2003 — Feb 26, Fire (set by patient), Greenwood Nursing Home, Hartford, CT — 16

— 16  Associated Press (Kathryn Masterson). “Nursing home fire leaves 10 dead.” 2-27-2002.

— 16  David Randolph Smith & Associates. NHC Fire Litigation, slide 10, October 15, 2004

— 16  Hartford Fire Department, CT. “Major Fires.”

— 16  Robinson, K. “Feature: Health Care Occupancies.” NFPA Fire Journal, Jan-Feb 2013.

— 16  U.S. Government Accountability Office. Nursing Home Fire Safety. July 2004, p. 1.

— 16  USA Today.  “Blind Oversight: Inspectors Miss Infractions,” October 6, 2005.

 

Narrative Information

 

CNN: “On February 26, 2003 16 nursing home patients died at the Greenwood Nursing Home in Hartford Connecticut. There were no sprinklers in this nursing home. There was a national call to install sprinklers in nursing homes. (CNN.  Feb 26, 2003).

 

“Fire broke out at about 2:30 in the morning. Some 148 patients were actually inside the residence there. Ten are reported dead, nine have been identified, 23 of them are hospitalized, 10 are in critical condition. Many of the patients were mobility (ph) impaired, so it was extremely difficult to get some of the residents out of the facility. Just a short while ago, we spoke to a representative from the chief State’s Attorney’s Office. He talked about the fact that because of what happened here, because of the fact that there were no sprinklers in this particular facility —

sprinklers not required — he says because of what happened here, laws are likely to be changed ….

 

“…an individual is in custody and is being questioned at this point. That individual described as a female patient here at the facility. The chief inspector here telling me that they’ve obtained some sort of a search warrant. What they are going to be doing is going through the facility, trying to secure any evidence for their case. This is a criminal investigation at this point. At this point, investigators are going to try and determine whether or not this was some sort of an accident or whether or not this fire was intentional.” (CNN. “Nursing Home Fire Leaves 10 Dead” Feb 26, 2003.)

 

USA Today: “As the fire spread at the Greenwood nursing home in 2003, three nurses on the midnight shift tried to save residents closest to the flames. The fire department in Hartford, Conn., later gave one nurse an award for heroism.

 

“But investigators from the Connecticut Department of Public Health later found that, despite the nurses’ “extraordinary” and “valiant efforts,” the facility’s emergency evacuation plans “were not properly followed during the fire” by others on duty.  The state report found “evidence that not all of the on-duty staff responded and … some of those that did had to be told what to do.”  For some of the 16 patients who died, mostly from smoke, those lapses may have been critical. If the staff had responded according to the emergency plan and gotten them out of the smoke, Hartford Fire Marshall Bill Abbott says, “I don’t think we would have lost so many people.”

 

“State investigators also said they learned that the staff hadn’t been doing required fire drills on the night shift. It was a violation of safety rules that had gone unnoticed during safety inspections by the state health department, including one just a month before the fire.

 

“Nationwide, three in five nursing homes are cited for violating fire safety codes. That percentage would be higher, but inspectors often miss problems.  In an audit last year by the Government Accountability Office, the investigative arm of Congress, spot checks of state inspections found that surveyors were missing an average of two fire safety violations at every nursing home they visited.  The inspections often are left to nurses or other health care workers with little fire safety training.

 

“The Centers for Medicare and Medicaid Services (CMS), the federal agency that contracts with states to check nursing homes’ compliance with federal standards, requires only that state inspectors have one 40-hour course in fire protection. Some states require more training or use fire marshals to do the work. But CMS does not track or monitor who is doing the inspections.  CMS is supposed to catch states’ mistakes during follow-up “monitoring surveys” each year at 5% of all nursing homes — about 800 facilities. In past years, the agency never has come close to that many.  “We had not pushed” to do the monitoring surveys, says Syrena Gatewood, who heads nursing home oversight at the Boston CMS office that monitors New England.

 

“After the Hartford fire and another disastrous nursing home blaze in Nashville in 2003, Gatewood says, CMS regional offices “were handed a new priority”: to meet the requirement of 800 monitoring checks a year. It’s a tough mandate. Six of the 10 CMS regional offices have no dedicated fire safety engineer to do the surveys.  To fill the gap, CMS has hired private fire safety consultants to do hundreds of monitoring surveys nationwide. And the agency is making progress: CMS has done 732 monitoring surveys for fire safety so far this year. In all of last year, it did 81; in 2003, it did 27.

 

“In Connecticut, the state’s investigation of the fire at Greenwood led the Department of Public Health to provide additional training for inspectors. The nursing home has new owners — and new sprinkler and fire alarm systems.”  (USA Today. “Blind Oversight…,” October 6, 2005.)

 

Hartford Fire Department: “Greenwood Health Center, 5 Greenwood St.  16 people lost their lives. As a result of this fire, laws governing the use of sprinklers in convalescent homes were changed so that all nursing homes in CT must have them.  This fire was the greatest disaster in the City’s History since the Niles Street Convalescent home fire of 1945. It was the nation’s deadliest nursing home fire in a half-century.”   (Hartford Fire Department, CT. Major Fires.)

 

Robinson: “By August 13 of this year, all new and existing nursing homes in the United States will be required to install automatic fire sprinklers, without waivers or exceptions, if they wish to continue to qualify for participation in the Medicare/Medicaid reimbursement program. The requirement was enacted by the Centers for Medicare & Medicaid Services (CMS), the federal agency that contracts with states to make sure nursing homes comply with federal standards.

 

“The requirement is a direct result of two deadly nursing home fires that occurred in 2003, as well as the culmination of a half-century of improvements in fire safety regulations aimed at reducing nursing home fires. From portable fire extinguishers to complete-coverage automatic sprinklers, fire and life safety code requirements have become stricter and more specific, and enforcement efforts more rigorous, making loss-of-life fires in these occupancies increasingly rare….

