Undertrained and Understaffed: Lessons from the Golden Age Nursing Home Fire

Nov 22, 2023

This November 23^rd marks the 60^th anniversary (1963) of the Golden Age Nursing Home Fire, a disaster that claimed 63 lives, led to industry-wide safety changes, and remains one of the deadliest nursing home fires in US History.

grayscale photography of firefighter holding equipment near houses — Photo by Andrew Gaines on Unsplash

The early morning of November 23, 1963 had been like any other in the rural Golden Age Nursing Home located just 2 miles North of Fitchville, Ohio (The Cincinnati Post, 1963). The one-story facility, which had been converted from an old toy factory in 1953 had a footprint of 186 by 65 feet and was constructed in a L formation (Juillerat, 1964). With 84 of the available 86 beds in use, the home was nearing capacity. Ranging in age from 68 to 93, the patients had come from all walks of life (Pearson, 1963a) and many of them were bedridden or had cognitive disabilities. The night-staffing team consisted of 4 persons (one of which was absent and another new to the job) while a cadre of around 21 nurses made up the daytime staff. (Anderson & Quarantelli, 1964).

At around 4:45 am electrical faults ignited a small fire in and around the home’s attic area and wall space. While the definitive cause is unknown, it is widely speculated that a faulty hotplate – regularly used to heat patients’ food before they awoke in the morning – was to blame as it had sparked and faulted in the past. Fueled by moderate early morning winds, the hidden blaze quickly grew in size and intensity and was first noticed by two passing motorists on State Route #250 at around 4:50 am. Inside the structure, no smoke or fire was yet visible to either the nurses or patients; but the temperature inside had started to rise.

The now stopped motorists, started banging on the locked doors which were eventually unlocked by one of the nurses on duty. After advising the staff of the developing situation, fire extinguishers were used in an attempt to extinguish the blaze. It did not work. The fire had expanded hidden from view. One nurse located the telephone and attempted to reach the nearest fire department in Norwalk but the attic-based phone line had been obliterated. With no way to call for help one of the assisting motorists flagged down a passing car and told them to drive to the nearest house and call for help. Then the lights failed (Anderson & Quarantelli, 1964).

While all this was happening, the process to start waking up and evacuating patients had begun, many of which had been given powerful sleeping medicine; and upon being suddenly awaken were very dazed and confused. So much so, some patients would end up physically fighting with those desperately trying to rescue them and others headed back into the engulfed building after being taken outside.

In all, the 5 personnel (3 nurses and 2 motorists) were able to save 21 patients until the operating environment became too extreme (Juillerat, 1964). It did not help that the nearest fire department with water trucking capabilities was located nearly 8 miles away in New London. By the time the first equipment arrived on scene, the fire had totally consumed the facility and it was too late to make any further rescue attempts. It soon became clear to all on-scene personnel that dozens were dead – most still in their beds.

The gusts of wind had created extreme conditions which spurred the fire like a blowtorch furnace (Zurcher, 2022). One victim in a wheelchair was found cremated in a linen closet after presumably mistaking it for an egress point (Pearson, 1963b), while another was found stuck in a doorframe that was too narrow for their wheelchair. With all paper records being destroyed, those still in their beds were only able to be identified though nurse memory. Those found in hallways were much more challenging to identify and required additional due-diligence. Due to the state of the bodies, not even families of the deceased were asked to participate in the confirmation process. It was utter horror.

Gov. Rhodes said “I have never seen a sight more devastating to the human eye than this. I don’t know any words that can express it” (Meeker, 1963).

The 21 unclaimed victims were buried in a mass grave at Woodlawn Cemetery in Norwalk, Ohio on November 29, 1963. Today, all that seems to remain of the tragedy are the recollections, an interview-based documentary called Fireland, very scarce official source material[1], and a historical marker.

[1] Although the Ohio Governor at the time James Rhodes ordered official investigations into the fire, it appears as though all of the official records have been lost. I requested the reports through the Ohio Fire Marshal and Highway Patrol (the two agencies tasked with the official investigation) only to receive the unfortunate news that the records had either been destroyed in a flood or were not found.

Lessons for Nursing Home Evacuations

“The were no specific written emergency procedures although the manager said she had shown all the patients where the exits were.” (Anderson & Quarantelli, 1964). And yet, the home had passed all inspections, including one a few months prior with flying colors.

