Code Red – Fire

Policy: All staff must be familiar with the Code Red Fire Policy and their individual responsibilities during a fire emergency. All staff must reassure residents during a Code Red.

Procedure

First Responder

1. Upon discovery of fire or smoke, ensure the R.E.A.C.T. sequence is initiated:

• Remove: Remove people from immediate danger in the room or area. Ensure washrooms, behind doors, under beds, behind privacy curtains, and closets are checked. Once a room has been evacuated, ensure the Evacu-check is enabled.
• Ensure: Room doors and windows are closed and hallways are cleared.
• Activate: Activate the fire alarm pull station closest to the site of the fire.
• Call: Call 9-1-1 and give the home name and address, and the exact location of the fire, including home area and room number.
• Try: Try to confine or extinguish the fire, if possible, without undue risk, using the nearest fire extinguisher. Fire extinguishers are located in all corridors and other areas of the building. Use extinguishers only if trained and confident to do so safely.

Note: Place wet towels, sheets, or blankets at the bottom of a closed door to restrict the rapid transfer of smoke unless otherwise directed by the local fire department.

2. Once a fire has been confined to a room or other confined area, concentrate on resident safety.
3. Proceed to use the paging system or delegate this step to another staff member. Press *3301 and announce “Code Red” and the exact location of the fire. Repeat the announcement three times. Speak slowly and calmly.
4. Proceed with evacuation of the wing or zone as required.

Chief Executive Officer (CEO)

1. Responsible for implementing all policies and procedures of the Emergency Preparedness Manual.
2. Ensure all staff receive adequate training to fulfill the requirements of the Code Red policy.
3. Ensure the Fire Safety Plan is completed with site-specific information and meets the requirements of the Chief Fire Official.
4. Submit the Fire Safety Plan to the Chief Fire Official for approval.

Incident Manager (Charge RN or Management Team Member)

1. Upon hearing the fire alarm, ensure the North Glengarry Fire Service has been notified by calling 9-1-1.
2. Check the fire panel.
3. Obtain the Emergency Preparedness Manual, clipboard, don the red vest, and proceed to the origin of the alarm.
4. If not already done, ensure the paging announcement “Code Red (location)” is made three times.
5. Ensure the fire location is identified and further entry is prevented. Post guards outside the fire room or area, exit doors, and zone separations where possible.
6. Upon arrival of the Fire Department, provide access keys and a copy of the Fire Safety Plan to the scene commander.
7. Advise Fire Department personnel of alarm status, actions taken, and any persons not accounted for.
8. Provide a current list of individuals requiring assistance.
9. Follow all directions from the Fire Department.
10. Do not allow re-entry until declared safe.
11. Once “Code Red – All Clear” is given, announce All Clear over the paging system and ensure all systems are reset and operational.
12. Maintain a resident tracking list and initiate Code Yellow if required.

Registered Nursing Staff (RN/RPN)

1. Put on the red vest to identify responsibility for direction in the fire zone.
2. Assign duties to staff present, including fire checks, evacuation, and resident accountability.
3. Ensure organized room-by-room searches and report fire location to the Fire Captain.
4. Continue evacuation until All Clear is announced.
5. Ensure a resident headcount is completed.

Note: During a drill, bedbound or palliative residents do not need to be evacuated.

Personal Support Workers (PSWs)

1. Upon hearing the fire alarm, check whether the fire is in the immediate area.
2. Report to the assigned nursing station unless directed otherwise.
3. If assigned to the fire zone, evacuate residents beyond fire doors and close doors and windows.
4. If not assigned, ensure residents are accounted for and kept calm.
5. Do not resume normal duties until “Code Red – All Clear” is announced.

Maintenance Staff

1. Proceed to the fire panel to identify the alarm location.
2. Assist with extinguishing the fire and evacuation as directed.
3. Approach smoke barriers with caution and check doors for heat before opening.

Administrative, Dietary, Activity, Outreach, and Housekeeping Staff

1. Shut down equipment safely and close doors.
2. Report to the assigned nursing station and await further direction.

Cooks

1. Turn off all gas sources.
2. Report to the main lobby and await direction from the Fire Captain.

Code Yellow – Missing Resident

Policy: As soon as a resident is missing, a Code Yellow procedure, defined as an immediate and systematic search of the home and surrounding area, will be followed. All staff must reassure residents during a Code Yellow.

