violent Behavoural Threat - Code White
• Chemical Spill/Release (Internal) and Natural Gas Leak - Code Brown
• Hostage Taking - Code Purple
• Outdoor Air Exclusion - Code Grey
• Natural Disaster/Extreme Weather and Community Disaster - Code Orange
• Bomb Threat - Code Black
• Active Shooter/Assailant - Code Silver

Policy Statement

Seniors Services uses overhead paging to communicate an emergency or to test an emergency response. Overhead paging is kept to a minimum to provide a homelike and least disruptive atmosphere for the residents, clients and tenants.

Procedure

• Overhead paging is used for emergencies or upon approval of a senior management/RN in charge.
• Dial from any phone in the building (including portables) to access overhead paging. Announce the emergency code and location three times, i.e. Code Red, Main Kitchen, three times.
• Dial 9-1-1 for all fire emergencies and other emergency codes, as necessary.
• Note: Supportive Housing is not equipped with an overhead paging system and therefore staff and tenants will not hear any overhead pages. Staff in Supportive Housing can page overhead by dialing which will be heard in Sunnyside Home.

In the event of an emergency, requiring support from external contractors or suppliers, this policy outlines the key steps to follow: and provides a listing of key contractors/suppliers and related contact numbers.

1. Locating Contractor and Suppliers Contact Info
   • Contact information for contractors and suppliers that Sunnyside Home utilizes are found in the Emergency Manual at Front Reception and with the Sunnyside Home Maintenance. If outside of business hours, follow instruction in point two below. A listing of contractors/suppliers is included in this policy, as Appendix 1.
2. Who to Call Outside of Normal Business Hours
   • The Maintenance on-call rotation is circulated quarterly with contact phone numbers. The on-call rotation is placed in the RN in Charge Manual and the Standby manual. Any changes to the rotation are communicated by the Supervisor, Facilities Management.
3. Determining Action to be Taken
   • The decision to contact a contractor or supplier is made by the Standby Manager and the Maintenance on-call person. In the unlikely event of failure of the on-call systems, the person in charge of the Home (at the time that support it needed) will make the call and direct actions to be taken.

Note: Contact information will be reviewed and updated by the Supervisor, Facilities Management regularly.

Appendix 1. Contact Information for Contractors and Suppliers in Case of Emergency

Policy

Sunnyside has an emergency call in procedure for staff to ensure that the needs of residents/clients/tenants are met in the event of an emergency.

The Emergency Call-In Procedure is initiated when additional staff and management are required at Sunnyside to manage a situation involving residents/clients/tenants.

Procedure - Call Out Systems

Technology

Everbridge - The preferred method of notifying staff will be through our automated "Everbridge" system. To activate Everbridge, follow the Everbridge Activation Guide (Appendix A).

Accountabilities

During business hours an available person familiar with Everbridge (i.e. someone from the Standby roaster, or someone familiar with the system) will put a message on Everbridge, and send it to recommended staff groups.

Outside of business hours the Standby Manager will be responsible to put a message on the Everbridge system, and send it to recommended staff groups.

If support is required in activating Everbridge, contact an "experienced" Sunnyside user. The names of experienced users can be found in the Standby Binder, accompanying the Everbridge instruction sheet: Appendix A within this policy.

The Message

The message will start with, "This is a call from Sunnyside Seniors' Services". It should also include the following:

• Information of the nature and specific location of the emergency, as directed
• Ask all available staff to report to the Control Centre (specify if it is at reception or another location)
• Advise employees to enter through the main entrance off Franklin Street (or an alternate location if designated)
• Advise employees to wear their I.D. badges

If there is no answer at a staff member's home, the Everbridge system will leave a message indicating the above information.

Staff receiving the call may notice a slight delay at the beginning of the message. Please do not hang up immediately, and pause a few seconds to ensure a message can be delivered. If you hang up prematurely, Everbridge will call you back. Please listen to the entire message.

Fan-Out List System (if Everbridge is not available)

In the event that Everbridge is not available (i.e. internet failure), we will use a paper-based fan out list procedure.

• The Emergency Fan-Out List is written in order of priority, such that calls to "Key Personnel" must be made first to get key staff into the building immediately.
• A copy of the updated Fan-Out List is kept in the Staffing Office. It will also be distributed to Key Personnel and Additional Personnel.
• The nurse or person in charge will delegate a staff member(s) to initiate the calls, according to this procedure.
• Referring to the Fan Out List, initial calls are made to those identified as "Key Personnel"; the delegated caller(s) will continue to make calls to the next "Additional Personnel", requesting them to make staff calls according to their list (which is based on staff last names). If unable to reach an "Additional Personnel", their calls are assigned to the others that you are able to reach, or to staff as listed as "Spares" at the bottom of the Emergency Fan Out List.
• The delegated caller(s) making the calls should document who they reached and last names of staff they are delegated to call.
• All "Additional Personnel" are required to keep a current staff list at home.
• This list will be revised with management/management support updates as soon as possible as changes occur. All other positions will be updated twice per year on June 30 and December 31. The Administrative Assistant will be responsible for updating the lists, placing updated lists in Staffing Office and distributing lists to Key Personnel and Additional Personnel.
• If the telephones are out of order, the delegated caller(s) will go to an emergency power failure phone in the Lobby at reception or Communication Centre or Woodside Communication Centre. If these are out of order, attempt to make calls from a personal cell phone or an occupied home in the neighbourhood.

Roles and Responsibilities

All Staff

• Make every effort to come into work when contacted
• Report to Sunnyside (or an alternate location if designated) as soon as possible, with identification/swipe card
• Park in the front parking lot and enter through the main entrance, unless otherwise advised
• Report to the Control Centre, usually at the reception area, for further instructions, unless otherwise directed

Director/or Designate

• Makes decision to initiate the call-procedure along with Standby Manager (if applicable)

RN

• Call the Standby Manager for after hours emergencies, for support on emergency call-ins
• In unable to use the Everbridge system (e.g. internet down), the RN will delegate a staff member(s) to initiate the calls, according to the fan out system

Standby Manager (if after hours)

• Contact Director for direction on whether to deploy the call out
• Initiate the fall out list

Experienced Everbridge Users

• Support in activation of Everbridge as necessary

Key Personnel Identified in the Fan Out List

• Proceed to the Home immediately, if able, to assist with the emergency

Additional Personnel Identified in the Fan Out List

• Keep a current copy of the fan out phone list at home
• Make calls to staff, as identified in the procedure 2-10
• Proceed to the Home after calls have been made

References: Management Standby Policy (DOC# 157528).

Appendix A: Everbridge User Guide

Everbridge is an enterprise solution used for mass communications via phone, text, or email.

