Policies, Procedures and Environment & Safety

This section has details on the following topics. Click on the topics below to browse this page:

• Deer Lodge Health Centre Abuse Policy
• Personal Health Information Act
• Pressure Injuries
• Use of Restraints
• Side Rail Use
• Falls Prevention
• Building Safety & Security
• Violence Prevention
• Infection Prevention and Control
• Fire and Emergencies
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Deer Lodge Health Centre Abuse Policy

The Protection for Persons in Care Act became law in Manitoba in May 2001. This law helps protect adults from abuse or neglect while receiving care in hospitals, personal care homes, or other designated health-care facilities.

Under this law, abuse may include physical, sexual, mental, emotional, or financial mistreatment. The law also requires that concerns about abuse or neglect be reported and investigated. The Protection for Persons in Care Office (PPCO) is responsible for receiving and investigating these reports.

All staff at DLHC have a duty to report suspected abuse or situations where abuse may occur. We are committed to maintaining a safe environment for residents and patients. We work to protect all patients and residents from abuse and to support the highest possible quality of life. Abuse of any kind will not be tolerated.

If you have concerns about possible abuse or if you would like more information on our policy or the PPCO, speak with the Manager of Health Services on your unit, your social worker, or contact the PPCO Office directly.

Protection for Persons in Care Office for Information or to Report Abuse
Phone: 204-788-6366
Toll-free: 1-866-440-6366
TTY Toll-Free: 1-800-855-0511
Fax: 204-775-8055
Email: [email protected]
Website: www.manitoba.ca/health/protection

Personal Health Information Act

At Deer Lodge Health Centre, we believe your health information is private.

Manitoba’s Personal Health Information Act (Manitoba) (PHIA) is the law that protects your personal health information. This law explains how health-care facilities must collect, use, store, and share personal health information.

Personal health information may include:

• Your name, address, and Personal Health Identification Number (PHIN)
• Information about your health and health-care history
• Information about the care and treatment you have received
• Information about payment for your health care

Deer Lodge Health Centre collects and uses this information only as allowed under PHIA.

Your Rights Under PHIA

Under this law, you have the right to:

• See your personal health information and health records
• Request corrections if you believe information in your record is incorrect
• Have your personal health information kept confidential
• Make a complaint about how your personal health information is collected, stored, used, or shared

Complaints can be made to the Manitoba Ombudsman, which reviews concerns about access to personal health information or how it is handled.

Questions About Privacy

If you would like more information about PHIA or about how your personal health information is protected, please contact the DLHC Privacy Officer:

Phone: 204-599-9744

Pressure Injuries

A pressure injury (sometimes called a “bedsore”) is damage to the skin or the tissue under the skin. It is usually caused by staying in one position for too long without moving. Pressure injuries most often develop on parts of the body where bones are close to the skin. These areas take more pressure when a person is lying in bed or sitting in a chair. Common areas include the: buttocks, hips, heels, elbows, shoulders

Preventing Pressure Injuries

There are several simple steps that can help prevent pressure injuries.

Avoid staying in one position for too long.

• When lying in bed, change your position often.
• If you cannot move on your own, ask for help to change position at least every two hours.

Shift your weight when sitting.

• When sitting in a chair or wheelchair, try to shift your weight or change position every 15 minutes.
• If you are unable to do this on your own, ask for help to change position at least once every hour.

Staff at Deer Lodge Health Centre can help you with repositioning and other ways to reduce pressure on your skin.

Use of Restraints

Deer Lodge Health Centre has a Restraint Policy that follows Manitoba Health guidelines and regional health authority policies for the safe use of restraints.

A restraint is any device, medication, or action that limits a person’s movement or behaviour.

Restraints may be used only when the health-care team believes that a resident’s actions place the resident or others at risk of serious harm. Restraints are used only after other approaches have been tried and have not been successful, unless there is an emergency situation.

Before a restraint is used, the health-care team will complete an assessment and discuss the situation with the resident and, when appropriate, their family or substitute decision maker. In most situations, verbal or written consent will be requested.

Restraints are used only for the shortest time necessary, and the resident’s condition is closely monitored. The care team regularly reviews the use of restraints and adjusts the care plan as needed. Restraints are never used for staff convenience, discipline, or punishment.

It is important to balance the risks of using a restraint with the risks of not using one. Staff will consider what other options have been tried. Research shows that the risks of restraints may sometimes be greater than the risks of falls or wandering.

Chemical Restraints

A chemical restraint is a medication used to control behaviour that may place a person or others at risk. Examples may include:

• sedatives
• hypnotics
• antipsychotics
• antidepressants

Medications used to treat a diagnosed medical or mental health condition are not considered chemical restraints. The use of chemical restraints must be reviewed regularly by the care team and during medication reviews with the physician and pharmacist. Residents, family members, or substitute decision makers will be informed and involved in decisions about their use.

Alternatives to Restraints

Whenever possible, staff will try other approaches before using a restraint. These approaches focus on keeping residents safe while supporting comfort, independence, and dignity. Examples may include:

• Changing the environment (for example, reducing noise or improving lighting)
• Providing supervision or assistance with walking or movement
• Using equipment such as low beds, floor mats, or supportive seating
• Addressing comfort needs, such as pain, hunger, thirst, or the need to use the washroom
• Offering activities or companionship to reduce restlessness or agitation

The health-care team will work with residents and families to find the safest and most appropriate options.

