Prior Planning Prevents Plaintiffs Petitions
Yesterday, after two days without power, I returned home to find my home in darkness, with the temperature hovering at 43 degrees. A massive ice storm broke trees like dried spaghetti, and cut power to over 44,000 homes in the Jefferson City, Mo. area. (See attachment at the bottom of this post for a photo of iced trees)
When I went to the drawer to find my flashlights after the power went off, only then did I recognize that I had no new batteries, and that my flashlights would be good for perhaps no more than one night. I had not planned well for an ice storm I knew was coming more than 24 hours earlier. Fortunately, I had a place to go, and no medical conditions to prevent me from going. Nursing home residents don't have that luxury.
Every nursing facility should have a plan to meet the problems associated with bad weather. While the owners of the now infamous St. Rita's in Louisiana escaped criminal conviction for the deaths of more than twenty residents during Hurricane Katrina, the civil liability will likely hound the owners and the insurers well into the second decade of this century. For a full report of the criminal trial, click here.
All health care facilities are under a duty to act reasonably under the circumstances. For the most part, weather emergencies are known for 12 to 24 hours before the actual emergency arrives. The time to start planning for a weather emergency, however, was yesterday. If you don't have plans, and you haven't tested those plans with drills, you're positioning yourself for civil liability.
Emergency preparedness starts with an analysis of the kinds of extreme weather conditions seen in the area where the facility operates. Along the Gulf Coast, Hurricanes are a bigger threat than ice storms, but both have been known to occur. Similarly, while Midwesterners get lots of snow, ice, and blizzard conditions during the Winter, conditions during Spring and Summer mandate a much higher level of alert readiness because those conditions change in the course of minutes, not over hours.
A Weather Emergency plan focuses on protecting residents from the perils of the weather; those that are obvious and those that are not. Lightning is an obvious peril associated with a summer thunderstorm, but so is hypothermia. Structural damage may lead to residents becoming wet and cold. Loss of electrical power may cut off hot water supplies. Planning for these events requires the planner to be a good science fiction writer. That means envisioning things that have never happened previously, as well as the natural and probable consequences of things that have happened before.
In my neighborhood we have underground utilities. For the last eight years we have never lost power. But the loss of a transformer in another subdivision less than 300 meters from the end of our subdivision took out the lights for over 1500 customers in the area, including us. Having never lost power, I did not have a plan for dealing with it. A nursing facility cannot get away with that.
The loss of electrical power in a nursing facility can often be fatal to patients, particularly if those patients require electrical power for ventilators or similar life-support equipment. Sometimes this can be worked around using a portable generator, although the "load" on the generator may require taking off all but the most essential of services. Also, care must be taken to ventilate the generator and avoid Carbon Monoxide poisoning. A recent article in the St. Louis Post-Dispatch reveals that most nursing homes don't have back-up generators.
In facilities with computer-based medical records, particularly those without battery back up systems, power failure can nearly shut down patient care, requiring a resort to paper-based record keeping during the emergency. That means paper, pens, flashlights, and additional staff. Someone has to hold the light, while others turn the patient.
Sometimes with the loss of power comes the loss of climate control. Extremes of heat and cold can have effects on the elderly beyond simply hypothermia. Disaster planning should include plans for how to deal with losses of environmental controls and safeguard patients not only from hypothermia, but from hyperthermia as well. See news report here.
There are two typical responses to extreme weather conditions. One is to shelter in place. Sheltering in place requires more than simply ensuring sufficient materials and supplies and back up power. It requires that employees have either a way to get to work, or a way to stay at work once the emergency hits. Having insufficient staffing during a weather emergency is almost certainly the kind of reckless behavior that would draw a claim for punitive damages.
The other response to imminent severe weather is to evacuate to a place of safety. Evacuations require that the facility enter a contract with transportation companies (usually a bus company and an ambulance company) for transport of the ambulatory residents and bedfast patients to other facilities or places of shelter. Evacuations require a great deal of planning. The facility must have at least three separate and different locations it might use as a shelter for its staff and residents. If one or two of the facilities fill up with other residents or with the general public, the facility cannot shelter its residents on the bus. hat requires a backup for the primary shelter, and a redundant backup for the secondary shelter.
Having a plan, however, doesn't do anyone any good if the plan isn't exercised. The plan for an ice emergency should be drilled in the early fall, and the plan for hazardous spring weather should be drilled in the early spring (preferably on a day when there is good weather). Staff should know their duties, and should be provided with checklists. All supplies and emergency items should be stored in a weatherproof bin such that they can be accessed quickly, but stored securely.
Planning for large-scale failure requires a great deal of thought and good coordination with other agencies. Some hospitals may be positioned to take in sick nursing home residents. Others may not. A protocol should be developed for where the sickest will be sent in an emergency, and what back up locations should be used.
Military officers say that no battle plan ever survives first contact with the enemy. The same can be said for emergency planning. No amount of planning will ever be able to anticipate all the problems that will result in an emergency. For this reason, once an emergency has passed and residents have returned, post-emergency analysis of the response is critical to ensuring that there are no surprises the next time.
Planning ahead is always a prudent response to a potential emergency. Not having a plan, not having attempted a plan, borders on reckless. Having a plan that has never been changed or updated with new information is also problematic. During Hurricane Katrina nursing homes across the states of Louisiana and Mississippi found out that the contracts they thought they had with bus companies and others were no longer valid, some of the companies having gone out of business in the years since the plans were originally drawn up. Validating the emergency plans should be done every six months at a minimum.
If you haven't dusted off the emergency plan recently (and that means within the last six months), now is the time to do it. Outside agencies and vendors who are central to the plan should be called. Their ability to respond to the facilities needs should be evaluated. If your facility uses a computer for charting, back up charting materials should be a part of the emergency plan because patient care does not stop during an emergency.
Proper emergency planning, and documented drilling in the basics of sheltering in place or evacuating, goes a long way toward convincing a jury that a facility did everything it could when faced with a looming catastrophic situation.