1. Logging into Everbridge
2. How to send a notification
3. How to maintain contact lists
4. How to update an employee contact list
5. How to upload resident contacts

This policy outlines key information and steps to follow in the event that Sunnyside acts as a Receiving Centre for persons coming from other healthcare facilities.

1. Sunnyside will act as a Receiving Centre for a manageable number of people for emergency evacuation from other long-term care homes or those eligible for long-term care, and clients of the Community Alzheimer Program. See procedure 8-20, for information about receiving evacuees from the Community.
2. The responsibility for the provision of staff and the provision of medications to meet the needs of evacuees shall rest with the evacuated facility.
3. When Sunnyside becomes a Receiving Centre, the Emergency Call In Procedure (procedure 2-10) may be activated if needed to assist in establishing a receiving area(s).
4. The receiving area(s) will be determined at the time of the call for support. Areas that may be designed as receiving areas include, but are not limited to: Heritage Hall and/or the Kitchener CAP program.
5. Emergency supplies for these occasions are kept in storage (lower level, Kenneth building). Some emergency supplies may also be brought along with evacuees from the evacuated facility, as applicable.
6. The Home may also act as a holding area, providing food, shelter and washroom facilities for a manageable number of ambulatory and semi-ambulatory persons for up to 12 hours. The location of a holding area(s) will be established at the time of the call for support. Examples of holding areas include, but are not limited to: Heritage Hall, lounges throughout the home, Kitchener CAP program, Supportive Housing and the Wellness Centre.

Sunnyside is committed to helping community organizations in the event that persons in their care require evacuation.

Dependent upon the situation, persons that may be relocated to Sunnyside include, but are not limited to: long-term care residents or those eligible for long-term care, and clients of the Community Alzheimer Program.

When a request is received for Sunnyside to receive evacuees from the community, the Director/designate (in consultation with the Administrator and Manager of Resident Care) will:

1. Determine the number of people we are able to accommodate. For an after hours request, the Registered Nurse in Charge collaborates with the Manager on Standby, Administrator, Manager of Resident Care, Social Work, Director Senior's Services (if available and time permits) before the decision is made.
2. Determine the location of placement within the Long Term Care Home (options may include, but are not limited to Heritage Hall, resident care areas, community program areas).
3. Determine number of staff and supplies required.
4. Contact off duty staff as required (refer to Emergency Call in Procedure 2-10).
5. Assign duties to extra staff.
6. Assign a Nurse, and additional organizational staff supports as necessary, to prepare facility and supplies of evacuees.
7. Facilitate set up of central receiving desk to check in evacuees.
8. Facilitate process to ensure names of evacuees are recorded and special conditions (e.g. diet, allergies) are documented.
9. Assign areas and responsibilities to incoming staff.
10. Facilitate orientation, to Sunnyside, for both evacuees and staff coming from other organization(s) to ensure a smooth transition.
11. Communicate regularly with staff and evacuees to ensure they are informed of real-time evacuation status.
12. Determine care needs for all evacuated people received.
13. Maintain Home's routines as normal as possible.

Important Procedural Considerations

• The facility that is sending evacuees is responsible for providing staff and medications to support the care needs of evacuees.
• When the Home becomes a Receiving Centre, the Emergency Call In Procedure (2-10) may be activated to assist in establishing receiving areas.
• Emergency supplies are kept in storage (lower level, Kenneth building). Some emergency supplies may be brought with evacuees from the evacuated facility.
• The Home may also act as a temporary Holding Area, providing food, shelter, and Washroom facilities for a determined number ambulatory and semi-ambulatory persons for up to 12 hours. The number of persons that could be accommodated will be determined at the time of the event.

In case of an electrical power failure, the building will go dark for approximately 10-15 seconds until the emergency power takes over. In Supportive Housing, there will only be power for approximately 30 minutes.

In case of sustained electrical failure (regular power is not restored within 15 minutes) the Manager/RN in Charge will:

• Request for staff to check and monitor all mag lock doors
• Request staff to ensure that all critical equipment is plugged into emergency outlets (red power sockets)
• Important: The mag locks may not automatically reset after going to generator power so staff must do this manually. Obtain the emergency keys the RN, go to the main fire panel next to the main front door, open the right hand panel with the key marked "fire" and follow the posted instructions to reset
• Contact Maintenance staff to request support or come in (if after hours)
• Notify the managers/standby manager via email of situation
• Communicate the situation with other registered staff and notify that maintenance has been called
• Notify the Director Senior's Services and the Administrator of Long Term Care (or delegate(s))

Maintenance staff, as required will:

1. Check the generator and safety systems.
2. Reset mag locks, if necessary. The mag locks will not automatically reset, you must reset. Obtain the emergency keys the RN go to the main fire panel next to the front door, open the right hand panel with the key marked "fire" and follow the posted instructions to reset.
3. Call Kitchener Wilmot Hydro and Facilities Management. This call is forwarded to the Call Centre after hours.
4. Arrange for diesel fuel supply by calling the following company, Boucher and Jones Fuels. The back-up fuel supplier is Hogg Fuel. May be used to top up generator take by transferring with Jerry cans (this method to be used when replacement fuel does not arrive in time for the generator).
5. If deemed necessary to switch the power from #4 passenger elevator to #6 service elevators as a temporary measure. Elevator power is switched by inserting a key in switch at elevator in staff corridor (first floor Kenneth Building). Before removing power from the operating elevator, bring it to the ground floor and have a staff person hold door open, until power is switched.

Key Considerations:

1. In case of electrical failure at Sunnyside Home, 247 Franklin Street North, the emergency diesel powered generator will operate the following equipment for approximately 24 hours and then it has to be refuelled:
   • perimeter hot water heating
   • emergency lighting in all areas
   • fire alarm system
   • telephone system
   • door alarms
   • one outlet in each bedroom
   • ventilation system
   • all med room fridges
   • nurse call system
   • all circulating pumps and boilers
   • water softeners in boiler room
   • sump pumps (sanitary and storm)
   • elevator #1 and #4 or #6
   • kitchen refrigerators and freezer
   • kitchen cooking equipment (some)
   • Note: Air conditioning does not work on emergency power.
2. Supportive Housing, 245 Franklin Street North does not have a generator to provide temporary electrical power. Emergency lighting, powered by a 30 minute battery, operates in public areas and stairwells of the Supportive Housing building. One elevator in Supportive Housing can be operated temporarily by maintenance staff.
3. Location of emergency generators - 350 KW Generator located outside near the receiving ramp at the East side of the Kenneth Building.
4. The mag lock doors will release even with a short interruption in power (small bumps) where the emergency power does not transfer. It is important to ensure that these are checked and secure after a power failure.
5. When the facility is operating on emergency power, only passenger elevator #1 in the Franklin building will operate and in the Kenneth building and one of the (#4) passenger elevators will operate. There is also the option of operating #6 service elevator to bring supplies from lower level.

