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Villa Caritas - Pre-OctlupanCV Hazard Assessment

Decenlber 15, 2010
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)liJIa.Carlt.s
Villa Caritas was designed to provide 3ppropri:ate, timely intel'\lention Ind care fe't sel\iors with complex
mental health and medica' needs with a focus on treating their conditions and tri!nsferrlng them back
home or to an appropriate cate setting. Fu""ermol'e, Villa Carita$ will serve an additional thirty seniol'$
who require lonser term, complex mental health care.

• Three-storey 13S,000 sq. ft building with 150 beds

• Designed specifically to meet the needs of patients, residents and their famllle5, facusins on
privacy and di81\ity of care in It 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 !
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• 30 beds for seniors with mental illness who are transltionlng to a more appropriate level of care.
• Modern envirDnmEnt with large private rJolh5 and bathrooms I

• Large windows and secure outdoor courtyard spaces provIde maximum sunlieht and opportunities
for pJtients and visitors to experience the outdoo~
• Special security measures to ensure i1 safe environment and enhance quality of care

B,clqroyU
On November 15, 20103 pre-occupanty ha%ard Ass~ssment 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, Manlier of Protective and Parldr,c Services, James
Prince, Manlser of Facilities Maintenance, and Rob Prou, Fire Officer.

pr,.Quupanc:v HfUrd Ass'ssment

During the rJme of the assessment construction activities were still ongOing, Therefore, the Team was
not able to identify all potential hazards that may ex~t at the opening of Villa Caritis,Following the
opening, another hazard assessment will be conducted at each unit with the participation of employees.

The pre-Dccupancy assessment consisted of the Team completing the follOWing:

• Identifying a safe route from Villa Carltas to the Misericordia Community Hospital
• Conducting an assessment of:
o Workplace environment outside
o Reception
Q Site Administration
o Kitchen
o loading Dock
o Outside of Loading Dock
o Basement
o Stairwells
o Elevators
o NurSing Station
o PatIent rooms
e Patient DIning
o Relaxation rooms
o Clean lin~n room
o Ph"rmilcy
o Treatment Rooms
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Findinn
Workplace envIronment ofltsJde
Villa caritas is located on the Misericordia Community Hospital (MCH} campus In west Edmonton.

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Lighting
lishting outside Villa Clrltas will meet Parking Structure CSA Standard S413, 2 foot-candJes. The or
lighting outside automatically t\olrns on ilt dusk, and lights lire replaced as they ,ecome damaged or
broken within a timelv manner bV MeH Facilities Maintenance.
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Video SlIrvel1ian,e I:,

No less than five CCI",e",~ serve the oubide video surveilhmce of Villa Carltas. ~esr cameras record
digitally and data are kept for a minimum of seven days. The exterior of the faC.ilitvhas 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 GNCI-t I
Protectille Services
Additional to the video surveillance, MCH ProtectIve Servites patrol the outside premise of Villa Caritas
several times per day and when suspiciDus activltv is reported. Throughout all shifts. Protective Servic:e$
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pi1trol~ the area and travels the premise In a marked vehicle to Increase vlslbllltv to emplo~'ees and CIS a
deterrent to any potential threets, A focus is placed on shift change times.

F~c;ilityentrances 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 CariMs - MCH I

For employee safety to and from the MCH to Villa cantas. it has been identified that the best route is for
emplovees to exit from the staff entrance/exit of Villa CariUs. proceed west to the staff parking lot and
proeeed south to lynwood sidewalk. FrOM the sIdewalk the emplovees then proceed west to tt,e
northeast corner of the MCH doctors efltrance. J,here all employee access cards will open the door. The
route is identified in red on the above map. I

Image shows emplovee entrance/exit at Villa Caritas Imase shows do\:tor'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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Workploce E""/ronmenr 'ltslde

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Site Internal Design

The site is designed as fourtile$ with three fteers each. The main floor has Administration, Recepticln, a
Chapel, Food Services Kitchen, Facilities Maintenance, LoadinB 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 ~Cl wings, i laundry room, a clean room. a pharmacy room, and a relaxation room. Shared space on
each floor Includes, it food service (dining-room), conferen(;t! room and treatment rooms. The facility
also has a penthouse where tne heating, ventilation and air-conditioning (HVAC)unit Is located, and a
basement where ele~ical equipment is hOllsed.

Reception
Villa Caritas is a stancf..alone facility located near the MCH hospital. Access Into the building is
monitored/controlled by card access control with rec~tion staffed durinl the hours of 0700 - 2200.

Identi/l«1t;on
All Covenant Health emplOyees are required to wear employee identification for recognition while on
Covenant Health property_ Additionally, ilil authorized visitors (such as contractors) will be required to
wear Identification cards, while all visitors will be required to sien-il'l at the reception desk prior to
visiting patients.

