Enhancing Fire Safety in Taiwan’s Elderly Welfare Institutions: An Analysis Based on Disaster Management Theory

Abstract

Elderly welfare institutions in Taiwan have experienced multiple severe fire incidents, with smoke inhalation accounting for the majority of fatalities. Hot smoke can rapidly propagate through interconnected ceiling spaces, complicating evacuation for residents with limited mobility who depend heavily on caregiving staff and external responders. Field inspections conducted in this study indicate that 82% of residents require assisted evacuation, underscoring the critical role of early detection, staff-mediated response, and effective smoke control. Drawing on disaster management theory, this study examines key determinants of fire safety performance in elderly welfare institutions, where caregiving staff are primarily trained in medical care rather than fire safety. A total of 64 licensed institutions in Tainan City were investigated through on-site inspections, structured checklist-based surveys, and statistical analyses of fire protection systems. In addition, a comparative review of building and fire safety regulations in Taiwan, the United States, Japan, and China was conducted to contextualize the findings. Using the defense-in-depth framework, this study proposes a three-layer fire safety strategy comprising (1) prevention of fire occurrence, (2) rapid fire detection and early suppression, and (3) containment of fire and smoke spread. From a sustainability perspective, this study conceptualizes fire safety in elderly welfare institutions as a problem of risk governance, illustrating how defense-in-depth can be operationalized as a governance-oriented framework for managing fire and smoke risks, safeguarding vulnerable older adults, and sustaining the resilience and continuity of long-term care systems in an aging society.

1. Research Motivation

1.1. Rapid Population Aging

Rapid population aging poses a major challenge to sustainable development (as shown in

Table 1. Projected population aging indicators in Taiwan.

Year	Percentage of Elderly (%)		Aging Index (Old-to-Young Ratio)	Median Age (Years)
	Population 65+ (%)	Population 85+ (%)
2040	30.2	4.6	305.9	52.7
2070	41.6	11.4	466.4	58.2

), particularly in the provision and governance of long-term care services. As the proportion of older adults increases, elderly welfare institutions play an increasingly critical role in maintaining social stability, health equity, and continuity of care. Within this context, fire safety should not be regarded solely as a technical or regulatory issue, but as an essential component of social sustainability and disaster risk reduction.

Fire incidents in elderly welfare institutions can lead to disproportionate human losses due to residents’ limited mobility, chronic health conditions, and high dependence on staff-assisted evacuation. Beyond immediate casualties, such incidents may disrupt caregiving systems, strain emergency response capacities, and undermine public trust in long-term care governance. Consequently, strengthening fire prevention, emergency preparedness, and institutional resilience is closely aligned with the objectives of sustainable development and resilient community building.

From a disaster management perspective, ensuring fire safety in long-term care facilities contributes to reducing systemic vulnerability by protecting high-risk populations and preserving the functional continuity of essential social infrastructure. As population aging accelerates in Taiwan, integrating fire safety considerations into the sustainability agenda of elderly welfare institutions becomes increasingly important for safeguarding vulnerable older adults and supporting the long-term viability of care services.

1.2. Fire Hazards Due to Structural Issues in Existing Facilities

Fire risk in elderly welfare institutions is strongly influenced by structural characteristics commonly found in existing facilities, particularly those established prior to recent regulatory revisions. Architectural features such as long corridors, interconnected ceiling voids, and vertical circulation spaces can significantly accelerate the spread of smoke during a fire, thereby reducing available evacuation and response time for mobility-impaired occupants.

Empirical fire investigation reports and post-incident analyses in Taiwan indicate that smoke propagation, rather than direct flame exposure, is the dominant cause of fatalities in fires occurring in hospitals and elderly care facilities [1,2]. In many existing institutions, compartment boundaries are incomplete or discontinuous, allowing hot smoke to spread horizontally along corridors and vertically through ceiling plenums or stair shafts. These structural conditions facilitate rapid smoke accumulation beneath ceilings, where high temperatures and toxic gases can quickly render evacuation routes untenable [3,4].

The risk associated with such configurations is further amplified in elderly welfare institutions due to resident characteristics. Older occupants often experience reduced mobility, sensory impairment, and delayed response capability, which limit their ability to perceive alarms and evacuate independently. Prior studies have shown that these factors are closely associated with elevated fire-related mortality in long-term care settings [5]. Consequently, even small, localized fires may escalate into life-threatening events when smoke spreads beyond the room of origin. Empirical analyses of evacuation performance in elderly living facilities further demonstrate that limited mobility and delayed response significantly constrain evacuation effectiveness and increase fatality risk during fire events [5].

These observations highlight a structural vulnerability that cannot be fully addressed through emergency response planning alone. Instead, they underscore the importance of integrating architectural considerations—particularly smoke containment and compartment integrity—into fire risk assessment and mitigation strategies for existing elderly welfare institutions. This structural dimension of fire risk provides a critical context for the subsequent application of the defense-in-depth framework in analyzing layered fire safety measures.

1.3. Deficiencies in Elder Care Facility Standards

In Taiwan, elderly welfare institutions operate under a regulatory framework that distinguishes between newly established facilities and those approved prior to major regulatory revisions. While updated building and fire safety standards have strengthened requirements for new facilities, a substantial proportion of existing institutions remain subject to exemption or transitional provisions, particularly with respect to architectural and compartmentation requirements.

Under the Standards for the Establishment of Elderly Welfare Institutions, facilities approved before 5 February 2021 are exempt from retroactive application of certain building-related provisions. Although fire safety equipment and operational management are required to comply with the Fire Services Act and related regulations, architectural elements—such as full fire and smoke compartmentation—are not uniformly mandated for these pre-existing facilities. This regulatory structure reflects practical considerations related to financial burden and retrofit feasibility, but it also results in persistent heterogeneity in fire safety performance across institutions.

To address these concerns, the Ministry of Health and Welfare implemented the Public Safety Enhancement Program for Long-Term Care Institutions (2019–2022), which provided subsidies and incentives for voluntary safety upgrades. While this program contributed to incremental improvements in equipment installation and management practices, participation in structural retrofitting measures—such as smoke control systems and fire-rated compartmentation—remained non-mandatory. As a result, critical structural vulnerabilities associated with smoke spread may persist even in facilities that are formally compliant with current fire safety regulations.

This regulatory context reveals a fundamental governance challenge: compliance with prescriptive requirements does not necessarily ensure functional fire safety in facilities characterized by high resident dependency and limited evacuation capacity. The coexistence of modern fire safety expectations with legacy building conditions creates a reliance on compensatory measures, including equipment performance, staff intervention, and emergency management.

Accordingly, there is a need for an analytical framework that can account for layered, interdependent safety functions rather than isolated regulatory components. This study adopts the defense-in-depth concept as a governance-oriented structure for evaluating how preventive measures, early detection and suppression, and fire and smoke containment collectively contribute to risk reduction in elderly welfare institutions operating under heterogeneous regulatory and structural constraints.

1.4. Research Objectives

The aim of this study is to conduct on-site evaluations of 64 elderly welfare institutions in Tainan City, assess their existing fire safety conditions, and develop improvement strategies using the defense-in-depth framework as an operationalization of disaster management theory. In this study, defense-in-depth is applied as a governance-oriented structure for organizing fire safety measures across multiple protective layers, rather than as a probabilistic engineering model. The defense-in-depth concept was originally developed in high-consequence industries, particularly the nuclear sector, to address low-probability but catastrophic risks through multiple, independent layers of protection [6,7,8].

2. Research Methodology

This study employed a census-based, checklist-driven field investigation of all 64 licensed elderly welfare institutions in Tainan City. On-site inspections and structured observations were conducted between 2019 and 2020 to document the status of fire safety equipment, management practices, and fire/smoke compartmentation features. The defense-in-depth framework(as shown in Figure 1) was adopted as a governance-oriented structure to organize and interpret findings across prevention (Layer 1), detection/suppression (Layer 2), and containment (Layer 3).

The goals for preventing fire spread are divided into three main objectives:

• Preventing Fires (Layer 1).
• Rapid Detection, Control, and Extinguishment of Fires (Layer 2).
• Containing Fire Spread and Reducing Fire Damage (Layer 3).

To achieve these primary goals, this study refers to domestic and international literature and designs a questionnaire and site visits based on the following components. The data collected is then compiled and subjected to statistical analysis:

• Installation of fire safety equipment such as indoor fire hydrants, automatic fire alarm systems, etc.
• Fire safety management, including building and resident characteristics, flame-retardant materials, electrical appliance control, and bilingual signage.
• Ensuring the quality and functionality of fire protection facilities and fire safety equipment, such as ensuring the effectiveness of fire compartments and detectors.
• Emergency response management during fires, including the suitability of fire extinguishers, the external environment of the facility, and the characteristics of staff and residents.

