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In the last 20 years, numerous disasters have struck the United States. Many of these events

have profoundly impacted health care settings.

These types of disasters can vary, including extreme weather events like hurricanes,

tornadoes, and flooding. Even normal seasonal events can morph into disasters if they grow

extreme enough. Massive snowfalls and the dangerous sub-freezing temperatures that can

accompany them are dangerous under certain conditions. Prolonged heat waves can evolve

into disaster settings, based on location.

In the past we’ve experienced wide-spread power outages such as the Eastern Seaboard

Power Outage of 2003, which left people scrambling for supplies. Lastly, we now also need

to be prepared for acts of violence such as terrorist attacks or active shooter situations,

both of which necessitate emergency preparedness.

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The California Office of the Governor’s Emergency Response stated that “…the Team found

that specific procedures for using alert and warning capabilities were uncoordinated and

included gaps, overlaps, and redundancies with regard to capabilities in various County

departments. While the loss of life was tragic, the silver lining in Sonoma valley was the

health care sector, which was found by the investigation to have policies and procedures in

place “…far exceeding the standards expected in the disaster and they took a proactive

approach, so there was no panic when they first heard about the fires that were forcing

mass evacuations.” There were two skilled nursing homes and three assisted living

communities, one of which was completely destroyed by fire, completely evacuated, with

zero loss of life.

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Health care practitioners must be prepared for extreme circumstances that leave the

organization vulnerable to litigation. Recent examples of large-scale events include

hurricanes Katrina, Irma, and Rita; the California wildfires in 2017, the Joplin, Missouri EF-5

tornado in 2011, ongoing terrorist attacks, and the H1N1 influenza epidemic of 2009.

During disasters, health care facilities could collapse or be seriously damaged, severely

depleting resources or preventing practitioners from providing care to residents. Health

care systems normally develop surge capacity and capability to provide care under these

unusual circumstances.

In addition to potentially damaging a facility’s infrastructure, natural disasters can seriously

injure people living in close geographic proximity, leading to a high number of causalities.

In these extreme circumstances, you, as manager, must make difficult care decisions to

avoid liability. The best way to avoid negative effects of any disaster is to be prepared

with emergency response plans and staff that are trained to respond according to policy

and procedures. An emergency plan should be documented and available to all staff at all

times.

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According to a study on senior care facility emergency planning, there are three special

areas for consideration:

Caregivers must consider communication challenges in extreme circumstances. Residents

with dementia may react adversely to extreme changes in routine and may not understand

how to act accordingly.

Additionally, caregivers have the challenge of personal care functions. Residents with

cognitive or physical impairments may not be able to feed themselves or meet their own

hygiene needs. This problem could be exacerbated during the tension associated with a

disaster.

Residents who live with some form of dementia may hurt themselves or others because they

are no longer in their normal environment. Caregivers have to be able to address behavioral

challenges, in addition to providing emergency evacuation and care. Dementia affects

emergency planning and implementation.

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Infrastructural issues such as water supply, sewage system, and electricity supply may alter

a senior care facility’s ability to carry out effective medical care to residents. Caregivers

need to pay special consideration to emergency evacuation measures for residents more

prone to physical disability.

Additionally, more than half of all residents suffer from some form of dementia. This makes

it difficult for caregivers to share information about infection contamination during

pandemics. A resident with cognitive impairment may not be able to carry out things like

regular handwashing and wearing masks.

Caregivers need to address hygiene needs and resident fears and concerns with creative

solutions. Direct caregivers need to utilize whatever resources are available. For example,

antibacterial hand gel may need be used when soap and water are not available. Caregivers

must support each other to manage energy and coping in these challenging situations.

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Every facility needs an emergency preparedness plan, and it can go by many names:

Disaster Plan, Emergency Evacuation Plan, Crisis Management Plan, etc. This plan should be

accessible to all staff members at any time of day, every day of the week, and be updated

regularly. It should outline the steps that need to be taken in the event of a disaster, and

should have different specific based on the type of disaster. It should also include transfer

agreements with other locations in the event that and evacuation needs to take place.

The written plan should include things such as contact names of staff, number of staff and

residents throughout the facility, specific disaster procedures with evacuation maps, and a

list of relocation site and their coordinator names.

Additionally, the written plan should document drill exercises and the feedback for those

drills. This way, residents and staff can note their weaknesses in the drills and work to

improve their relocation strategy. The disaster-related measure that caregivers must take,

such as a relocation and emergency supply kit plan, must be documented in written form

and shared with all residents and staff. Drills and feedback on drills is singularly the most

effective way to prepare for a disaster.

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In addition to a checklist, assisted living facilities should have emergency supply kits that

contain a daily supply of 1 gallon of water and a three-day supply of nonperishable food per

resident.

