Subject: Fire Prevention/Evacuation Page: 1 of 5 Policy Date: 1994 Revised: 10/06, 09/08, 09/09, 8/12 Approval: Date: I. P O L I C Y Hospice of Rutherford County identifies and corrects potential fire hazards, makes advance preparations for fire emergency, provides evacuation training, and conducts regular drills. II. P R O C E D U R E A. Fire prevention: 1. The Safety Officer or designee is responsible for ensuring the following: Storage of flammable materials. Removal of accumulation of combustible waste materials. Monthly inspections of fire extinguishers. Regular inspection, maintenance, and testing of the alarm system. 2. All employees report any recognized fire hazards immediately to his or her Supervisor. 3. Advance Precautions / Fire Plan Training. Evacuation routes are posted in major corridor(s) and/or work areas with illumination of exit routes. All employees receive a review of the Fire Emergency Plan during orientation, annually, and whenever it is revised. All employees are oriented to the location and use of alarm pull boxes and fire extinguishers. Drills are conducted quarterly for each shift. Drills are initiated by placing a replica of a fire in a location where an employee discovers it; the employee who discovers the fire initiates emergency procedures described herein. Individuals specifically named to monitor an area during a drill receive instructions from the Safety Committee before hand. A representative from the Safety Committee is designated to check with supervisors after drill to ensure all staff, volunteers and visitors in their area are present; when this is completed, and the all-clear is given signaling that the emergency is over. The Safety Committee reviews each drill.
Subject: Fire Prevention/Evacuation Page: 2 of 5 Containable fires: 1. In the event a fire is contained to a small area, and is safe to approach, the following procedure is followed: The individual discovering the fire immediately uses the nearest fire extinguisher, or other safe means, to put out the fire. Once the fire is completely extinguished, the individual immediately notifies the Safety Committee or designee and completes an Incident Report. If efforts to put out the fire are unsuccessful, the individual immediately implements the fire emergency procedures below: B. Actual Fire Emergency---- PROCEDURES 1. Center of Living and Carolina Event & Conference Center Offices A. In the event of fire, the person discovering the fire will remain calm, will obtain the nearest fire extinguisher and attempt to extinguish the fire. If unable to put out the fire, the person will pull the closest fire alarm and announce Code Red over the intercom with the location of the fire. The Customer Service Representative will then call 911 to insure the fire department is aware. If the Customer Service Representative is not in the building, the Health Information Coordinator assumes the responsibility. B. Personnel should then evacuate the building, closing all interior doors while exiting using the posted evacuation routes. C. All evacuated personnel and visitors should gather in the Hospice Employee parking area to be accounted for. Designated sweepers will check all rooms to be sure they have been vacated. The Customer Service Representative should secure the roster of all staff, volunteers and visitors present in the building and a head count should be done. D. When the alert is over, an ALL CLEAR signal will be given by the Safety Officer and /or designee. E. If it is necessary to vacate the office for an extended period of time, the clinical staff will telephone patients/families and advise them that the office has been temporarily relocated. Measures will be taken to insure home care services continue as normal 2. Hospice House 8:00 am 5:00 p.m. Patients are assigned an ambulation level to in order to assist moving patients in the event of a fire. Below is criteria for each level: Level 1: Ambulatory Level 2: Ambulatory with assistance Level 3: Bed bound Any individual discovering a non extinguishable fire or hazard at the facility immediately activates the nearest fire alarm and press the page button on the telephone and state the presence and location of the fire.
Subject: Fire Prevention/Evacuation Page: 3 of 5 Staff in the main office building reports to the facility to assist with evacuation if necessary. All staff present at the time of an emergency assists with moving patients from danger and into designated safe areas and/or evacuation if necessary. The Manager or designee is responsible for fire-fighting/evacuation decisions prior to arrival of the Fire Department. Procedure: At the sound of the fire alarm the charge nurse shall turn off central oxygen system. Panel beside nurses station. Patients are removed from danger. Patients are relocated to areas behind the fire door located to the side of the nurses station. Staff should relocate patients using the posted routes on the fire/safety evacuation plan. Staff shall move patients based upon location of the fire using the closest route. If complete evacuation of the building is ordered, patients will be relocated to the outside of the building. Portable oxygen tanks are obtained for patients in need. When appropriate, staffs are assigned to remain with patients until the emergency is over. In the event of a sustained period of evacuation, all patients are taken to the nearest shelter and/or transferred to another location for care. The nurse manager/ designee will secure all patient records if time permits and it is prudent to do so. 3. Hospice House 5:00PM and 8:00AM Procedures are the same as before 5:00PM with the following exceptions: The Facility nurse or designee notifies the appropriate manager of the fire emergency once patients and staff are safely evacuated. 4. Securing of Offices and Records The nurse exiting an area closes windows and doors, and turns off electricity, as long as personal safety is not jeopardized. Patient medical records are secured in file cabinets, if time permits and it is prudent to do so; the facility nurse manager or designee is responsible for securing records. 5. Kitchen fire safety Turn off stove/oven. Evacuate the area Close all doors to area
Subject: Fire Prevention/Evacuation Page: 4 of 5 III. INSPECTION Certification and inspections of each fire extinguisher are performed by a licensed inspector and appropriately tagged on an annual basis. In addition, routine monthly inspections are noted on the Monthly Inspection Record Tag. A. Procedure 1. Building /Grounds Maintenance Tech. is responsible for the monthly inspection and the yearly certification of all portable fire extinguishers and is responsible for maintaining records of all inspections. 2. All extinguishers receive an annual inspection and maintenance check by a certified, licensed fire extinguisher service contractor to insure proper working conditions, and seals are in place. 3. Building /Grounds Maintenance Tech. checks all portable fire extinguishers once a month with appropriate notations on the Monthly Inspection Tag of each extinguisher. 4. Building /Grounds Maintenance Tech. performing this inspection check for proper location of each extinguisher, correct certification date (tagged), unbroken seals, gauge reading, approximate weight by feel, and broken hoses and connections. 5. Any portable fire extinguisher found to be out of certification date, with a broken seal, or removed from the designated location, is immediately replaced; any portable fire extinguisher requiring service is tagged DO NOT USE, NEEDS SERVICE and turned over to the Building /Grounds Maintenance Tech. or designee for proper attention 6. As a matter of daily routine, Building /Grounds Maintenance Tech. staff make spot checks of portable fire extinguishers in the course of the routine duties to insure units are in their proper areas/locations, unobstructed, appear to be in proper working order, and have seals in place.
Subject: Fire Prevention/Evacuation Page: 5 0f 5 IV. FIRE DRILL PROCEDURE During the fire drill staff will initiate procedures for actual emergencies as listed in this policy: A. Initiate the drill: Give a staff member a oral message that there is a fire emergency at location and that they are to initiate the fire plan. B. Record the amount of time it takes from message delivery to announcement, alarm, and/or evacuation. C. Record the amount of time from announcement until the last person has left the building and/or relocated behind the fire door. D. Evaluate/assess doors shut within the building. E. Evaluate/assess assembly and accounting of employees/patients. F. Complete Fire Drill Evaluation Worksheet.