POLICY AND PROCEDURE
EMERGENCY RESPONSE PLAN
SECTION 2
FIRE
Fire Policy – General Information
Charge Nurse Duties
Fire Watch Policy
Fire Procedure
POLICY AND PROCEDURE
EMERGENCY RESPONSE PLAN
SECTION 2
Fire Policy1
General Information
Every employee must know how to turn on a fire alarm, must know the locations of the fire
extinguishers in the facility and must be familiar with the operations of the extinguisher.
The orientation coordinator is responsible for showing new employees the location of
extinguishers.
Good housekeeping is the best guarantee against fire. Maintain order and cleanliness in the
interest of fire protection. Make it a habit to watch for fire hazards. Focus on fire prevention.
If you see or smell smoke, report it immediately for investigation. Early detection means prompt
extinguishing of fire.
Each residential care facility shall provide paths of clear and unobstructed access to egress exits.
Additionally, the propping open of a door through the use of door stops, wedges or other devices
shall be prohibited.
The order for total evacuation is the responsibility of the person in charge of the facility or
officer of the fire department. Never evacuate an entire area until told by person in charge,
unless the residents are in immediate danger of fire.
Never return to the building after evacuation is completed until ordered to do so by the fire
department.
If a fire is in a Residential suite, then the affected room and the two immediate adjoining rooms
(one on each side) are also to be evacuated.
The facility will be inspected for fire safety in accordance with paragraph A of Rule 3701-17-53
of the Administrative Code.
The facility will comply with all applicable State Fire Code Standards of Chapter 1301.7-7 of the
Administrative Code.
1
Ohio Department of Health Rule 3701-17-63 G, H
Ohio Revised Code 3721.03
POLICY AND PROCEDURE
EMERGENCY RESPONSE PLAN
SECTION 2
Fire Policy
Charge Nurse Duties2
When the fire alarm sounds, go to the fire panel and determine the location of the fire. All
alarms (except planned drills) are to be assessed by the fire department, even if the alarm is
suspected to be false. The alarm is monitored and the fire department will automatically be
called. The monitoring company will also notify the Administrators and Maintenance Director.
Immediately go to designated area and assess fire. Determine rescue procedure in regard to
those Residents nearest to the fire. Delegate duties to all other staff with primary goal of safety
to all Residents and staff.
Note: The master key to all suites is always in the nurse's possession and an additional Master is
also located at the reception desk. If additional keys are needed they may be obtained from
Housekeeping.
Duties to be assigned:
1. Assign staff to secure Residents in the immediate fire and surrounding area.
2. Remind everyone ALL DOORS ARE TO BE CLOSED.
3. Assign staff to secure other Residents.
4. Assign staff to extinguish fire.
5. If building or area is to be evacuated, assign staff to be responsible for
removing Residents, and if possible, Resident charts.
6. Account for all Residents and staff by utilizing current Resident and staff
rosters.
7. If not evacuating, assign one staff member to remain at nurse's station or
reception area to monitor telephone calls and inquiries for optimal
communication.
8. Staff will be assigned to Resident areas.
2
Ohio Department of Health Rule 3701-17-63 I 1, 2
POLICY AND PROCEDURE
EMERGENCY RESPONSE PLAN
SECTION 2
Fire Watch3
It is our policy to have a plan for protection of all persons in the event of fire and procedures for
fire control and evacuation, including a fire watch and the prompt notification of the local fire
authority and state fire marshal’s office when a fire detection, fire alarm, or sprinkler system is
impaired or inoperable. For purposes of this rule, “fire watch” means the process required in the
Ohio fire code for detecting and immediately alerting residents, staff, and the responding fire
department of a fire or other emergency while the building’s fire alarm or sprinkler system is
impaired, inoperable or undergoing testing.
A Fire Watch shall be enforced upon the fire alarm system and/or sprinkler system becoming
inoperable or malfunctioning. In this scenario the Charge Nurse will:
1. Position “bullhorn” at Resident Hub Desk for audible sound if needed.
2. Instruct all Nursing Staff to conduct continuous checks including all areas of the building.
3. Use cell phones and\or two-way radios for communication with local fire and rescue
departments.
4. Fire Watch shall remain in effect until fire alarm and/or sprinkler system are operational.
3
Reference: Ohio Code 1301:7 Division of State Fire Marshall Table – 901.7
POLICY AND PROCEDURE
EMERGENCY RESPONSE PLAN
SECTION 2
Fire Procedure
All employees are to know in detail the entire emergency fire plan and execute the procedure
under the direction of the Charge Nurse (and Fire Department if applicable).
The Charge Nurse has a master key to the Resident suites and has access to more if needed.
When facility fire alarm is sounded all employees will respond as indicated:
Any employee that is in the area where the fire is located, is to respond immediately with
the rescue and extinguishing procedure; otherwise report to Nursing Station.
Charge Nurse
Dietary Staff
Housekeeping
Maintenance
Nursing
Administration
Activities
Fire Location
Any Location
Assignment
Check fire panel for location
Assess fire
Direct all reporting staff
Notify staff when all clear and resolved
Kitchen
Other location
Any Location
Any Location
Any Location
Any Location
Any Location
Activate alarm/Attempt to contain fire
Shut down kitchen/Report to Nursing station
Report to Nursing Station
Report to Nursing Station
Report to Nursing Station
Report to Nursing Station
Secure Residents in group
Report to Nursing Station
RACE - Stay Calm!
R=RESCUE
If you find a fire burning, first remove the Residents in immediate danger to a safe area. If you
find a Resident on fire, use bedspread, blanket, curtains, etc., to smother the flames and remove
Resident from any other fire hazard.
A=ALARM
Activate fire alarm (Fire Department is automatically called, fire doors will immediately close
when fire alarm is pulled). The charge nurse will assess the fire and give instructions and assign
duties.
C=CLOSE DOORS/CONTAIN
Staff in their assigned areas are to close all doors. These act as a smoke and fire barrier.
E=EVACUATE AND EXTINGUISH
Evacuation routes are posted and are to be followed unless nature of fire makes this impossible.
Evacuation to outside only if absolutely necessary (under the direction of the fire department). If
evacuation occurs, your primary concern is the wellbeing of the Residents. Make sure all
Residents are accounted for and make them as safe and comfortable as possible. Attempt to
extinguish only small fires with the fire extinguishers, which are located in each area.