Emergency Policies and Plans

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Emergency Policies and Plans

Sunnyside is committed to the safety of everyone in our community and will take precautions to provide a safe environment. Find out more below. Please note: Sensitive content within our Emergency Code policies has been redacted to protect confidentiality. Please reach out to Gerard Reuss, Coordinator of Quality Improvement and Risk Management at 519-893-8494, ext. 6336 if you have questions.

Code Red: Fire Procedures

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 the 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 a fire, a fire alarm or smell of smoke.

3.0 Decision to Activate the Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

However, in some circumstances a larger response and additional supports may be required (e.g. additional management team members, corporate supports such as health and safety, emergency management, communications, facilities, and security).

Notifying these areas occurs through a BERT notification.

In Seniors' Services, the decision to activate BERT, during day-time business hours, will be made at the discretion of the management team member(s) responding to the incident. Outside of normal business hours, the Manager on Standby will make the decision to activate BERT (if uncertain about activation of BERT consult with Management Team).

For important information about the BERT, please reference the Building Emergency Response Team policy.

4.0 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 system. 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.

5.0 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.

6.0 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. Use the access code to enter the stairs.
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:

Check closest enunciator panel for location of fire.
(redacted)
Go to the fire area, using stairwells to provide direction.
Check to determine if fire exists. If any indication of fire (smoke, heat, flames) is detected, escalate to second stage.
(redacted)
Page Code Green three times, indicating area of evacuation (if required). Note: Stairwell and exit doors unlock when Code Green is activated.
Call the Fire Department to update on status.
Provide direction and communicate with the RPN in charge of the area.
Communicate with the RN in charge of Control Centre.
Contact Manager on Standby.
In collaboration with the Manager on Standby and the Fire Department, determine if Voicenet or the emergency fan-out list should be implemented.
Call maintenance staff on call, if after hours.
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.
Complete fire drill (#12-60-A) report and forward to Coordinator, Staff Education and Quality Improvement and Risk Management.
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:

Wear vest to be easily identifiable.
Return to home area if not already there.
Take charge of the home area and remain in visible location.
Advise RN if a real fire exists (if determined prior to their arrival).
Coordinate the fire procedures by directing staff to prioritize the room/location of the first first, and then remainder of wing/area.
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).
Communicate with RN at Control Centre to send more staff, if needed.
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.
Remind staff not to cross in front of fire if the fire is not contained in a room where the door is closed.
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).
Report any issues to the RN (for example, residents who are unable to be evacuated from the fire area).
Take roll call of residents, using the census located in the emergency fire box and account for all residents on the home area.
If safe to do so, have staff re-check Evac alert signs to ensure evacuation complete.
If code green is called, coordinate evacuation of residents and prepare to move resident charts and medication cart.
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:

Check closest enunciator panel for location of fire.
(redacted)
(redacted)
Ensure that CAP staff and Supportive Housing staff are kept informed of the situation.
Ask Security to unlock reception (if locked) and obtain the fire vest from emergency fire box.
Use the Control Centre Emergency Procedures Checklist, stored in the emergency fire box to assign staff to emergency tasks. Complete the checklist.
Advise non-emergency callers to call back as we are having a fire alarm.
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.
The staff person/Security will return to Control Centre to give report of fire situation to RN in charge of Control Centre.
Assign staff to check public areas and ensure safety of residents and visitors, as per checklist.
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.
Maintain contact and take direction from RN/RPN in charge of fire area.
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).
Complete Control Centre Emergency Procedures Checklist and forward to Coordinator, Staff Education.

Role of RPN in Non-Fire Areas

Upon hearing Stage 1 fire alarm the RPN will:

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

7.0 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

Code Green: Evacuation

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, staff, volunteers, students and others as applicable 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 takes place.

3.0 Decision to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

In Seniors' Services, the decision to activate BERT, during day-time business hours will be made at the discretion of the management team member(s) responding to the incident. Outside of normal business hours, the Manager on Standby will make the decision to activate BERT (if uncertain about activation of BERT consult with Management Team).

For important information about the BERT, please reference the Building Emergency Response Team policy.

4.0 Evacuation Types

Evacuation types are provided below. Reference section 6.0 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.

Note: If a vertical evacuation is necessary (and elevators have not been approved for use by the Fire Department) the stairwells will need to be used.