Policy Statement

This policy provides direction for steps to be taken when an elevator is not working, and directs action to determine if someone is trapped in an elevator.

Procedure for all staff when an elevator is down:

• Ensure that someone is not trapped in the elevator
• If someone is trapped, notify the RN immediately (refer to policy Emergency Manual 9-26)

Elevator Locations:

• Kenneth Passenger
• Franklin Passenger
• Kenneth Service
• Franklin Service
• Supportive Housing (Passenger and Service)

Procedure for the RN During Business Hours

When a Service and Passenger Elevator is down:

• Notify Maintenance via email: CSD SEN Maintenance or call
• Notify Security 
• Submit work-order to Maintenance
• Maintenance to call Thyssen Krupp (LTCH) or Delta Elevate (Supportive Housing), if required
• Ensure that signage is placed (on all floors) indicating elevator is "Closed for Maintenance": signage located at Reception
• Notify the Manager of the Program Area

Procedure for the RN Outside of Business Hours

Service Elevators:

• Call Thyssen Krupp (LTCH) or Delta Elevator (Supportive Housing) and obtain reference number (i.e. work order number)
• Create work order with reference number for Maintenance
• Ensure that signage is placed (on all floors) indicating elevator is "Closed for Maintenance": signage located at Reception
• Notify the Standby Manager

Passenger Elevator: One Elevator Not Working

• Email CSD SEN Maintenance and create work order for maintenance
• Ensure that signage is placed (on all floors) indicating elevator is "Closed for Maintenance": signage located at Reception
• Notify the Standby Manager

Passenger Elevators: Both Elevators Not Working

• Call Thyssen Krupp (LTCH) or Delta Elevator (Supportive Housing) and obtain work order number
• Create work order with reference number for Maintenance
• Ensure that signage is placed (on all floors) indicating elevator is "Closed for Maintenance": signage located at Reception
• Notify the Standby Manager

Reference: Person trapped in elevator, Emergency Manual (9-26).

1.0 Background 

Boil water advisories are public announcements advising the public that they should boil water prior to consumption, or using it to prepare foods to eliminate any disease-causing microorganisms that are suspected to be in the water. Decisions concerning boil water advisories are made by the responsible authorities at the provincial or local level.

2.0 Policy

This policy provides direction on what to do during a Boil Water Advisory.

When a boil water advisory is in effect, all water used for drinking, preparing food, making beverages and ice cubes, washing fruits and vegetable, and dental hygiene must be boiled. Under most circumstances, it is not necessary to boil tap water used for other household purposes, such as bathing, showering, laundry, or washing dishes.

3.0 How to Boil Water

Research indicates that holding water at a rolling boil (defined as vigorous boil where bubbles appear at the centre and do not disappear when the water is stirred for one minute) will inactivate waterborne pathogens.

Waterloo can be boiled in a heat-resistant container on a stove, in an electric kettle, or in a microwave oven. The water should then be cooled and poured into a clean container with a cover and refrigerated until used.

4.0 Procedures

All Staff (Person becoming aware of boil water advisory)

• When notified of a boil water advisory, immediately inform the Administrator and/or Director of Senior's Services (or other member of Management Team) or Standby Manager if outside of regular business hours.
• Update communications and messaging if/when circumstances to the emergency change.

Administrator/Director (Management Team Member) or Standby Manager

To inform:

• Food Service Manager, Manager of Care and Community Services Manager by phone
• Management/Management Support Group by email
• Notifies corporate Health and Safety (as per sequence below, until you have made contact)
• Complete E-Risk Report
• If applicable, ensures support for persons who experience distress post emergency is offered. This may take the form of a debrief/follow-up call or meeting, or referral to the Region of Waterloo's Employee Assistance Program
• Update communications and messaging if/when circumstances to the emergency change

Food Service Manager or Delegate, RN in Charge (outside normal business hours)

• Inform dietary staff of required actions (see table on next page)
• Distribute bottled water (stored in pandemic supply room): 24 500mL bottles per home area and 24 bottles to Supportive Housing. Note: water should be poured into cups and glasses when consumed
• Create and distribute Do Not Drink signage to all home areas
• Create and post signage at main entrance to LTCH and Supportive Housing indicating that a boil water advisory is in effect
• Update communications and messaging if/when circumstances to the emergency change

Manager of Care

• Inform Registered staff
• Registered staff to inform all home area staff; ensure communication to incoming shifts occurs at shift reports
• Complete critical incident report MOLTC
• Update communications and messaging if/when circumstances to the emergency change

Maintenance

• Disconnect water fountains, and hot water towers
• Turn off ice machines/discard ice

Director/Delegate

• Notify (and continue to provide updates) to Commissioner of Community Services, if applicable
• Liaise with Region of Waterloo Senior Management and Region of Waterloo Emergency Management, if applicable
• Lead or assign delegate to lead debrief

Required Action: Boil Water Advisory is in Effect

Water for home areas:

• Boil in main kitchen kettles and distribute to home areas in water pitchers
• Responsible: FSS or FSM

Dishes:

• Use dishwasher only
• Responsible: Kitchen staff

Washing fruits and vegetables to be eaten raw:

• Use boiled tap water
• Responsible: Kitchen staff

Making tea, coffee, drinks:

• Use boiled water
• Responsible: Dietary Aids, RHAs, PSWs

Sanitizing Prep areas and dining tables:

• Follow normal procedures ensuring good sanitization
• Responsible: Kitchen staff/home area staff

Hand washing:

• Continue to be washed using tap water
• Alcohol-based hand gel disinfectant can also be used if it contains more than 70% alcohol
• Responsible: All staff and residents

Menu items that call for added water:

• Use boiled water if food is not cooked to 100 degrees Celsius
• Responsible: Food Services staff

Warm drinks:

• Make using previously boiled water. Heat in microwave
• Responsible: All staff

CPAPs:

• Use boiled water
• Responsible: RPNs

Bathing:

• Bed baths only
• Responsible: PSWs

Oral hygiene:

• Bring boiled water in cups to resident rooms for oral hygiene
• Responsible: PSW

5.0 Debrief

The Director/Administrator will lead or assign a delegate to lead the debrief.

The incident debrief should be attended by both persons who were impacted by the incident, and persons who were involved in supporting the resolution of the incident, as applicable.

Consideration should be given to including the following stakeholders as part of the debrief, as applicable: staff, residents and substitute decision makers, volunteers, students and external responders if applicable (e.g. Police, Fire Department, Region of Waterloo Emergency Management, Region of Waterloo Health and Safety).

The debrief will serve to commence an evaluation of the emergency plan that was activated. If changes to the emergency plan are required they must be made within 30 days of the emergency being declared over.

