The need to care for a growing elder population shouldn’t become a soccer ball kicked around due to a difference of definitions. Typically, the difference between a nursing home and an assisted living facility is: a) the assisted or medical services provided; b) physical facility layout; and/or c) the living arrangements.1
Residents of ALFs (Assisted Living Facilities) are usually more self-sufficient when dealing with medical and daily mobility needs. In contrast, those living in nursing homes often need 24/7 medical care or monitoring and more in-depth mobility assistance. ALF “campuses” emulate a community setting, whereas nursing homes possess a more institutional setting. Nursing home residents typically share a room. Residents in ALFs usually have their own apartment. 1 Due to the denser proximity of residents in a nursing home, and the additional medical care needs, a more critical planning and response effort is necessary.
As a young command officer, I recall an event at a nursing home that remains on my internal hard drive. Central Florida is self-dubbed the lightening capital of the world. And, for good reason. In the summertime, the almost certain afternoon rainstorm is usually accompanied by lightning strikes. Most hits result in nothing more than close calls, spotty power outages, and automatic fire alarms. However, on one stormy afternoon, a nursing home on the west side of Orlando sustained a direct hit to the main power panel causing fire to the panel and adjacent hallway. Heavy smoke moved throughout the “H” shaped building.
Initial units arrived, requested additional companies and made a quick stop on the electrical fire. Upon my arrival, however I noticed the evacuation of the approximately 100 residents going slowly. Residents who were removed from smoke and other direct harm were corralled in a holding area under an open portico. With rain still falling, and more stormy weather threatening, my first task upon arrival was to get a handle on the obvious remaining issue – evacuation – without delay. Although the companies were focused on an emergency, they weren’t focused on the emergency. That is removing the vulnerable to a place of safety and security, attending to any medical or emotional needs and reassuring the efficient reunification with their loved-ones.
Now for some numbers to continue setting the stage. The National Center for Health Statistics (February 2019) states:
- 800,000 Americans live in assisted living facilities.
- 57% Assisted Living Facilities (ALFs) are part of a chain or collaborative system.
- 42% are individually owned (“mom-and-pop”) operations.
- 3% are dementia units.
- 85% residents over 65 years old.
- 43% are over 85 years old.
And to further establish the setting; according to the NFPA (2018), there are 1,115,000 firefighters in the United States. 370,000 (33%) are affiliated with career departments and 67% of American communities are protected by the remaining 745,000 volunteers. I won’t do the math, but it’s fair to assume that ALF calls for service will grow as the population continues to age. The following contains those issues, challenges and tasks that fire and rescue planners, commanders and partners must address. Some are pre-event, while many are challenges, questions and affirmations that are necessary to manage the unmanageable event.
Common Causes of Nursing Home Fires
The predominant cause of nursing home fires (72%) is cooking according to the US Fire Administration. And while 83.3% of those fires are contained to the object of origin such as a coffee maker or stove, the residual effect is the collection of smoke, potentially toxic gases, and fire byproducts that often permeate the building(s). Residents, because of the very nature of their age, pre-existing or underlying medical conditions, necessitate the need for rapid evacuation to a safer atmosphere. Therein lies the need for rapid, accurate decision making to call for additional resources:
- Additional Fire Units
- Red Cross
- Emergency Management
- CERT/Fire Corps
- Mental Health Specialists
- Partner (mutual aid) neighboring ALFs
- Law Enforcement; and
- Public Transit
The saying, “You can’t un-ring the bell”, applies to the absolute critical value of pre-planning for this potentially catastrophic fire event in your jurisdiction. Once the tones drop, it’s too late to consider what are the specifics of the facility, its staff’s capabilities, building construction and configuration, and the ability of neighboring response units to fit into the game plan. And all these interrelated aspects take on a more critical nature hampered by inclement weather or challenged by nighttime operations.
If you have senior living communities, nursing homes or ALFs in your jurisdiction or neighboring jurisdictions they must be part of your pre-planning and fire risk analysis program. In addition to your fire prevention staff efforts, operational personnel must be brought into the planning process to “what if” the potential event(s) and develop clear, realistic strategies to respond, mitigate and recover.
Many departments minimize the value of an effective logistics officer. While some have been relegated to “supply officer” status, the wise leader relies heavily on the expertise of an involved logistics officer who must be an active participant during the pre-planning stages and throughout the emergency operation. He or she will have answers to questions such as:
- Number of wheelchairs needed to move all non-ambulatory residents quickly and safely?
- Number of bed-ridden residents who might not survive evacuation via wheelchair versus hospital bed due to the need for constant medical support such as oxygen or IV infusion?
- Are there sufficient caches of portable oxygen tanks and regulators?
- Are adequate warming and weather shrouding supplies available on sight or available for rapid delivery?
- Are all necessary medications stocked and ready for use – and secured, documented with sufficient medical staffing?
- Where can I request and receive these unique items 24/7?
Most importantly, the involved logistics officer will be ready to supplement the need for those critical resources during and following the event.
Command and Communications at a Nursing Home Fire
Few incidents that responders will serve at possess the gravity and seriousness of an MCI – especially at a nursing home. Quick, deliberate decision-making is the immediate and ongoing responsibility that all members – especially command staff – must demonstrate to determine the outcome of this event. How many times have you heard that the lynchpin of an emergency that goes well is good communications? Without over-dramatizing this, if communications start well, remain effective throughout the event, and continue through the demob process, chances are losses can be minimized. Inclusive, robust communication starts during the planning process and is documented via multiple platforms, so all members and partners know and can execute Plan A, Plan B, and Plan C.