In areas without fixed fire suppression systems, human intervention becomes necessary to extinguish fires when both active and passive fire protection systems fail to control the fire. This manual intervention supplements areas not covered by the automatic suppression system [9].

Up to this point, the fire protection defense-in-depth theory has effectively protected nuclear power plants from fire hazards. Studies have also demonstrated the feasibility of this strategy, which is applicable across various industries [10,11,12]. This study aims to apply these strategies to fire protection in elderly welfare facilities.

The application of the fire protection defense-in-depth theory to fire prevention strategies in elderly welfare institutions focuses on treating mobility-impaired residents as “targets that must not be harmed.” Developing appropriate fire protection strategies for such facilities is critical. An effective protection system should integrate passive architectural features, active fire safety systems, and robust fire management [13,14].

For instance, flame-retardant materials like carpets and curtains are used in venues such as bars and restaurants, and similar materials are required in elderly welfare facilities to enhance fire safety standards [15,16]. This is the first layer of protection, aimed at preventing fires. In accordance with fire safety regulations, the installation of fire suppression equipment, alarm systems, and evacuation equipment constitutes the second layer of protection [17]. Building technical regulations mandate the installation of fire compartments, fireproof doors, and fire-rated windows, forming the third layer of protection to prevent the spread of fires [18].

Questionnaire Design and Data Collection

The questionnaire was developed as a structured inspection checklist rather than a psychometric scale. Its design was based on a comprehensive review of domestic and international regulations, fire safety standards, and prior studies on fire protection in healthcare and elderly care facilities. Draft items were reviewed by experts in fire safety engineering and elderly care administration to ensure regulatory relevance and practical applicability, and minor revisions were made following pilot field inspections.

The instrument focused on objective, observable conditions—such as the presence or absence of equipment, compliance with installation standards, architectural features, and staffing arrangements—and data were collected through on-site inspections conducted by trained investigators. Because the questionnaire primarily consisted of factual yes/no and categorical items rather than latent constructs or attitudinal measures, internal consistency reliability metrics such as Cronbach’s α were not applicable.

This study adopted a census-based approach. All 64 licensed elderly welfare institutions registered in Tainan City during the investigation period were included, resulting in complete institutional coverage. Data collection was conducted through direct observation, document review, and interviews with on-duty managerial or supervisory staff to confirm operational practices. Field inspections and questionnaire surveys were carried out during on-site visits between 2019 and 2020.

In addition to descriptive statistics, inferential analyses were conducted to examine institutional differences by ownership type (private vs. corporate). Given the census-based nature of the dataset and the regulatory compliance–oriented research objectives, inferential statistical tools were selectively applied to assess structural differences rather than to develop predictive or causal models. Specifically, chi-square tests of independence were used for key categorical fire safety indicators, with effect sizes reported using Cramér’s V to assess practical significance. Independent-samples t-tests were conducted for continuous variables where applicable. Statistical significance was set at p < 0.05.

Because the investigation period preceded the major regulatory revisions implemented in February 2021, the findings primarily reflect fire safety conditions under the pre-amendment regulatory framework. Inspections were conducted across different months to minimize potential seasonal bias, and no major fire-related policy changes occurred during the fieldwork period that would have systematically influenced the results.

3. Results and Discussion

Conventional fire safety management in institutional buildings is often organized in a fragmented manner, with passive measures (e.g., fire compartments and fire-resistant materials), active systems (e.g., alarms, sprinklers, and hydrants), and procedural controls (e.g., training and drills) addressed as separate compliance items. Such silo-based approaches may satisfy regulatory requirements but often fail to capture how weaknesses in one domain can propagate and undermine overall safety, particularly in facilities housing mobility-impaired occupants.

In contrast, the defense-in-depth framework adopted in this study conceptualizes fire safety as an integrated, layered protection system. Passive, active, and managerial measures are treated as interdependent layers with distinct safety objectives: prevention of fire occurrence (Layer 1), rapid detection and suppression (Layer 2), and containment of fire and smoke spread (Layer 3). Using this framework as an analytical lens, the following sections synthesize the on-site inspection and survey results by examining how observed deficiencies in elderly welfare institutions correspond to specific layers of protection and collectively contribute to systemic fire risk.

3.1. On-Site Facility Inspections

This section provides an overview of the baseline findings from on-site inspections of elderly welfare institutions, outlining general institutional characteristics and overall regulatory compliance to contextualize the subsequent thematic analyses.

A total of 64 elderly welfare institutions in Tainan City were inspected, including 11 corporate-type institutions and 53 private institutions. All inspected facilities were found to be formally compliant with the applicable fire safety regulations in force at the time of inspection.

This overall compliance status indicates that the surveyed institutions satisfied existing regulatory requirements; however, the extent to which such compliance translates into effective functional fire safety performance varies across facilities. Accordingly, the following sections examine detailed inspection findings by linking observed structural, equipment-related, managerial, and operational conditions to specific layers of the defense-in-depth framework.

3.2. Current Facility Analysis

This section presents the on-site inspection and survey findings across the surveyed elderly welfare institutions, describing observed conditions related to building characteristics, fire safety equipment, fire and smoke compartmentation, staff and resident profiles, and emergency response capacity. The results are organized to reflect how these observed conditions correspond to different functional aspects of fire safety, which are subsequently examined through the lens of the defense-in-depth framework.

3.2.1. Building Types and Spatial Distribution

This subsection examines building height, spatial configuration, and evacuation-related constraints, which primarily affect the third layer of defense-in-depth—fire and smoke containment.

Inferential analyses did not reveal statistically significant differences between private and corporate institutions for the examined fire safety indicators (χ² tests, p > 0.05).

Among the elderly welfare institutions studied, 36 (56%) were multi-story buildings, as shown in Figure 2. Of these, 27 (75%) had interior staircases that could create a chimney effect during a fire, as shown in Figure 3. According to the current standards for elderly welfare institutions in Taiwan, facilities established before the revision of regulations are permitted to be located above the 10th floor and are not required to comply with current building laws. As a result, pre-existing elderly welfare facilities face significant challenges in emergency evacuation and increased fire risks, emphasizing the need for enhanced third-layer protection. Recent evacuation simulation and post-incident analyses have demonstrated that vertical building layouts and interior stairwells significantly prolong evacuation time and exacerbate smoke exposure risks for elderly occupants [19].

The vertical spread of smoke through stair shafts has been identified as a critical factor in several fatal nursing-home fires in Taiwan. For example, in a widely reported nursing-home fire incident in recent years, ignition occurred on a lower floor, while smoke rapidly propagated upward through an interior staircase and interconnected ceiling spaces. Although the fire itself was spatially limited, dense smoke quickly accumulated on upper floors, leading to multiple casualties primarily due to smoke inhalation rather than direct flame exposure. Post-incident analyses indicated that the absence of effective smoke compartmentation and the presence of open stair shafts significantly accelerated vertical smoke movement, severely constraining evacuation time for mobility-impaired residents. This case illustrates how architectural features can directly transform a localized fire into a multi-floor life-threatening event, underscoring the importance of the third layer of defense-in-depth—fire and smoke containment—in elderly welfare institutions.

Based on the inspection findings, this study recommends that the height of elderly care facilities be limited. For instance, standalone buildings should be capped at three floors. If certain conditions are met, facilities may be permitted to operate on floors above the fourth, in order to reduce difficulties with rescue and evacuation. These conditions are as follows:

• At least two smoke-proof staircases (or one outdoor evacuation staircase) must be provided for access to all floors above the third.
• More than half of the ceiling and walls must be constructed with non-combustible materials.
• Residential areas must be equipped with fire-resistant structures, fireproof doors, and windows.

Sixty-seven percent (43) of the facilities have outdoor areas that are not spacious, as shown in Figure 4. This indicates that, in the event of a fire, the narrow alleys and lack of open outdoor space would make it difficult to evacuate residents or provide space for firefighting vehicles to approach. Based on regulations in China, the U.S., and Japan, facilities should establish emergency response plans and safety management measures, which would contribute to the third layer of protection. In some cases, facilities are adjacent to high-risk neighbors, such as recycling businesses or small traditional factories, which pose a heightened fire hazard. If a neighboring fire occurs, the elderly care facilities are also at risk, highlighting the need for attention to the first layer of protection.