One inspection in 1962, and also one in 1963 reported that there existed an established and documented evacuation plan. The post-disaster investigation, however, noted that there were no specific, written, emergency evacuation procedure. In fact, according to the transcribed record of witnesses, no employee had been briefed or given any instruction on how to evacuate the building.” (Anderson & Quarantelli, 1964).

Today, the law requires all nursing homes to have a basic Emergency Plan (EP) that delineates among other things, roles during an emergency, contact information, exit locations, and relocation sites (California Department of Social Services, n.d.). In practice however, the notion of relocation requires existing transportation agreements (often with third parties) to be activated. A recent Office of the Inspector General (OIG) report proclaimed that 77% of nursing homes reported significant concerns preparing for emergencies; with the major challenges revolving around emergency transportation and staffing (Maxwell, 2023). These, sadly, often go hand-in-hand.

This disaster, like many other disastrous nursing home fires – including one that occurred only a few days prior at the Surfside Hotel in Atlantic City, New Jersey, took place in the early morning (United Press International, 1963) – a time when many homes are understaffed and therefore unprepared to handle such crises. While basic emergency plans require that drills be conducted bi-annually (at minimum), there appears to be little guidance on what exactly that looks like and who must participate.

While nursing homes are expected to practice emergency procedures like fire drills and physical evacuations throughout all shifts, reports seem to suggest that the 11pm to 7am timeframe is most overlooked; leaving night-shift staff less prepared and trained than their day-shift peers (GAO, 2004; 102^nd Congress, 1994; 94^th Congress, 1975; Archea, 1979; Nelson et al., 1983; Moore, 2012). Unfortunately, it is evident that this topic has been greatly understudied in recent years.

Hesitancy in conducting emergency drills and exercises that require active staff and patient involvement during this period of time (night-early morning) often forms from the desire to not disturb sleeping residents. This mentality is completely understandable when considering that a significant number of nurses have never received training in regards to patient sleep disturbances or its management (Wilfling et al., 2023).

As was the case in the Golden Age Nursing Home disaster, many patients were on sleeping pills and had compounding cognitive issues – which greatly increased the load placed on the few available nurses that now had to physically battle and successfully evacuate residents in an already challenging environment. With approximately 70% of nursing home staff facing regular workplace violence in their jobs (Hall & Chapman, 2009), the need for integrated all-hazards training for emergency evacuations is greatly warranted.

When picturing an evacuation, it is easy to imagine a scenario in which patients have the same perceived end-goals as the staff – evacuation. But in reality, and as seen in this disaster, this may not always be the case; when in a state of confusion, many patients reentered the facility to their deaths or physically attacked the very nurses attempting to come to their aid. This extra load placed on the few available on-site personnel proved to be a death sentence for many still trapped inside.

Today in the United States, a large percentage of nursing home residents are prescribed hypnotic or antipsychotic medications (Ye & Richards, 2018; Grimm, 2022) which can create obstacles for effective evacuation. If this was not bad enough, a functional needs-based evacuation is of great complexity and requires well trained staff in its methodologies and procedures. A non-ambulatory patient, for instance, will need a minimum of two persons to carry them using the “two-handed seat” or “chair carry” while other methods like a “blanket carry” may require three or more persons (CDC, 2009; California Hospital Association, n.d.). Taking this into account, one may be shocked to learn that the federal government has not standardized minimum staff to patient ratio requirements.

Some studies seem to indicate that many nursing home staff are untrained to be part of “patient lift teams” (either manual or equipment-based), which constitute a primary method for vertical non-ambulatory patient evacuation (ECRI Institute, 2013). In fact, many drills do not seem to take these factors into account either (VanDevanter et al., 2017).