Note: Residents are considered missing when they are not in a location where staff can find them. Residents are encouraged to move freely in the Manor except in areas considered hazardous or restricted for health and safety reasons.

Procedure

When a Resident Is Missing – Incident Manager Responsibilities

1. Assume responsibility for the incident when notified that a resident has not been located after an initial five-minute search.
2. Use the Incident Manager Checklist – Code Yellow to track actions and log response times.
3. Assign search areas to staff, including resident rooms, washrooms, lounges, activity rooms, dining rooms, outdoor areas, Town Square, physiotherapy room, chapel, hair salon, library, day centre, resource rooms, and surrounding exterior grounds.
4. Obtain a description and photo of the resident from the resident profile.
5. Re-check the leave-of-absence log.
6. Follow up with anyone who may have visited the resident that day.
7. Delegate a staff member to contact the resident’s family to confirm whether the resident has left the building.
8. Announce or delegate an announcement by dialing *3301 and stating, “Attention please, would (Resident Name) please return to (Unit) immediately.” Repeat the announcement three times.
9. Repeat the announcement after three minutes if the resident does not return.
10. Contact nurses on other units to determine whether the resident is in their areas.
11. Check external sitting areas. If the resident is reported to have exited the building, begin searching the exterior grounds and neighbourhood immediately.

Escalation – Resident Not Located

1. If the resident is not located within ten minutes of notification, announce or delegate the announcement (three times): “Code Yellow (Resident Name and Unit)”.
2. Repeat the Code Yellow announcement after five minutes.
3. Notify police by calling 9-1-1 and provide a description of the resident.
4. Complete a Missing Person Report.
5. Provide police with the Missing Person Report and a summary of actions taken prior to their arrival.
6. Ensure staff searches continue in support of police action.
7. Notify the Chief Executive Officer and Director of Care.
8. Initiate the staff call-back list if the incident occurs outside peak staffing hours.
9. Establish an Emergency Operations Centre where responding staff report for instructions.
10. Print and distribute the resident’s photo and description to staff and responders.
11. Assign staff to search areas they are most familiar with and ask residents if they have seen the missing resident.
12. Direct staff to conduct external searches in pairs when required.
13. Instruct staff to report back at minimum every ten minutes.

When the Resident Is Found

1. Announce or delegate an announcement (three times): “Code Yellow (Resident Name) – All Clear.”
2. Notify all searchers and authorities that the resident has been located, including the CEO, family, and police (if applicable).
3. Complete the Missing Person Report and Code Yellow Emergency Checklist.
4. Provide documentation to the CEO and Director of Care within 24 hours.
5. Conduct a brief debriefing to gather feedback on the handling of the event.

All Staff Responsibilities

1. Conduct a preliminary unit search when a resident is suspected missing.
2. Check the leave-of-absence log.
3. Notify the Incident Manager if the resident is not located after a five-minute search.
4. Report to assigned units or areas when Code Yellow is announced.
5. Ensure at least one staff member remains in each wing to maintain resident safety.
6. Search assigned areas thoroughly, including rooms, closets, washrooms, lounges, and utility rooms.
7. Conduct external searches in pairs and report findings every ten minutes.

Code Green – Evacuation

Policy: All staff must be familiar with emergency evacuation processes. An evacuation drill is required annually. Staff must reassure residents during a Code Green.

Background: A Code Green emergency is a critical incident requiring evacuation. Delays increase risk to residents, staff, and visitors. Evacuation may be required during events such as fire, explosion, bomb threat, community disaster, or structural failure.

Procedure

Incident Manager

1. Determine the evacuation level based on the emergency.
2. In fire emergencies, initiate partial evacuation beyond fire doors as the initial response.
3. Assess fire or smoke spread and determine whether a larger area requires evacuation.
4. When there is no immediate danger and time allows, coordinate evacuation decisions with emergency services.
5. When emergency evacuation is required, announce or delegate the announcement three times by dialing *3301: “Code Green (Location)”.

