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Fire Watch Procedure Template
Health Care Facilities

Return to DSL-BQA-00-017

PURPOSE: A plan of action should the fire alarm system fail to work properly so as to not provide continuous facility-wide fire detection and alarm capabilities. A fire alarm system could include but is not limited to: fire alarm panel, smoke or heat detection system, sprinkler system, and fire department notification system.

ACCESS: Available in writing at staff stations and comprehended by training of all facility staff.

STAFF: Facility staff trained in Rescue, Alarm, Contain, and Extinguish/ Evacuate (RACE) and the implementation of a facility-wide fire watch.

DOCUMENTATION: Each tour is recorded with findings noting date, time, and staff initials. A fire watch tour is a periodic walking tour of the entire facility by one or more assigned and trained staff. The tour monitors the facility through direct observation of all rooms for possible signs of fire.

OCCURANCES: Fire alarm system outages can occur during construction, renovation, electrical storms or other unplanned events which eliminate part or all of the fire alarm system.

  1. Contact the facility administrator, nurse director, and maintenance manager when any problems are encountered with the fire alarm system. (Action: staff)

  2. Contact the fire alarm company should the maintenance manager be unable to correct the problem. (Action: administrator/nurse director/maintenance manager). Fire alarm company shall be on site or on contract until system is repaired, replaced or reinitialized and working.

  3. Notify the Chief of the fire department at XXX-XXXX that the fire alarm system is not working correctly. (Action: administrator/nurse director/maintenance manager).

  4. If the alarm system is inoperable for a time period of four (4) hours or more, notify the Wisconsin Department of Health and Family Services (DHFS) Bureau of Quality Assurance (BQA) through the Regional Field Operations Director (RFOD). They can be contacted at (XXX) XXX-XXXX. (Action: administrator/nurse director/maintenance manager).

  5. Fire watch procedure shall designate facility tours designating wing, floor, or building identifier. (Action: Facility Administrator)

  6. Fire watch tours shall occur at ½ hour intervals, 24 hours a day. (Action: Administration)

  7. Fire watch shall be performed by personnel solely dedicated to the fire watch and no other facility-related activities or events. (Action: Administration)

  8. A fire watch should check and document the following in all rooms including:

  • Resident rooms (remove smoking materials and extension cords),

  • Dietary and Laundry rooms (remove lint from dryers and soiled linen),

  • Mechanical and Electrical rooms (remove combustible/flammable materials),

  • Fire department access to the facility (remove snow and ice from exits),

  • Fire department access to hydrants, sprinkler connections, standpipes, and fire extinguishers,

  • Exit access, exits, and exit discharge are unobstructed,

  • Storage of combustible or flammable materials shall be in approved containers or designated storage areas,

  • Identify temporary heating devices and have them removed,

  • Fire and Smoke doors closed properly,

  • Machinery unnecessary to be running continuous is turned off,

  • Sprinkler valves shall be open and sealed, gauges indicate normal pressures, and sprinkler heads shall be unobstructed,

  • Construction or renovation work areas shall be monitored continuously.

  1. Maintenance staff shall be available on site or on call for equipment emergency shutdown situations.

  2. Additional fire extinguishers shall be distributed facility-wide and staff shall be informed of locations.

Fire

In the event a potential fire situation is identified behind a door:

  1. Do Not Open Door.

  2. Touch door handle and door leaf and verify raised temperature. (Yes-proceed)

  3. Smell for smoke or fumes. (Yes-proceed)

  4. Implement ‘RACE’ program: Rescue, Alarm, Contain and Extinguish/Evacuate.

  5. Rescue/remove residents from immediate danger.

  6. Activate a call to local fire department at XXX-XXXX if the fire alarm is not directly connected to the fire station.

  7. Contain fire by shutting doors.

  8. Extinguish and/or evacuate area.