The Mt. Carmel Fire: A Cautionary Tale for Assisted Living Facilities

Last week’s fire in the Mt. Carmel Adult Residential Facility (ARF)¹ resulted in the death of five of its six residents, according to the LA Times.  ARFs and RCFEs are similarly regulated by the state, and they share many common features; of the lessons learned from the ARF fire, many will be applicable to the RCFE.  In fact, the new reorganization of CCLD will now require Licensing Program Analysts (inspectors) to inspect both RCFEs and ARFs.  This blog explores how well an RCFE is prepared to protect resident safety in times of emergency. 

For three years CARR’s staff has spent upwards of 2,000 hours reviewing the public documents in the files of over 700 RCFEs located in San Diego and Imperial counties. In black and white, the public documents reveal gaps in resident safety caused by understaffing, failures to conduct regular fire drills, blocked emergency exits, and bedridden individuals needing assistance to get out of bed. We’ve also seen sham documents that pass for Emergency Disaster Plans, evidence of unrefreshed fire extinguishers and non-functioning smoke detectors. 

Staffing  RCFEs have no required staffing levels; regulations only require that the Licensee provide “adequate staffing” to meet residents’ needs. Most 6-bed facilities (about 80% of all facilities state-wide) run lean,  generally only having one individual on staff at night, and maybe two during the day. Mt. Carmel had two night staff and six residents - five of whom needed assistance to walk. 5 of the 6 residents died in the fire. 

Fire Drills  By regulation, Licensees are required to conduct and document periodic fire drills. The truth is that many facilities do not conduct fire drills; if a facility actually does a fire drill or simulated evacuation, odds are high that the residents are not included. The way I surmise that fire drills haven’t actually been conducted, you ask? See Emergency Exits.

Emergency Exits  Facility owners and staff frequently block emergency exits. The files are replete with cited deficiencies for blocked emergency exits. Let me count the ways:

• Indoor Emergency Exits blocked with wooden sticks in the tracks of sliding doors, lamps,  plants, chairs, sofas, exercise equipment, tables, TVs, and walkers.

• Outdoor Emergency Exists and Passageways blocked with planters, ladders, carpet cleaning machines, rolling carts, five-gallon buckets, a twin mattress, a large linen bin, and a bulldozer. 

• Locked Exits account for many citations:  padlocks, chains, and multi-action locks locking front, back, and bathroom doors and perimeter gates.

While state inspectors have cited Licensees for blocked emergency exits, do not take comfort: the state is only required to be a facility once every 1825 days (or 5 years). Can your resident be evacuated to safety the other 1824 days?

Bedridden Title 22 allows RCFE Licensees to accept and retain bedridden individuals. By regulatory definition, a resident is considered bedridden if she requires assistance in turning or repositioning in bed, is unable to independently transfer to and from bed, and is unable to leave a building unassisted under emergency conditions. CARR has found several licenses in the file where the state has approved 100% of the bed capacity for bedridden individuals - with no mandatory requirement for additional staff.  

The LA Times reports the Mt. Carmel home has only one resident “who had been able to walk on her own,” and its two staff couldn’t evacuate the other five residents. Why would anyone think the outcome in an RCFE would be different? Exactly how does any sane person expect an understaffed facility to evacuate a facility full of bedridden residents?

Emergency Disaster Plan  CCLD requires each Licensee to prepare and submit at the time of application a LIC 610 Emergency Disaster Plan. The form is intended to guide the Licensee through planning necessary to protect resident safety in case of emergency (i.e who would be responsible for the many necessary responses). Frequently what we find in the file is a LIC 610 that was completed and the time of licensing, and that now, years’ later, a revised and updated document has never been submitted to CCLD. We’ve seen documents so old that the area codes have changed since the form was completed, where the Licensee lists her name and number as the person to handle all responses in a disaster, and where the emergency shelter location listed is the house next door! Yet this is the go-to document - the roadmap telling staff what their responsibilities are in time of emergency. In CARR's view, LIC 610s are perfunctory, outdated, and ineffectual pieces of paper that leave resident safety to chance. 

Fire Marshal  In theory, fire districts conduct annual reviews of RCFEs within their jurisdiction. Also, by Title 22 regulation, each facility is required to have working smoke detectors and fire extinguishers in their facility. CARR has obtained inspection reports from many fire jurisdictions within San Diego County; frequently RCFEs have violations resulting from having dead batteries in smoke detectors, and from having stale or un-recharged fire extinguishers in their facilities. The  accounts of Mt. Carmel's fire indicate that a passing motorist called 9-1-1 seeing the house engulfed in flames; only time will tell whether the smoke detectors were working.

Automatic Sprinklers  What would have helped those Mt. Carmel residents survive the fire is automatic sprinklers. It is CARR's view that automatic sprinklers should be required for any facility that accepts and retains elderly, disabled, or otherwise impaired individuals where the impairments limit the individual’s capacity to escape during emergency conditions. Two bills (2006 and 2007) made it to the Governor's desk for signature; the bills required RCFEs having six or fewer residents (about 80% of all RCFEs in California) to be fitted with automatic sprinklers; Schwarzenegger vetoed both, lest the expense of putting in sprinklers would put the owners out of business. 

That no devastating loss of life has occurred in an RCFE in many years is more a matter of luck than design, as California continues to bet against resident safety through its regulatory and political failures. When will the legislature do the right thing for all vulnerable residents living in group homes and elder care facilities and address these issues?  Must we wait for more tragedy before legislators and bureaucrats stand up to powerful special interests to institute regulatory change creating mandatory staffing requirements and common-sense safety precautions?  When will our consumer outrage create an Occupy movement for elder and vulnerable adults’ safety? 

The outcome at Mt. Carmel could easily be replayed at any of California’s RCFEs. Let us keep our fingers crossed that it won’t be. It appears that is what legislators, Community Care Licensing and the Licensees are doing.

1. An ARF is licensed and regulated by the same agency that licenses and regulates Residential Care Facilities for the Elderly (RCFEs), Department of Social Services, Community Care Licensing Department.

- Chris Murphy