To remove residents, evacuation sheets will be used for these persons who are unable to evacuate. Info about evacuation sheets is included in Appendix 1.

See Appendix 2 for an illustration of Evacuation Flow.

5.0 Initiating a Code Green

Any staff can request a Code Green by notifying the RN in Charge.

The RN in Charge makes the decisions 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 BERT is not being activated).

If 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.

6.0 Options for Evacuated Residents

6.1 On campus relocation options available for residents who are displaced due to evacuation.

Implications for Evacuating Residents:

Consider relocating residents to another building prior to moving them off campus due to fire/smoke.

In the Home, if the need for evacuation presents (due to fire/smoke), consider moving residents horizontally (e.g. from GF to RS) or from one building to the other (e.g. Kenneth to Franklin) as necessary.

If it is determined there is a need to evacuate residents from both the Kenneth and Franklin building, discussion about moving residents (as many as possible) to Supportive Housing should take place. If tenants need to be evacuated from Supportive Housing, discussion should be had about moving them to the Home.

6.2 Off campus relocation options available for residents who are displaced due to a building evacuation include:

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

As applicable, and necessary, staff, volunteers, students and others, will accompany residents to the evacuation location(s). This will be undertaken to ensure appropriate resident safety and care is maintained.

6.2.1 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. The evacuation location will also be used as a safe place for others (staff, volunteers, students) to reside as necessary and applicable.

6.2.2 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 3 for a summary table to support decisions for triaging residents.

6.2.3 Activating Emergency Reception Centre

The RN in Charge (in consultation with Management and/or Emergency Services) determines if an emergency reception centre needs to be activated (if BERT is not being 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).

Initial transportation (of people, medications, supplies and equipment) to the reception centre is coordinated by Fire or Police Services (via contacting GRT and/or Mobility Plus for support). Secondary supports for coordinating transportation, if necessary, will be coordinated by the Region's Community Emergency Management Coordinator.

7.0 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/other persons' safety
Isolate the area of concern and do not let others in
Inform RN in affected area

RN in Evacuation:

The decision for a horizontal evacuation within the building is made by the RN in the evacuation area. If total or vertical evacuation is deemed necessary the RN will consult with Senior Management or the Standby Manager (the BERT may also be involved in making the decision).
- Note: 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 the evacuation area (in consultation with Management and/or Emergency Services) determines if an emergency reception centre needs to be activated.
The RN in Charge of the Control Centre 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).
Maintain communication with the RN in the evacuation area.

RPN (Area of Evacuation)

Takes direction from RN in the evacuation area.
Responsible to direct the evacuation of their Home area.

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/others are accounted for, safe and monitored during evacuation.
Ensures critical medications, necessary medical supplies, and resident charts and laptop computers are removed and sent to new locations with residents (via Ambulance, commercial transportation, family, GRT or Mobility Plus/other). See Appendix 4. Essential Medical Supplies and Equipment. All medications transferred must be transported with a Registered Nurse present.
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.
Manually bypass necessary air handling units via the Building Automation System (BAS) and reprogram the fire panel, as necessary (e.g. evacuation of residents to another building on campus).
Turns off gas valves to prevent potential for explosion.
Assigns person for traffic control of parking lot.
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.

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 resident 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:

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.

Grand River Transit (GRT) (includes regular and Mobility +) or Alternate:

Notified by Police/Fire on site, as required.
In addition to other transportation resources needed (i.e. ambulances, resident's family), GRT/Mobility Plus, will be requested by Fire/Police to transport residents, staff, volunteers, students and others as applicable.
Note: In escalated situations where additional transportation resources are required: Sunnyside Home staff may request support through the Region's CEMC, who liaises with partners to access additional options such as mutual aid supports, accessible taxis, other commercial transportation).

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.

Region of Waterloo Corporate Communications:

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

8.0 Communications

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

Staff - Messaging includes what has happened and how they can assist.
Residents - With guidance from Manager of Care, 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.
Contractors and Suppliers - With support from Manager of Care, messaging may include Pharmacy, Respiratory Therapy Services, Continence Product Supplier, Food Suppliers and should include name, phone numbers of key contacts at Sunnyside (cell numbers).

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.

9.0 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.

10.0 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).

