Villa Caritas Hazard Assessment

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Covenant Health - Villa Caritas, Health and Safety

Agenda —January 10, 2011

1. 14:00 meet at reception for tour of Villa Caritas — led by Scott Baerg

2. Tour approx. 30-45 mins

3. Meeting to discuss Villa Caritas Health and Safety

3.1 Discussion of Pre-occupancy Hazard Assessment handout

3.2 Post-occupancy Hazard Assessment — Violence, Position

3.3 AHE AHS Protective Services in comparison to Covenant Health

3.4 Orientations 3.4.1 Site Orientation handout 3.4.2 Corporate Orientation handouts 3.4.3. OHS/Protective Services Orientation for Villa Caritas

3.5 Violence Program 3.5.1 Current Violence Program

• Respect in the Workplace Policy Corporate Orientation

• Protective Services

• Hazard Assessment for Violence

• JWHS committees

• Incident/Injury Process

• Incident Based Response

3.5.2 Enhanced Covenant Health Violence Program Spring 2011

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Villa Caritas — Pre-Occupancy Hazard Assessment Detember 15, 2010

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Villa Caritas

Villa Caritas was designed to provide appropriate, timely intervention and care for seniors with complex mental health and medical needs with a focus on treating their conditions and transferring them back home or to an appropriate care setting. Furthermore, Villa Caritas will serve an additional thirty seniors who require longer term, complex mental health care.

• Three-storey 135,000 sq. ft building with 150 beds • Designed specifically to meet the needs of patients, residents and their families, focusing on

privacy and dignity of care in a home-like environment • 120 beds for acute geriatric mental health patients—including the transfer of the 106- bed

geriatric psychiatry program from Alberta Hospital Edmonton • 30 beds for seniors with mental illness who are transitionlng to a more appropriate level of care. • Modern environment with large private rooms and bathrooms • Large windows and secure outdoor courtyard spaces provide maximum sunlight and opportunities

for patients and visitors to experience the outdoors • Special security measures to ensure a safe environment and enhance quality of care

Backeround

On November 15, 2010 a pre-occupancy hazard Assessment was conducted at Villa Caritas. Those involved in the assessment included hereby identified as the Team; Steve Kovacic, Director of Occupational Health and Safety, Stephen Slater, Manager of Protective and Parking Services, James Prince, Manager of Facilities Maintenance, and Rob Protz, Fire Officer.

Pre-Occuoancv Hazard Assessment

During the time of the assessment construction activities were still ongoing. Therefore, the Team was not able to identify all potential hazards that may exist at the opening of Villa Caritas. Following the opening, another hazard assessment will be conducted at each unit with the participation of employees.

The pre-occupancy assessment consisted of the Team completing the following: • Identifying a safe route from Villa Caritas to the Misericordia Community Hospital • Conducting an assessment of:

o Workplace environment outside o Reception o Site Administration o Kitchen o Loading Dock o Outside of Loading Dock o Basement o Stairwells 40 Elevators o Nursing Station o Patient rooms o Patient Dining O Relaxation rooms o Clean Linen room O Pharmacy o Treatment Rooms

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Mani Workplace environment outside Villa Caritas is located on the Misericordia Community Hospital MCH campus in west Edmonton.

Lighting

Lighting outside Villa Caritas will meet Parking Structure CSA Standard S413, of 2 foot-candles. The lighting outside automatically turns on at dusk, and lights are replaced as they I iiecome damaged or broken within a timely manner by MCH Facilities Maintenance.

Video Surveillance

No less than five cameras serve the outside video surveillance of Villa Caritas. These cameras record digitally and data are kept for a minimum of seven days. The exterior of the facility has good natural surveillance from all sides and is monitored via closed circuit television CCTV, which Is observed from Protective Services offices at MCH, Villa Caritas and GNCH.

Protective Services Additional to the video surveillance, MCH Protective Services patrol the outside premise of ViHa Caritas several times per day and when suspicious activity is reported. Throughout all shifts, Protective Services

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patrols the area and travels the premise in a marked vehicle to increase visibility to employees and as a deterrent to any potential threats. A focus is placed on shift change times.

Facility entrances are mixed with marked and unmarked depending on the type of entrance Main entrance vs. Fire stairwell entrance- however, all personnel with card access will be able to enter any exterior door in the event of an emergency.

Walking Route: Villa Caritas - MCH

For employee safety to and from the MCH to Villa Caritas, It has been identified that the best route is for employees to exit from the staff entrance/exit of Villa Caritas, proceed west to the staff parking lot and proceed south to Lynwood sidewalk. From the sidewalk the employees then proceed west to the northeast corner of the MCH doctors entrance, where all employee access cards will open the door. The route is identified in red on the above map.

