Where there's smoke ...

From the perspective of fire safety, a private home is the most dangerous place for an elderly person to live. The most recent statistics of the National Fire Protection Association (NFPA) indicate that an annual average of 610 people aged 75 and over die in fires in private residences. Nearly 40% are believed to have died in their sleep, while roughly 20% had a physical impairment that might have prevented their escaping the fire. NFPA also reports that roughly half of these fatal home fires involving the elderly had one of two causes: tobacco use, including falling asleep while smoking, and faulty or inappropriate heating equipment.

During the same six-year period (1994-1999), the U.S. Government Accountability Office (GAO) reports that "annually, the average number of fire-related nursing home deaths nationwide was about five." The GAO number is misleading because it includes SNF employees who died in fire-related kitchen accidents. Nevertheless, even the inflated GAO statistics suggest that the elderly are at least ten times more likely to die from fire in their own residence than in a SNF.

The differences in risk pose no mystery for SNF administrators and staff. Long-term care facilities eliminate the single largest cause of fatal home fires among the elderly by supervising or prohibiting tobacco use among residents. Requirements to adhere to state fire codes, to maintain heating equipment in good condition, and to submit to periodic inspections reduce most of the other risk factors that transform the private homes of the elderly into firetraps. Finally, the dedication of trained staff who know the emergency plans reduces the risk of harm even when fires do occur.

The generally good news about SNF fire safety is reinforced by a 2003 study prepared by NFPA's Fire Analysis and Research Division. NFPA notes that the annual number of "fires in facilities that care for the aged fell 27% from 1980 to 1999." Most of these fires were limited to kitchens or laundry rooms, and only one-sixth began in a residential area.

Tragically, 2003 witnessed the first multiple fatality nursing home fires since 1995 (table). In Hartford, Connecticut, a young psychiatric patient housed in a facility with elderly SNF residents apparently set fire to the building. Seven months later, a fire in a Nashville long-term care facility resulted in death by smoke inhalation of several residents, including the elderly mother of a local fire department official. Casualties in the two incidents totaled 31 deaths--more than the combined number of fire-related nursing home deaths during the previous five years.

Although no similar incidents have occurred since the Nashville fire, Congressman John Larson (D-Conn.) seized upon the tragedies to introduce the Nursing Home Fire Safety Act of 2004 (HR 4967). Larson's bill reported a series of congressional "findings" that sounded as if legislators uncovered a series of glaring gaps in SNF fire prevention. Specifically, Larson claimed that the congressional findings justify a national requirement that all older nursing facilities be equipped with a fully operational automatic fire sprinkler system. The act would have allowed between three and five years for SNFs to comply with this new federal standard, and asked CMS to pay the cost of retrofitting facilities that lack sprinkler systems.

The act was hardly a blazing success as a legislative initiative. It attracted barely a dozen congressional cosponsors and was never introduced in the Senate. According to the American Health Care Association (AHCA), Larson plans to reintroduce the legislation this session, and the association already is attempting to enlist the support of its membership. AHCA Chair Steven Chies recently stated, "The Nursing Facility Fire Safety Act [sic] would facilitate the process by which existing nursing homes and those to be constructed are able to retrofit and install fire sprinkler systems in an affordable, intelligent, timely manner."

Despite the "findings" reported in Larson's legislation, long-term care facilities must adhere to multiple fire-prevention regulations. CMS insists that all SNFs conform to fire-prevention codes formulated by the NFPA, but allows older buildings constructed of noncombustible materials to apply for a waiver that avoids retrofitting with automatic sprinkler systems. About one-third of state governments impose more stringent fire safety requirements specific to SNFs, including installation of automatic sprinkler systems. Local jurisdictions also mandate fire safety codes applicable to "congregate residences," including long-term care facilities, and conduct frequent inspections. Larson's bill would not have replaced any of these existing requirements, while it adds a demand for compliance with a new, costly fire safety mandate.

AHCA may support Larson's legislation because it calls upon CMS to pay for a safety enhancement for long-term care residents in several thousand existing facilities. However, unless Congress also votes to appropriate funds for the retrofitting program, CMS legally would be unable to help SNFs with the cost of installing automatic fire sprinkler systems. Without such appropriations, passage of the act would impose a fiscal burden falling most heavily on small, older buildings converted to long-term care use.

Beyond the cost implications, however, another reason to rethink long-term care industry support for the act is that it may send the wrong message to legislators and the public. It implies that fatal nursing home fires are such a large problem that all Americans must contribute through their taxes to making SNFs safer for their vulnerable elderly residents. It draws public attention to a very small number of fire-related nursing home deaths and detracts public attention from the 50 or more elderly Americans who die every month in house fires.

Table. Fires resulting in multiple deaths in skilled nursing facilities,
1989-2003

Year       State        Comments

1989       Virginia     12 deaths resulted from a fire, prompting
                        several states to require sprinkler system
                        installation in older SNFs.
1990       Arkansas     3 deaths resulted from a fire.
1991-1994  Nationwide   No multiple-death fires in any SNF.
1995       Mississippi  3 deaths resulted from a fire.
1996-2002  Nationwide   No multiple-death fires in any SNF.
2003       Connecticut  Arson committed by young resident with history
                        of mental illness resulted in 16 deaths in
                        facility housing both older residents and
                        psychiatric patients.
2003       Tennessee    Fire of unknown origin resulted in 15 deaths
                        from smoke inhalation, including the mother of a
                        senior local fire official.

Source: U.S. Government Accountability Office, 2004.

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