11.0 Education

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

12.0 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.
Guelph General Hospital 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

13.0 Appendices

Appendix 1: Evacuation Sheets

A. Product Details

Sunnyside uses the S-capepod product. It is an under-mattress evacuation sheet, allowing the bed occupant and mattress to be easily and safely moved out from a room/ward and down stairs in an emergency evacuation scenario.

B. Location of Evacuation Sheets

The campus is equipped with five evacuation sheets.

C. Instructions on How to Use Evacuation Sheets

instructional Video: https://www.youtube.com/watch?v=F6CHFjlTcFo

Place the evacuation sheet directly onto the bed from/deck (you will need to remove the mattress).
Fold the side and end flaps of the evacuation sheet, making sure to match the orange marking as you go.
Reposition the mattress on top of the evacuation sheet.
At the head section of the bed, pull the elastic straps over the corners of the mattress to secure the evacuation sheet in place.
The evacuation sheet is now in place and ready to deploy during an emergency.
With the resident in the bed and the evacuation sheet in place, first pull the flaps on the right side of the bed and drape it over the resident (this is the longest flap and will make the cocooning process faster).
Pull out the second flap and attach it to the first using the velcro fasteners.
Instruct the resident to place their arms at their side and explain that they are safest under the flaps.
From the foot end of the bed, reach for the bottom flap. Pull the bottom flap up towards the resident and attach it securely. Secure the straps at the foot end of the bed carefully.
Pivot the mattress so that the resident's feet are at the side of the bed.
Pull the mattress off the side of the bed and slowly lower the resident to the floor.
One staff can pull the resident to the desired location (e.g. down hallway and down stairs).

Appendix 2: Evacuation Flow

Evacuation Flow Chart information

Appendix 3: 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%

Appendix 4: Essential Medical Supplies and Equipment (in the event of off-site evacuation)

Medication cart with medication administration supplies (medication crusher, spoons, cups, pitcher, insulin and injection supplies-swaps, tips, syringes).
Diabetic scanner for blood sugar sensors (eMAR is electronic), but also need narcotic count and insulin card book.
Emergency Starter Boxes.
Treatment cart with treatment and dressing supplies.
Nurse on a stick/vital sign machine, oximeter, flashlight, thermometer.
Catheter and oxygen supplies.
Fall prevention supplies (anti-slip socks, floor/chair alarms)
Continence supplies.
i-Phones to access DOCit; BSPs.
Physical carts if possible (appreciating most data is electronic).

Note: If additional medical mobility equipment is needed (walker or wheelchairs), check the Greenfield storage room. If further equipment is required, contact Motions Specialities (519-885-3160).

Code Orange: Natural or Community Disaster/Extreme Weather

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: flood, tornado, hurricane, severe thunderstorm, extreme heat, or earthquake.

3.0 Deciding to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

In Seniors' Services, the decision to activate BERT during the day-time business hours, will be made at the discretion of the management team member(s) responding to the incident. Outside of normal business hours, the Manager on Standby will make the decision to activate BERT (if uncertain about activation of BERT consult with Management Team).

For important information about the BERT, please reference the Building Emergency Response Team policy.

4.0 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 Charge 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 to inform them of the situation and provides updates.

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.

5.0 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.

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.

6.0 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 person's 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

Code Brown: Natural Gas Leak

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 Deciding to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

For important information about the BERT, please reference the Building Emergency Response Team policy.

4.0 General Awareness About Gas Leaks:

Natural gas has no odour. Gas companies add a harmless chemical called Mercaptan to give it its distinctive rotten egg smell.

High levels of natural gas exposure can cause natural gas poisoning, which can include fatigue, severe headaches, memory problems, loss of concentration, nausea, loss of consciousness, and suffocation. A gas leak can catch on fire and trigger an explosion from other fire source or electrical spark.

5.0 Procedures: Gas leak or fumes

Staff Finding Gas Leak or Fumes:

Contact Management or RN in Charge/delegate, 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".
Establish a Control Centre in a safe place of the Campus (e.g. by Reception desk at main entrance of LTCH, Classroom, Heritage Hall, Boardroom).
Meet or designate someone to meet with first responders to update on location and status of incident.
Organize necessary staff (and information/documentation) to support critical next steps to ensure safety and mitigate further damage and/or risk.
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 (only if BERT has not been activated). The CEMC will assess broader notification and available resource options.
Notifies corporate Community Emergency Management.
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 6.0 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.