Oftentimes information gathered supporting the planning process is treated by the nursing home or ALF owner-operator like nuclear launch codes. Depending on statutes governing assisted care management, certain information, such as specific patient data must be handled with confident-iality and secured from those not in need of the information.
However, data related to building construction and configuration, ingress/egress pathways, service and utility systems, medication and medical support stocks should be made readily available to planning staff and shared with operational units. If the fire department’s relationship with the senior home director is based on trust and mutual benefit, gathering information may be relatively easy. This can be achieved if the director is assured that the information is handled with the highest level of security and confidentiality.
RESIDENT EVACUATION AND SUPPORT
The decision to evacuate patients is often delayed as long as possible by staff, with good reason. Some residents possess a tenuous medical status requiring constant monitoring and/or medical care. The stakes increase exponentially should the patient be deemed emotionally or mentally fragile. Evacuation often takes on two distinct characteristics based on timing. If the evacuation order is delayed, arriving fire rescue personnel must determine which is the most beneficial – rescue or direct firefighting. On many occasions, Command splits resources to attempt both strategies simultaneously. Depending on the type or location of the fire and available resources on scene, Command must weigh the efficacy of evacuation versus sheltering in place. However, once the evac order is given, the dynamics of the incident transition significantly. In doing so, Command then deals with questions and issues posed below. Some must be answered prior to the event, thus the critical importance of pre-planning, and some can be answered during the event.
RESIDENT IMMEDIATE NEEDS
- What ongoing medical or behavioral care activities are necessary to maintain a safe, survivable residential population?
- Exactly, how many patients and staff members are operating in or sequestered in the immediate area of concern or active operations?
- When patients are removed to an appropriate shelter, is it secure, safe, free from other activities or threats that may interfere with the safe successful re-sheltering?
- Are all necessary medications, treatment and mobility equipment available before patients arrive?
ACCOUNTABILITY/TRACKING AND DOCUMENTATION
- Does an accurate (up-to-date) roster of all residents and staff members exist and available to operating responders to support effective search and rescue, evacuation, re-positioning and care?
- Are accurate diagrams (containing current remodeling features or building re-configurations) exist and available to responders?
- Do the rosters or other readily-available documents contain all medical and/or emotional care needs: medications, extraordinary personal communication needs, mobility; including nursing home staff?
- Has an accountability unit been established to ensure no resident or staff member is overlooked?
- Has law enforcement been activated to ensure proper documentation and access is established and allowed for responders, next-of-kin and other support agencies?
- If a decision is made to reunify residents with loved ones, has a system been established for controlling access, verifying legal relationships/guardianship and documenting release with all appropriate legal documentation and witnesses?
- When residents are transferred to partner receiving sites (i.e., hospitals or other nursing homes or ALFs) are tracking documents successfully shared with transport and receipt agencies? A checks-and-balance process is critical.
- How are notices sent to potential receiving relatives or guardians in a timely, accurate manner to avoid lost souls?
- Is there an adequate medical support unit (MSU) established?
- Is the MSU co-staffed with nursing home, mental health, community health (hospital) and EMS members?
- Are sufficient medical support supplies and equipment made available with an effective logistics support unit managing the effort?
MENTAL HEALTH SUPPORT
- Are trained mental health support members on-scene capable of dealing with residents, nursing home staff, responders and relatives?
- If not staffed by a department member, is someone directly associated with Command or trained to complement command managing the effort?
- Has a Rehab Unit been established for responders?
- Is the rehab area secluded from the operational activities to afford comprehensive physical and mental rehabilitation?
- Is the Rehab Unit staffed and stocked for extended operations?
- Is the Responder Rehab area secured by law enforcement personnel?
- Is the evacuee temporary shelter area secluded and away from prying onlookers and the media?
- Have adequate safety and security measures been established and properly staffed?
- Are adjacent traffic routes controlled allowing quick medical and relative ingress?
- Are all response partners vetted, equipped and prepared to provide tasks and duties as promised?
- Have crews been established to ensure long-term service with fidelity?
- Are all partner responders signed-in and documented as part of the comprehensive response effort?
- Has a trained, experienced PIO and Assistant PIO been assigned to manage the message and represent an adequate message from Incident Command, the nursing home, and the community?
- Are all messages delivered through the PIO/APIO?
- Are separate, distinct messages prepared for and delivered to relatives.
- Are timely messages prepared and delivered to the media?
- Is the media placed in a separate, controlled, secure area?
This is not an exhaustive list, but the intent is to get the juices flowing in developing one’s own pre-and post-planning effort to ensure that when that event occurs in your jurisdiction, responders will be better prepared to serve our loved ones and community.
- Five Star Senior Living
Frank Montes de Oca served as a firefighter/paramedic for over 38 years, appointed fire chief in Springfield, Ohio, and Osceola County, Florida. Recently, he was the Emergency Services Director in Orange County (Chapel Hill), NC. Throughout his career, he has been involved in training, managing, and developing firefighter safety programs, disaster management, leadership, and organizational change. Chief Montes de Oca is an adjunct instructor for the National Fire Academy and qualified to present programs for OSHA and the EPA. He can be reached at firstname.lastname@example.org or responder1.org.