Priority Evacuation Responsibilities

1. Track and maintain records of evacuees, including residents, staff, volunteers, contractors, and visitors.
2. Identify residents using name badges, wristbands, or other identification.
3. Transport resident charts, medications, communication devices, and essential equipment to relocation sites where safe to do so.
4. Inform emergency services of any persons not accounted for.
5. Assign staff or volunteers to care for evacuees and maintain safety in evacuation areas.
6. Notify families of residents of the evacuation.
7. Notify the Ministry of Long-Term Care and other reporting authorities as required.

Initiation of Incident Management System (IMS) Roles

1. Participate in assessing the situation with emergency services.
2. Ensure continuity of resident care through coordination with care staff.
3. Notify the Chief Executive Officer, who will initiate the staff call-back list and activate the IMS team.
4. Appoint a Liaison Officer to communicate with emergency services.
5. Appoint a Safety Officer to monitor staff, volunteers, and residents.
6. Appoint a Public Information Officer to manage communications and media inquiries.
7. Establish a Family Information Support Centre.
8. If relocation to the area of refuge is required, coordinate transportation of residents.

Director of Care

1. Activate emergency access to electronic health records as required to support care continuity during evacuation.

Nursing Staff and Directors

1. Provide direction and guidance to staff participating in evacuation.
2. Report to and follow direction from the Incident Manager or IMS leaders.
3. Remove the disaster box from the building.
4. Identify evacuees using wristbands or other identification.
5. Maintain a headcount of residents and staff and report updates regularly.
6. Remove resident charts where time and safety permit.
7. Track resident destinations and provide for ongoing care.

All Staff

1. Listen for the announced Code Green location.
2. Evacuate immediately when directed.
3. Ensure residents and visitors in work areas are safe.
4. Shut down equipment safely and close doors where appropriate.
5. Proceed to designated evacuation or safe areas.
6. Search assigned areas thoroughly, including resident rooms, washrooms, and closets.
7. Use evacuated indicators to identify rooms that have been cleared.

Off-Duty Staff

1. Report to the evacuation meeting area for further instruction when contacted.

Code Blue – Medical Emergency

Policy: A nursing and/or first aid trained staff member must render aid for an acute medical emergency involving residents, staff, volunteers, visitors, or others. Staff who discover a medical emergency anywhere on the property must respond as directed by this policy. Staff must reassure residents during a Code Blue.

Background: This policy guides staff in responding to cardiac arrest or other acute medical emergencies requiring immediate and coordinated action to save life and provide appropriate care.

Procedure

Incident Manager / Charge Nurse

1. Upon notification of a medical emergency, attend the scene immediately and bring required emergency equipment.
2. Determine whether Emergency Medical Services (EMS) are required and call 9-1-1 when necessary.
3. Provide First Aid and/or CPR as required.
4. If the emergency involves a resident, review the Goals of Care (if available) to determine whether CPR should be initiated. If wishes are unknown, proceed with CPR.
5. Delegate a staff member to meet EMS or Fire Department personnel if 9-1-1 has been called.
6. Advise staff or volunteers who are not required to return to their duties.
7. As soon as possible after the code is resolved, conduct a review of the incident to determine effective aspects of the response and opportunities for improvement.
8. Ensure all reporting requirements are met, including Incident Reports and Ministry of Long-Term Care reporting where applicable.

Note: The decision not to provide CPR does not preclude the use of other appropriate treatments intended to increase comfort and quality of life, such as clearing a blocked airway.

All Staff

1. If you discover a medical emergency, summon help immediately by calling out: “Code Blue. I need help in (location).”
2. If a cardiac arrest is suspected and you are trained in CPR, begin CPR following current Basic Cardiac Life Support guidelines.
3. If you are the second staff member on the scene, initiate an all-page Code Blue by dialing *3301.
4. Call 9-1-1 and state, “Medical emergency,” and provide required details including consciousness, breathing status, nature of the emergency, location, and telephone number.
5. Return to the emergency scene once calls are complete.
6. The responding nurse will bring the crash cart containing emergency equipment.
7. If time allows, ensure the resident’s next of kin is informed as soon as possible.
8. Assign one staff member to direct EMS to the scene.