This study recommends that facilities be required to develop an emergency response plan and relevant safety management measures, which include the following:

• Emergency Response Plan
  • The plan should include a risk assessment of both the facility and the surrounding community.
  • The Social Affairs Bureau, which oversees elderly welfare institutions, should review and update the plan annually.
  • The emergency response plan should actively involve local residents during training exercises.
  • The plan should establish clear procedures for coordination with local fire departments to ensure cooperation during disasters or emergencies.
  • The plan should include details on how the facility can support other institutions during emergencies, as well as strategies for maintaining operational continuity.
  • Consideration must be given to the residents’ care and medical needs during evacuation, including transport logistics, designated evacuation sites, and communication with support units.
  • The plan must address medical needs and the provision of essential services, such as food, emergency lighting, and backup power, to maintain the health and safety of residents during a disaster.
• Regular Drills and Testing of the Emergency Plan
  • The emergency response plan should be regularly drilled or tested, with a training mechanism in place for new employees.
  • Full-scale drills should involve cooperation with local community residents.
  • Fire department participation in these drills should be ensured.
• Emergency Medical Access
  • The facility should have designated emergency medical access points, such as an ambulance parking area located at the building entrance.
• Accessible Pathways
  • Passageways must be designed to accommodate wheelchairs and stretchers for ease of transport.
• Road Requirements
  • When the ambulance parking area is on a public road, the road should have at least two lanes to ensure accessibility.
• Handicap-Accessible Parking
  • Spaces for individuals with disabilities should be positioned closest to the building’s main entrance, considering the needs of elderly residents who use wheelchairs.
• Emergency Rescue Windows
  • In contrast to China’s approach, Taiwan lacks clear regulations on emergency access points for rescue operations. It is recommended that rescue windows be required as part of the facility’s design to ensure accessibility for emergency responders.

3.2.2. Status of Fire Safety Equipment Installation in Institutions

This subsection focuses on the installation and operability of active fire protection equipment, including extinguishers, detectors, and hydrant systems, corresponding to the second layer of defense-in-depth.

Inferential statistical analyses indicated no statistically significant differences between private and corporate elderly welfare institutions in key categorical fire safety indicators. Specifically, smoke detector placement compliance and partition wall continuity were not significantly associated with ownership type (χ² tests, p > 0.05), indicating that observed fire safety deficiencies are systemic rather than ownership-specific (

Table 2. Chi-square analysis of key fire safety indicators by institution ownership.

Variable	Category	Private Institutions	Corporate Institutions	χ2	p-Value	Cramér’s V
		(n = 53)	(n = 11)
Smoke detector placement compliance	Yes	37	7	0.16	0.69	0.05
	No	16	4
Partition wall connected to slab	Yes	8	1	0.27	0.6	0.07
	No	45	10

). Our previous experimental study using model-scale tests and Schlieren photography demonstrated that ceiling fan–induced airflow can significantly disturb smoke transport and delay detector activation [20]. When combined with the high non-compliance rate observed in this field investigation, these findings indicate an elevated risk of delayed fire detection in elderly welfare institutions [20].

Fire extinguishers are one of the most essential fire safety devices required in any facility. Among the surveyed institutions, 55 (86%) employed foreign workers, with 48 (75%) being private institutions. Additionally, 45 (70%) of these facilities had fewer night-shift workers than half of the number of daytime workers. Given that many of the staff members in these facilities are female, it is crucial to ensure that fire extinguishers can be operated easily by them. According to the data, 17 institutions (27%) were equipped with 20 P dry powder extinguishers, as shown in

Table 3. Distribution of fire extinguisher types in elderly welfare institutions.

Fire Extinguisher Type	Private Institutions, n (%)	Corporate Institutions, n (%)	Total, n (%)
20 P dry powder	13 (25%)	4 (36%)	17 (27%)
10 P dry powder	40 (75%)	7 (64%)	47 (73%)
Total	53 (100%)	11 (100%)	64 (100%)

. The 20 P extinguisher weighs approximately 6.5 kg of powder, with a total weight of about 9.8 kg [21]. Due to its weight, operating the 20 P dry powder extinguisher can be challenging for female staff members. In terms of fire engineering management measures, using a 10 P extinguisher—while still meeting the legal fire suppression performance standards—would be easier to operate than the 20 P model, thus enhancing the second layer of fire protection.

As shown in Figure 5, 60 institutions (94%) were equipped with automatic fire alarm systems. Among these, 57 institutions (89%) had a floor area exceeding 300 m², while 3 institutions (5%) with a smaller floor area voluntarily installed the system. The remaining four institutions (6%) did not install an automatic fire alarm system and were equipped only with basic fire safety equipment. In accordance with Article 6 of the Fire Services Act, all such institutions had installed standalone fire detectors, which was confirmed during on-site inspections.

A common fire safety device in small private elderly care facilities is the fire alarm system, which includes smoke detectors installed in residents’ rooms. Given the reduced number of staff at night, effective smoke detectors are crucial for the early detection of fires, allowing for the extinguishing of small fires in their initial stages, thus contributing to the second layer of fire protection.

During on-site inspections, it was observed that many institutions had installed ceiling fans, with some detectors placed directly above these fans, as shown in Figure 6. In certain cases, the only detector in a room was positioned above the ceiling fan. This improper placement of detectors can significantly impair their functionality. Poor fire safety management, inadequate fire protection measures, and failure to perform regular fire safety inspections prevent the second layer of fire protection from functioning effectively.

The figure presents the number of institutions with smoke detectors installed at distances compliant (≥1.5 m) or non-compliant (<1.5 m) with the minimum regulatory requirement specified in the Standard for Installation of Fire Safety Equipment Based on Use and Occupancy. Detectors installed within the airflow influence zone of ceiling fans may experience delayed smoke accumulation and alarm activation due to airflow disturbance, thereby reducing the effectiveness of early fire detection. Such improper placement directly compromises Layer 2 of the defense-in-depth framework, which focuses on rapid detection and initial fire response.

According to Article 115 of the Standard for Installation of Fire Safety Equipment Based on Use and Occupancy [17], smoke detectors should be installed at least 1.5 m away from ceiling fans. Field inspections showed that 44 institutions (69%) had detectors installed at distances shorter than the prescribed 1.5 m, and therefore did not meet this installation requirement, while only 20 institutions (31%) met the standard (Figure 6). This indicates that more than two-thirds of the surveyed institutions exhibited detector placement conditions that may delay smoke accumulation at the sensing element during the early fire growth stage. Experimental and computational studies have shown that ceiling fans can significantly alter local airflow patterns, dispersing hot smoke layers and reducing smoke concentration near ceiling-mounted detectors. As demonstrated by Hung et al. [20], airflow generated by ceiling fans may delay detector activation by diverting buoyant smoke away from the sensing zone. When detectors are installed within the fan-induced airflow region, early fire detection—critical for initiating suppression and evacuation—may be substantially compromised. This mechanism provides a quantitative and physical basis for the observed non-compliance, reinforcing the regulatory requirement for minimum separation distances.

Figure 7 shows that the placement of some detectors is affected by the airflow from ceiling or wall-mounted fans, which can compromise their functionality. Improper detector placement and airflow interference compromise Layer 2 (Rapid Detection, Control, and Extinguishment of Fires) by delaying alarm activation during the critical initial stage of fire development.

As shown in Figure 8, 17 institutions (27%) have installed the first type of indoor fire hydrant system, with standalone buildings accounting for the majority at 13 institutions (21%). Due to the multi-story nature of standalone buildings, evacuation and initial fire response can take longer, particularly during the early stages of a fire. Given the reduced night-shift staffing, female caregivers in these facilities must be able to independently operate the indoor fire hydrant system. If institutions adopt the second type of indoor fire hydrant system, the amount of water required for firefighting is reduced, and the recoil force is lower, making it easier for one person to operate [17]. Implementing this second type of hydrant system in fire safety management would significantly improve the emergency response efficiency of elderly welfare facilities, which are typically staffed by female caregivers, and would reduce the time needed to extinguish a fire in its early stages, enhancing the second layer of protection.

All institutions equipped with indoor fire hydrant systems used Type I systems, while no institutions in the study sample were equipped with Type II systems. This zero count reflects the current installation status observed during on-site inspections rather than missing or unreported data. Although Type II systems are not mandated under existing regulations, they are designed to operate with lower recoil force and reduced water discharge, making them more suitable for single-person operation under constrained nighttime staffing conditions. The absence of Type II systems, therefore, highlights a gap between current equipment adoption and operational suitability in elderly welfare institutions.