Vi$itors to the fat;iUtywho demonstrate ",gressive behavior or violence will be banned from entering the
facility. On duty Community Peace Officers have author/tv 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 weapon~ are
brought en-slte I

Secured Areas
Areas where only Covenant He~lth employees are permitted are secured with either security keys or
Lenel Security card access.

Elevators I

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

Stalrwells/Oeors
The fire stairwell doors on each unit are magnetically locked with card access. Once a cardholder has
entered the $talrwell they may aceess any floor without a card In the event of an emergency. The fire
stairwell doon remain magneticallv locked Llntil a stage Z alarm is initiated, at whidt time they r~leue.

The exterior doors exiting the fire stairwell onto the grounds are alarmed and magnetically locked.
Approximately 20 pounds offorte is required to depress the cr~h bar sufficientlv to activate the alarm,
at which point the magnetically locked door will release In lS seconds. Alarms on these doors are
monitored via the Lenelliccess ~o"trol program.
All Entrances, exits, fire and security alarms are clearly marke1d for emergency _Kress.

Emergency Codes
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There are ten Cov~n~ntHealth emersency codes that cover all health care relatl ac:tivities/$Ituatlorls.
Two $peclflc 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 forcek 5;0 as to cause Injury
and Indudes any throat.nins statement or behavior which gives a persC)n reason~bll! cause to bellevle
that he or she is at risk of physical injury. The goal In the management of aggre$$ive 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 sit\lation before an individual/s is Injured or property is damaged.

Code Purple:
A Code Purple intervention is used in anv situation in which there is real or perceiVE~drisk of physical
harm to staff or other "ersons as a result of being held against th@irwill. Assistance should be soughl:
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 dev~loped fire plan. The facilitv has a combination of manual pull stations Icfated in
non-patient care areas and key aetivated pull stations In patient care areas. All nursIng staff will carrv 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 evacuCltlon. The beeps will
Increue to 120 beepsl minute.

When the alarm Is activated, pre recorded messages will be announced over the fire alarm system.

Stage 1 Alert:
Code Red, Code Red. Code Red. Employees proceed to the nearest fire panel for fire location.

Staee 2 Fire Alarm Activation

Stage two has been aC1:ivatfd. Follow Unit S~eCifiCCode Red procedures. Your Incident commander l
Fire Warden will give further directions.

On st ••ge 1 - Tt1e electronic hold open on the floor of activation will release closing all hallwav doors.
The Electronic Magnetic: locks will release on the doors in the fire lone of activation.

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

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When P,••• "lv ••• ",Ices are on-site, they will me.t and dl,ect the ft,. depa~t to theloca';"n.
Alterntltiveiy, when Protective Services are not on-site, or not available the SUP1Nisorfrom unit lA will
meet the fire depa"ment. The altetnate to lA Is the supervisor from 28.

Addnianallv,
use.
all Fire extlnluishers cabinets will be secured within Villa Carita$ t, prevent unauthoriz:ed

Afarm Systems
Alarm systems Including personal alarms are handled through an ASCOMtelephon~ system which alert
the unit hand held phones as well as Protective Services. Protective Services personnel carry these
ASCOM phone and once nDtified, will proceed to Ithe area of concern. I

All employees working alone will carry ASCOM p~ones and need to notify addjtl~nal personnel of their
activities Clnd check-In iSt predetermined intervals. Cellular phones will be available for emplovees
transporti"g patients to the MCH. I I
VJdeo Surveillance
There ire 19 CelV carneras located within and e," the exterior of Villa Caritas. These CClV cameras ate
monitored from the site itself. as well as frDm GNCH and MCH Protective services, All door alarms are
similarly monitored. Alarm records are retained for 2 years and cav footaee is retained for a minimum
of 7 days and can be saved to OVO for Indefinite storage when required.

• • CCTVlocated outside Villa Carltas

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z·~ and s" floor

NursIng Stotlons
The nursinl stations are clearly identifiable on the uniU and are ,staffed at all times, unless emplovee
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
lOti, or using the panic button on
the ASCOM phones. The nursing
station also has other means of
eom rnuniC:ation such as
telephones. Employees within the
nursin8 station are able to de;rly
see the surrounding area.

Image shows view of nursing $tation desiBn within Villa Carltas

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FQod Se(v;c;e~- Oining Area In Unit I

The dining area within the unlts is desIgned to maximize comfort and avoid overC:101Ndlng.

Image shows view inside dining area within vlilla 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 ~Iiminate or minimjz~ the possible exposure of
emplovees to the risk.