Code Grey – System Power Failure / Loss of Essential Services

Policy: Maxville Manor is equipped with a standby generator to provide electrical power to critical points within the home during a power failure. Generator tests are conducted monthly. Staff must reassure residents during a Code Grey.

Background: Power failures or loss of essential services may be internal or external and may affect the entire home or specific areas. Emergency lighting will activate immediately in key locations. Non-essential services may be suspended during prolonged outages.

Procedure

All Staff

1. Consider all electrical wiring and equipment live until proven otherwise.
2. Inspect equipment power cords and fittings for damage before use.
3. Report damaged or suspicious equipment immediately to maintenance.
4. Use flashlights kept at nursing stations as needed.

Incident Manager

1. Assume responsibility for emergency response upon notification of a power failure or loss of service.
2. Delegate staff to monitor mag-lock doors when generator power is activated.
3. Determine whether the outage is internal or community-wide.
4. Assess which areas have power and which do not.
5. If community-wide, contact the utility provider to determine extent and estimated restoration time.
6. Communicate with staff to maintain essential resident care and dietary services.
7. Ensure all life safety systems are operational.
8. Notify the CEO if the outage exceeds 30 minutes and provide status updates.
9. If the outage exceeds three hours, notify the Ministry of Long-Term Care.
10. Direct maintenance to monitor generator operation and fuel levels when running longer than four hours.

Kitchen Supervisor

1. Plan alternate meals as required.
2. Monitor and record refrigerator and freezer temperatures.
3. Discard refrigerated food exceeding safe temperature limits.

Building Maintenance

1. Determine the cause, extent, and expected duration of the outage.
2. Ensure the generator is operating correctly and supplying emergency power.
3. Check generator fuel levels every four hours.
4. Arrange refuelling when fuel approaches 50% capacity.

Care Staff

1. If call bells are not functioning, perform resident checks at least every 15 minutes and document accordingly.
2. Notify families using designated communication devices if outages are prolonged.

Code Brown – Hazardous / Chemical Spill

Policy: Code Brown is initiated when there is a hazardous or chemical spill that may pose a risk to residents, staff, or visitors. All staff must reassure residents during a Code Brown.

Background: Hazardous or chemical spills may occur internally or externally and require immediate action to prevent exposure, injury, or environmental damage.

Procedure

All Staff

1. Report the spill immediately to the Nurse in Charge or Incident Manager.
2. Isolate the area and prevent residents, staff, and visitors from entering.
3. Do not attempt to clean up the spill unless trained and authorized to do so.
4. Use appropriate personal protective equipment (PPE) if required.

Incident Manager

1. Assess the nature and extent of the hazardous or chemical spill.
2. Notify Environmental Services and Maintenance immediately.
3. Determine whether external emergency services or specialized cleanup contractors are required.
4. Notify the Chief Executive Officer and On-Call Lead.
5. Initiate evacuation of affected areas if necessary.
6. Ensure appropriate authorities are notified as required.
7. Complete an Incident Report and conduct a post-incident review.

Environmental Services / Maintenance

1. Secure and ventilate the affected area where safe to do so.
2. Arrange for safe containment and cleanup in accordance with regulations.
3. Ensure disposal of hazardous materials is completed safely and legally.

Code Orange – External / Natural Disaster

Policy: Code Orange is initiated in response to an external or natural disaster that may disrupt services or pose a risk to residents, staff, or visitors. All staff must reassure residents during a Code Orange.

Background: External or natural disasters may include severe weather events, community-wide emergencies, or other incidents outside the home that impact safety or operations.

Procedure

Incident Manager

1. Monitor official alerts and information from emergency authorities.
2. Assess the potential impact on the home and determine required actions.
3. Notify the Chief Executive Officer and activate the Incident Management System as required.
4. Announce or delegate the announcement of “Code Orange” using the paging system when appropriate.
5. Determine whether shelter-in-place or evacuation is required.
6. Ensure adequate staffing levels and initiate the staff call-back list if required.
7. Ensure emergency supplies, food, water, medications, and equipment are available.
8. Maintain communication with emergency services and community partners.