It is worth noting that none of the surveyed institutions had installed Type II indoor fire hydrant systems. This is not a sampling bias, but rather reflects that Taiwan’s fire safety regulations at the time did not mandate the installation of Type II systems in elderly care facilities. Therefore, despite the many operational advantages of Type II systems in situations of staff shortage at night, existing institutions still primarily opted for Type I systems.

Although no institutions in the present sample were equipped with Type II indoor fire hydrant systems, this finding highlights a regulatory–operational gap rather than an equipment deficiency. Given the reduced operating force and lower water discharge requirements of Type II systems, their potential suitability for elderly welfare institutions—particularly under reduced nighttime staffing—warrants further policy consideration. Rather than mandating immediate replacement, a risk-informed and phased implementation strategy may be more feasible, prioritizing facilities with multi-story layouts, limited nighttime staffing, or higher resident dependency.

The government should provide subsidies to institutions equipped with the first type of indoor fire hydrant system to upgrade to the second type. The recoil force of the second system is 2.3 times smaller than that of the first, making it more manageable for a single operator, particularly for female staff, thus strengthening the second layer of fire protection.

This reduction places the operating force within the range manageable by a single caregiver, even under nighttime staffing conditions, whereas the recoil force of Type I systems typically requires two operators for stable handling.

To address the issue of incorrect detector installation and fan management in fire safety engineering, this study recommends installing detectors at a distance of at least three times the fan’s diameter from any ceiling fan [20]. The study also found that while the hot air may be displaced by the fan, it still tends to accumulate under the ceiling at certain points. Therefore, installing additional smoke detectors is an effective solution to this problem.

In terms of fan facility management, institutions that use ceiling fans should ensure that detectors are installed at least three times the fan’s diameter away from the fan and include this requirement in the fan installation regulations. If ventilation systems are replaced with other types of equipment, the functionality of the detectors will not be affected. This is an issue that must be addressed by facility management to ensure the second layer of fire protection functions properly.

To quantitatively support the operational feasibility discussion above, the recoil force of the two indoor fire hydrant types was calculated as follows.

F = 1.5 × D² × P

(1)

This calculation follows a standard fire engineering formulation for estimating fire hose recoil force under steady discharge conditions. D is the nozzle diameter (cm), and P is the discharge pressure (kg/cm²).

Recoil force for the first type of fire hydrant:

F = 1.5 × 3.8² × 1.7 = 36.8 kg

(2)

Recoil force for the second type of fire hydrant:

1.5 × 2.5² ×1.7 = 15.9 kg

(3)

For 47 institutions (73%), there is no legal requirement to install indoor fire hydrant systems. According to the China Academy of Building Research Institute of Building Fire Protection [22], for facilities not required to install these systems, it may be worthwhile to explore the possibility of implementing fire hose reels connected directly to the domestic water supply, as is done in China. This would provide a practical solution for small private institutions without indoor fire hydrant systems. However, Taiwan currently lacks standards for the installation of such fire safety equipment, and further discussion on implementing these systems is recommended. This operational constraint weakens Layer 2 (Rapid Detection, Control, and Extinguishment of Fires), particularly under reduced nighttime staffing conditions. Notably, none of the surveyed institutions had installed Type II indoor fire hydrant systems, indicating a gap between operational suitability and current implementation practices.

When interpreted in conjunction with nighttime staffing patterns, the absence of Type II indoor fire hydrant systems reveals a compounded operational risk. In 70% of the surveyed institutions, nighttime staffing levels were less than half of daytime levels, and emergency response during nocturnal fire events often relies on single caregivers. Under such conditions, the higher recoil force and water discharge requirements of Type I systems may exceed the practical operating capacity of a single staff member, particularly in facilities staffed predominantly by female caregivers. This mismatch between equipment design and operational context weakens the effectiveness of Layer 2 (Rapid Detection, Control, and Extinguishment of Fires) during the critical early stage of fire development.

Under such constrained nighttime staffing conditions, manual fire suppression systems that can be effectively operated by a single caregiver become particularly critical. Therefore, the operational characteristics of indoor fire hydrant systems should be evaluated not only for regulatory compliance but also for compatibility with realistic staffing scenarios in elderly welfare institutions.

The absence of significant differences between private and corporate institutions indicates that ownership structure alone does not guarantee higher fire safety performance. This finding underscores the need for system-wide regulatory oversight and risk-informed governance measures rather than relying on organizational form as a proxy for safety.

Although Type II indoor fire hydrant systems offer clear operational advantages in terms of reduced recoil force and lower water discharge, none of the surveyed institutions had adopted this system. This absence reflects regulatory inertia and the lack of targeted retrofit incentives, rather than technical infeasibility. In facilities characterized by reduced nighttime staffing and predominantly female caregivers, reliance on Type I systems may delay manual fire suppression during the critical early stage of fire development. Direct field comparison of suppression time and water consumption was not feasible due to the absence of Type II systems in existing facilities; however, the substantial reduction in operating force provides a robust proxy for improved deployability and earlier intervention, which are decisive factors in small-compartment fire control. From a defense-in-depth perspective, the limited operability of Type I systems under realistic staffing conditions weakens Layer 2 by constraining timely manual suppression, whereas Type II systems are more consistent with the functional requirements of early-stage fire control in elderly welfare institutions.

3.2.3. Current Status of Fire and Smoke Compartmentalization in Institutions

This subsection analyzes the existing fire and smoke compartmentation conditions in elderly welfare institutions, focusing on architectural features that influence smoke propagation and fire containment in facilities housing mobility-impaired residents.

Field inspections revealed that 55 institutions (86%) were legally exempt from requirements for full fire and smoke compartmentation under the pre-2021 regulatory framework. In addition, 55 institutions (86%) were not required to install smoke ventilation systems, with 51 of these facilities (80%) classified as private institutions. At the time of inspection, no dedicated public subsidy programs were available to support the installation of smoke ventilation systems, smoke compartmentation measures, or fire-rated doors and windows in existing facilities.

Among the surveyed institutions, only two private facilities (3%) were equipped with smoke ventilation systems. In the absence of such systems, vertical and horizontal smoke movement is primarily governed by architectural features such as interior stairwells and interconnected ceiling voids, increasing the likelihood of rapid smoke spread during early fire stages.

As shown in

Table 4. Statistics on Fire Compartmentalization and Smoke Resistance in Institutional Bedrooms.

	Partition Walls Extend to Floor Slab	Bedroom Doors Are Fire-Rated	Bedroom Doors Are Smoke-Resistant	Bedroom Doors Have Glass Windows
Yes	9 institutions (14%)	22 institutions (34%)	36 institutions (56%)	46 institutions (72%)
No	55 institutions (86%)	42 institutions (66%)	28 institutions (44%)	18 institutions (26%)

, 28 institutions (44%) were equipped with bedroom doors that could not effectively prevent smoke infiltration. Furthermore, 46 institutions (72%) had bedroom doors containing glass windows, and 42 institutions (66%) did not install fire-rated doors. In addition, 55 institutions (86%) had bedroom partition walls that did not extend to the floor slab, leaving ceiling voids fully interconnected across adjacent rooms.

Field observations indicate that bedroom doors in elderly welfare institutions are commonly designed to prioritize ventilation and visual monitoring of residents rather than fire and smoke containment (Figure 9). While such designs support caregiving needs under normal conditions, they provide limited resistance to smoke spread during fire incidents.

Only two institutions (3%) satisfied all evaluated fire and smoke compartmentation criteria, including partition walls extending to the ceiling or slab, installation of fire-rated doors, smoke-resistant door assemblies, and the absence of glass windows in bedroom doors. Consequently, 62 institutions (97%) met existing legal standards without achieving effective room-level fire and smoke containment.

In facilities where partition walls do not extend to the floor slab, the ceiling void forms a continuous horizontal pathway filled with electrical wiring and mechanical ducts (Figure 10). In the event of a fire, smoke and hot gases can rapidly propagate through these interconnected spaces, bypassing room boundaries and compromising containment at the compartment level.

Although the 2021 revision of the Elderly Welfare Institution Establishment Standards requires new facilities to connect partition walls to the ceiling or slab, the subsidy program supporting such retrofits in pre-existing facilities remains voluntary. As a result, a substantial proportion of grandfathered institutions retain architectural configurations that permit uncontrolled smoke spread despite formal regulatory compliance.