Besides food and water, an emergency supply kit should also contain miscellaneous items

for other challenges that may occur during a state of emergency. These items include, but

are not limited to: first aid kits, pain medications, blankets, flashlights, and an AM/FM radio

for each resident. With all of these supplies, residents will have their basic needs met

should a disaster strike.

Direct caregivers require these items to assist residents. Caregivers also need to manage

themselves during long shifts under difficult conditions. If staff are not relieved in a

routine schedule, an impromptu schedule of breaks and plans for food and rest needs to be

addressed.

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There are a few really simple preparation steps direct caregivers can take that can mean

the difference between life and death in disaster situations. For example, it is necessary to

know where the exits of the facility are located. When exiting the premises is not an

option, knowing the designated location to safely shelter in place is another measure one

can take to ensure their own safety and that of others.

Knowing the residents is another key factor when dealing with a disaster situation.

Understanding the mobility or cognitive condition of residents that may need to evacuate

will allow staff to properly prepare mentally and physically. Supplies and assisted devices

may be needed in some cases, and knowing the residents allows you to plan ahead for

resource needs.

Direct caregivers need to stay in contact with each other and with administrators at all

times. Families may also need communication updates. Be prepared for loss of cell service.

Knowing who to stay in contact with and knowing the specific roles of staff in a disaster is

also vital. Health care facilities should have these elements, as well as many others,

clearly defined in an emergency preparedness plan.

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Monthly updated lists of all residents on each floor should cite specific mental and physical

disabilities of residents and relocation needs for these residents in case of emergency. This

information is kept in each resident’s main chart.

Knowing who you need to stay in contact with and knowing your specific role in a disaster is

also vital. Your facility should clearly define where you and the residents should go in an

evacuation situation.

First and foremost, 9-1-1 is the best place to contact because they will advise regarding

what agencies can help. In severe circumstances emergency responders may not arrive for a

while. In this situation it is important for staff to function optimally without injury. Before

a disaster strikes, caregivers can always take advantage of other resources that can educate

and advise, including The Red Cross, FEMA, and your local office of emergency

management, police, and fire departments.

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One of the most crucial ways of lessening the impact of a disaster is to have a relocation

plan for residents. When coordinating this plan, have an accurate number of residents being

evacuated. It’s also important to note any special needs, like physical or cognitive

disabilities.

In the case that a relocation plan falls through, there should be a list of other potential

facilities to evacuate to. This plan will also include evacuation procedures like modes of

transportation. Being prepared will make the process for residents less stressful in an

otherwise harrowing situation.

All long-term care facilities should have an overall emergency procedure plan book,

approved per state and city guidelines, readily available in an easily accessible location

that all staff is aware of.

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A standard emergency procedure plan should contain information on the following:

– Communications – both internal and external to community care partners, and

state/federal agencies

– Supplies – Adequate levels and appropriateness to hazard vulnerabilities

– Security – Enabling normal operations and protection of staff and property

– Staff – Roles and responsibilities within a standard incident command structure

– Utilities – Enabling self-sufficiency for as long as possible, with a goal of 96 hours

– Clinical Activity – Maintaining care, supporting vulnerable populations, and alternate

standards of care

Caregivers can refer to the written plan for things such as contact names of staff, number

of staff and residents through the facility, specific disaster procedures with evacuation

maps, and a list of relocation sites and their coordinator names.

Additionally, the written plan should document drill exercises and the feedback for those

drills. This way, residents and staff can note their weaknesses and work to improve their

relocation strategy. Drills and their feedback are singularly the most effective way to

prepare for a disaster.

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While preventing a disaster isn’t always possible, what direct caregivers do during its first

moments could be the difference between life and death. No two situations will ever be

the same, but there are several steps that should be taken to ensure that when a disaster

does strike, the care team is ready.

As a direct caregiver be prepared by participating regularly in disaster preparedness

training. These courses are usually given by local Red Cross locations, or your local Office of

Emergency Management. Involve local emergency response teams and consider conducting

at least one full evacuation per year. Reinforce evacuation procedures as part of new

employee orientation.

The Joint Commission (TJC), which is the organization that accredits more than 21,000 US

health care organizations and programs, recommends a minimum of two disaster drill per

year; some states require more than two, up to one per month, depending on the health

care setting. Caregivers can ask employers or research independently self-protection

techniques to use during a disaster situation. In some cases these courses are free, in other

cases there is a small fee.

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Disasters like Hurricane Katrina demonstrate that caregivers may have to make tough

decisions about life-saving medical equipment, rendering them vulnerable to legal

conflicts.