All Staff

1. Remain alert to announcements and follow instructions from the Incident Manager.
2. Reassure residents and provide ongoing support.
3. Secure work areas and equipment as directed.
4. Assist with preparation for sheltering or evacuation if required.
5. Continue essential resident care and report concerns promptly.

Code White – Security / Violent Situation

Policy: Code White is initiated when there is a security incident or violent situation that may pose a risk to residents, staff, or visitors. All staff must reassure residents during a Code White.

Background: Security or violent situations may involve aggressive behaviour, threats, or physical violence and require immediate action to protect safety.

Procedure

All Staff

1. Ensure personal safety and the safety of residents and visitors.
2. Remove residents and others from the immediate area if safe to do so.
3. Use de-escalation techniques if trained and appropriate.
4. Do not place yourself at risk.
5. Call 9-1-1 if there is an immediate threat to safety.
6. Notify the Incident Manager or Nurse in Charge immediately.

Incident Manager

1. Assess the situation and determine the level of response required.
2. Ensure emergency services have been contacted when necessary.
3. Coordinate staff response and maintain resident safety.
4. Initiate lockdown or restricted access measures if required.
5. Notify the Chief Executive Officer and On-Call Lead.
6. Ensure documentation and reporting requirements are completed.

Code Black – Bomb Threat

Policy: Code Black is initiated when a bomb threat is received or a suspicious package or device is identified. All staff must reassure residents during a Code Black.

Background: Bomb threats may be received by phone, email, written communication, or through discovery of a suspicious object. All threats must be taken seriously and handled according to this procedure.

Procedure

Staff Receiving a Bomb Threat

1. Remain calm and listen carefully.
2. Do not interrupt the caller or attempt to transfer the call.
3. Obtain as much information as possible, including:
   • Exact wording of the threat
   • Location of the device
   • Time the device is set to explode
   • Description of the device
   • Caller’s voice, tone, accent, and background noises
4. Keep the caller on the line as long as possible.
5. Immediately notify the Incident Manager or Nurse in Charge once the call ends.

Incident Manager

1. Call 9-1-1 immediately and report the bomb threat.
2. Notify the Chief Executive Officer and On-Call Lead.
3. Announce or delegate the announcement of “Code Black” as appropriate.
4. Do not use radios or cell phones in the area of a suspected device.
5. Follow police direction regarding search, evacuation, or shelter-in-place.
6. Ensure residents, staff, and visitors are kept away from the threat area.
7. Maintain communication with emergency services.
8. Complete all required documentation, including a Code Black Information Form and Incident Report.

Incident Report Checklist

• Date and time of incident
• Type of emergency or incident
• Location within the home
• Names of persons involved
• Incident description
• Immediate actions taken
• Notifications made (internal and external)
• Follow-up actions required

Incident Progress Notes Checklist

• Type of incident
• Date, start time, and finish time
• Name of Incident Manager and note taker
• Summary of key events and decisions
• Actions taken and outcomes

Fire Drill Evaluation Checklist

• Immediate staff response (rooms checked, doors closed, evacuation steps)
• Staff knowledge (exits, pull stations, extinguishers, safe zones)
• Alarm and equipment performance (paging, doors, devices functioning)
• Debrief items and improvements

Evacuation Checklist

• Evacuation order received and communicated
• Resident movement to safe zone or area of refuge
• Records and essential items secured (where safe to do so)
• Resident and staff accountability completed
• Transportation and destination tracking completed if relocation occurs

Generator-Supported Systems

In the event of a power outage, key systems and selected outlets may be supported by generator power to maintain safety and essential services.

• Emergency lighting
• Fire and life safety systems as applicable
• Selected emergency outlets (for example, one emergency outlet per resident room where applicable)
• Selected kitchen refrigeration where applicable

Transportation Resources

Transportation resources may be used to support resident relocation during an evacuation. The home maintains agreements and contact information as part of its emergency preparedness resources.

Reporting Requirements

All emergencies must be reported according to internal policy and applicable Ministry of Long-Term Care reporting requirements.