Field inspections showed that only two institutions (3%) met all examined criteria for fire and smoke compartmentation, including bedroom partition walls extending to the ceiling, the installation of fire-rated doors, smoke-resistant room doors, and the absence of glass windows in bedroom doors. This indicates that 97% meet legal standards without achieving effective fire and smoke compartmentalization. In the event of a fire in one bedroom, smoke can quickly spread through the corridors to other rooms on the same floor or through the ceiling space to adjacent rooms, significantly hindering the third layer of fire protection.

In 55 institutions (86%), the partition walls between rooms do not extend all the way to the ceiling, leaving the space above the ceilings fully interconnected. While this design is legally permissible in existing elderly care facilities, it poses significant risks during a fire. As shown in this study, the ceiling space is continuous between rooms (Figure 10) and is often filled with various electrical wires and pipes. In the event of a fire, smoke and flames can easily spread through this connected space, making it impossible to contain the fire within a single room. This compromises the effectiveness of the third layer of fire protection. The lack of effective fire and smoke compartmentation fundamentally compromises Layer 3 (Containing Fire Spread and Reducing Fire Damage), allowing rapid horizontal and vertical smoke spread.

The health authorities provide subsidies for connecting partition walls to the floor slab, while Article 4 of the Elderly Welfare Institution Establishment Standards mandates that, for institutions established before the 5 February 2021 revision, the partition walls between rooms must be connected to the ceiling. This creates a regulatory discrepancy. In 55 institutions (86%), the partition walls in bedrooms do not extend to the floor slab. Prior to the 5 February 2021 revision of the Elderly Welfare Institution Establishment Standards, this design was “forcibly legalized.” While the regulations now require that partition walls between rooms must connect to the ceiling, the subsidy program to encourage connecting the walls to the floor slab remains voluntary and not mandatory. This voluntary nature may discourage some institutions from applying for the subsidies, potentially leading to situations like the one shown in Figure 11.

The fire protection defense-in-depth theory is crucial in formulating fire protection strategies for elderly welfare institutions, especially considering immobile residents as “vulnerable targets” who must be safeguarded. In addition to using fire compartments to block the spread of flames, it is equally important to prevent the spread of smoke. Each bedroom should be designed as an “independent smoke-proof and fire-resistant room” to fully implement the third layer of protection. To fully realize Layer 3 protection, each bedroom should function as an independent fire and smoke compartment, supported by smoke-resistant door assemblies and feasible natural smoke ventilation provisions (

Table 5. Smoke-Proof Bedroom Design Concept.

	Smoke-Proof Bedroom	Design Concept
Fire in the Bedroom	Each bedroom is separated into independent fire and smoke compartments, referred to as “smoke-proof bedrooms.”	In the event of a fire, even if one or two bedrooms catch fire and produce smoke, the fire and smoke will be contained within the affected bedroom and will not spread to other rooms. If the fire in the affected bedroom cannot be controlled or extinguished, the residents in that room should be quickly evacuated, and the fire door of the burning room should be closed. This will confine the fire and smoke within the “fire and smoke-proof bedroom,” preventing the spread to other rooms.
Fire outside the Bedroom		Residents can shelter in place within the independent “fire and smoke-proof bedroom,” where they will be protected from fire and smoke. The fire and smoke will not spread into the bedroom.

).

• Ceilings
  • Walls covering more than half of the interior height should be constructed from non-combustible materials.
  • The use of non-combustible materials for ceilings is essential; the thicker the material, the longer it will take for fire to burn through.
  • The ceiling material should have a unit weight of no less than 4.5 kg/cm² to ensure structural stability. Thicker materials delay burn-through, providing greater protection.
  • The amount of smoke leakage is related to the smoothness between the frame and the edges of the ceiling material. It is recommended that connection points be filled with non-combustible materials to prevent high-temperature smoke from spreading above the ceiling, thus confining the fire within the floor-to-ceiling range of the room where the fire originated.
  • Regular inspections should be carried out to ensure that ceilings are free from damage or missing sections, ensuring the third layer of protection remains effective.
  • For institutions with central air conditioning, systems should be shut down during a fire. Additionally, fire and smoke dampers should be installed at air intake and return vents to prevent smoke from entering the air ducts. This will help stop flames from spreading into the ceiling space and through interconnected areas, enhancing the third layer of protection.
  • Openings below the ceiling along both sides of hallways (above half of the room height), such as bedroom doors or windows, should be fitted with fire-resistant curtains, shutters, or converted to smoke-proof fire-rated glass windows or fire-rated doors.
  • As shown in Figure 12, ventilation openings should either be sealed or fitted with fire-resistant curtains or replaced with fire-rated glass windows.

2.

Bedroom Doors

• Smoke-proof fire-rated doors: These doors should remain closed at all times and include a glass window to allow observation of bedridden residents. For areas with frequent traffic, normally open fire doors that automatically close during a fire and provide signal feedback are recommended, reducing the need for manual door closure and providing more time for evacuation.
• Fire-rated doors or shutters: Bedroom doors can be equipped with fire-rated doors or fire shutters. Fire shutters should have an automatic activation feature that operates by gravity, automatically closing during a fire and providing signal feedback in compliance with national standards.

3.

Windows in Bedrooms

• The standard for bedroom lighting is clearly outlined in the Elderly Welfare Institution Establishment Standards.
• The effective ventilation area must be no less than 30% of the window area, with windows directly connected to outside air.
• Each bedroom should have at least one window, with a window-to-floor area ratio (A_c: A_d) of at least 1:8, where A_c is the window opening area and A_d is the floor area.
• Openings below the ceiling on both sides of hallways (above half the room height), such as bedroom windows, should be equipped with fire-resistant curtains, shutters, or converted to smoke-proof fire-rated glass windows.
• Windows facing indoor areas should be equipped with glass fire windows or fire curtains for additional protection.

4.

Natural Smoke Ventilation Openings in Bedrooms

• Natural smoke ventilation window area: Bedrooms with external openings (with an effective ventilation area of more than 2% of the room’s floor area) can utilize these openings as natural smoke ventilation windows.
• Location of natural smoke ventilation windows: In areas where the ceiling height is less than 3 m, natural smoke ventilation windows should be installed at a height of at least half the room’s total height.
• Opening mechanisms for natural smoke ventilation windows:

  ⮚

  Manual switch for operating the smoke ventilation window.

  ⮚

  Automatic switch linked to detectors, which should operate within 60 s.

  ⮚

  Remote-operated switch for opening the window.

  ⮚

  Control linked to a temperature-release mechanism, where the release temperature should be at least 30 °C above ambient temperature but less than 100 °C.

• Considerations for high-rise buildings: As wind pressure increases with building height, smoke ventilation windows may be affected by external wind forces. For high-rise buildings, the critical point typically falls between the 7th and 10th floors, and the location of natural smoke ventilation windows should be carefully selected [23].

Following the revision of the Elderly Welfare Institution Establishment Standards in February 2021, newly established facilities are required to comply with enhanced building and fire compartmentation requirements [24]. In contrast, facilities approved prior to this revision are exempt from the retroactive application of certain architectural provisions, particularly those related to full fire and smoke compartmentation. This exemption framework reflects an attempt to address the financial and practical constraints associated with upgrading existing institutions while allowing for incremental improvements in fire safety.

Our inspection results indicate that a substantial proportion of pre-2021 facilities remain without effective fire and smoke compartmentation. Specifically, 86% of institutions had bedroom partition walls that did not extend to the floor slab, and only 3% achieved full compliance with fire and smoke compartmentation requirements.

These conditions, while legally permitted under the exemption policy, constitute structural risk indicators associated with the potential for rapid smoke spread during fire events. Although post-2021 fire incident trends were beyond the scope of this study, the concentration of structural vulnerabilities observed in grandfathered facilities suggests that the exemption policy may warrant periodic re-evaluation from a fire risk governance perspective.

3.2.4. Characteristics of Staff and Residents in Institutions

This subsection examines staff composition, language capacity, and resident mobility characteristics that influence emergency response conditions in elderly welfare institutions.

Among the surveyed institutions, 55 facilities (86%) employed foreign caregivers to support residents with limited mobility. National regulations require that the number of local caregivers must not be lower than the number of foreign caregivers, with a maximum allowable ratio of 1:1. Across the study sample, the average local-to-foreign caregiver ratio was 2.2:1, with private institutions exhibiting a higher proportion of foreign staff (

Table 6. Ratio of Local to Foreign Staff in Institutions.