As relevant, use information collected during the debrief to generate a formal Risk Review report. The report should clearly articulate who was involved in the debrief, details about the incident, immediate actions taken and other actions/recommendations that should be implemented or explored further to mitigate risk and future occurrence.

During the Summer Season, service interruption to natural gas will result in lack of domestic hot water and food preparation difficulties as the gas stove in the main kitchen will not function.

1. Supervisor, Facilities Management will ensure that the City of Kitchener Emergency Services is notified.
2. If the natural gas disruption lasts longer than the RN in Charge (in consultation with Maintenance) feels that the home can safely manage, the RN in Charge will contact the Manager on Standby to inform of the situation. The Manager on Standby will notify the Director, Seniors' Services and the Administrator of Long Term Care (or delegate(s)).
3. Nursing staff may obtain small quantities of warm water for resident hygiene and for preparation of warm beverages from electrically operated hot water dispensing units in kitchenettes, café and main kitchen.
4. Dietary Supervisor will implement menu plan No. 1 or schedule barbecues. A catering service may also be utilized. 

During Winter Season, service interruption would also seriously affect space heating. It is anticipated that the building would remain reasonable warm for approximately eight hours, depending on weather conditions.

1. Supervisor, Facilities Management will ensure that the City of Kitchener Emergency Services is notified.
2. Facilities Management will run only HVAC units that have heat reclaim capabilities. Shut down all other ventilation systems (supply to exhaust) to maintain heated air in the building as long as possible.
3. The Supervisor, Facilities Management will try to obtain electric heaters to be distributed to critical areas. (Purchase new or borrow from staff offices).
4. Nursing services may obtain small quantities of warm water for resident hygiene and for preparation of hot beverages from hot water dispensers, located in the kitchenettes and main kitchen.
5. Nursing services ensure that residents are dressed in warm clothing and encourage residents to aggregate in electrically heated areas.
6. Dietary Supervisor will implement menu plan No. 1. Catering services may also be utilized.
7. All residents to be temporarily transferred to electrically heated areas if gas company officials advise that interruption will remain in excess of eight hours.
8. Consider evacuation if an interruption is expected to remain in excess of 12 hours.

Telephone Failure

1. A new number is our main phone after switchboard closes.
2. If this fails, power it down and then remove the battery and obtain the second phone number from GF/RS Team Lead office and use the phone. Complete an ITS request.
3. If the second number fails: another phone will receive the calls. Call Service First Call Centre (SFCC) and ask for them to dispatch IT technician. 
4. Major telephone systems failure: Call SFCC and explain the situation. One or two low-risk extensions down do not represent an emergency. 

In case of Home wide failure of the telephone system, cellular phones can be used (i.e. iPhones).

There are 12 two way radios that can be used. They are fully charged.

Distribution as follows:

• RNs - 2
• RPNs - 10
• Security - One has their own two way radio

Reminder when using the two way radio confidentiality is important; be mindful of what is appropriate to say on the radios as others will be able to hear their conversation.

Nurse Call Failure

• Nurse call system failure would be calls not received from the resident rooms or washrooms to call the panel at the communication centre. Notify Maintenance according to the circulated maintenance on call rotation.
• Non-emergency (i.e.) a pager or phone not getting calls, but are still able to see calls on the enunciator panel. Try changing the batteries and restarting the phone. If this still doesn't work, submit facilities work order.

Fire Alarm (Alarms, trouble)

• For all fire alarm and trouble alarms on fire panel, notify Maintenance immediately. After hours call Maintenance on call according to the circulated maintenance on call rotation.

Building Security

• Failure to security system, doors will not lock. Card readers not working, Roam Alert failures, etc. notify Maintenance immediately after hours according to the circulated maintenance on call rotation. 

Policy Statement

This policy provides direction on how to respond when a person(s) is trapped in an elevator.

Procedure for all staff when someone is trapped in an elevator:

• Notify the RN in Charge
• Stay with the person(s), or ask someone to stay, to reassure that person that help is on the way

Roles and Responsibilities

RN in Charge (during business hours)

• Notify maintenance (email CSD SEN Maintenance) and call to notify that someone is trapped in the elevator
• Notify Security
• Ensure that signage is placed (on all floors) indicating elevator is "Closed for Maintenance": signage located at Reception
• Ensure that a staff person is stationed at the elevator to reassure the person
• If a medical emergency occurs, dial 9-911
• Notify the Manager of the Program Area
• Complete risk report (if a resident) or public incident report (if a member of the public)
• If applicable, notify the SDM

RN In Charge (after business hours)

• Call Thyssen Krupp (LTCH) or Delta Elevator (Supportive Housing)
• Notify Security
• Provide details of the elevator location, floor elevator is stuck, number of people trapped
• Identify that this is an emergency
• Obtain estimated time for arrival of elevator repair technician
• Ensure that a staff person is stationed at the elevator to reassure the person
• If a medical emergency occurs dial 9-911
• Notify the Standby Manager
• Ensure that signage is placed (on all floors) indicating elevator is "Closed for Maintenance": signage located at Reception
• Complete risk report (if a resident) or public incident report (if a member of the public)
• If applicable, notify the SDM

Security

• Security to attend and support as necessary/applicable

Maintenance (during business hours)

• Call Thyssen Krupp (LTCH) or Delta Elevators (Supportive Housing)
• Provide details of the elevator location, floor elevator is stuck, number of people trapped
• Identify that this is an emergency
• Get an estimated time of the arrival of the elevator repair technician
• Place signage on elevator door(s): indicating elevator is "Closed for Maintenance": signage located at Reception
• Update the RN of the status of the request with Thyssen Krupp (LTCH) or Delta Elevator (Supportive Housing) 

1.  In the event of water failure (no water pressure in the building) the RN in Charge will:
   • Phone Maintenance staff/Maintenance on Call (if after hours) to notify of issue and request support, and
   • Notify staff of the issue and communicate that maintenance has been contacted
   • If the water disruption lasts longer than the RN in Charge (in consultation with Maintenance) feels that the home can safely manage, the RN in Charge will contact the Manager on Standby to inform of the situation.
2. Maintenance staff will:
   • Call "Bright Water Services" and request them to bring a truck load of portable water to pressurize the building.
   • Call the City of Kitchener Utilities Dispatch and let them know that we are shuttling off our main supply valve from the City (inside the building) and will be pressurizing the building using a portable water truck. Also, as City of Kitchener Utilities to call the person in charge of the home when they city water is restored.
   • Shut off city water supply valve at the water meter and hook up the Bright Water truck to the 1.5 inch line by the water meters and slowly build up the pressure in the building to 60 pounds.
   • Meet the Manager/RN in Charge and instruct them to only use water where absolutely necessary (e.g. toilet flushing, food preparation) until Bright Water Services has supplied water to the facility. Communicate to staff.
   • When city water has been restored, disconnect water truck and slowly open main city water valve.
   • Remind Manager/RN in charge to overhead page that city water to home is back on and temporary water usage restrictions are over.
3. Dietary supervisors will implement the emergency menu (with Synergy).
4. Resident Care will carry out only essential hygienic procedures until adequate supply of water is obtained. Moist wipes may be obtained from the Pandemic stock, by Manager/Rn in Charge.

