Two Fatality Board and Care Facility Fire Salvation Army Rehabilitation Center - (Miami, Florida - November 11, 1995) » Lessons Learned

1. Adequate, functioning fire detection and alarm systems are critical.

A working fire detection and alarm system would have alerted the staff and residents to the fire’s danger and the need to evacuate. The early warning factor is particularly important in a facility with fluctuating and sometimes transient populations, where evacuation time may be longer because occupants are unfamiliar with the building layout. A working fire detection and alarm system warns residents of a fire; it is no longer necessary to rely on staff and fellow residents to alert others individually of a fire. Many of the residents had already retired for the evening; an alarm system would have provided additional time to escape.

2. Emergency plans and fire drills identify problems, increase awareness and are integral to the fire safety of a facility.

Both staff and residents of Board and Care facilities should be aware of and trained in what to do in an emergency situation. An up-to-date Emergency Plan and routine fire drills are essential to provide this awareness. Regular drills can highlight shortcomings or problems with the Plan or with the facility’s fire protection systems. For example, a fire drill held in the Salvation Army Center would have revealed that the fire alarm system had been shut off. Drills also increase general awareness in the resident population, and may improve reaction time to a fire situation.

3. Routine and thorough inspections by the fire department for code violations and unsafe conditions can prevent tragedies.

The facility had not been recently inspected by the city Fire Marshal’s office and there were no indications that the fire alarm system had been tested or inspected by a fire alarm service. Routine inspections could have provided the opportunity to address the shortcomings of the fire alarm system, in addition to assisting the Center’s staff with emergency planning, fire drills and other educational services to improve the Center’s fire safety.

4. Incidents with large numbers of casualties require procedures to effectively identify, process and treat victims.

Effective planning and practiced procedures are necessary to deal with mass casualty incidents. A good plan should stress organizing patients by medical need as well as decreasing congestion at the treatment sites. Although the majority of the patients in this fire were adequately treated at the scene, they crowded the treatment areas and wandered throughout the area. Some were left untreated after seeking attention for minor injuries.

There should be a procedure to track ambulatory patients in the treatment area to ensure that follow-up treatment is administered, especially in cases where more critical patients delay treatment of large numbers who are less seriously injured. Holding areas must be monitored by individuals who can provide assistance until a secondary exam is performed and the patients are released. The police department can provide security and control of the treatment area.

5. All responders in an incident should be aware of their assignment and be available to perform it when needed.

Ambulance drivers who left their vehicles made them unavailable for patient transport. This taxed the Fire/Rescue resources on scene, as they had to provide both treatment and transportation. The importance of fulfilling assignments should be stressed to all participants in an incident, including individuals who may be unfamiliar with structured operational plans, such as mutual aid personnel. Response personnel must be assigned to direct mutual aid resources who may not be familiar with the operational plan. Mass Casualty Drills involving the fire department and other service providers can be an effective means to familiarize participants with operational plans and task assignments.