Staff Ratio	Private Institutions	Corporate Institutions	Average	Description
Local/Foreign Ratio	2:1	2.8:1	2.2:1	Indicates a higher proportion of foreign staff in private elderly care institutions

).

Language capacity was evaluated through the presence of multilingual signage and operating instructions for fire safety equipment. As shown in

Table 7. Statistics on whether fire safety equipment labels and operating instructions have foreign-language versions.

Signs	Institutions Type
	Private Institutions	Corporate Institutions	Total (%)
Foreign Language Signs	31 institutions (49%)	4 institutions (6%)	35 institutions (55%)
No Foreign Language Signs	22 institutions (34%)	7 institutions (11%)	29 institutions (45%)

, 29 institutions (45%) did not provide foreign-language labels or instructions. The absence of multilingual guidance may hinder effective communication during routine fire safety training and emergency response situations involving foreign caregivers.

Resident mobility characteristics were assessed for all 2448 residents housed in the surveyed institutions (

Table 8. Mobility characteristics of residents in surveyed elderly welfare institutions (N = 2448).

Mobility Category	Number of Residents	Percentage (%)
Independent walkers	507	18%
Wheelchair users	1890	66%
Bedridden/respirator users	451	16%
Total with limited mobility	2341	82%
Total residents	2448	100%

). Of these residents, 507 (18%) were independent walkers, 1890 (66%) required wheelchairs, and 451 (16%) were bedridden or dependent on respiratory support. Overall, 2341 residents (82%) had limited mobility and required caregiver assistance during evacuation.

These findings indicate a high level of resident dependency on staff-mediated assistance during fire emergencies. Prior studies have shown that elderly occupants face compounded evacuation barriers due to reduced mobility, sensory impairments, and cognitive decline, resulting in limited autonomous evacuation capacity and increased reliance on caregiver decision-making and intervention [25].

The employment of foreign workers presents challenges related to language barriers, including difficulties in listening and reading comprehension. Effective communication is essential not only for daily caregiving tasks but also for routine fire safety training and emergency response situations. This study also examined whether fire safety equipment labels and operating instructions in each institution were available in foreign languages. As shown in Table 7, 29 institutions (45%) did not provide such labels. This issue impacts the effectiveness of the second layer of protection.

Table 8 presents the mobility characteristics of the residents in the surveyed institutions. The total number of residents is 2448. Among them, 507 residents (18%) are fully mobile, 1890 residents (66%) require a wheelchair for mobility, and 451 residents (16%) are bedridden. The data shows that 2341 residents (82%) have limited mobility. In this study, the presence of bilingual or foreign-language signage and operating instructions was treated as an operational proxy for task-level communication accessibility during fire emergencies. Prior evacuation and emergency-response studies indicate that language barriers increase task completion errors, delay response initiation, and reduce procedural compliance under stress, particularly among foreign caregivers unfamiliar with local emergency terminology [11,25,26]. Simulation- and drill-based research has further shown that bilingual instructions improve task success rates and reduce hesitation time during alarm response. In the present survey, 29 institutions (45%) lacked foreign-language labels or instructions for fire safety equipment, suggesting a high likelihood of delayed or incorrect equipment operation during emergencies involving foreign caregivers. From a risk-governance perspective, multilingual signage represents a low-cost, high-impact intervention that directly targets task-level response reliability. Its effectiveness can be evaluated through future drills by comparing response initiation time and task completion accuracy before and after signage implementation. Within the defense-in-depth framework, language barriers primarily undermine Layer 2 by delaying alarm recognition and manual fire-response actions, while multilingual instructions enhance the reliability of human-dependent safety functions.

As shown in Table 8, 82% of elderly residents require caregiver assistance to evacuate, highlighting the high dependence on staff during emergencies [25].

This finding is consistent with prior studies indicating that older adults face compounded barriers during fire emergencies, including mobility limitations, sensory impairments, cognitive decline, and a high dependence on staff-mediated decision-making [27], which collectively constrain independent evacuation capacity [5]. Elderly residents in welfare institutions benefit less from evacuation and alarm systems [11], placing greater demands on staff time and resources during emergencies. Based on Kose [28], in the event of a fire, if fire safety systems fail or there is insufficient time for evacuation, the consequences could be catastrophic. These residents may wait for staff instructions when alarms sound due to their limited cognitive and mobility abilities and unfamiliarity with emergency response procedures. As a result, staff play a critical role in executing fire response strategies [26]. Empirical fire studies in residential care facilities further indicate that occupant decision-making during fire emergencies is largely staff-mediated, with evacuation initiation, route choice, and protective actions predominantly shaped by staff intervention rather than autonomous resident behavior [29].

During a fire, every staff member must perform their duties and attempt to save as many residents as possible, even without direct instruction [30]. Institutions should have clear emergency fire response plans and ensure adequate, well-trained staff are available [29,31]. This is especially critical during nighttime emergencies, where staff response can significantly impact the scale of the disaster. Prior evacuation research has shown that reductions in available staff not only delay evacuation initiation but also alter decision-making quality and task prioritization, thereby amplifying evacuation failure risks in residential care fires, particularly under constrained resource-allocation conditions [32].

3.2.5. Fire Emergency Response Assessment

This subsection evaluates nighttime staffing levels and emergency response capacity in elderly welfare institutions, with particular attention to conditions affecting early fire control and evacuation feasibility.

Inspection data indicate that 45 institutions (70%) operated with nighttime staffing levels that were less than half of daytime staffing levels (

Table 9. Statistics on Nighttime Staffing in Institutions.

Institution Type	Private	Corporate	Total	Description
Number (%)	35 (54%)	10 (16%)	45 (70%)	Night/Day Ratio (<0.5). Number of night shift staff is less than half of the day shift staff.

). This reduction in available personnel substantially constrains emergency response capacity during nocturnal fire events, when immediate staff intervention is often required.

The impact of reduced nighttime staffing is amplified by the high proportion of residents requiring assisted evacuation. With 82% of residents dependent on caregiver support for mobility, fewer staff members are available to perform simultaneous tasks such as fire suppression, alarm confirmation, resident evacuation, and coordination with external responders.

Cross-national comparisons further contextualize these findings. Taiwan permits a nighttime caregiver-to-resident ratio of approximately 1:15, compared with China’s mandatory 1:3 ratio maintained both day and night, and Japan’s requirement for higher nighttime staffing than daytime operations. In the United States, minimum staffing ratios are typically maintained at no less than 1:15 regardless of time period. These differences indicate that Taiwan’s regulatory framework places greater reliance on staff performance under constrained nighttime conditions.

In addition to staffing levels, interior environmental conditions were observed to influence fire risk. Hanging flammable decorations were identified in 13 institutions (20%) (

Table 10. Statistics on Hanging Flammable Decorations in Institutions.

	Private	Corporate	Total (%)
Flammable Materials Hanging in Rooms	11 institutions (21%)	2 institutions (18%)	13 institutions (20%)
Non-Flammable Materials Hanging in Rooms	42 institutions (79%)	9 institutions (82%)	51 institutions (80%)

), despite regulatory requirements mandating the use of flame-retardant materials for interior finishes. Furthermore, electrical wiring systems in 86% of institutions had been in use for more than 20 years (

Table 11. Statistics on the Construction Year of Electrical Wiring Inside Buildings.

Year	1971–1980	1981–1990	1991–2000	2001–2010	2011
Number of institutions (%)	7 (11%)	10 (15%)	19 (30%)	19 (30%)	9 (14%)
Years in Use	50+	40+	30+	20+	10+

), increasing the likelihood of electrical overload and ignition, particularly in facilities with insufficient power outlets and frequent use of extension cords (Figure 13).

Collectively, these findings indicate that nighttime emergency response capacity in elderly welfare institutions is constrained by reduced staffing, high resident dependency, and legacy building conditions. These structural and operational characteristics underscore the importance of addressing emergency preparedness, staffing adequacy, and ignition risk factors in facilities housing vulnerable elderly populations.

This study shows that Taiwan’s regulations for nighttime caregiving staff are relatively lenient. Compared to daytime, the caregiver-to-resident ratio at night is more than three times higher. The ratio during the day is 1:5, while at night it is 1:15. In contrast, China mandates a 1:3 ratio both day and night, and the United States requires no less than a 1:15 ratio at all times. In Japan, nighttime staffing is 1.5 times that of daytime, with additional requirements that for every three additional residents, at least one more staff member must be assigned.