Key Considerations:

• Estimated that there is approximately 2,250 gallons of water in domesticated hot water storage tanks that could be used for toileting and drinking.
• Location of water storage tanks:
  • Main boiler room of Franklin Building has two 750 gallon tanks
  • Kenneth Building mechanical room has one 750 gallon tank

Items on Hand for Two Days

Paper Goods:

• Garbage bags - 4 cases
• Serviettes - 2 cases
• Plastic Silverware (knife) - 3 cases
• Plastic Silverware (fork) - 3 cases
• Plastic Silverware (teaspoon) - 3 cases
• Hot Drink Cups - 4 cases
• Cold Drink Cups - 2 cases
• Plastic Dinner Plates - 6 cases
• Plastic Soup Bowls - 4 cases
• Plastic Dessert Dishes - 2 cases
• Six Inch Plates - 4 cases

Water:

• Bottled - 12 cases

Food Supplies:

• Soup Concentrates (canned or dehydrated)
• Canned Pork and Beans
• Canned Vegetables (Green Beans, Wax Beans, Beets, Tomatoes)
• Canned Fish
• Processed Cheese
• Jam, Jelly, Peanut Butter, Honey Portions
• Dry Cereals
• Canned Juice
• Powdered Milk
• Carnation Milk
• Pickles
• Single Serving Jars Pureed Food (Meat, Fruit, Vegetables)
• Canned Fruit
• Canned Puddings
• Cookies (ready to use)
• Crackers (ready to use)
• Potato Chips
• Dehydrated Mashed Potatoes

Telephone Numbers for Emergency Supplies (Local K-W Area)

• Baden Coffee (coffee and equipment): 519-634-5807
• Canada Bread: 1-877-229-1042
• Don's Produce (fresh fruit and vegetables): 519-579-9794
• Flanagan's Food Service: 1-855-352-6242
• Stop Food Service Equipment (small equipment): 519-749-2710
• Sysco Food Services (food, supplies, and milk): 1-855-373-4555 extension 4234

Standard

An emergency menu will be available for use in the event of a power failure.

Procedure

1.  In the event of a power failure, the Food Service Department will provide an emergency menu. In order to meet the nutritional requirements of the Residents, the following two (2) day menu may be used as a guide.
2. The home will stock a three-day supply of disposable dishes, cups and cutlery.

Sample Menu #1

Limited cooking facilities, water, refrigeration/freezers.

• Breakfast: Canned juice, cold cereal, cheese/peanut butter, milk, bread, butter or margarine, jam
• AM Snack: Canned juice
• Lunch: Juice, milk, tuna or peanut butter and jam sandwich, mixed salad/fruit cocktail, canned pudding
• PM Snack: Cookies, canned juice
• Dinner: Juice, milk, tuna salad sandwich, pickled beets, bread and butter pickles, canned fruit
• HS Snack: Cheese and crackers, canned juice

Sample Menu #2

Limited electricity, refrigerators or freezers.

• Breakfast: Canned juice, hot cereal (porridge), muffins/margarine, jam, scrambled eggs, coffee
• AM Snack: Juice
• Lunch: Soup (canned or dehydrated)/Crackers, canned baked beans, casserole/vegetables and cheese, pickled beets, bread and butter, canned pudding, tea, milk
• PM Snack: Cookies
• Dinner: Canned juice, salmon loaf, canned luncheon loaf, whipped potatoes, green beans, bread and butter, canned fruit, cookies, tea, milk
• HS Snack: Banana loaf or other purchased cake

This procedure outlines actions to be taken in the event of an internal flood on campus. The procedure outlines the accountabilities of Management, the Registered Nurse in Charge and Maintenance.

Flood From Broken Water Pipes

1. Management, in consultation with the Registered Nurse in Charge, will assess the situation and facilitate moving residents/tenants/clients to safely as necessary.
2. Management or Registered Nurse in Charge will email CSD SEN maintenance on call (during regular business hours). Call Maintenance person on call after regular hours.
3. Management or Registered Nurse in Charge will designate someone to keep systematic watch on the flood level.
4. The Registered Nurse will initiate a census taking to ensure that al residents are safe, as necessary.
5. Management will ensure that essential supplies, both perishable and non-perishable, are moved from storage rooms to a dry location of water damage is likely.
6. Initiate evacuation from areas as necessary following Code Green Policy.
7. After front line emergency response procedures are notified and underway (9-1-1, Sunnyside staff engaged in response); a designated person at Sunnyside (Security/RN/Management) notifies the Community Emergency Management Coordinator (CEMC) of the incident and current situation. The CEMC will assess broader notification and available resource options.

Notifies corporate Community Emergency Management Coordinator (CEMC).

Community Wide Flooding

Regional Municipality of Waterloo Flood Warning System will be activated and directives will be given to the Home with regard to contingency procedures.

Role of Maintenance

Please reference policy, Maintenance Communications: System Failure/Organization Risk. This policy outlines key communication guidelines for Maintenance staff (and relevant stakeholders) in the event of an organizational system failure or issue that poses risk to the organization, residents, tenants, clients, or staff.

Reference

• Sunnyside Home Evaluation-Code Green, Policy #6-10, Emergency Manual
• Maintenance Communications: System Failure/Organization Risk, Policy # 5-11, Quality Improvement and Risk Management

Severe Weather Warning

A severe weather warning means that a severe thunderstorm and/or tornado is either occurring or is expected to occur within the hour.

The following procedure has been established to minimize personal injury, loss of life and property damage through proactive measures.

Note: The Region's Emergency Management Office (EMO) maintains the Regional Emergency Response Plan. This plan describes how the Region responds to emergencies. The plan describes the roles and responsibilities of the Region and our partners, including fire departments, police, and community agencies. 

If a tornado occurs or is likely to occur the following steps must be taken:

1. Stay tuned to the local radio, television or weather website for weather advisories. 
2. Do not alarm residents.
3. Using a reassuring and calm manner, move all persons to the nearest interior corridor away from windows and close bedroom doors.
4. Where appropriate, ambulatory residents not requiring assistance should be directed to the basement.
5. Secure outside objects (chairs, etc.) that would become hazardous if blown by a high speed wind.
6. Take a census to ensure residents are accounted for.
7. Avoid gathering people in Heritage Hall.
8. At least one staff should remain on each wing, on all home areas, until All Clear is sounded over the P.A. system.
9. If the Home is struck by a tornado:
   • Provide name and address of facility
   • Name of Most Responsible person or Registered Nurse in Charge
   • Provide essential details
   • Call ambulances if required
10. If partial or total evacuation is necessary, follow organization's Code Green policy.
11. After front line emergency response procedures are notified and underway (9-1-1, Sunnyside staff engaged in response); a designated person at Sunnyside (Security/RN/Management) notifies the Community Emergency Management Coordinator (CEMC) of the incident and current situation. The CEMC will assess broader notification and available resource options.

