Legislative Requirements

Since 2010, long-term care homes have been required to have written emergency plans for specified emergencies. Emergency planning requirements were expanded in 2021 under the Fixing Long-Term Care Act (O. Reg. 246/22). Emergency plans are written with the intent of meeting and ensuring compliance with a variety of applicable Acts and associated legislation. Key applicable legislation can be found in the following Acts.

• Fixing Long-Term Care Act, 2021
• Fire Protection and Prevention Act, 1997
• Occupational Health and Safety Act, 1990
• Accessibility for Ontarians with Disabilities Act, 2005
• Health Protection and Promotion Act, 1990
• Emergency Management and Civil Protection Act, 1990
• Health and Safety Act, 1990
• Fire Protection and Prevention Act, 1997

Emergency Defined

An Emergency is defined by the “Emergency Management and Civil Protection Act, 1990” as: "A situation or an impending situation that constitutes a danger of major proportions that could result in serious harm to persons or substantial damage to property and that is caused by the forces of nature, a disease or other health risk, an accident, or an act whether intentional or otherwise."

Process for Managing Emergencies

To ensure that Sunnyside is prepared for dealing with the legislatively designated emergencies, a management plan has been created that reflects the listed legislation in O. Reg 246/22 s 268. (Fixing Long Term Care Act, 2021)

The emergency plans include five key components to effectively manage an emergency:

• Prevention: actions taken to prevent emergencies from occurring
• Mitigation: actions taken to minimize impacts to the organization that cannot be reasonably prevented
• Preparedness: actions completed in advance to ensure the organization is ready to deal with the emergency issue as it arises
• Response: actions taken before, during and immediately after an emergency to manage related consequences
• Recovery: steps taken to return the organization back to normal operation

List of Primary Emergency Procedures at Sunnyside

• Code Red: Fire
• Code Green: Evacuation
• Code White: Violent/Behavioural Threat
• Code Blue: Medical Emergency
• Code Brown: Chemical Spill/Release
• Code Purple: Hostage Taking
• Code Grey: Loss of Essential Systems
• Code Black: Bomb Threat
• Code Silver: Active Shooter/Assailant
• Code Orange: Natural Disaster/Extreme Weather
• Code Aqua: Hold and Secure in Place

List of Secondary Emergency Procedures at Sunnyside (Not Colour Coded)

• Outbreaks of communicable diseases, outbreaks of a disease of public health significance, epidemics, and pandemics
• Boil water advisory
• Floods

Stakeholder Consultation

To support emergency policy development and oversight of necessary changes, Sunnyside engages internal and external stakeholders, as applicable. Stakeholders engaged include, but are not limited to staff, residents, and community partners.

Internal stakeholders include:

• Management
• Staff
• Resident Leadership Team
• Residents
• Joint Health and Safety Committee

External stakeholders include:

• Health Organizations (Ministry of Long Term Care)
• First Responders (Police, Fire, Ambulance)
• Region of Waterloo (Health and Safety, Emergency Management, Public Health)
• Contractors
• Other Long Term Care Homes
• Legislative Bodies

Emergency Plan Content

Emergency plans, at Sunnyside, follow a standardized format to support comprehension and an effective response should an emergency occur. Each emergency plan articulates:

• Plan Activation: defines how the plan will be activated
• Lines of Authority: defines the roles and responsibilities of individuals/positions
• Communication: defines processes for communications
• Roles and Responsibilities: defines roles for all responders
• Recovery: defines the processes to return back to normal operations after dealing with an emergency
• Debrief: learning from the emergency and updating emergency policies and plans as applicable

Testing/Evaluating and Improving Emergency Plans

Emergency plans at Sunnyside are tested/evaluated, and improvements to the plans are made as necessary. Testing of emergency plans at Sunnyside aligns with the requirements of the FLTCA:

• Either annual or every three-year testing of emergency plans completed (based on an internal schedule).
• Testing takes the form of table-top exercises, drills, and functional exercises/simulations.
• If an emergency response takes place, an evaluation is conducted within 30 days following the emergency being declared over and necessary plan improvements are made.  

In addition to internally facilitated testing of emergency plans, annual testing of Sunnyside’s fire and evacuation emergency plans are led by the local Municipal Fire Department. This testing tests and evaluates the organization’s response to fire and evacuation. For all table-top exercises, drills and functional exercises/simulations an audit and evaluation is completed and corresponding documentation about what went well and what needs improvement is captured and followed up on.