6.0 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

7.0 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).

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.

Code Grey: Exclusion of External Air

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.

Note: Notification of contaminated external air will be made to the LTCH by way of government officials or media.

3.0 Decision to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

In Seniors' Services, the decision to activate BERT, during day-time business hours, will be made at the discretion of management team member(s) responding to the incident. Outside of normal business hours, the Manager on Standby will make the decision to activate BERT (if uncertain about activation of BERT consult with Management Team).

For more information about the BERT, please reference the Building Emergency Response Team policy.

4.0 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)

Person/Group Notified of Event:

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

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.
- After front line emergency response procedures are notified and underway (only if BERT is not being activated):
  - Notifies the Community Emergency Management Coordinator (CEMC) of the incident and current situation. The CEMC will assess broader notification and available resource options.
- 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.

5.0 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).

Code White: Violent/Behavioural Threat (Inside/Outside Building)

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 initial de-escalation strategies have been ineffective.

3.0 Decision to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

For important information about the BERT, please reference the Building Emergency Response Team policy.

4.0 Activation and Procedure for Code White

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

All staff can activate the Code White response.

Note: If the Code White pendant system is down in LTC see section 4 of this policy.

See Appendix A for more information about Code White Pendants.

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

The Code White alert, when activated by the Code White pendants used in the LTC, is sent to designated staff phones to initiate a response. If Code White is 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
- RPN (on Greenfield)
- RNs
Kitchener 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 by pushing the pendant or calling out to other staff (describe in section 3A)
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 required 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/tenant)
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

5.0 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 and supported
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 an E-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
Ensure that staff impacted by the incident (stress or trauma) are supported in an effective and timely manner. Compliance with the organization's Post Critical/Traumatic Incident Response policy must be followed.

Training Requirements:

To ensure awareness and compliance with the Code White policy, annual drills will be undertaken for all Seniors' Services locations/sites. In addition, annual review of the Code White policy will be completed by all staff via the related Surge Learning module.

Appendix A: Code White Pendants: Technology and Activation for LTC

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.

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, basement kitchen and in Social Work Offices.

Additional pendants are available to be signed-out at 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 during activation).

Preventative Maintenance

Quality and Risk Management tests the batteries in the Code White pendants during monthly tests and replace when necessary (i.e. reading not going to phones promptly). If pendants are deemed defective, a new pendant is put in circulation by Quality and Risk Management.

Code Aqua: External Human Threat (Outside Building)

1.0 Policy Statement

Code Aqua is a planned response to ensure the safety of all persons when there is a threat or emergency situation on Campus or in the immediate surrounding area.

Threats include, but are not limited to: intimidation, harassment or physical violence, which may place building occupants (e.g. employees, visitors, tenants, clients, residents, other) at risk. Threats may also include damage to property.

In the event of an external threat or emergency situation, that cannot be de-escalated or controlled quickly.

2.0 Definitions

Emergency Situation: a situation that which may significantly impact the safety of building occupants.

Hold & Secure: preventive measures to prevent individuals from entering and/or leaving the facility, or to prevent the threat from entering the facility. Examples of incidents may include but are not limited to a violent crime nearby, an active shooter in the area, etc.

Lockdown: all entry points of the facility are secured to restrict access to the building during a threat or emergency situation.

3.0 Decision to Activate Building Emergency Response Team (BERT)

In Seniors' Services, the activation of Code Aqua (and BERT) during the day-time business hours, will be made at the discretion of the Management Team member(s) responding to the incident. Outside of normal business hours, the Manager on Standby will make the decision (if uncertain consult with the Management Team).

For important information about BERT, please reference the Building Emergency Response Team policy.

4.0 Procedure

Roles and Responsibilities

Senior Management (or Designate) - During normal business hours
Standby Manager - Outside of normal business hours
RN in Charge
Staff
Security
RN at Control Centre

5.0 Debrief and Follow-up: Facilitated by RN in Charge or Management Member (or assigned person)

Complete an E-Risk Report (if applicable).
The incident debrief should be attended by both persons who were impacted by the incident, and the persons who were involved in supporting the resolution of the incident.
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. 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.
Ensure that staff and residents impacted by the incident (stress or trauma) are supported in an effective and timely manner. Compliance with the organizations Post Critical/Traumatic Incident Response policy should be followed.