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StaitWells possess Medium Convex mirrors January 2011 - James Prince/Scott

many blind spots strategically Mirrors are Baerg
throughout Villa placed, biilSed on ordered
Caritas Protective Senrices
recommendations
Potential blind Medium Convex mirrors Jan\ulrY 2011- James Prince/Scott
spot located near stra1e,lcally Mirrors are Baerg
reception on lit placed, b~ed on ordered
floor Protective Servitll!~
recommendations
Potential blind Medium Convex mirrorS Januarv 2011 - James Prince/Scott
spot located strategically Mirrors are Baerg
between nursing placed, basled on ordered
stations and Protective Services
pharmacy on all recommendations
units ,
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cannot identify If Medium Placl! peepholes January 2011 Jiimes Prince/Scott

potential hazard within door to Baerg
Is located outside allow for I
the doors I
increased visibility
• Nursing
I
nation
eXit/entrance
door
• Pharmacy
door in units
• Laundry room
doors in units
• Kitchen where
food
preparation
occurs (lit
floor)
low level lighting low Increase lighting Januarv 2011 James Prince/Scott.
between nursing levels -I.e. tnsert 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 emplovees to
weapon evaluate best
control
Toilet tank lids Medium Set",rlty,OHS, January 2011 Villa Camas i
are removable Management and Manasem e nt/fa e;1ities
and may be used Villa Caritas
as a weapon employees to
evaluate best I

control
Patient eteset Low Leek shelves in January 2011 James Prince
shelves are place
removable and
may be used as a
potential weaDDn
Th ermO$tiJU tan low Sec:urlty, OHS, February 2010 VJIlaCaritas I
be adjusted by Management and Monasementlfad!",.,
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 caRe around Janllary 2010 Rob Kinsman
Ladder in ladder
Penthouse and
loading dock
No access control Medium Install Controlled access Rob Kinsman
on loc:ker roorn combination door to be installed
doors lOCk of card reader I
access. I

Pre=OCrupqnCIt' ytqlCPC! Hgzqrd Assessment 'qnclus/on \

Based upon the conducted ha13rd assessment a number of 10w·medil.lM hazard~ we •.• identified.
Speaking with the Senior Operating Officer of VII!a Carltas, the hazards Identlfje~ will be mitigated or
eliminated prior to occupancy.

Future Attjvjtiss
To complv with Covenant Health's strategic direaion of ensuring a safe work environment for
employees, and Alberta Occupational Health and Safety legislation 3 number of ~ctlvjtles will be
conducted to protect the health and safety of Covenant Health employees.

These activities Include:

• Corporate Orientation
• Site Orientation
• Unit Orientation
• Post Occ;upancy hazard assessments

Feedback and involvement from emplovees will be sought throughout the activItIes.
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Part 2 Hazard Assessment, Elimination and Control
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Section 7 Hazard assessment
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~ 1. An employer must assess a work site and identify existing and potential hazards ~efore work
begins at the work site or prior to the construction of a new work site.
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2. An employer must prepare a report of the results of a hazard assessment and the methods used
to control or eliminate the hazards identified.

3. An employer must ensure that the date on which the hazard assessment is prepared or revised
is recorded on it.

~ 4. An employer must ensure that the h~ard assessment is repeated

a. at reasonably practicable intervals to prevent the development of unsa£:f and unhealthy

working conditions,
b. when a new work process is introduced,
c. when a work process or operation changes, or
d. before the construction of significant additions or alterations to a work site.

5. A prime contractor must ensure that any employer on a work site is made aware of any
existing or potential work site hazards that may affect that employe •.•. s workers.

Section 8 Worker participation

~. An employer must involve affected workers in the hazard assessment and in the control or
elimination of the hazards identified .

.!:¥:- 2. An employer must ensure that workers affected by the hazards identified in a hazard
assessment report are informed of the hazards and the methods used to control or eliminate
the hazards.

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Section 9 Hazard elimination and control

I. If an existing or potential hazard to workers is identified during a hazard assessment, an
employer must take measures in accordance with this section to

a. eliminate the hazards, or

b. if elimination is not reasonably practicable, control the hazard.

2. If reasonably practicable, an employer must eliminate or control-a hazard through the use of
..
engmecnng contro s.
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3. If a hazard cannot be eliminated or controlled under subsection (2), the employer must use
administrative controls that control the hazard to a level as low as reasonably achievable.

4. If the hazard cannot be eliminated or controlled under subsections (2) or (3), the employer
must ensure that the appropriate personal protective equipment is used by workers affected by
the hazard.

5. If the hazard cannot be eliminated or controlled under subsections (2), (3) or (4), the employer
may use a combination of engineering controls, administrative controls or personal protective
equipment if there is a greater level of worker safety because a combination is used.

Section 10 Emergency control of hazard

1. If emergency action is required to control or eliminate a hazard that is dangerous to the safety
or health of workers,

a. only those workers competent in correcting the condition, and the minimum number
necessary to correct the condition, may be exposed to the hazard, and

b. every reasonable effort must be made to control the hazard while the condition is being
corrected.

2. Sections 7(2) and 7(3) do not apply to an emergency response during the period that
emergency action is required.

Section 11 Health and safety plan

If ordered to do so by a Director, an employer must prepare and implement a health and safety plan
that includes the policies, procedures and plans to prevent work site incidents and occupational
diseases at the work site.

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Covenant ..•
H.ealth - Villa Caritas, Health.~nd 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

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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 carnas

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)