Notifies corporate Community Emergency Management Coordinator (CEMC).

Role of Maintenance

Please reference policy, Maintenance Communications: System Failure/Organization Risk. This policy outlines key communication guidelines for Maintenance staff (and relevant stakeholders) in the event of an organizational system failure or issue that poses risk to the organization, residents, tenants, clients or staff.

Reference

• Sunnyside Home Evaluation-Code Green, Policy #6-10, Emergency Manual.
• Maintenance Communications: System Failure/Organization Risk, Policy #5-11, Quality Improvement and Risk Management.

Policy Statement

Sunnyside has a process for determine which staff are essential to operations in an emergency, and a process to identify when/how staff can be deployed to areas of essential needs.

Business Continuity Plan

Sunnyside has a Business Continuity Plan (BCP) which identifies the number of staff required in an emergency for short term and longer term operations.

Emergency Staffing Contingency Plan

Staffing should utilize the Emergency Staffing Contingency Plan.

Staff to be Deployed

The following is a lift of staff which can be redeployed during an emergency:

• Management/management support staff
• Administration (reception deployed to staffing, other admin to cover reception)
• Resident Engagement Team
• Social Work Team
• BSO Team
• Volunteers
• Café Staff (café to close)
• All non-essential Community Programs staff
• All non-essential housekeeping and laundry

In some circumstances other Regional staff may be deployed.

Essential Duties in Resident Care

The following are steps that could be taken if required in the event of an emergency that reduced the number of staff:

1. Basic Resident Care only: Essentials are toileting, washing as required, meals, medications and treatments, and getting up in a chair at least once per day. Assessments for condition changes would remain in place.
2. In emergency: No formal baths on that day, but a plan will be made to catch up.
3. Weights and BPs and any other extras can wait until emergency is over.
4. Bed making would be attempted, but is not essential.
5. Dressing of residents in day clothing would be attempted, but is not an essential.
6. Staff redeployed to essential/critical needs.
7. Staff could be asked to stay overnight to ensure they are at work the next day or extend their tour of duty.

Essential Duties in Supportive Housing

The following are steps that could be taken if required in the event of an emergency that reduce the number of staff:

1. Basic tasks only in tenant apartments - medications, meal support and necessary activities of daily living.
2. Lunch meal to be delivered to apartment - no congregate meal.
3. Recreation staff to be deployed to help and support with necessary tasks - may need to cancel recreation groups.
4. Redeployment of other staff to Supportive Housing, i.e. CAP staff to help with essential needs.

The following fire prevention measures will be undertaken:

1. All identified fire hazards on the Sunnyside Campus are eliminated, the Home and Supportive Housing are inspected at least once a year by an officer authorized to inspect buildings under the Fire Marshall's Act and the recommendations of the officer are carried out.
2. There is adequate protection from radiators or other heating equipment.
3. The water supplies are adequate for all normal needs, including those of fire protection.
4. The fire protection equipment, including the sprinkler system and fire extinguishers, are visually inspected at least once a month and serviced at least once every year by qualified personnel.
5. The fire detection and alarm system is inspected at least once a year by qualified fire alarm maintenance personnel, and tested at least once every month.
6. The fire hydrants (exterior) are tested, inspected and serviced annually by qualified personnel.
7. At least once a year the heating equipment is serviced by qualified personnel and the chimneys are inspected and cleaned if necessary.
8. A written record is kept by the Supervisor, Facility Management, of inspections and tests of equipment, fire drill, the fire detection and alarm system, the heating system, chimneys and smoke detectors, and each record shall be retained for at least two years from the date of the inspection or test.
9. The staff and residents are instructed in the method of sounding the fire detection and alarm system.
10. The maintenance staff is trained in the proper use of the fire extinguishing equipment.
11. Staff are instructed in the fire procedures at time of hire and through regular fire drills and de-briefing session.
12. Security guard checks all areas of the home for fire or potential at least twice per shift.
13. An inspection of the building is completed at least monthly by maintenance staff monthly, including the equipment in the kitchen and laundry, to ensure that there is no danger of fire and that all doors to stairwells, all fire doors and all smoke barrier doors close properly.
14. Adequate supervision is provided at all times for the security of the residents and the home.
15. Combustible rubbish is kept to a minimum.
16. All exits are clear and unobstructed at all times.
17. Combustible draperies, mattresses, carpeting, curtains, decorations and similar materials are suitably treated to render them resistant to the spread of flame and are retreated when necessary.
18. Lint traps in the laundry are cleaned out after each use of the equipment.
19. Flammable liquids and paint supplies are stored in suitable containers.
20. Smoking is permitted outdoors only. Self extinguishing cigarette ashtrays are provided.
21. No portable electric heaters are used on the premises that are not in accordance with standards of approval set down by the Canadian Standards Association.
22. No sprinkler heads, fire or smoke detector heads are painted or otherwise covered with any material or substance. 

Sunnyside Home is equipped with a two-stage fire alarm system. 

1. The First Stage Alarm (Alert Stage; Code Red) - The first stage, which rings in the Franklin and Kenneth buildings, at approximately 20 beats per minute, indicates that there is an alarm.
2. The Second Stage Alarm (Alarm Stage; Code Green) - The second stage which rings in the Franklin and Kenneth buildings, at a higher frequency, and indicates evacuation is required of the alarmed area. All other areas must prepare to evacuate upon notice. Total evacuation shall only be determined by the Fire Department, Director, Seniors' Services or designate of the RN in charge. The second stage alarm is activated by an RN using keyring, upon detection of a fire or smoke in the alert area.

Upon activation of the first stage alarm:

• The fire alarm alerts the fire department (directly connected)
• Mag locked doors close and local door releases
• Air intake and exhaust systems shut down

Upon activation of second stage alarm:

• All locked doors are released
• Elevators park on main floor

Location of Annunciator Panels

1. Near the main entrance foyer beside the visitor's washroom
2. At the Communication Centre in each house

Automatic Detectors

Automatic smoke and heat detectors may activate the fire alarm system before the location of the fire has been identified by staff.

In the event the fire alarm system is initiated by the automatic detection system, the exact location of the fire may not be immediately known. After Code Red and the zone has been announced over the P.A. system, employees in the immediate area shall seek out the fire as quickly as possible, forward the exact location by dialing zero (0) on the nearest telephone and then follow normal fire procedures.

