After reviewing nursing homes' emergency plans and outcomes of evacuations and sheltering for the last two hurricane seasons, the Health and Human Services Department's Office of Inspector General is suggesting that the Centers for Medicare and Medicaid Services strengthen federal emergency management standards for long-term care facilities.
Of the 16,125 nursing homes inspected nationwide in 2004 and 2005, 94% met federal standards for emergency plans, and 80% met those standards for emergency training, the OIG said.
The rates were similar for the 2,526 facilities in the Gulf states of Alabama, Florida, Louisiana, Mississippi, and Texas, according to the OIG's report. But it found in many cases that nursing home administrators and staff did not follow their own plans, or lacked transportation or other resources to effect those plans in a crisis.
The office reviewed state survey data for emergency preparedness and interviewed nursing home staff and administrators and local authorities in nine counties across the five affected states. The OIG took an in-depth look at plans from 20 nursing homes caught in hurricanes Ivan in September 2004, Katrina in August 2005, Rita in September 2005, and Wilma in October 2005, and compared those plans with provisions required by state law.
All 20 homes ran into challenges, whether they evacuated or not. All administrators said evacuation was not necessarily the best course of action as it could cause physical and mental stress. They also cited transportation contracts that weren't honored, complicated medication needs, and host facilities that were not available or prepared to receive evacuees.
Homes where patients were sheltered in place did not have as many problems overall but still had staffing and supplies issues.
At 5 of the 20 homes, administrators said they deviated from the prepared plan because the plan wasn't up to date or did not address their situation.
Six homes did not have instructions on how to evacuate to an alternative site, nine did not have any guidance on how to decide whether to evacuate or shelter in place, and 11 did not have any instructions on how to return to the homes after an evacuation.
Still, Dr. John Morley, director of the division of geriatric medicine for St. Louis University, said there is a need for an additional plan, saying this is an issue that “goes beyond a local plan and expecting nursing homes to do everything themselves.” He said “local police, emergency units, and everyone needs to be involved.”
The reality is that evacuation plans have to go beyond the facility because “if something goes wrong, it will affect” the entire area, Dr. Morley said. A facility may plan to use local buildings in an extended outage, but if there is a major disaster, “you probably have to move to another county.” Dr. Morley said the issue is not only having a plan and following it but “knowing when to evacuate,” given the risks of moving such a vulnerable population.
Indeed, during Katrina, facilities that did not evacuate were criticized, and others that tried to move to Houston had tragic deaths, Dr. Morley noted. He said emergency planning falls apart in older populations, including those in home care and hospice care, because “no one is very interested. We're an ageist society–we don't like old people so we don't plan for them. Then, we get all upset when things go wrong.” Dr. Morley also stressed the need for an “electronic database” to track patients as part of disaster preparedness.
The challenge of evacuations was underscored in the Sept. 21 grand jury indictments against two nursing home owners in New Orleans' St. Bernard Parish. The Katrina surge flooded the one-story facility to the ceiling in 20 minutes. The owners, Mabel and Salvador Mangano, were charged with negligent homicide in the drowning of 35 residents. However, they have maintained their innocence, saying they were worried that frail residents wouldn't survive the ordeal of an evacuation. The couple also has filed a legal document asking a judge to name a slew of local, state and federal officials as co-defendants in related complaints. The case is not likely to be resolved soon.
On a larger scale, to ensure better preparedness, CMS should develop a core set of required elements tailored to specific local risks, the OIG said, adding that the agency should also encourage greater collaboration between nursing homes and emergency management authorities.