Many Nursing Homes Need Better Fire and Smoke Protection

The recent Government Accountability Office report Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal Standards and Oversight, thoroughly assesses the fire protection situation in the nation's nursing homes. The report (available at www.gao.gov/new.items/d04660.pdf) itemizes waivers granted to nursing homes, which allow them to operate with substandard smoke and fire detection and containment measures, but concludes that the installation of sprinklers would alleviate the risk without requiring corrections to the deficiencies identified. This is a dangerous assumption for several reasons.

The report says that multiple deaths in two nursing home fires resulted from smoke inhalation rather than the fire itself. It also itemizes several contributing factors which allowed the smoke that killed the residents to migrate basically undetected and unimpeded from the source of the fire to the resident rooms nearby. These factors include lack of working smoke detectors, lack of automatic smoke dampers in the ductwork, open fire doors, failure of the nursing home staff to respond according to emergency plans, and the ability of smoke to travel in the open and undivided area above the suspended ceiling into resident rooms.

The report faults the night staff at one facility for not responding properly to the existing fire emergency plans, but only touches on how realistic those plans might have been. It suggests that staffing was inadequate, averaging at best one nursing staff person per nine residents. This ratio would allow less than seven minutes of care per resident per hour under normal conditions. If the plan was merely to ensure that fire doors were closed once an alarm went off, perhaps the staff was at fault. However, the emergency plans might have involved moving residents to another area in the facility, which cannot be done quickly-if at all-by one staff person responsible for nine residents, especially when many residents have physical limitations that prevent their rapid removal.

Reliance on nursing staff to assume the role of emergency responders requires closer scrutiny. Often there is not enough staff to respond appropriately, and that trend may worsen. In 2000, Peter Buerhaus, PhD, RN, FAAN, reported in the Journal of the American Medical Association that by the year 2020, there will be an estimated shortage of nearly 500,000 nurses. That figure is alarming considering our aging population and the U.S. Department of Labor's projection of a 27.3% increase in nursing jobs between 2004 and 2012.

Therefore, resident rooms must be built so in an emergency, residents can survive until trained rescue personnel can safely remove them. This argues for more vigorous enforcement of requirements that prevent the movement of fire and smoke between patient rooms, regardless of whether sprinklers are installed and whether nursing staff is available or not.

A popular trend among designers and building owners is to rely on a sprinkler system to prevent the development and movement of smoke, often assuming that the sprinklers nearly always activate satisfactorily. This was the primary conclusion reached in the report.

The report states that according to National Fire Protection Association (NFPA) figures, only 82% of nursing home fires are contained by properly installed and maintained sprinkler systems. This statistic is consistent with other NFPA statistics showing that sprinklers fail to operate satisfactorily approximately 20% of the time in healthcare facilities for various reasons, including lack of maintenance and water supply. An 18% record of failures represents potentially disastrous fire incidents in literally thousands of facilities in which the elderly or infirm are at risk. If, in fact, there are insufficient resources to ensure that smoke detectors, fire doors, and dampers are properly installed and functioning, and that smoke barriers are properly constructed and maintained, how are nursing homes likely to obtain financial resources and personnel required to regularly inspect and maintain a sprinkler system?

Even when sprinklers successfully activate, a smoldering mattress or upholstered piece of furniture may develop lethal volumes of smoke and toxic gases without creating sufficient heat to activate the sprinklers immediately. Sprinkler systems are designed to control a fire, not to extinguish it. Once a sprinkler is activated, the resulting drop in temperature and the downward discharge of the water from the sprinkler can actually cause the smoke layer to drop to the floor level, reducing visibility and cutting off possible escape routes.

Properly functioning detection and containment devices are as important as the protection offered by fully functional and properly maintained sprinkler systems. Human error in design, maintenance, and repairs, and microbiologically induced corrosion are often cited as reasons for unsatisfactory sprinkler performance. Human error also contributes to open fire doors and compromised fire and smoke barriers. That is why it is essential to have redundant protection systems and a balanced fire protection design approach in these facilities, rather than relying mainly on automatic sprinkler systems and nursing staff for rescue.

The report states several times that the primary impediment to installing sprinklers has been the cost, but it fails to mention what it would cost to bring the existing detection and containment features up to ideal performance levels. Adequate and reliable fire safety can only be achieved in these facilities by spending the time and money to improve detection and compartmentation, in addition to installing and properly maintaining automatic sprinkler systems. Such a balanced approach combined with a committed maintenance program will significantly minimize the probability of disasters occurring from a fire.

In most tragic fires, a series of mistakes turns what should have been an insignificant event into a disaster. Had smoke detection and control features such as smoke dampers been designed into the facilities cited in the report, and the protection that the closed fire doors offered been properly utilized, the events would probably have gone unreported.

History has taught us that the human element must be factored into the risk equation; thus the need for redundant safety systems in automobiles, aircraft, elevators, ocean liners, amusement park rides-and fire and smoke protection systems designed for the built environment. Cutting costs for such protection in nursing care facilities cannot be the primary consideration when the lives of elderly or disabled residents are at stake.