Image shows employee entrance/exit at Villa Caritas Image shows doctor's entrance at MCH

Safe walk program

Safe walk program - A safe walk program is made available by MCH Protective Services for all staff to use If they are uncomfortable walking to their vehicles- contacting 780-735-2605 will initiate this process.

Workplace Environment Inside

Staff entrance/Exit

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Site Internal Design The site is designed as four tiles with three floors each. The main floor has Administration, Reception, a Chapel, Food Services Kitchen, Facilities Maintenance, Loading Dock, Staff Entrance, locker rooms, and one unit with two wings. The subsequent floors above 2 & 3 each have two nursing stations that care for two wings, a laundry room, a dean room, a pharmacy room, and a relaxation room. Shared space on each floor includes, a food service dining-room, conference room and treatment rooms. The facility also has a penthouse where the heating, ventilation and air-conditioning HVAC unit is located, and a basement where electrical equipment is housed.

Reception

Villa Caritas is a stand-alone facifity located near the MCH hospital. Access into the building is

monitored/controlled by card access control with reception staffed during the hours of 0700 — 2200.

Identification

All Covenant Health employees are required to wear employee identification for recognition while on Covenant Health property. Additionally, all authorized visitors such as contractors will be required to wear identification cards, while all visitors will be required to sign-in at the reception desk prior to visiting patients.

Visitors to the facility who demonstrate aggressive behavior or violence will be banned from entering the facility. On duty Community Peace Officers have authority to ticket or arrest persons breaching any ban.

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Patient Admission

All incoming patients are screened and searched by Protective Services to ensure no weapons are brought on-slte

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Secured Areas

Areas where only Covenant Health employees are permitted are secured with either security keys or Lenel Security card access.

Elevators

Elevators are equipped with an emergency call button that is monitored by switchboard at MCH for emergency situations, and public elevator access is restricted between the hours of 2100 - 0700. A Lenel security card for employee use controls operation of these elevators during restricted access.

Stairwells/Doors

The fire stairwell doors on each unit are magnetically locked with card access. Once a cardholder has entered the stairwell they may access any floor without a card in the event of an emergency. The fire stairwell doors remain magnetically locked until a stage 2 alarm is initiated, at which time they release.

The exterior doors exiting the fire stairwell onto the grounds are alarmed and magnetically locked. Approximately 20 pounds of force is required to depress the crash bar sufficiently to activate the alarm, at which point the magnetically locked door will release in 15 seconds. Alarms on these doors are monitored via the Lenel access control program.

All Entrances, exits, fire and security alarms are clearly marked far emergency egress.

Emergency Codes

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There are ten Covenant Health emergency codes that cover all health care related activities/situations, Two specific codes that are of importance given the environment are Code White — Violence/Aggression and Code Purple — Hostage.

Code White:

Is identified as the attempted or actual exercise by a person of any physical forces so as to cause injury and includes any threatening statement or behavior which gives a person reasonable cause to believe that he or she is at risk of physical injury. The goal in the management of aggressive behaviors within the healthcare setting Is to address this behavior in a safe, respectful and caring manner. The focus of a Code White Team also referred to as Effective De-Escalation Technique response is to de-escalate a threatening situation before an individual/s is injured or property is damaged.

Code Purple:

A Code Purple intervention is used in any situation in which there is real or perceived risk of physical harm to staff or other persons as a result of being held against their will. Assistance should be sought immediately. Employees calling for help will not be challenged about their call for assistance, as the decision to call for assistance is a subjective one.

Assistance should be sought when: • Employees perceive themselves or others to be in danger of physical harm as a result of being

held against their will. • A person has confined another in a manner that is dangerous to themselves or others • The situation has escalated beyond the unit/staffs ability to control.

Fire

Villa Caritas has a developed fire plan. The facility has a combination of manual pull stations located in non-patient care areas and key activated pull stations in patient care areas. All nursing staff will carry a key to activate the pull stations.

Inserting the key into stage one will place the system in alert mode, with slow beeps and strobes. Placing the key into stage 2 will activate the system to alert staff of possible evacuation. The beeps will increase to 120 beeps/ minute.

When the alarm is activated, pre recorded messages will be announced ove e fire alarm syste

Stage 1 Alert

Code Red, Code Red, Code Red. Employees proceed to the nearest fire panel for fire loca

Stage 2 Fire Alarm Activation

Stage two has been activated. Follow Unit Specific Code Red procedures. Your incident Commander/ Fire Warden will give further directions.

