Built for Individual LTC Homes and Hospitals

EMERGENCY COLOR CODES

AUDIT READINESS &

EMERGENCY COMPLIANCE

Eliminate Gaps & Ensure 100% Protocol Compliance During Inspections

EMERGENCY COLOR CODES

AUDIT READINESS &

EMERGENCY

COMPLIANCE

Eliminate Gaps & Ensure 100% Protocol Compliance During Inspections

At-a-Glance Summary:
  • Primary Objective: Isolate hazardous spills, prevent cross-contamination, deploy appropriate Personal Protective Equipment (PPE), and ensure safe containment.
  • Mandatory Frequency: Annual operational drill and WHMIS/SDS competency review for all staff shifts.
  • Governing Standard: Ontario FLTCA O. Reg. 246/22 | Occupational Health and Safety Act (OHSA) | WHMIS 2015 Standards.
  • Top Audit Risk: Inaccessible Safety Data Sheets (SDS) during a spill event and improper PPE selection for specialized chemicals.

1. Regulatory & Compliance Requirements

Under occupational health and safety laws and long-term care regulations, facilities must maintain strict protocols for hazardous substance handling and spill response. Compliance inspectors evaluate accessibility to Safety Data Sheets (SDS), staff knowledge of spill kit locations, containment protocols, and proper disposal documentation.

2. Step-by-Step Drill Scenario Execution

Phase 1: Identification & Area Isolation (0–2 Minutes)

Upon discovering an unknown chemical, biohazard, or hazardous substance leak:

  • Assess & Identify: Evaluate the spill size and hazard type without directly touching or inhaling the substance.
  • Isolate Immediate Zone: Block off physical access to the affected area, move residents away, and close nearby ventilation or HVAC returns if airborne hazards are suspected.
  • Notify Leadership: Immediately inform the Charge Nurse / Maintenance Lead of the spill location and estimated volume.

Phase 2: Code Brown Activation & SDS Consultation (Minutes 2–5)

  • Overhead Announcement: Page clearly three times over the PA system: "Code Brown – [Location/Unit/Room Number]".
  • SDS Retrieval: Access the physical or electronic Safety Data Sheet (SDS) binder to determine chemical properties, neutralizing agents, and required PPE.
  • Spill Kit Deployment: Designated spill response staff retrieve the centralized Chemical & Biohazard Emergency Spill Kit.

Phase 3: Containment, Cleanup & Neutralization (Minutes 5–20)

  • Don Protective Gear: Responders equip full PPE specified by the SDS (e.g., chemical-resistant gloves, goggles, face shields, aprons).
  • Dike & Contain: Apply absorbent dikes, pads, or spill-granules around the perimeter of the liquid to halt migration toward floor drains or resident corridors.
  • Safe Disposal: Sweep or scoop contained materials into designated yellow biohazard or hazardous waste bags, sealing and labeling them according to environmental regulations.

Phase 4: Decontamination, Incident Logging & All-Clear (Post-Event)

  • Decontaminate Surface: Sanitize the spill site using approved secondary disinfectants and allow required wet contact time.
  • Overhead Announcement: Once the zone is fully decontaminated and safe for foot traffic, page: "Code Brown – All Clear, Code Brown – All Clear."
  • Restock & Record: Restock used spill kit contents immediately and log the spill volume, root cause, and response steps in the facility safety binder.

3. Common Audit Failures & Corrective Actions

Audit Area Common Failure Point Compliant Action Required
SDS Accessibility Staff are unable to find or access the SDS binder within 3 minutes of a chemical spill. Ensure digital or physical SDS stations are clearly marked and accessible on every care floor.
Inadequate PPE Usage Cleanup is attempted using standard examination gloves rather than chemical-rated gear. Store chemical-resistant gloves, goggles, and aprons directly inside every emergency spill kit box.
Drain Contamination Spilled liquids are flushed down sink or floor drains, violating environmental laws. Use absorbent socks to block floor drains immediately prior to applying spill absorption granules.

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