Office of Operations
21st Century Operations Using 21st Century Technologies

Evacuating Populations With Special Needs

Routes to Effective Evacuation Planning Primer Series

Annex 5: Congregate and Residential Care Facilities Case Studies

The following three case studies focus on a hazardous materials fire at the Teris, LLC facility in El Dorado, Arkansas, on January 2, 2005, which involved evacuating two nursing homes and a county jail facility.[108]

Case Study #1: Oakridge Nursing Home

On Sunday at 9:30 am, the Assistant Administrator was contacted at home and informed by the 911 system that the Teris plant was exploding. Within 10 minutes of the phone call, the Assistant Administrator arrived at the nursing home. At this point, it was decided to start shelter-in-place procedures.

The air conditioning was turned off, windows and doors were closed, and the building was secured. In preparation for an evacuation, staff were instructed to get residents out of their rooms, place them in the hallway, and place wet towels in the doorways to prevent contaminated air from coming into the facility. Bed-ridden residents were moved to the front of the line, while ambulatory residents were moved to the back of the building where they were met with buses.

After this initial activity, the Assistant Administrator was waiting for the word to evacuate Oakridge. Approximately 1 hour after the initial call, someone from a church arrived to help Oakridge evacuate. This individual informed the Assistant Administrator that “everyone was evacuating,” and the evacuation started at this point.

A local church offered the use of its facility as an evacuation site. This facility was located 5 miles away, and has an auditorium, restroom, and kitchen facility. Residents were evacuated to this location. However, not all residents were evacuated to the church; a few residents were evacuated by ambulance to the hospital or another nursing home due to their condition.

Since the church did not have cots, staff went to a former nursing home, 17 miles south of town, and took the beds from that facility.

The evacuation took approximately 2.5 hours for 176 residents and 100 staff.


The Assistant Administrator was concerned that Oakridge did not receive an official call to evacuate the facility. He feels it may have been due to a mistake in their address, which is on Hudson, and he feels the Hudson Memorial Nursing Home may have received the notice to evacuate by mistake. However, the Hudson Memorial Nursing Home was contacted, and no evacuation call was received by them.

There was no official call from the local emergency management officials for an evacuation, nor were there Red Cross officials assisting in the evacuation. The Assistant Administrator would have liked to have emergency officials helping during the evacuation. “If not for the churches and family members, we would have had a problem.”

The Assistant Administrator would have liked to know who they could call on and who would call on them for any future event. He did not like volunteers informing him of the need to evacuate. There needs to be “better communication from an official person.” He called after the incident and received an apology.


At the beginning of the evacuation, the focus was on “do we shelter in place or evacuate.” There was no worry about Teris exploding, but there was worry about the fumes, since Oakridge is located 5,000 feet from the Teris facility. In addition, the focus was on keeping the communication lines open since people were calling in seeking information, tying up the telephone lines.

During the evacuation, the focus was on the safety of the residents and the transportation of the wheelchair-bound residents. There was a concern with the slowness of the ambulances used to transport the wheelchair-bound residents.

During the evacuation, volunteers arrived and helped transport ambulatory residents to the church.

After the evacuation, the focus was on making residents comfortable and taking care of them. Staff volunteered to come in and help out, and there was a concern to make sure that the facility could handle the crowd.


There are written procedures for the evacuation of the facility, and they may not have been followed. However, Oakridge self-evacuated, and it went smoothly without injury or death.

Every month, Oakridge practices a fire drill, along with semi-annual disaster drills for tornadoes and a shelter-in-place scenario. In addition, the county has a tape on sheltering in place, and the video has been seen several times by the staff and is incorporated into their training.


Oakridge has a contract with a nearby church for evacuation purposes in case of a fire or a tornado. However, since the church was in the evacuation zone, residents could not be evacuated to that site. Upon re-examination of their needs after the incident, Oakridge determined that the facility was not big enough for them.


A total of six church and school buses were used to evacuate the residents. One of the school buses was wheelchair lift-equipped, and Oakridge could have used more of those types of buses.

Lessons Learned

  • Examine the space of a facility to be used as a shelter and ensure it meets your needs for space, accommodations, restrooms, and a kitchen.
  • Not everything needed for an overnight evacuation was taken initially, such as diapers, supplies, feeding pumps, and other supplies. Have re-thought the need to gather up supplies during an evacuation and have assigned staff to gather up the supplies.