“A good plan, however, is just the beginning. All people responsible for carrying out the plan need to know the plan very well and their required actions need to be well rehearsed. Factors such as emotional arousal caused by danger, obscured vision caused by smoke, and the soporific state caused by carbon monoxide can affect memory of a plan and one’s ability to carry it out effectively. Only if the plan has been so well rehearsed that the responses are automatic, meaning they do not involve conscious deliberation, is the plan likely to be carried out successfully under grave emergency.” (Still, 2019)

In Memorium:

Joseph Gromeck, Mary Boyer, Ruby Hohlfelder, Lucy Holmes, Anna Lahti, Louise Kehres, Agnes Dricol, Manie Mallory, Grace Water, Mrs. Sydney Underwood, Lonie Clark, Robert Carey, William Cox, John Kershner, Leslie Benethun, John Hanson, Frank Bandeen, Logan Lamb, Gottlieb Schulke, Charles Steirert, Sam Rood, Henry Panell, John Kuczski, Andrew Pavulus, Harry Berman, George Juhanz, Charles Sharmek, John While, Clayton Hires, William Brockman, John Linder, Sam Sactor, Tony Marlitti, Walter Milander, Louis Rosenberg, James Rouk, Geo. Krueger, August Solli, Rubin Ecklebarger, John Doran, Upson Todd, Katy Lepis, Lena Linn, Margaret McNerney, Ella Ehle, Maude Reid, Clara Heil, Pauline Charnecky, Meta Trechel, Luba Smoley, Oned Davis, Maude Lehman, Charlotte Whelan, Christine DeMuth, Mary Berganski, Angelina Traut, Margaret MacDonald, Martha Carpenter, Marguerite Hermes, Emma Johnson, Marie DeFrank, Mary Baldo, Minnie Dwyer

Memorial/Historic Marker: https://remarkableohio.org/marker/8-39-golden-age-nursing-home-fire-killed-in-the-fire/

Additional Golden Age Nursing Home Fire Resources:

Fireland – Documentary: https://www.youtube.com/watch?v=AaVTrmx-59o&ab_channel=Bricker-Down

British Pathe Archival Video [Warning – Graphic Images] https://www.britishpathe.com/asset/117951/

Sample Templates & Guides:

Evacuating Non-Ambulatory Patients for Home Healthcare [Index/Guide] (ASPR TRACIE) https://files.asprtracie.hhs.gov/documents/aspr-tracie-ta-evacuating-non-ambulatory-patients-for-home-healthcare-022017-508.pdf

Evacuation and Shelter in Place Guidance for Healthcare Facilities (Los Angeles County Emergency Medical Services Agency) https://www.calhospitalprepare.org/sites/main/files/file-attachments/evac_sip_ii_0.pdf & https://www.calhospitalprepare.org/post/evacuation-and-shelter-place-guidelines-healthcare-entities

Safe Evacuation for Long-Term Care [Index/Guide] (California Association of Health Facilities) https://www.cahfdisasterprep.com/evacuation

Worksheets for Determining Evacuation Capability (2012 Life Safety Code) https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms2786m.pdf

References:

94th Congress. (1975). Nursing Home Care in the United States: Failure in Public Policy (Supporting Paper 94–00). United States Senate. https://www.aging.senate.gov/imo/media/doc/reports/rpt475.pdf

102nd Congress. (1994). A State-by-State Analysis of Fire Safety in Nursing Facilities (Staff Report 102–M). United States Senate. https://www.aging.senate.gov/imo/media/doc/reports/rpt292.pdf

Anderson, W., & Quarantelli, E. L. (1964). A Description of Organizational Activities in the Fitchville, Ohio Nursing Home Fire (1963–1123). The Disaster Research Center Ohio State University. https://udspace.udel.edu/server/api/core/bitstreams/ba68b63d-6efe-4775-ac87-3e342c7829ee/content

Archea, J. (1979). The Evacuation of Non-Ambulatory Patients from Hospital and Nursing Home Fires: A Framework for A Model (NBSIR 79-1906). Center for Fire Research, National Engineering Laboratory; US Department of Commerce.