Training

All staff regardless of discipline or position in the organization receive education at time of hire and annually thereafter via Sunnyside’s online learning modules. Further training on emergency procedures, for staff, is provided by Sunnyside’s Staff Education Coordinator and the Coordinator, Quality Improvement and Risk Management. This training uses diverse modalities including: table-top exercises, drills, and functional exercises so that staff understand how to respond in the event of an emergency. Volunteers are also oriented to emergency plans.  This is led by Sunnyside’s Volunteer Coordinator.

Access to Information

Emergency plans can be accessed via multiple means:

• Emergency posters with information on all colour coded emergencies (located throughout facility in direct care areas and meeting rooms)
• Hardcopies in Master Emergency Binder (onsite)
• Hardcopy in Café Library in Emergency binder (onsite)
• (For Sunnyside staff only) Sunnyside’s Policy Manager online application

Staff Procedures

Follow these steps during a building-related emergency

Code Red: Fire

Action: Evacuate

• Page code red overhead
• Remove persons in immediate danger
• Alarm: pull the alarm if not sounding
• Close windows and doors to contain smoke
• Evacuate persons beyond the area of danger
• Search rooms and turn up EVAC alert sign
• Do not use elevators
• Shut off equipment/appliances if safe to do so
• Follow direction from the lead RN/RPN

Code Green: Evacuate

Action: Evacuate

• Page code green overhead
• Notify security
• Assist all persons who need to be evacuated (RN to provide direction as applicable)
• Move residents to safety as directed by RN
• Report to RN if resident remains in room

Code White: Violent/Behavioural Threat

Action: Manage Situation

• Activate code white (pendant/call for help)
• Respond to code white in your area
• Respond to code white (outside of your area) if phone alert is received
• If safe, redirect/distract
• Help others to safety
• Wait in safe location for help if necessary 
• Take direction from Lead RN/RPN

Code Blue: Medical Emergency

Action: Assess and respond

• Page code blue overhead
• Assist as directed
• RN/RPN respond immediately
• Bring code blue cart

Code Brown: Chemical Spill/Release

Action: Shelter-in-place

• Notify RNs
• Call 911
• Page code brown overhead
• Stay away from/open windows and close exterior doors and move others to safety
• Disable all automatic doors
• Remain inside and do not leave unless directed to do so
• Place wet towels at openings
• Do not use elevators
• Listen for emergency announcements

Code Purple: Hostage Taking

Action: Run-Hide-Act

• Call 911
• Notify security if safe to do so
• Notify RN
• Direct others to stay clear
• Do not place yourself in an unsafe situation
• Do not negotiate unless necessary
• Do not page overhead 

Code Grey: Loss of Essential Systems

Actions: Assess and respond, Notify management, Notify RN  

Policy covers:

• Telephone and fax failure
• Nurse call failure
• Fire alarms
• Building security
• Mag lock failure
• Loss of cooling
• Loss of heating

Code Black: Bomb Threat

Action: Report and follow directions

• If you receive a suspicious letter/package, call 911 and wait for emergency responders for direction
• If you receive a verbal bomb threat, follow bomb threat checklist
• Notify security and RN
• If evacuation is called, follow code green
• Take direction from emergency responders re: paging overhead

Code Silver: Active Shooter/Assailant

Action: Run-Hide-Act

• If you see or hear an active shooter/assailant, call 911/security
• Do not page overhead
• If you receive a code silver notification, assess risk and get yourself to safety:
  • Run - if it is safe to do so
  • Hide - if it is unsafe to run
  • Act - if it is unsafe to hide, take action to protect yourself

Code Orange: Natural Disaster/Extreme Weather

Action: Shelter-in-place

• Notify RNs
• Call 911
• Page code orange overhead
• Stay away from/open windows and close exterior doors and move others to safety
• Disable all automatic doors
• Remain inside and do not leave unless directed to do so
• Do not use elevators
• Listen for emergency announcements

Code Aqua: Hold and Secure in Place

Action: Hold and secure

• Page code aqua overhead
• Notify security
• Move to an area which can be safely locked
• Direct/assist others to do the same
• Close and lock all main access doors to your area
• Stay away from any windows and doors
• Remain inside and do not leave the building unless directed
• Listen for any emergency announcements
• Wait for all-clear announcement before resuming normal operations

Building Emergency Response Team (BERT)

BERT is comprised of senior leaders and will convene during an emergency to manage the initial response and determine if a secondary response is needed.

For more information about Sunnyside’s Emergency Plan please feel free to contact Gerard Reuss, Coordinator, Quality Improvement and Risk Management at greuss@regionofwaterloo.ca