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Bethany Lodge

Emergency Plan


The purpose of the Emergency Policies and Procedures Manual is to provide all staff of Bethany Lodge and Manor with the information and knowledge necessary to deal in an effective and efficient manner with any emergency or disaster that threatens the safety of the residents, visitors to the home and the staff.


  1. Home-specific response procedures will be in place for emergencies and disaster situations that threaten the safety of residents, visitors and staff of the home, and such procedures will be included as part of the “Emergency Response Manual”.
  2. Each Manager is responsible for ensuring that the staff of the respective department are given orientation and participate in on-going training in respect to emergency response procedures.
  3. The Administrator is responsible for routinely reviewing (at least annually) and up-dating, as needed, all home-specific emergency response procedures to ensure:
    • consistency with the optimum safety needs of residents, visitors and staff;
    • compliance is met with the relevant legislation; and,
    • staff understand and is aware of the emergency response policies and procedures.
  4. Contingency plans for managing internal and external disasters will have protocols for:
    • assignment of personnel to specific tasks and responsibilities;
    • specifications of evacuation routes and procedures;
    • arrangements/agreements for alternative shelter in the event of evacuation;
    • arrangements for maintaining records and providing sufficient medications, nursing equipment and supplies; and,
    • a system to supervise evacuated residents.
  5. One copy of the Emergency Response Manual will be kept at each of the Communication Centres and at the Front Desk in a prominent and easily accessible location.


  • Code Red – Fire
  • Code Blue – Medical Emergency
  • Code White- Violent/Aggressive Person • Code Yellow – Missing Resident
  • Code Green – Evacuation
  • Code Brown – Hazardous Substances Exposure
  • Code Black – Bomb Threat, Suspicious Object Or Other Threat
  • Code Orange – External Disaster
  • Code Grey – System Loss or Failure
  • Code Purple – Hostage Taking
  • Code Silver – Person with a Weapon
  • Code Pink – Medical Emergency Child/Infant
  • Outbreak/Pandemic

Definitions & Terms:


Exists when a situation compromises the home’s ability to provide safety for individuals using routine, standard resources. Abandonment of routine methods and realignment of resources are necessary to expand or reinstate the home’s capacity to minimize risk and maintain a safe environment.

External Disaster:

Exists when situations/circumstances outside of the home impact on the home and the safety of the residents, visitors and staff, with the potential of causing disruption to the operation of the home.

Internal Disaster:

Exists when the home is confronted with urgent internal problems that may require partial or complete evacuation, and/or endanger the safety of residents, visitors and staff, and prevent the delivery of care/service or threaten property.


The removal of residents, visitors and staff from the site or building to another area, site or multiple sites.


When an Emergency occurs immediate steps are taken by the internal onsite team, which is led by the most Senior Manager and outside of working hours by the Charge Nurse, in consultation with the on-call Manager. The Administrator and DOC will be notified. The Executive Director
or delegate will initiate emergency procedures.

Incidents that require external emergency personnel will results in some or all of the following to be notified using the 911 system: Paramedics, Police, Fire personnel.

The home keeps an up-to-date list of all staff for emergencies and has created a fan out list to assist the call-out procedure during an emergency response.