California Department of Social Services. (n.d.). Emergency Disaster Plan for Residential Care Facilities for the Elderly. State of California - Health and Human Services Agency. https://www.cdss.ca.gov/cdssweb/entres/forms/english/lic610e.pdf

California Hospital Association. (n.d.). Evacuation and Shelter-in-Place Guidelines for Healthcare Entities. California Hospital Association . https://www.calhospitalprepare.org/post/evacuation-and-shelter-place-guidelines-healthcare-entities & ttps://www.calhospitalprepare.org/sites/main/files/file-attachments/evac_sip_ii_0.pdf

CDC. (n.d.). Safe Patient Handling Training for Schools of Nursing: Curricular Materials. Centers for Disease Control and Prevention. https://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf

ECRI Institute. (2013). Safe Resident Handling and Movement. Continuing Care Risk Management , 1(9). https://alnursing.org/wp-content/uploads/2020/03/Safe-Resident-Handling-and-Movement-2.pdf

GAO. (2004). Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal Standards and Oversight (GAO-04-660). Government Accountability Office . https://www.gao.gov/assets/gao-04-660.pdf

Grimm, C. A. (2022). Long-Term Trends of Psychotropic Drug Use in Nursing Homes (OEI-07-20-00500). Office of Inspector General. https://oig.hhs.gov/oei/reports/OEI-07-20-00500.pdf

Hall, R. C. W., & Chapman, M. J. (2009). Nursing Home Violence: Occurrence, Risks, and Interventions. Annals of Long-Term Care; Population Health LEarning Network. https://www.hmpgloballearningnetwork.com/site/altc/content/nursing-home-violence-occurrence-risks-and-interventions

Juillerat, E. E. (1964). The Golden Age Nursing Home Fire. National Fire Protection Association , 57(3), 207–211. https://nfpa.access.preservica.com/uncategorized/IO_82f71490-13e1-4580-9b3d-1e935f979645/

Maxwell, A. (2023). Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters (OEI-06-22-00100). Office of Inspector General. https://oig.hhs.gov/oei/reports/OEI-06-22-00100.pdf

Meeker, D. (1963, November 24). 63 Charred Bodies Found in Ohio Rest Home Ruins. Akron Beacon Journal, 1 & 17. https://www.newspapers.com/image/151229277/ & https://www.newspapers.com/image/151230258/

Moore. (2012). Assessment of Fire Safety and Evacuation Management in Nursing Homes [Masters, Technological University Dublin]. https://arrow.tudublin.ie/cgi/viewcontent.cgi?article=1075&context=scienmas

Nelson, H. E., Levin, B. M., Shibe, A. J., Groner, N. E., Paulsen, R. L., Alvord, D. M., & Thorne, S. D. (1983). A Fire Safety Evaluation System for Board and Care Homes (NBSIR 83-2659). US Department of Commerce . https://nvlpubs.nist.gov/nistpubs/Legacy/IR/nbsir83-2659.pdf

Pearson, D. (1963a, December 10). Cites Fatal Ohio Fire: Links Rest Home Tragedy to Delay on Medical Care. Akron Beacon Journal, 6. https://www.newspapers.com/image/151244062

Pearson, D. (1963b, December 11). The Washington Merry-Go-Round. Guam Daily News, 4. https://www.newspapers.com/image/608780171

Still, G. K. (2019). Introduction to crowd science. CRC PRESS.

The Cincinnati Post . (1963, November 26). Flaming Death of 63 Aged May Win New Rules. The Cincinnati Post, 4. https://www.newspapers.com/image/763107388

United Press International. (1963, November 18). 23 Elderly Persons Die in N.J. Hotel-Home Fire. The Tribune, 1. https://www.firefighterclosecalls.com/firefighter-history-11-18-5/

VanDevanter, N., Raveis, V. H., Kovner, C. T., McCollum, M., & Keller, R. (2017). Challenges and resources for nurses participating in a hurricane sandy hospital evacuation. Journal of Nursing Scholarship, 49(6), 635–643. https://doi.org/10.1111/jnu.12329

Wilfling, D., Berg, A., Dörner, J., Bartmann, N., Klatt, T., Meyer, G., Halek, M., Möhler, R., Köpke, S., & Dichter, M. N. (2023). Attitudes and knowledge of nurses working at night and sleep promotion in nursing home residents: Multicenter cross-sectional survey. BMC Geriatrics, 23(1), 206. https://doi.org/10.1186/s12877-023-03928-9

Ye, L., & Richards, K. C. (2018). Sleep and long-term care. Sleep Medicine Clinics, 13(1), 117–125. https://doi.org/10.1016/j.jsmc.2017.09.011

Zurcher, N. (2022). Ten Ohio Disasters: Stories of Tragedy and Courage that Should Not Be Forgotten. Gray & Company Publishers.

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