All areas of the Home are protected by heat or smoke detectors. Smoke detectors are activated by, and are very sensitive to smoke, fumes, tiny insects or vaporized substances, such as hair spray, aerosol sprays or dust. Smoke detectors have a red indicator light.

Heat detectors are activated by a rapid increase in temperature.

All bedrooms in resident home areas have a red indicator light beside the door in the corridor which comes on when the detector in the room is activated.

Magnetically Locked Doors

All mag locked doors will open on a second stage alarm. A mag locked door can be opened individually by pulling the pull station at the door.

Kitchen Hood Fire Suppression System

If there is a fire in the Food Services Department in the kitchen stove areas, the fire suppression system will automatically be activated by the heat, and the gas supply will automatically shut off. When the fire suppressant system is activated, all staff must leave the area.

Sprinklers

Sprinklers are located in all rooms except for electrical rooms.

Elevators

The Fire Department can override the elevators with the key located in the firefighter's key box (located outside the main entrance door).

Fans

Air intake and exhaust systems shut down automatically by activation of the fire alarm.

Note: The fire alarm system is directly connected to the Fire Department through Direct Detect. In the event that an alarm pull station is pulled and bells fail to ring, you are to go to the nearest telephone and dial 9-1-1.

If fire or smoke is detected:

The Code Red is escalated to second stage by the RN in Charge.

1. Activate first stage alarm by pulling the nearest manual pull station if not already pulled.
2. use the fire panel key on the RN keyring.
3. Insert key in switch on face of the manual pull station, turn key slightly to the right.
4. Key can be removed once pull station is in Stage 2.
5. Dial and announce Code Green and area of evacuation three times. 

1. All staff shall be familiar with current emergency procedures.
2. Fire prevention rules shall be observed by all staff at all times.
3. Fire hazards and/or infractions with fire safety regulations shall be reported to their supervisor immediately.
4. During fire emergencies the Registered Nurse in charge will assume authority to direct evacuation and fire procedures.
5. Staff shall assist with emergency removal of residents as directed by the Registered Nurse/Designate.
6. In the absence of the Registered Nurse/Designate/Supervisor, the first person discovering the fire will take charge in the fire area until the Registered Nurse/Designate/Supervisor arrives.
7. When maintenance staff is not scheduled for duty, the Supervisor, Facilities Management, Environmental or designate shall be notified immediately by phone in case of actual fire. (See emergency fan out list for phone numbers).
8. In case of actual fire, the person in charge shall contact the Manager On Standby (if outside of normal business hours) as soon as possible.
9. When the emergency is over, the Registered Nurse of the fire area shall complete a written Fire Alarm report (including false alarms) and forward it to the Coordinator, Staff Education as soon as possible.
10. Non-compliance with the Home's Fire Safety policies may result in disciplinary action.

Policy

Fire drills will be held on each shift, monthly to give staff an opportunity to practice and become familiar with Fire Emergency procedures and in accordance with the Fixing Long-Term Care Act. The scenarios presented during fire drills are changed to provide staff with an opportunity to practice and become familiar with what to do in various situations. The Kitchener Fire Department (KFD) shall be present to witness one fire drill on an annual basis. Coordination of the KFD's attendance will be booked directly with the Fire Prevention Officer.

Procedure

1. Actual alarms can be used as a drill. Planned drills can be silent or with alarms.
2. The alarm monitoring agency shall be notified prior to commencement of a drill with alarms to ensure they do not contact the Fire Department unnecessarily.
3. The person in charge of the drill will plan a mock scenario and when assistance is required. they will affirm roles with those involved.
4. Fire drills shall be taken seriously by all employees and appropriate procedures must be followed during such exercises. All staff must remain on-site during an alarm, until the all clear has been issued.
5. A fire alarm report (DOC# 12-60-A) is to be completed by those involved in running the drill, (or by the Fire Marshalls in the case of an unplanned alarm), and forwarded to the Coordinator, Staff Education.

6. Specifically, they need to be aware of the following during the drill:

   • Was the fire notification loud enough to be heard throughout the building?
   • Did the person in charge know the appropriate steps to follow?
   • Were staff directed to appropriately prioritize when evacuating residents?
   • Did staff follow directions provided by the person in charge?
   • Did staff respond in a timely manner?
   • Were occupants relocated to an appropriate refuge area?
   • Were residents who were left in their room adequately identified to the person in charge?
   • How quickly was the fire zone evacuated?
   • Were all exists accessible without any obstructions or obstacles?
   • Was the drill executed in a timely, calm and efficient manner?
   • Were staff aware of next steps to be followed if a fire continued to spread? 
7. Following a drill with alarm, the person in charge of the alarm shall meet with the staff to debrief and discuss any deficiencies that arose as a result of the drill.
8. All fire drill reports are to be retained for a period of 24 months after the fire drill.

References

Fire Alarm Report DOC# 12-60-A (DOC# 361458)

The RNs in Charge shall be those individuals assigned phone. Emergency Fire Box is located in the bottom drawer of the outside desk in the communication centres labelled Fire Box.

Role of RN in Charge of Fire Area

General Duties:

1. Investigate source of Source 1 alarm.
2. Put the system to Stage 2 with any indication of fire (i.e. smoke heat or flames).
3. Call the Fire Department to update on status.
4. Assist the RPN in the area as required.
5. Communicate with the Control Centre.
6. Contact the Manager on Standby in event of a real fire.
7. Page all clear. 

Specific Duties:

Upon hearing Stage 1 fire alarm, the RN shall:

1. Check closest enunciator panel for location of fire.
2. Page overhead to announce Code Red and exact location, three times, f it has not already been done.
3. Go to the fire area, using stairwells to provide direction.
4. If there is indication of fire, escalate to second stage, using the small fire panel key on the RN keyring. Insert the small key into the nearest manual pull station (you do not need to pull the station to do this). Turn the key slightly to the right until you hear the alarm beeping faster. Turn the key back and remove the key. Do not leave keys in the pull station.
5. Page Code Green time times, indicating area of evacuation.
6. Provide direction and communicate with the RPN in charge of fire area.
7. Communicate with the RN in charge of Control Centre.
8. Contact Manager on Standby if actual fire.
9. In collaboration with the Manager on Standby and the Fire Department, determine if an Auto-Dialler (Everbridge) call or the emergency fan-out list should be initiated.
10. Call maintenance staff on call, if after hours.
11. Page Code Red (and Code Green, if applicable), All Clear, three times, when the situation is over, and all residents have been accounted for, or as directed by the fire department.
12. Complete fire drill (#12-60-A) report and forward to Coordinator, Staff Education. 