In emergencies, facilities and caregivers make themselves liable because they must make

difficult allocation decisions when resources are scarce. Governments have established

standards that immunize health care workers from some negligence claims in declared

emergencies.

However, ordinary negligence does not have the same liability protections. Residents can

still seek compensation funds for negligence, even in an emergency setting. For health care

workers, there are no legal protections for wanton or criminal acts. Ordinary negligence

still applies.

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As we saw with Hurricane Katrina, health care providers were charged with murder for

euthanizing 25 patients. It wasn’t until a thorough investigation determined that no

adequate plan was in place for those individuals that the doctor and nurses were cleared of

any wrongdoing. Disaster situations can lead to tough decisions about who is denied

services and who is allocated resources. Some residents’ care might be sacrificed for the

overall support of public health.

Although there are legal protections, such as the federal Public Readiness and Emergency

Protection Act and the Good Samaritan Act, many health care workers still believe they’re

vulnerable to liability.

Threat of liability might make caregivers unwilling to participate in emergency responses.

Although the medical procedures may change in an emergency response, the standard legal

protections for practitioners don’t change significantly. That’s why following the facility’s

emergency preparedness plan is vital, as it maintains as much of the liability as possible on

the shoulders of the facility.

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In emergency cases, the scarcity of resources may leave a facility open to legal challenges.

Unfortunately, there is no way for a facility to insulate itself from legal challenges, no

matter how careful. One legal issue is the access to treatment. A facility must have a

strategy to conduct medical triage under legal requirements for both current and incoming

residents. Health care providers must be able to divert excess numbers of residents to

comply with the Emergency Medical Treatment and Active Labor Act.

Another legal consideration is the coordination of health services. In the case of disaster,

care providers should be aware of the shift in standards relating to a declared state of

emergency. This includes an understanding of the FDA’s issuance of emergency use

authorizations. As part of the coordination effort, care providers should comply with

reporting, testing, partner notification, quarantine, and isolation standards as public health

mandates. An understanding of these mandates will avoid liability for the facility.

Another thing to consider is volunteer health professionals. When developing an emergency

plan, healthcare facilities should include the legal implications of using volunteer services

in an emergency situation. If care providers are aware of their role in “access to care”

situations, they will be better equipped to allocate lifesaving care and medical equipment

to patients.

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In the case of natural disasters, war/terrorist attacks, and epidemics, health care providers

must be prepared to make ethical decisions, both swiftly and effectively. High ethical

standards must always be maintained.

The Institute of Medicine identifies three principles for health care providers to follow in

order to carry out ethical care: fairness, duty to care, and duty to steward resources.

Prioritize residents in critical condition. Attempt to keep equipment near or with them

that can be run by generator or battery whenever possible to maintain optimal care in an

adverse situation.

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In addition to legal and ethical considerations following a disaster, you must consider the

mental health of residents following emergency circumstances. Older adults with mental or

physical impairments, who are socially isolated, or who suffer from Post-Traumatic Stress

Disorder), may be especially vulnerable to changes in mental health.

Immediately following a major disaster, older adults in care facilities may suffer from an

increased level of anxiety and fear. They may have serious concerns about their personal

safety, and the emergency may trigger Post-Traumatic Stress Disorder. These immediate

symptoms hold particularly true for older adults. It’s this demographic that, statistically, is

the least likely to receive warning about disasters, as well as the least likely to evacuate

disaster situations. Following disasters, caregivers should be aware that they may need to

overcome special barriers in order to carry out mental health treatment for older residents.

Older residents may have a stigma about mental health, and they may be unwilling to

receive help for such issues.

Caregivers should be educated about disaster mental health interventions. For instance,

studies have shown that older adults may be more receptive to mental health treatment if

it’s conducted with other types of medical evaluations. Organizations such as the Centers

for Disease Control American Association of Retired Persons, and Substance Abuse and

Mental Health Services Administration’s should be enlisted to promote disaster crisis-

counseling services for older adults. Further, caregivers can provide written information

about the difference between crisis counseling and psychotherapy. This may destigmatize

mental healthcare for older residents living in facilities.

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First of all, do not panic. The way you react can and will determine how those around you

react. Having a plan in place and following it will keep everyone safe. Communicating in a

calm manner allows for the information to be absorbed rather than the panic to ensue.

Your facility’s plan should designate “who” is in charge and keep that leader informed of

who’s carrying what messages, and to where. Having one voice, one source of information

ensures that it doesn’t get distorted along the way. Communications should be both

internal and external to community care partners, and state/federal agencies. Alert all

involved parties, staff, residents, patients, and families, of evacuation locations.

Say “yes” to the five KNOWS:

– Know your exit routes

– Know your “shelter in place” location

– Know your residents/patients

– Know emergency contact information

– Know your role

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