Fire safety: is your facility legal? The legal structure governing nursing home fire safety: a guide to self-examination

Nursing Homes, Sept, 2004 by Julie A. Braun

Federal regulations expect facilities to "be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public," (1) plus satisfy applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA, www.nfpa.org). (2) The regulatory framework also demands that nursing homes have "detailed written plans and procedures to meet all potential emergencies and disasters, such as fire[.]" (1) The facility must, according to federal regulations, train employees in disaster and emergency procedures when they begin working in the facility, periodically review these procedures with existing staff, and conduct unannounced drills (with care not to disturb or excite residents) to test the efficiency, knowledge, and response of institutional personnel in the event of an emergency. (1) Local laws may surpass federal requirements for staff training in emergencies, as is the circumstance in New York. (2)

Two deadly nursing home fires in Hartford, Connecticut, and Nashville, Tennessee, last year focused considerable attention on the safety of our nation's nursing home residents, a highly vulnerable population of elderly and disabled individuals. The general statements in the previous paragraph notwithstanding, examination of the lessons learned from these two fires found systemic problems with the adequacy and enforcement of federal fire safety standards that go well beyond these two tragic events. (3)

Frequency of Nursing Home Fires

The most recent data show that an average of 2,300 of the country's approximately 16,300 nursing homes reported a structural fire each year from 1994 through 1999, and that there was an average of five fire-related nursing home deaths nationwide annually. (3) While cooking and laundry dryers represented the leading causes of fires, resident deaths were chiefly associated with smoking, and resident rooms were the principal areas of fire origin. (3) During this same period, one multiple-death nursing home fire resulted in three fatalities. (3)

In contrast, the fire-related death toll in 2003 was considerably higher--31 residents died in the nursing home fires in Hartford (16) and Nashville (15) (3) (table 1). Neither home was required to have an automatic sprinkler system, even though such systems are effective in reducing the number of multiple deaths from fires. (3) Federal fire safety standards do not require sprinklers in older nursing homes, such as the Hartford and Nashville facilities (built in 1970 and 1967, respectively), constructed with certain noncombustible materials (e.g., concrete, steel, or brick) that have a certain minimum ability to resist fire. (3) It is estimated that 20 to 30% percent of nursing homes nationwide lack full automatic sprinkler systems. (3)

[ILLUSTRATION OMITTED]

Nursing Home Fire Safety Standards

Nursing home fire safety standards are built on principles that combine certain construction and operational features along with an acceptable staff response. These standards reflect the mobility and cognitive limitations of many elderly and disabled residents who cannot be evacuated easily during a fire. The principles include:

* appropriate facility design and construction, particularly compartmentalization to contain fire and smoke;

* provision for fire detection, alarm, and extinguishment (e.g., smoke detectors and sprinkler systems); and

* fire prevention policies and the testing of staff response (e.g., taking steps to isolate the fire and transferring residents to areas of refuge). (3)

Examples of specific requirements. The fire safety standards for nursing homes cover 18 categories, ranging from building construction to furnishings. Examples of specific requirements include:

* use of fire-or smoke-resistant construction materials for interior walls and doors;

* installation and testing of fire alarms and smoke detectors;

* protection of hazardous areas (e.g., laundry rooms);

* regulation of smoking by residents; and

* development and routine testing of a fire emergency plan. (3)

New versus existing nursing homes. In the past, whenever a new edition of the NFPA code was adopted by the Centers for Medicare & Medicaid Services (CMS), nursing homes had the option of complying with the new standards or an earlier edition. (1) Therefore, a nursing home that began serving Medicare and Medicaid residents under the 1967 edition of the standards could continue to be surveyed under those standards up until 2003. (3) With the implementation of the 2000 edition of the NFPA standards, however, CMS eliminated the option for facilities to be grandfathered under earlier Life Safety Code editions. (4) All nursing homes participating in Medicare and Medicaid as of March 2003 must comply with the 2000 standards for existing facilities with CMS changes (e.g., strengthened emergency lighting requirements). (3)

Federal nursing home fire safety standards in unsprinklered facilities. The nursing home fires in Hartford and Nashville revealed weaknesses in federal nursing home fire safety standards for unsprinklered facilities. For example, federal standards did not require either facility to have smoke detectors in resident rooms where the fires originated, and fire department investigations suggest that their absence might have delayed the notification of staff and activation of the buildings' fire alarms. In light of inadequate staff response to the Hartford fire, the degree to which the standards rely on staff to protect and evacuate residents may be unrealistic.