Side Rail Use

Every resident at Deer Lodge Health Centre deserves a safe and comfortable bed environment. In some cases, reducing or avoiding the use of bed side rails may be the safest option. Research has shown that side rails can sometimes increase the risk of entrapment, serious injury, or death, rather than prevent falls.

For this reason, side rails are not used routinely.

Each resident is assessed by the care team to determine whether side rails are appropriate. Before using side rails, the care team will consider other options and safety measures.

Different residents respond to different approaches. What works well for one person may not work for another. The care team will review each situation and choose the option that best supports the resident’s safety and comfort. Residents, families, and the interdisciplinary care team work together to support a safe and comfortable sleeping and bed environment.

Falls Prevention

Deer Lodge Health Centre is committed to supporting residents in maintaining mobility and independence in a safe way. Mobility includes many everyday movements, such as:

• moving in bed
• standing up
• transferring from bed to chair
• moving in a wheelchair
• walking

Ways We Help Prevent Falls

• reviewing medications
• providing mobility aids (walkers, wheelchairs)
• ensuring proper footwear
• keeping rooms and hallways clear of obstacles
• helping residents move safely when needed

The care team will assess each resident to identify factors that may increase the risk of falls or injury. Staff will then work with residents and their families to develop a plan that supports safe movement and reduces risk. Our goal is to help residents remain as active, safe, and independent as possible.

Building Safety & Security

Deer Lodge Health Centre is committed to providing a safe and healthy environment for residents, patients, visitors, volunteers, and staff.

The Centre works to identify and address safety risks in the workplace. Safety, health, and environmental standards are followed to help ensure a safe environment for everyone.

Residents are encouraged to move throughout the Centre and remain as active and independent as possible. For added safety, hallways and washrooms are equipped with handrails to provide support while walking.

To help protect residents who may be at risk of becoming lost, the Centre uses an electronic security system. This system alerts staff if a resident who may be at risk of wandering approaches an exit. Staff can then respond quickly to ensure the residents’ safety.

Violence Prevention

When residents are admitted to the Centre, staff assess whether there may be a risk of behaviours that could harm themselves or others. Any identified risk factors are documented in the resident’s care plan so staff can respond safely and provide appropriate care.

For residents who may be at risk of behaviours that could harm others, a visual safety indicator may be placed on the resident’s room door. At Deer Lodge Health Centre, this indicator is shown as two purple circles. This alerts staff to take appropriate precautions when providing care.

After an Incident

If an incident involving violence occurs, staff will respond immediately to ensure everyone’s safety.

The incident will be documented and reviewed. The Manager of Health Services will be informed, and the families of residents involved will be notified.

When required, incidents are reported to the Protection for Persons in Care Office under the Protection for Persons in Care Act (Manitoba).

Tracking and reviewing incidents helps staff identify patterns and risk factors so they can take steps to prevent similar situations in the future.

Understanding Responsive Behaviours

Some residents may experience responsive behaviours, especially if they are living with dementia or other cognitive changes. Responsive behaviours may include actions such as shouting, resisting care, or acting aggressively. These behaviours are often a way for a person to communicate discomfort, fear, confusion, pain, or an unmet need.

Staff are trained to look for the causes of these behaviours and to respond in a calm and supportive way. The care team works with residents and families to identify triggers and develop strategies that help reduce distress and support a safe environment for everyone.

Infection Prevention and Control

Deer Lodge Health Centre has an Infection Prevention and Control Program to help keep residents, patients, visitors, and staff safe from infections that can happen in healthcare settings.

Outbreaks

Outbreaks such as influenza can occur on units.  Check the Outbreak Page on our website regularly and make note of any outbreaks at the Centre. When an outbreak is declared, you can expect the following measures:

• Visitation may be impacted for confirmed or potential outbreak units. Exceptions to visitor restrictions will be made for compassionate or end of life care situations.
• Residents will be asked to stay on the outbreak unit excluding for medically indicated reasons.
• Medical masks will be available for Residents and visitors on the outbreak unit.
• We continue to use cleaning and disinfection products known to be effective against germs. We have enhanced the frequency of cleaning and disinfection on the units.
• Staff continue to wear personal protective equipment and perform hand hygiene to protect themselves, residents and prevent spreading of illnesses on the units.
• Groups activities may be impacted for outbreak units although one-on-one sessions for occupational therapy, physical therapy, recreational therapy etc. will continue.
• Infection control professionals work with staff, residents, and visitors to prevent infections and stop germs from spreading.

Everyone at the Centre plays a role in infection prevention, including:

• staying home if sick
• washing hands regularly
• following safe practices when caring for residents

Fire and Emergencies

Deer Lodge Health Centre is committed to keeping everyone safe during emergencies. Fire drills, emergency drills, and inspections are carried out regularly to make sure staff and residents know what to do. We ask for your cooperation during these exercises.

Emergency Codes

Different situations at the Centre are identified by colour-coded emergency codes. Staff are trained to respond quickly to each type of emergency:

If you see a situation that may be dangerous, notify staff immediately. During any emergency, follow staff instructions calmly to ensure your safety and the safety of others.

Your Role

• Listen carefully to staff instructions
• Stay with your unit or group unless directed otherwise
• Keep hallways and exits clear at all times

Regular drills help everyone stay prepared and safe. Thank you for helping us maintain a secure environment.