6.0 Training Requirements:

To ensure awareness and compliance with the Code of Aqua policy, annual drills will be undertaken for all Seniors' Services locations/sites. In addition, annual review of the Code Aqua policy will be completed by all staff via the related Surge Learning module.

Appendix 1. Debrief Template

Date and Time of Debrief:

Name and Position of Person Leading Debrief:

Date/time of incident:

Location of incident:

Persons involved in incident:

Incident details and triggers if known:

Action taken to resolve incident:

Outcome (impacts) of incident:

Identification of immediate actions and planned actions:

Submit completed debrief report to Coordinator, Quality Improvement and Risk Management.

Code Purple: Hostage Taking

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 Decision to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

For important information about BERT, please reference the Building Emergency Response Team policy.

5.0 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 18s, 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 6.0

6.0 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

7.0 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).

8.0 Education

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

Code Silver: Active Shooter/Assailant

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 Decision to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

For important information about the BERT, please reference the Building Emergency Response Team policy.

5.0 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 6.0

6.0 Safety Procedures (redacted)

7.0 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.

8.0 Education

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

Code Black: Bomb Threat

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 Decision to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

For important information about the BERT, please reference the Building Emergency Response Team policy.

5.0 Person Receiving Threat - Roles and Responsibilities

Suspicious Phone Call
Suspicious Letter/Email/Social Media
Suspicious Object Identified or Found
Verbal Threat

6.0 All Responders - Roles and Responsibilities

All Staff

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

RN in Charge

(Redacted)

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

7.0 Conducting a Search (Response to Threat)

8.0 Evacuating the Building

9.0 Code Black Box

10.0 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.

11.0 Education

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

Code Blue: Medical Emergency

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 Decision to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

For important information about the BERT, please reference the Building Emergency Response Team policy.

3.0 Procedure

3.1 Initial Response to Event

Any/All Staff

Page Code Blue overhead and 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: RN, RPN Greenfield

Will respond immediately to the scene upon hearing overhead page.
Assess the situation and initiate the most appropriate emergency response.

Nurse Practitioner

Respond to all Code Blue events if onsite.
Provide support as requested by registered staff.

Security

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

Physician

Attend and support Code response, if requested.

3.2 Post Event: Once Code is All Clear

Registered Staff (Code Blue Team)

Call or facilitate 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).

Charge Nurse

Complete Ministry Critical Incident report, if applicable.
Notifies the Manager of Care and Administrator of the event, if applicable.
Call Manager-on-Call if the incident occurred after business hours, if applicable.
Complete E-Risk form, if applicable.

Management/Supervisor

Provide support to staff as needed.
Recommend Employee Assistance Program for assistance, as needed.
Facilitate completion of HR18s, if applicable.

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

The RPN will lead the debrief and complete the electronic Code Blue Flowsheet and Debrief report immediately following the event. The form is found on the desktops of all computers at Sunnyside.
The incident debrief should be attended by both persons who were affected by the incident 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, including: 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 evaluate 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.
Based on the outcome of the debrief, a Risk Review report may need to be completed. 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.

5.0 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
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.

Code Yellow: Missing Person

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:

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

2.0 Decision to Activate Building Emergency Response Team (BERT)

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

For important information about BERT, please reference the Building Emergency Response Team policy.

3.0 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.

4.0 Procedure

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

4.1 Searching for a Resident

Stage 1) Initial Search (approximately 5-10 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.

4.2 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.

5.0 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

6.0 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.
Documentation includes:
- Person who noticed resident missing
- What the missing resident was wearing
- Time and place the resident was last seen
- Any other notes

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 (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.

Loss of One or More Essential Services

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

Outbreaks, Pandemics and Epidemics

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:

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

The Infection Prevention and Control Lead or designate will:

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).
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.
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.

Pandemic Plan

Please see this PDF for a copy of our Pandemic Plan.

Boil Water Advisory

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.