 

“The last straw. In 2003…in what can only be described as a setback, two deadly fires again focused attention on fire safety in nursing homes.

 

“The first occurred in February at the Greenwood Health Center in Hartford, Connecticut, when a mentally disturbed patient set her bedding on fire with a cigarette lighter. According to NFPA’s investigation report, the fire spread to adjacent rooms and entered the building’s eaves before firefighters extinguished it. Ten residents died at the scene, and six more died later.

 

“Unlike Golden Age[1] or Katie Jane,[2] the Greenwood Health Center largely complied with the state fire safety code. Interior walls of gypsum board provided a half-hour fire-resistance rating. Concrete block walls extending from the floor slab to the roof deck separated patient rooms, and the rooms’ solid-core wood doors, which opened directly onto the corridor, had positive latching hardware. Smoke barriers divided the facility into 11 smoke compartments, with corridor doors that closed automatically when the fire alarm system activated. The facility also had an emergency generator, a fire alarm system connected to the Hartford Fire Department, and smoke detectors in the corridors and common areas that were tested monthly by staff and twice a year by an outside contractor. A chemical extinguishing system in the kitchen protected the exhaust hood. It, too, was inspected and maintained by an outside contractor. In addition, a single automatic sprinkler protected the laundry chute between the first floor and the basement, and portable fire extinguishers had been installed throughout.

 

“But an important fire safety feature was missing: complete-coverage automatic sprinklers, which were not required by the state. (A discrepancy in how the staff responded to the fire — a key component in the “total concept” safety idea — was also noted as a contributing factor in the outcome of the fire.)….

 

“In 2004, the Government Accountability Office (GAO) issued a study that looked at the entire oversight program dealing with nursing home fire safety and recommended, among other things, that the CMS[3] explore the feasibility of requiring sprinklers in all nursing homes. A discussion was already underway with the NFPA Technical Committee about changing the Life Safety Code to require sprinklers in all existing nursing homes in the aftermath of the two fires in 2003, and NFPA’s review of the draft GAO report in May 2004 simply confirmed and reinforced the concept, says Robert Solomon, NFPA division manager for Building Fire Protection and Life Safety.

 

“Knowing there would be pressure to improve fire safety in its facilities, the nursing home industry decided to become proactive, asking itself which fire protection systems would provide the best protection for the money. The answer was sprinklers. As a result, the industry submitted a proposal to the Life Safety Code committee and to CMS to mandate sprinklers in all existing nursing homes. (The 1991 edition of NFPA 101 had been revised to require all new health care occupancies, including nursing homes, to be protected with automatic sprinklers.) NFPA accepted the proposed revisions to the 2006 edition of the Life Safety Code, requiring the installation of automatic sprinklers in all existing nursing homes. CMS issued its final rule on August 13, 2008, requiring nursing homes across the United States to install automatic fire sprinklers, without waivers or exceptions, by August 13, 2013, if they wish to continue to qualify for participation in the Medicare/Medicaid reimbursement program. If they do not, they will face financial penalties or even loss of their ability to participate in their reimbursement program altogether.

 

“Brave new sprinklered world.

 

“NFPA statistics for 2006–2010 showed that sprinklers were present in 70 percent of the reported fires in licensed nursing homes. Faced with nursing home fires large enough to activate an operational sprinkler system, sprinklers operated 89 percent of the time and operated effectively 87 percent of the time. Of the 13 percent of cases where there was not effective operation, roughly half were because the sprinklers were turned off before the fire began….” (Robinson, Kathleen. “Feature: Health Care Occupancies.” NFPA Fire Journal, Jan-Feb 2013.)

 

Sources

 

Associated Press (Kathryn Masterson). “Nursing home fire leaves 10 dead.” 2-27-2002, Collegiatetimes.com, Blacksburg, VA. Accessed 5-25-2016 at: http://www.collegiatetimes.com/news/nursing-home-fire-leaves-dead/article_d20befae-36be-5f1d-a35f-4c2ecad37627.html

 

CNN. “Nursing Home Fire Leaves 10 Dead.” 2-26-2003. Accessed at:  http://www.drslawfirm.com/nhcfire.pdf {slide 12} [Link inoperative when checked 5-25-2016.]

 

Hartford Fire Department. Major Fires. Hartford, CT. Accessed 5-5-2005 at:  http://www.hartford.gov/fire/MajorFires/major_fires.htm

 

Robinson, Kathleen. “Feature: Health Care Occupancies.” NFPA Fire Journal, Jan-Feb 2013. Accessed 5-31-2015 at: http://www.nfpa.org/newsandpublications/nfpa-journal/2013/january-february-2013/features/long-time-coming/?p=1

 

Smith, David Randolph & Associates. NHC Fire Litigation, slide 10, 10-15-2004. Accessed 5-25-2016 at:  http://www.drslawfirm.com/nhcfire.pdf

 

United States Government Accountability Office. Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal Standards and Oversight (Report to Congressional Requesters GAO-04-660). Washington, DC: US GAO, July 2004. Accessed 10-11-2015 at: http://www.gao.gov/products/GAO-04-660

 

USA Today. “Blind Oversight: Inspectors Miss Infractions.” 10-6-2005. Accessed 5-25-2016 at:  http://www.usatoday.com/news/nation/2005-10-06-nursing-homes-oversight_x.htm

 

[1] 11-23-1963 Nursing/Rest Home fire in Fitchville, OH, in which 63 died.

[2] 2-17-1957 Nursing Home fire in Warrington, MO, in which 72 died.

[3] Centers for Medicare & Medicaid Service, the federal agency that contracts with states to make sure nursing homes comply with federal standards. (Robinson)