Main Sprinkler Valve Turned Off in Pennsylvania Nursing Home Fire Where Four Residents Died
Failure to safely evacuate all residents and monitor sprinkler systems to ensure they are in working order as part of a facility’s Emergency Response Plan may result in charges of neglect and substandard quality of care, with the submission of false claims
Compliance Perspective – Sprinkler System
Policies/Procedures: The Compliance and Ethics Officer with the Administrator will review policies and procedures involving the Emergency Response Plan and maintenance of the facility’s sprinkler system.
Training: The Compliance and Ethics Officer, as well as every department head, will ensure that staff are knowledgeable about the facility’s Emergency Preparedness Plan and trained to respond in a timely manner to emergency situations and safe evacuation of all residents. Maintenance staff will receive training on ensuring that the sprinkler system is properly managed and functioning.
Audit: The Compliance and Ethics Officer should personally conduct an audit by scheduling periodic emergency resident evacuation drills and determining the effectiveness of staff in safely carrying out those mock evacuations. The Maintenance Director should routinely audit to ensure that the facility’s fire suppression sprinkler system is fully functional at all times.
The final investigative report from the U.S. Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) on a five-alarm fire that killed four residents and injured two dozen others in November 2017, has been released. The report indicates that while the exact origin or cause of the fire could not be determined due to the extensive damage, investigators were able to determine that the main valve for the facility’s internal sprinklers had been turned off. It could not be determined when the valve had been turned off or by whom. The fire started near a patio under an overhang at the large, multiple-building facility.
A spokesperson for the ATF reported that the fire was not deliberate, and no criminal charges are anticipated. There will be no further investigation into the sprinkler valves.
The report did not speculate about the internal sprinklers or the length of time it took more than 400 firefighters to put out the extremely hot fire. It was noted in the report that external sprinklers would have been helpful, but are not required under building codes. One fireman commented that the heat was so intense, he discovered his helmet was melting. The fire was made worse by strong winds that pushed the flames up the vinyl siding and onto the rooftops of the buildings.
Several lawsuits have been filed against the nursing home by the estates of the four residents who died.
Staff and about 150 residents were evacuated out of the buildings into near-freezing temperatures. Neighbors around the facility offered help by wrapping resident in blankets and helping them get to the ambulances. The county coroner determined that the four deaths were due to smoke inhalation.