Water 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.
Complete E-Risk Report.
Facilitates timely communications about the advisory and necessary actions for staff, residents and others as applicable (including written communications)
Ensures that the Boil Water Advisory is paged overhead. See Appendix A for script.
Facilities placement of signage across the facility to ensure awareness to the situation and safety measures are visible for all to see. See Appendix B for example signage content and placement locations for signage.
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)

Ensure that any water (e.g. jugs of water) or foods previously prepared with contaminated water are immediately disposed of.
Inform dietary staff of required actions (see info below).
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.
Update communications and messaging if/when circumstances to the emergency change.

Manager of Care

Inform Registered staff of advisory.
Ensure that symptoms/impacts to residents are assessed by registered staff, in the event that residents ingested contaminated water (prior to advisory notification and being acted on).
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, and water supply to sources of water that might be ingested by residents (e.g. all sinks in residents' room).
Turn off ice machines/discard ice
Note: If water supply valve is seized (e.g. for sink in resident room), remove faucet handles, or place garbage bag over sink and faucet (i.e. water source) to ensure access to water is restricted. In this situation, the Supervisor of Maintenance may need to call upon support from Management/Management Support to complete these tasks in a timely manner.

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:

Continue to use distilled water (only)
Responsible: RPNs

Bathing:

Stop bathing for all residents at the onset of the advisory
Use only wipes until direction from responsible authority is provided
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).

Appendix A. Script for Boil Water Advisory Overhead Paging

The script below should be used in the event of a Boil Water Advisory coming into effect at Sunnyside. Please repeat the script three times when paging overhead.

Boil Water Advisory

Attention: Staff, Resident, Visitors and Volunteers

We have been advised, by health authorities, that our facility is currently under a boil water advisory.
For your safety, please do not ingest any water from taps, fountains or other water sources.
Staff have been informed, and will be reminded, about necessary procedures to follow to ensure safety for all.
We will continue to update you as more information becomes available.

If you have questions, please reach out to a member of our leadership team.

Thank you.

On behalf of the Management Team

Appendix B. Signage and Placement Locations for Signage

Boil Water Advisory in Effect at Sunnyside

Effective Date: DD/MM/YY

For Your Safety, Do Not:

Ingest water from taps or use water that isn't boiled.
Follow direction from facility staff.

We will provide an update when the advisory is lifted.

Thank you.

On behalf of the Management Team

Locations for signage placement include, but are not necessarily limited to:

All entrances to facility
Staff lounge
All home area communication centres
All home area dining areas
In Cafe (public facing and in kitchen area)
In Main Kitchen (basement)
On public facing e-board/TV
Admin area (by photocopiers)

Building Emergency Response Team (BERT)

1.0 Overview

Building Emergency Response Team (BERT) is a building specific team of management who convene and collaborate for decision making related to building colour code emergencies.

2.0 Purpose

This protocol provides a framework for BERT to support the decision-making process for Seniors' Services, as well as expectations surrounding a building specific emergency response. The response requirements are specific to Seniors' Services colour code emergencies that have the potential to result in service disruption and pose an actual or potential threat to people and/or property. For a listing of building emergency codes for Seniors' Services, refer to policy.

3.0 Decision to Activate Building Emergency (BERT) Team Response

Most emergencies will be managed by the RN or Supervisor on-site during the emergency code being called.

However, in some circumstances a larger response requiring additional supports may required (e.g. additional management team members, corporate supports such as health and safety, emergency management, communications, facilities, and security).

4.0 Roles and Responsibilities: Activating and Facilitating BERT

When BERT is activated, assigned stakeholders from Seniors' Services, in conjunction with Corporate Services from the Region of Waterloo and Community Services are engaged to support facilitation, management and resolve of the emergency.

4.1 Sunnyside BERT Members

The BERT at Seniors' Services is internally composed of the Management Team, the Coordinator, Quality Improvement and Risk Management and the Supervisor of Facilities Operations.

Note: Roles and accountabilities for the above responders will be assigned at the time of the Emergency Code BERT response.

4.2 Activating BERT Response at Sunnyside

At the point that Senior's Services has decided to activate BERT, a call will be made to the (redacted) by the most appropriate Seniors' Services delegate (i.e. Sunnyside Management member or the Manager on Standby).

They will require the following information:

The type of emergency and/or colour code being activated (based on Seniors' Services colour codes).
The building impacted by the emergency (Sunnyside, 150 Main and/or University Gates).

4.3 Convening BERT and BERT Communication Process

Convening protocols for BERT and BERT supports will occur for all BERT colour code emergencies.