On stage 1 - The electronic hold open on the floor of activation will release closing all hallway doors. The Electronic Magnetic locks will release on the doors in the fire zone of activation.

On stage 2 - All Electronic Magnetic locks release in the building.

CCTV located inside Villa Caritas CCTV located outside Villa Caritas

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When Protective services are on-site, they will meet and direct the fire department to the location. Alternatively, when Protective Services are not on-site, or not available the supervisor from unit 1A will meet the fire department. The alternate to lA is the supervisor from 29.

Additionally, all Fire extinguishers cabinets will be secured within Villa Caritas to prevent unauthorized use.

Alarm Systems

Alarm systems including personal alarms are handled through an ASCOM telephone system which alert the unit hand held phones as well as Protective Services. Protective Services personnel carry these ASCOM phone and once notified, will proceed to the area of concern.

All employees working alone will carry ASCOM phones and need to notify additional personnel of their activities and check-in at predetermined intervals. Cellular phones will be available for employees transporting patients to the MCH.

Video Surveillance

There are 19 CCTV cameras located within and on the exterior of Villa Caritas. These CCTV cameras are monitored from the site itself, as well as from GNCH and MCH Protective Services. All door alarms are similarly monitored. Alarm records are retained for 2 years and CCTV footage is retained for a minimum of 7 days and can be saved to DVD for indefinite storage when required.

Image shows view of nursing station design within Villa Caritas

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Nursing Stations The nursing stations are dearly identifiable on the units and are staffed at all times, unless employee duties require them to be away from the station. In cases of emergency employees within the station can contact Protective Services for assistance by calling 104, or using the panic button on the ASCOM phones. The nursing station also has other means of communication such as telephones. Employees within the nursing station are able to dearly see the surrounding area.

Stairwells possess Medium many blind spots throughout Villa Caritas

Potential blind spot located near reception on 14 floor

Potential blind

Medium spot located between nursing stations and pharmacy on all units

Convex mirrors strategically placed, based on Protective Services recommendations Convex mirrors strategically placed, based on Protective Services recommendations Convex mirrors strategically placed, based on Protective Services recommendations

James Prince/Scott Baerg


James Prince/Scott !berg

January 2011 — Mirrors are ordered

Medium January 2011 — Mirrors are ordered

January 201.1 — Mirrors are ordered

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Food Services - Dining Area in Unit

The dining area within the units is designed to maximize comfort and avoid overcrowding.

Image shows view inside dining area within Villa Caritas

Potential Hazards

Upon completion of the walkthrough, a number of potential hazards were identified. We then assessed the risk and identified potential control measures to eliminate or minimize the possible exposure of employees to the risk.

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Cannot identify if Medium potential hazard is located outside the doors

• Nursing station exit/entrance door

• Pharmacy door in units

• Laundry room doors in units

• Kitchen where food preparation occurs 1 st floor

Place peepholes January 2011 within door to allow for

increased visibility


Low Low level lighting between nursing station and pharmacy within units

Increase lighting levels — Le. insert and additional light

January 2011 James Prince/Scott Baerg

Patient closet rods are removable and may be used as a weapon

Medium January 2011 Villa Caritas Management/Facilities

Security, OHS, Management and Villa Caritas employees to evaluate best control

Toilet tank lids are removable and may be used as a weapon


Medium January 2011 Villa Caritas Management/Facilities

Low Patient closet shelves are removable and may be used as a potential weapon

Lock shelves in place

January 2011 James Prince

Low Thermostats can be adjusted by patients and potentially removed from wall and used as


February 2010 Villa Caritas

Management/Facilities

weapon Fall Protection — Ladder in Penthouse and Loading dock

Medium Install cage around ladder

January 2010 Rob Kinsman

No access control on locker room doors

Install combination door lock or card reader access.

Controlled access to be installed

Medium Rob Kinsman

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Pre-Occupancy Violence Hazard Assessment Conclusion Based upon the conducted hazard assessment a number of low-medium hazards were identified. Speaking with the Senior Operating Officer of Villa Caritas, the hazards identified will be mitigated or eliminated prior to occupancy.

Future Activities To comply with Covenant Health's strategic direction of ensuring a safe work environment for employees, and Alberta Occupational Health and Safety Legislation a number of activities will be conducted to protect the health and safety of Covenant Health employees.

These activities include: • Corporate Orientation • Site Orientation • Unit Orientation • Post Occupancy hazard assessments

Feedback and involvement from employees will be sought throughout the activities.

Documents

Villa Caritas Hazard Assessment