Role of RPN in Charge of Fire Area

General Duties:

1. Wears the vest to be easily identifiable.
2. Directs the evacuation on the unit and instructs where to gather residents.
3. Remains in a central and visible location.
4. Communicates with the RN in Charge.
5. Takes roll call and accounts for all residents.

Specific Duties:

Upon hearing Stage 1 fire alarm, the RPN shall:

1. Return to home area if not already there.
2. Take charge of the home area.
3. Obtain vest from the emergency fire box on the floor.
4. Advise RN if a real fire exists.
5. Coordinate the fire procedures by directing staff to prioritize the room or fire first, and move out there.
6. Remind staff how to safely check doors before opening, to enter a room to be checked (i.e. use back of hand, start at the bottom, check handle last if door is not hot, crouch down and open slowly if handle not hot).
7. Communicate with RN at Control Centre to send more staff, if needed.
8. Ensure resident rooms have been fully searched (behind doors, in closet, washroom, under beds) and Evac-alert signs are turned up, as rooms are cleared.
9. Remind staff not to cross in front of fire if the fire is not contained in a room where the door is closed.
10. Determine most appropriate place for staff to bring residents, ensuring they are moved beyond a fire door. (i.e. if fire in resident room, evacuate residents to dining room in centre core; i.e. if fire in central core, evacuate residents to resident wing(s)).
11. Remain in a central location to direct activities of staff.
12. Report any issues to the RN (for example, residents who are unable to be evacuated from the fire area).
13. Take roll call of residents, using the census located in the emergency fire box and account for all residents on the home area.
14. If safe to do so, have staff re-check Evac-alert signs to ensure evacuation complete.
15. If Code Green is called, prepare to move resident charts and medication cart.
16. If Code Green is called, assign staff members to watch exit doors to ensure residents do not leave the floor unattended.

Role of RN in Non-Fire Area

General Duties:

1. Establish the Control Centre
2. Follow the Control Centre Emergency Procedures Checklist found in the emergency fire box at reception.
3. Maintain communication with the RN in charge of the Fire Area.

Specific Duties:

Upon hearing Stage 1 fire alarm the RN will:

1. Check closest enunciator panel for location of fire.
2. Page overhead to announce Code Red and exact location, three times, if it has not already been done.
3. Establish the Control Centre at reception or the classroom if reception is in the fire zone. page overhead new location if location of Control Centre has been changed.
4. Unlock reception (if locked) and obtain the fire vest from reception desk emergency fire box.
5. use the Control Centre Emergency Procedures Checklist, stored in the emergency fire box at reception to assign staff to emergency tasks. Complete the checklist.
6. Advise non-emergency callers to call back as we are having a fire alarm (may delegate someone to answer switchboard phone).
7. Assign security to meet the fire department at the main entrance and escort them to the fire area to connect them with the RPN in charge of the fire area. Then security to return to Control Centre to give report of the fire situation to RN in charge of Control Centre.
8. Assign staff to check public areas and ensure safety of residents and visitors.
9. Assign staff to areas of the home as needed as per request from RPN in charge of fire area to assist in the fire area.
10. Maintain contact and take direction from RN/RPN in charge of fire area.
11. If maintenance is not yet on site, silence the panel when the all clear has been paged and on direction of the Fire Department. Do not reset the fire panel (maintenance will do so, on direction from the Fire Department).
12. Complete Control Centre Emergency Procedures Checklist and forward to Coordinator, Staff Education.

Role of RPN in Non-Fire Areas

General Duties:

1. Remain in the home area.
2. Take roll call and account for residents by checking sign out book. Communicate with RN if unable to accounted for all residents.
3. Prepare to move medication cart and resident chart rack in event of Code Green.

Specific Duties:

1. Remain in home area with residents, unless sent to assist in the fire area.
2. Assign staff members to watch exit doors to ensure residents do not leave the unit.
3. If night shift, send PSWs to assist in area of fire, and RPN to oversee both units.
4. Take roll call of residents to ensure all are accounted for.
5. Remain calm and reassure residents and staff.

Note: Manager on Standby will notify the Director of all real fire situations.

1. The Home's Maintenance Department and/or other designated staff shall ensure that the Fire Alarm System is operational at all times to provide continuous protection to staff and residents.
2. Maintenance staff when scheduled for work, are responsible for re-setting the fire alarm system following the activation of the alarm, on the direction of the Registered Nurse/Supervisor of the affected area.
3. Direct Detect shall be notified when the Fire Alarm System is being adjusted or repaired. Any adjustments to the system notification shall be carried out only by the Supervisor, Facilities Management/Designate and only with the approval of the Director or designate.

Maintenance must be called when fire alarm has been activated:

1. After hours the RN will call maintenance person on standby (this procedure is to be used for all problems with the fire alarm).
2. When Maintenance staff is not immediately available, the Registered Nurse/Supervisor will direct the fire department to the fire panel near main entrance on the ground floor in the Kenneth Building. 

Repairs or upgrades are done by Facilities Management staff or contractors hired to test/repair the system. No matter who repairs or upgrades the system, the following procedures must be followed:

Prior to and upon completion of any approved procedure that disrupts the effectiveness of the system, the Supervisor Facilities Management/Designate shall notify all concerned, that the fire alarm system is temporarily shut down:

• Send division wide building notice or page overhead (if emergency)
• Direct Detect
• Fire Department
• Supervisor/Registered Nurse of affected area(s)
• Reception
• Maintenance

A fire watch shall be appointed to conduct a tour of the building in areas normally served by fire detection devices. 

Tours shall be conducted once per hour until the fire alarm system has been reactivated.

The fire watch person shall record their patrols and also have some means of communication that can be used to notify a supervisor to call the fire department.

In the event of a fire, efforts should be taken to notify persons in the building that a fire emergency exists.

Total Disconnect

Upon direction by the Supervisor, Facilities Management or Director, Reception/Designate is responsible for informing all staff, using the public address system, prior to and upon completion of the Total Disconnect Procedure.

In the event of an actual fire during the Total Disconnect Procedure the first person to discover a fire must activate the closest pull station and call reception ("0") who will then phone 9-911. Reception will then page overhead to announce Code Red and exact location, three times. The fire procedures outlined in the Fire Plan and policies are then followed. 

Partial Disconnect

The Supervisor/Registered Nurse of the affected area is responsible for informing staff prior to and upon completion of the Partial Disconnect Procedure.

In the event of an actual fire in a disconnected area during the Partial Disconnect Procedure, the first person to discover the fire must activate a pull station in the closest fire zone not affected by the adjustment of the alarm system and call reception ("0") who will then phone 9-911. Reception will then page overhead to announce Code Red and exact location, three times. The fire procedures outlined in the Fire Plan and policies are then followed.

Note: The location of closest functional alarm box will be indicated on the Fire Alarm System Adjustment Report.