During a Colour Code Emergency:

Seniors' Services BERT and additional external supports will be notified of the current situation.
BERT will be informed of the emergency code taking place at Seniors' Services: this will prompt BERT to convene.
BERT members have access to a specific group and will meet via the platform. In the event of service disruption, a TEAMS teleconference number is made available to connect with each other.
Seniors' Services BERT will connect with any other Region of Waterloo building teams if support is required and/or if the emergency has affected more than one Regional location.

If an evacuation has been initiated by BERT and the evacuation location is offsite, it is recommended that post decision making, etc. a BERT member(s) attends to the evacuation location for an in-person update where possible. The person(s) to attend to the evacuation location will be assigned by the Management Team.

As part of building evacuation, inform police and update them on the current situation and provide contact information for further communications during the response phase of the emergency.

4.4 Key BERT Response Activities

BERT members receive and respond to the incoming notification sent via the system.
Convene with BERT and BERT support member to assess the current situation and determine immediate next steps.
If delivery of critical services are impacted, please refer to (redacted) for making alternate arrangements to continue critical services.
Maintain contact and updates with BERT and BERT support throughout the response.

Note: If a BERT member(s) is on vacation or unavailable to answer a call, the other BERT members, in attendance, will send an invite (email and/or phone call) to those who are acting as delegates or who are able to help.

4.5 External BERT Supports (Regional support outside of Sunnyside):

A BERT Support team external to Sunnyside provides advice and guidance during building emergencies. When BERT is activated, BERT Support members will convene with BERT and will participate in the conversation as required by BERT.

Corporate Region of Waterloo supports includes representatives from various Regional departments that assist with decision-making and/or action specific tasks as requested by Seniors' Services BERT. These positions include (but are not limited to):

Facilities Management
Health and Safety
Security
Service First Call Centre (SFCC)
Emergency Management Office (EMO)
Corporate Communications

Responders:

Corporate Communications
Security Operations Centre (SOC)
Emergency Management Office/Community Emergency Management Coordinator (CEMC)

5.0 Building Emergency Recovery

BERT will assess if the emergency had a sustained impact on business operations at Sunnyside:

If No, provide all-clear for employees when safe to do so
If Yes, Senior BERT leader notifies

Note: Under the leadership of CAO, the core Crisis Management Team consists of alternates.

The BERT will determine steps needed to return to normal operations and develop a transition plan.

6.0 Debriefs

The Director/Administrator of Seniors' Services 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.

7.0 Testing and Education of BERT

Testing and education of the BERT, for Seniors' Services, will be facilitated by the Emergency Management Office.

Flood Procedures

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

Management, in consultation with the Registered Nurse in Charge, will assess the situation and facilitate moving residents/tenants/clients to safely as necessary.
Management or Registered Nurse in Charge will email maintenance on call (during regular business hours). Call Maintenance person on call after regular hours.
Management or Registered Nurse in Charge will designate someone to keep systematic watch on the flood level.
The Registered Nurse will initiate a census taking to ensure that all residents are safe, as necessary.
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.
Initiate evacuation from areas as necessary following Code Green Policy.
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.

Supporting Documents

Emergency Policies and Procedures (Listing of Additional Documents for Emergencies)

Emergency Plan Structure

Emergency Planning and Code List
Paging Overhead Procedure
Contacting Contractors and Suppliers in an Emergency

Fan Out List Procedures

Staff Emergency Call-in

Receiving Centre - Evacuation Specific

Sunnyside Home Receiving Centre
Receiving Evacuees from the Community

Utility Failures

Electrical Failures - Emergency Generator
Elevator(s) Not Working
Natural Gas - Interrupted Service
Systems/Equipment Failure
Person(s) Trapped in an Elevator
Water Failure
Emergency Supplies
Emergency Menus

Weather Emergencies

Tornado Procedures
Essential Staffing During an Emergency

Code Red - Fire Emergencies

Fire Prevention/Safety
Fire Alarm System
Activation of Second Stage Alarm
Fire Safety Responsibilities - Employees
Fire Drills
Code Red - Registered Staff Responsibilities
Fire Alarm System - Operation
Fire Alarm Adjustment

Note: Sensitive content within the Emergency Policies have been redacted to protect confidentiality.