From a regulatory perspective, Taiwan permits a nighttime caregiver-to-resident ratio of 1:15, compared with China’s mandatory 1:3 staffing level maintained both day and night, and the United States’ minimum standard of no less than 1:15. Importantly, Taiwan’s staffing allowance operates in the context of many grandfathered facilities with multi-story configurations, which further increases evacuation difficulty during nighttime fire events. This cross-national contrast underscores the urgency of strengthening nighttime response capacity in Taiwan’s elderly welfare institutions.

As a result, each caregiver is responsible for a larger number of residents during nighttime periods. This staffing condition poses substantial challenges for effective fire response when personnel availability is limited, thereby necessitating alternative management measures to enhance emergency preparedness. Empirical analyses of residential care facility fires further indicate that reduced nighttime staffing is associated with delayed evacuation initiation and greater reliance on staff-mediated intervention, conditions that have been linked to higher mortality among elderly occupants during fire incidents [32].

These findings indicate that current nighttime staffing patterns substantially constrain emergency response capacity in elderly welfare institutions, particularly under conditions of high resident dependency, with a caregiver-to-resident ratio of 1:5. In multi-story facilities, staffing levels should be even higher than in single-story facilities to meet the demands of evacuating elderly residents during emergencies, thereby improving evacuation efficiency and strengthening the second layer of fire protection.

The interior decorations of elderly care institutions are often required to create a “warm and welcoming” atmosphere. Upon inspection, 13 institutions (20%) were found to have hanging flammable materials or decorations, as shown in Table 9. These items can easily contribute to the spread and intensification of a fire. Government regulations mandate that carpets, curtains, and similar items in elderly welfare institutions must be made from flame-retardant materials, which is a key aspect of the first layer of fire protection.

As shown in Table 10, 86% of electrical wiring systems in the institutions were installed over 20 years ago. To enhance the first layer of fire protection, the government provides subsidies for upgrading outdated electrical systems.

In older buildings, the insufficient number of electrical outlets often leads to the frequent use of extension cords for appliances such as fans, as shown in Figure 13. This increases the risk of fire due to electrical overloading [33,34]. According to Martinho et al. [35], in Japan, regulations require the installation of leakage fire alarms, and in China, elderly care facilities are required to install electrical fire monitoring systems for non-fire-related electrical loads. This relates to the first layer of fire protection. These conditions directly undermine Layer 1 (Preventing Fires) of the defense-in-depth framework by increasing the likelihood of fire ignition at the source.

The Elderly Welfare Institution Establishment Standards only specify that long-term care facilities must have generators or other power generation equipment. However, there are no regulations specifying which systems the generator should supply, such as life support systems or connections to emergency fire safety generators. In the event of a fire and power outage, life support systems may fail, posing a risk to residents, which directly affects the third layer of fire protection.

• The standards for long-term care facilities should specify that generators must supply power to life support systems and essential equipment.
• Emergency power capacity regulations should ensure that the generator capacity in elderly welfare institutions can maintain the operation of life support systems and equipment in case the facility’s primary generator fails.
• Regular checks and testing mechanisms for emergency generators should be in place.
• A fuel replenishment mechanism should be established for emergency generators to ensure continuous operation during emergencies unless an evacuation occurs.

To clarify the regulatory context, a concise international comparison of key fire safety requirements for elderly care facilities is summarized in

Table 12. International comparison of key fire safety regulatory requirements for elderly welfare institutions.

Item	Taiwan	China	Japan	United States
Maximum building height	≤10 floors (grandfathered before 2021)	Typically low-rise (≈3–5 floors)	Generally low-rise	Varies by state
Fire compartment	Partial (exemptions for existing facilities)	Mandatory	Mandatory	Mandatory
requirement
Smoke control provisions	Limited for existing facilities	Required	Required	Required
Night staffing ratio	1:15	1:3	Higher than daytime	≥1:15
Detector/	Use-based prescription	Code-based	Performance-based	Performance-based
system approach

Note: The comparison focuses on regulatory orientation rather than exhaustive legal detail. Differences reflect policy priorities regarding evacuation feasibility, staffing dependency, and smoke control for mobility-impaired occupants.

. These cross-national differences highlight how Taiwan’s grandfathering and staffing policies place greater reliance on human response, underscoring the need for layered compensatory measures.

Within the defense-in-depth framework, inadequate nighttime staffing weakens Layer 2 (Rapid Detection, Control, and Extinguishment of Fires) and Layer 3 (Containing Fire Spread and Reducing Fire Damage), thereby increasing the probability of catastrophic outcomes during night hours.

3.2.6. Limitations

This study has several limitations that should be acknowledged. First, the empirical data were collected from all licensed elderly welfare institutions located in Tainan City, which may limit the generalizability of the findings to regions with different regulatory enforcement practices, building characteristics, or institutional scales. Second, the study relied on cross-sectional on-site inspections and checklist-based assessments; therefore, outcome-based performance indicators—such as evacuation time, smoke containment effectiveness, or real-time staff response performance—were not directly measured. Third, although inferential statistical analyses were conducted for selected variables, the study was not designed to establish causal relationships between regulatory requirements and fire outcomes. Fourth, while the defense-in-depth framework provides a useful structure for organizing fire safety strategies, its application in this study is governance-oriented and conceptual, rather than a dynamic fire simulation or probabilistic reliability analysis.

In addition, because the field investigations were conducted between 2019 and 2020—prior to the regulatory revision implemented in February 2021—a direct empirical comparison between pre- and post-amendment facilities was not feasible. Nevertheless, the observed deficiencies provide an important baseline for evaluating the potential impact of subsequent regulatory changes. Future research incorporating multi-city datasets, performance-based simulations, and longitudinal fire incident analyses would help strengthen the evidence base for sustainability-oriented fire risk governance in long-term care facilities.

4. Conclusions and Recommendations

This study demonstrates that fire safety in elderly welfare institutions cannot be adequately addressed through technical compliance alone, but must be understood and managed as a problem of risk governance within long-term care systems.

Based on a census of 64 licensed elderly welfare institutions in Tainan City, the findings show that while formal regulatory compliance is generally achieved, substantial functional vulnerabilities persist due to legacy building conditions, high resident dependency, and staff-mediated emergency response under constrained nighttime staffing. These conditions reveal a governance gap in which prescriptive regulations do not fully translate into effective fire and smoke risk control for mobility-impaired residents.

By adopting defense-in-depth as a governance-oriented analytical framework, this study illustrates how fire risk in elderly welfare institutions is distributed across interdependent layers of prevention, early detection and suppression, and fire and smoke containment. Rather than treating these layers as isolated technical measures, the findings highlight their role as coordinated governance mechanisms that compensate for structural exemptions, operational constraints, and human dependency in existing facilities.

From a sustainability perspective, strengthening fire safety through risk governance contributes to social sustainability by prioritizing the protection of vulnerable older adults, enhancing institutional resilience, and safeguarding the continuity of long-term care services under rapid population aging. Accordingly, this study proposes a phased, risk-informed governance strategy that integrates low-cost managerial interventions, targeted equipment and usability upgrades, and long-term structural retrofits supported by sustained public policy instruments.

Future research should further operationalize sustainability-oriented fire risk governance by incorporating outcome-based performance indicators, longitudinal compliance monitoring, and cross-regional comparisons, thereby supporting continuous improvement in the governance of high-consequence risks in long-term care systems.

4.1. First Layer: Preventing Fires

Within Layer 1, fire safety interventions are primarily concerned with reducing ignition probability and constraining early fire growth at the source. In elderly welfare institutions, this layer is implemented through material selection and routine facility management practices that directly influence fire initiation mechanisms and initial heat release characteristics. Measures at this level operate continuously and independently of system activation or staff intervention, thereby forming the foundational barrier against fire development.

Typical first-layer measures include the use of flame-retardant or non-combustible interior finishes, systematic electrical system management, and the control of combustible decorative elements. By lowering the likelihood that a fire will develop beyond its incipient stage, these measures reduce the probability that subsequent protective layers—such as detection, suppression, and compartmentation—will be challenged.

From an implementation perspective, first-layer interventions differ from higher-layer measures in that they generally involve limited structural modification and rely largely on routine maintenance, material replacement cycles, and day-to-day management practices. Consequently, their adoption is often shaped by institutional resource constraints, renovation schedules, and operational priorities rather than by dedicated retrofit programs alone. While some material-related improvements can be introduced rapidly through routine maintenance, others may be incorporated incrementally as part of longer-term facility improvement planning, reflecting the phased nature of safety enhancement in existing institutions.