Why A Success

Oakridge staff have received training on evacuation and have reviewed the shelter-in-place video. That information combined with the knowledge of how to handle other types of emergencies led to a successful self-evacuation.

Case Study #2: Hillsboro Manor Nursing Home

The Director of Nursing received a page from the 911 system while attending church and was told (a) to be prepared to evacuate and (b) to prepare for a return call to evacuate. After this initial contact, Hillsboro started to evacuate the residents before the order to evacuate was received. Shortly thereafter, a call was received to evacuate the nursing home. Upon arrival at the nursing home, the Director coordinated the evacuation of residents and staff.


In the meantime, the Police Department and volunteers from the community acquired buses for the transportation of residents to their designated public shelter. There were approximately 96 patients and over 50 staff that needed to be evacuated. Most of the residents could be moved by either school or church bus (regular and wheelchair accessible), but residents who could not walk were transported by ambulances to the hospital or other nursing homes.

One man from a church brought a truck that was used to move wheelchairs, bedding, linen, the medicine carts, and food prepared for lunch.

The Police Department provided an escort to the public shelter.


The evacuation started at approximately 11:00 and by 13:00 was completed. However, due to possible explosions at the Teris facility, residents were not allowed to return to Hillsboro until the next afternoon.


Hillsboro conducts an annual emergency response drill. With this drill, procedures are followed and steps are taken to complete an evacuation of the home without an actual evacuation.

In the past, parts of the home have been evacuated due to smoke or electrical issues, but never on a full-scale evacuation basis.


The focus during the start of the evacuation was to get patients out of the facility, and gather up bedding, linen, other items, and food. The Supervisor of Housekeeping was charged with gathering linen, bedding, medicine, and other items. Others were charged with gathering toiletries and adult diapers. The kitchen staff was charged with gathering formula and food. “Everyone was assigned a job and everyone completed it well.”

During the evacuation, the focus was on trying not to upset the residents, contacting family members, and not fielding calls from outside the facility. Some of the residents do not take well to strangers and a break in their routine, so they needed to be reassured. In addition, staff were assigned to contact families to inform them of the situation. People were asked to defer calling the facility until the evacuation was completed, since it interfered with the evacuation.

After arrival at the public shelter, the focus was on contacting the Red Cross for the cots, setting up the cots, and feeding and calming the residents. During the evacuation, residents were told that there was a fire and it was better to leave the nursing home. Some residents thought of it as a picnic outing since some do not get out often.

Public Shelter

Hillsboro was directed to a public shelter in a church located a few miles away from the nursing home. When the residents and staff arrived at the public shelter, the Red Cross was contacted for cots and Wal-Mart was contacted for pillows and blankets for the evacuees.

Initially, two to three residents were picked up by their families during the initial evacuation, but when they found out where they went and the level of comfort achieved, the residents were returned to the public shelter and the care of the nursing home.

During the evacuation, homebound citizens and other citizens in need were taken into the public shelter and treated like the nursing home residents.

Initially, the Director was informed that the public shelter they were to go to was the Municipal Auditorium. The Director sent staff as part of the first team. In the meantime, she voiced concern over the facility due to the location of bathrooms (not on the same level as the sleep facilities) and because there was no place to cook food. They listened to her advice and the evacuation point was moved to a church. The first team staff was contacted and informed of the new location.

Police officers were assigned to stay with the residents at the public shelter. They stopped curious people from entering the facility and provided security. At least two officers spent the night at the public shelter.

Lessons Learned

  • Be prepared and delegate responsibility to others to help during an emergency.
  • Give people a designated assignment.
  • Have drills and know what everyone’s role is.
  • “It was a good experience, something deadly could have happened. It makes you understand and appreciate who you rely on. Take care of your own.”
  • Next time, request wheelchair lift-equipped buses. This type of equipment facilitates the entry and exit of the residents onto and off the buses.
  • Through firsthand experience, Hillsboro knows their own abilities, which churches have what form of transportation, and who to contact first.

Why a Success

There are numerous reasons why the evacuation was a success.

