With all the scrutiny on emergency preparedness, take a fresh look at your fire plan. Do you have one complete plan or do you have multiple versions in your disaster manual? Do you have multiple ‘sections’ that are not incorporated into one complete plan? Make sure that everything is in one plan, so there are no conflicts and that the reader does not think they are done reading ‘the’ plan when in fact there are multiple editions/sections. Also make sure every manual in your facility has been updated.
Are the numbers in your plan or calling tree out of date? Or did you use a sister facility’s plan that has different phone numbers for your area – Fire Marshal, Health Department and Fire Department?
Do you have an assignment for an evacuation point outside? If you used a sister facility’s plan, is the evacuation point accurate for your facility? Have you shared this plan with the local fire department? They might want to set up command in that very spot.
Do you have an assignment for who will be the designee to call 911? This is a new requirement to the 2012 Life Safety Code. This might be a redundant concept, but there is a good reason – what if the fire alarm did not transmit? Or, if it did transmit and the fire department is on the way, staff can now give them good information: (for example) yes, we have a real fire, it is this big, in this room, we used two fire extinguishers and it is not extinguished, we are evacuating to this wing and we will meet you at the front door. Don’t forget to have a backup for the night shift if your assignment is the receptionist and that is not a 24/7 position.
Does everyone know to pull a pull station for a fire no matter what? Old plans for ‘major’ and ‘minor’ fires are not current/acceptable.
Do you have a plan for the preparation and evacuation of a floor or wing?
Do you have a smoke compartment evacuation plan? Once staff determine the need to evacuate, start with residents in immediate surrounding area of fire, then the triangle of rooms around the room of fire origin (next to and across the hall from the room of origin), then the remaining rooms in the smoke compartment working away from the room of origin, trying not to cross the line of fire with the residents. Some residents may be evacuated outside while others may be evacuated beyond a set of smoke doors.
Do your evacuation and fire plans say to evacuate based on if the residents are ambulatory, use wheelchairs or are bedridden? After evacuation of the compartment of origin, and you find the need to evacuate further away, then it would be prudent to evacuate based on ambulation status (ambulatory, wheelchair, bedridden) since you can move faster. But it would not be fair to residents occupying the triangle of rooms around the room of fire origin to be last out because they are bedridden. If you have separate fire and evacuation plans, make sure they are consistent.
Keep this as simple as possible – if you have a smoke compartment plan from every smoke zone in your building, will staff be able to remember all of those instructions? If they know the above information, they should be able to find the safe zone every time, no matter where they are in the building (and be able to articulate this to a surveyor).
Do you have cross-corridor doors? Examples might be at the entrance to a memory care unit or doors to a service hall. Cross-corridor doors are access control doors that are not smoke barrier doors. You need to evaluate your building and identify where all of your smoke/fire barriers are and if you have cross-corridor doors. Make sure staff know these are not part of the smoke compartment plan as they sometimes look like smoke barrier doors.
If you care for residents with specialized needs (such as ventilator or bariatric units), have a general plan in place and make sure staff know what to do. If the bed won’t fit through the door, you need to have a plan in place for rescue. Always make sure you are adequately staffed for emergencies when you are providing care to special populations.
Does your plan or training materials cover all aspects of what your facility offers staff to fight a fire? Does it cover a bit about the construction, the fire alarm and sprinkler systems, the generator, the smoke barriers, identification of smoke doors, identification of cross–corridor doors that are not smoke barrier doors, all types of fire extinguishers in your facility – including the K or halon, the range hood, etc. It is important for all staff to know what equipment is in the kitchen. There was a recent IJ as a result of a fire where the night shift nursing staff were unable to extinguish the fire because they used the wrong type of extinguisher and didn’t know about the range hood or how to activate it.
Do you have the required print copies at the security station or nurse’s station? Don’t just rely on the computer – it will be the first thing to go down in the event of an emergency.
Don’t forget to in-service staff when you change your policies.
19.7.2.1* Protection of Patients.
19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.
19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy’s fire safety plan
19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