Among material-related factors, ceiling construction plays a critical role in limiting early fire development and smoke generation. During the growth stage of compartment fires, ceiling and upper-wall surfaces are directly exposed to the hottest smoke layers. Non-combustible ceiling systems with sufficient thickness and structural integrity can delay burn-through, reduce downward flame spread, and limit the accumulation of combustible gases above the compartment. These effects contribute to confining the fire to the room of origin and extending the available time for detection and response.

Based on field observations and relevant standards, the following design and maintenance principles are presented as reference benchmarks for strengthening first-layer fire prevention performance:

Interior wall finishes covering more than half of the room height should be constructed from non-combustible materials.

• Ceilings should preferentially use non-combustible materials, with increased thickness providing greater resistance to early fire penetration.
• Ceiling materials with higher unit weight and structural stability (e.g., ≥4.5 kg/cm²) are associated with improved fire resistance performance [36].
• Junctions between ceiling panels and framing elements should be sealed with non-combustible materials to minimize smoke leakage into ceiling voids, thereby limiting fire and smoke spread beyond the compartment of origin.

4.2. Second Layer: Rapid Detection, Control, and Extinguishment of Fires

Within Layer 2, fire safety performance is governed by the timely detection of fire and the capacity for effective early suppression under realistic operating conditions. In elderly welfare institutions, this layer plays a decisive role because early fire response is predominantly staff-mediated rather than driven by autonomous occupant evacuation. The functional reliability of detection and initial suppression, therefore, directly determines the available time window for evacuation, smoke control, and external firefighting intervention.

The findings presented in the Results section indicate that the effectiveness of Layer 2 is frequently constrained by a mismatch between equipment design, installation practices, and actual operational conditions. In particular, improper detector placement and the use of suppression equipment that exceeds the practical operating capacity of a single caregiver can delay alarm activation and suppressive action during the critical early stage of fire development. Under reduced nighttime staffing—common in elderly welfare institutions—such delays can rapidly escalate smoke exposure risk before organized evacuation becomes feasible.

From a system-performance perspective, strengthening Layer 2 requires shifting emphasis from nominal regulatory compliance toward functional operability under constrained staffing scenarios. Fire safety equipment must not only meet technical standards but also remain usable, reliable, and effective when operated by a limited number of caregivers, often working alone at night. Enhancing the human–equipment fit of active fire protection systems is therefore a central component of second-layer resilience in care-based institutional environments.

From a governance and implementation standpoint, second-layer improvements are well-suited to a combination of regulatory guidance and targeted incentive mechanisms. Rather than mandating uniform equipment replacement across all facilities, a risk-informed prioritization strategy can maximize safety benefits by focusing on institutions with multi-story layouts, limited nighttime staffing, or high levels of resident dependency. Through such targeted interventions, Layer 2 functions as a critical buffer between fire ignition and large-scale evacuation failure, reinforcing overall life-safety performance without imposing unrealistic compliance burdens on existing institutions.

4.2.1. Fire Safety Equipment

Incorrectly installed detectors were found in 44 institutions (69%), impacting their effectiveness. Improvements in fire safety engineering, management, and equipment maintenance are necessary to strengthen the second layer of protection.

• In terms of fire safety engineering, detectors should be installed at a distance of at least three times the diameter of any ceiling fan. The study also found that, although hot air may be dispersed by ceiling fans, it tends to accumulate beneath the ceiling. Therefore, installing additional detectors is an effective solution.
• Fire safety management should ensure that equipment is inspected monthly, and any improperly installed detectors should be corrected immediately.
• Fire safety inspections should be regularly conducted, and professional personnel should recommend improvements to facility management if any installation issues are found.
• In managing fan facilities, ceiling fans should be installed at least three times the fan’s diameter away from detectors, and this should be clearly stated in fan installation regulations. If the ventilation system is replaced with a different type, the detectors’ functionality should not be compromised.

From an implementation perspective, upgrading indoor fire hydrant systems represents a higher-cost structural measure that may not be immediately feasible for all institutions. Therefore, this study suggests that Type II indoor fire hydrant systems be prioritized through targeted subsidy programs rather than universal mandates. Such programs could focus on facilities with reduced nighttime staffing, multi-story buildings, or a high proportion of mobility-impaired residents, thereby maximizing risk reduction per unit of public investment.

In facilities with reduced nighttime staffing, improving the human–equipment fit of manual fire suppression systems represents a critical and often overlooked component of Layer 2 resilience.

4.2.2. Fire Response

Field data indicate that in 45 institutions (70%), nighttime staffing levels are less than half of daytime levels, substantially constraining emergency response capacity during nocturnal fire events. This staffing pattern is particularly critical in elderly welfare institutions, where a large majority of residents require assisted evacuation and early fire response is predominantly staff-mediated. Under such conditions, reduced nighttime staffing directly weakens the functional performance of the second layer of defense-in-depth by delaying initial fire control actions and evacuation initiation.

From a risk-governance perspective, strengthening nighttime response capacity should be regarded as a priority intervention for improving Layer 2 effectiveness. Ideally, maintaining staffing levels at night comparable to daytime operations—corresponding to a caregiver-to-resident ratio of approximately 1:5—would provide the highest level of safety assurance. In multi-story facilities, higher nighttime staffing levels are particularly important due to the increased time and effort required for vertical evacuation of mobility-impaired residents.

Recognizing the operational and financial constraints faced by many institutions, especially small private facilities, a phased and risk-informed implementation approach is recommended. Priority measures may include gradually increasing nighttime staffing in high-risk facilities (e.g., multi-story buildings or institutions with high resident dependency), integrating staffing requirements into subsidy eligibility criteria, and coupling staffing enhancements with improvements in equipment operability and evacuation planning. Such an approach balances feasibility with safety objectives while substantially strengthening the reliability of second-layer fire response functions during the most vulnerable time periods.

4.3. Third Layer: Containing Fire Spread and Reducing Fire Damage

Within Layer 3, fire safety is achieved by limiting the spread of fire and smoke through effective compartmentation, thereby protecting mobility-impaired residents when evacuation is delayed or infeasible. In elderly welfare institutions, where survivability is strongly influenced by smoke exposure rather than direct flame contact, the ability to confine smoke at the room or compartment level represents a fundamental life-safety function.

From a life-safety perspective, immobile and semi-mobile residents constitute high-priority protection targets because their survival during fire events depends less on rapid self-evacuation and more on the availability of protected spaces. Accordingly, the third layer should be conceptualized as a containment strategy that enables temporary shelter-in-place or delayed, staff-assisted evacuation under deteriorating fire conditions. When earlier layers are compromised, effective smoke containment becomes the final safeguard against catastrophic outcomes.

Structural measures such as fire- and smoke-resistant partitions, fire-rated doors, and compartment boundary integrity play a central role in maintaining Layer 3 performance. When implemented at the room or compartment scale, these measures reduce the rate of smoke propagation, preserve tenable conditions, and slow the escalation of fire consequences. In this context, bedroom-level compartmentation is particularly important in elderly welfare institutions, where residents spend prolonged periods in private rooms and staff-assisted evacuation requires additional time.

At the same time, full fire and smoke compartmentation represents the most resource-intensive layer of protection, often requiring architectural modification, system integration, and substantial financial investment. As such, immediate and uniform retrofitting is not feasible for all institutions, particularly smaller facilities operating under existing regulatory exemptions. Rather than treating full compartmentation as a binary compliance requirement, this study supports a risk-informed and phased implementation approach.

The long-term objective of third-layer enhancement is to achieve effective room-level fire and smoke containment, conceptualized as independent fire- and smoke-resistant compartments. In the short term, priority should be given to low-cost, high-impact measures that reduce smoke leakage and inter-compartment connectivity, such as sealing ceiling voids, improving door smoke resistance, and limiting uncontrolled openings. More comprehensive structural upgrades can then be implemented progressively through sustained public subsidy programs and long-term retrofit planning. From a smoke control perspective, the integrity and material properties of ceilings and upper boundary interfaces are critical determinants of smoke leakage and containment performance, as reflected in technical standards for building smoke control and exhaust systems [37].

By aligning third-layer improvements with facility size, building configuration, resident dependency, and available public support mechanisms, policymakers and administrators can promote meaningful gains in smoke containment performance while maintaining institutional feasibility and financial sustainability. Within the defense-in-depth framework, strengthening Layer 3 in this manner provides a critical safeguard that mitigates catastrophic fire consequences when prevention and early response measures are insufficient.