Covenant Health

Compa.i,male .careI Catholic values'

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.
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Workplace Environment Inside

Staff entrance/Exit

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

'NM

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.

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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.

CCTV located inside Villa Caritas

CCTV located outside 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.

Image shows view of nursing station design within Villa Caritas

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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.

Stairwells possess Medium Convex mirrors January 2011 — James Prince/Scott

many blind spots strategically Mirrors are Baerg
throughout Villa placed, based on ordered
Caritas Protective Services
recommendations
Potential blind Medium Convex mirrors January 2011 — James Prince/Scott
spot located near strategically Mirrors are Baerg
reception on 1 4 placed, based on ordered
floor Protective Services
recommendations
Potential blind Medium Convex mirrors January 201.1 — James Prince/Scott
spot located strategically Mirrors are !berg
between nursing placed, based on ordered
stations and Protective Services
pharmacy on all recommendations
units
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Cannot identify if Medium Place peepholes January 2011 James Prince/Scott

potential hazard within door to Baerg
is located outside allow for
the doors increased visibility
• Nursing
station
exit/entrance
door
• Pharmacy
door in units
• Laundry room
doors in units
• Kitchen where
food
preparation
occurs 1 st
floor
Low level lighting Low Increase lighting January 2011 James Prince/Scott
between nursing levels — Le. insert Baerg
station and and additional
pharmacy within light
units
Patient closet Medium Security, OHS, January 2011 Villa Caritas
rods are Management and Management/Facilities
removable and Villa Caritas
may be used as a employees to
weapon evaluate best
control
Toilet tank lids Medium Security, OHS, January 2011 Villa Caritas
are removable Management and Management/Facilities
and may be used Villa Caritas
as a weapon employees to
evaluate best
control
Patient closet Low Lock shelves in January 2011 James Prince
shelves are place
removable and
may be used as a
potential weapon
Thermostats can Low Security, OHS, February 2010 Villa Caritas
be adjusted by Management and Management/Facilities
patients and Villa Caritas
potentially employees to
removed from evaluate best
wall and used as control
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weapon
Fall Protection — Medium Install cage around January 2010 Rob Kinsman
Ladder in ladder
Penthouse and
Loading dock
No access control Medium Install Controlled access Rob Kinsman
on locker room combination door to be installed
doors lock or card reader
access.

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.