  • Community volunteers assisted in the evacuation, such as providing a truck to transport items or church buses to transport residents and staff.
  • There was easy access to transportation.
  • Hillsboro had written procedures on evacuations. The nursing home had practiced, at least annually, an emergency drill for evacuation of the nursing home.
  • The delegation and assignment of activities to staff kept the staff focused on the evacuation and not on what-if scenarios.
  • There was the experience of previous partial evacuations.

Case Study #3: El Dorado County Jail Facility

The Teris facility is located on the edge of the city limits, and the county jail facility is approximately 400 yards from it. The Sheriff found out about the incident by either hearing or seeing the explosion and fire. The Sheriff directly went to the Teris facility for information on the incident and was told of the recommendation to evacuate the jail facility. Upon receipt of this information, the Sheriff contacted the Local Emergency Planning Committee, and it was determined that the county jail needed to be evacuated and his staff was needed for that purpose.

When the decision was made to evacuate the jail, the Sheriff called the local school district regarding school buses for the transportation of the 170 prisoners and the use of a temporary detention facility. Six school buses were provided by the school district, in addition to the offer of the use of an unused school at Old Union, Arkansas, built for 400 students, approximately 8 to 10 miles away.

Prior to the school buses arriving, the Sheriff’s staff, through an earlier purchase, cuffed each of the prisoners with plastic handcuffs such as those currently being used by American troops overseas.

The evacuation took approximately 1 hour.

The school buses arrived, and the prisoners boarded with a police escort of 12 police cars. At the school, the prisoners were placed in the school gym, since it could accommodate a large crowd, and were separated to maintain control.

While the county jail was being evacuated, the Sheriff determined that the facility still needed to provide dispatch services to the community. The Sheriff and one deputy remained at the office to man the phones, while the other remaining staff of 59 was evacuated. At this time, the ventilation was turned off at the jail facility to ensure that contaminated air was not brought in from outside.

After approximately 6 to 8 hours, the Sheriff determined that the situation was not as bad as it initially appeared and asked for volunteers to return to help operate dispatch. A few staff volunteered to return.

The Sheriff knew that the prisoners could not be kept in the school gym overnight, so he contacted another Sheriff in Farmerville, Louisiana, to ask if they had enough space to accommodate the prisoners overnight. They did, and the prisoners along with their jailers were transported approximately 30 miles to Louisiana. The Sheriff felt that there was not a close-by Arkansas jail facility that could accommodate the prisoners.

The next day, the all clear was received from Teris, and the prisoners and jailers returned to El Dorado. However, the Sheriff brought back the prisoners before the public was allowed to return because he did not want to have the prisoners on the road with the general public due to the possibility of an incident.

The Sheriff’s impressions of the experience, “No failure in the mission, protected the prisoners and took calls from the community, while the jail was evacuated.”

Transportation Impacts

When the Sheriff decided to evacuate the jail facility, a choice of roadways to use was also made. It was determined that the convoy would proceed down state roadways rather than county roadways due to several factors: (a) the state roadways were felt to be more secure; (b) there were wide shoulders and, in case of an accident, the buses could be moved off to the shoulder or, in the case of an automobile accident, the automobile could be moved off to the shoulder not impeding the movement of the buses; and (c) there are more lanes allowing for faster speeds and allowing for the movement past an accident.

Lessons Learned

There were some lessons learned regarding “little bitty things such as how to coordinate prisoners and separate them and secure them.”

After the evacuation of the jail facility, the Sheriff looked into the feasibility of providing a separate air supply for the emergency dispatch center, but it was determined to be too costly. However, approximately four to five self-breathing apparatuses were purchased and are on site at the county jail in case of need.

Why a Success

The Sheriff felt that there has always been the threat of an evacuation, and he had “years to think about it.” He communicated the plan with two others on his staff, the Chief Deputy and the Jail Administrator, so they knew what to do in case the Sheriff was incapacitated. To ensure someone is available who knows the plan, the Sheriff requires that all three people are not off duty at the same time. There is at least one of them on site at all times. The Sheriff realizes that the evacuation plan should be written down and taught to others of his staff, but this may not happen in the foreseeable future due to a lack of resources.

[108] Technical Memorandum for Federal Highway Administration (ITS-JPO) on Case Studies: Assessment of the State of the Practice and the State of the Art in Evacuation Transportation Management, Booz Allen Hamilton, February 6, 2006.