Public Health Emergency Preparedness

3.3. Potential Roles of Nursing Homes

Nursing homes represented are willing to accept residents from area hospitals but voiced concerns about patient acuity and facility capacity and staffing.

Nearly all focus group participants reported that they would be able to accommodate their residents if area hospitals needed to discharge them after an emergency. One participant remarked, "I think [accepting former residents] would be the appropriate thing to do at that point in time...; If I thought it was safe, I'd put them back in my rooms...; we'd figure out a way to do it." Several facilities also acknowledged that area hospitals would ask them to take patients that had not been former residents. Most of these facilities agreed they would do what they could to accommodate those patients. One participant remarked, "...; we would need to say 'yes' to the hospitals to help them discharge those we could care for...; That's a role we would play." Other participants had similar sentiments:

The hospitals know where our facility is...; they know the size of our facility. We know we'll be overrun with people coming and going from the hospitals because we're right there. We have no doubt about that.

When we had a tornado, the surrounding hospitals did call us up and we were set up to receive their less critical patients that were on their way to being discharged anyway. So we gave so many beds that we would take their patients. We're certainly willing to do that...; take people that are on the verge of being discharged from the hospital.

All participants agreed that their ability to accept transfers depends on patients' level of acuity and the level of care required. Focus group participants said that most nursing homes do not have the staff or equipment to care for high acuity patients or patients with certain conditions, which is why these patients were hospitalized:

I would think we could handle the numbers, but it would depend on what acute care they were needing...; These were people we couldn't handle in an SNF, some we could take back, and some we couldn't provide the care to keep them alive.

If their needs were something I could attend to...; it would depend on what their needs were at that time.

Focus group participants explained that many nursing facilities specialize in caring for patients with certain conditions, such as Alzheimer's, ventilator dependency, or cognitive impairment. Several participants remarked that they could not accommodate patients with certain conditions while several facilities stated they would simply not be able to accept high acuity patients. According to a couple of participants, "Our facility couldn't take ventilator patients." However, other facilities were willing to accept higher acuity patients from hospitals because they have specialized staff and skills to care for individuals with more complex conditions. Focus group participants suggested that area hospitals wanting to transfer residents would need to know "not just where our facility is, but what we are skilled in."

One concern voiced by several facilities was figuring out "who do you let in" especially in the case of bioterrorist or infectious agents. Participants did not want to place their residents at risk by accepting potentially infected individuals from outside the facility. According to one participant, "We would be prepared to take back people we've sent...; But if we have a bioagent or pandemic flu and it's not in the building yet...; if we take somebody back, we risk exposing other people and we'd say we can't do that."

Adequacy of staffing was a major concern voiced by all the facilities during the focus groups. Facilities were concerned that they would not have enough staff to care for their residents, much less potential transfers from area hospitals, in the aftermath of a disaster. According to one participant:

Our nursing staff is very stretched; we expect a lot of them. We could certainly receive patients from hospitals but I don't think we would be able to offer care to them because it takes all our resources to take care of the residents we have.

Many participants were concerned that staff would not be able to reach the facility or would not want to leave their families to come to work. One participant remarked, "I would be concerned about staff...; people are going to want to stay home and take care of their families." Focus group participants also shared a concern that staff members would leave work in order to attend to their families, even though most facilities have policies restricting staff from leaving:

Technically they [the staff] should not leave the facility. But in the middle of a disaster how many are going to be trying to get to their own families? How many really won't leave?

Several participants suggested that hospitals would need to transfer residents with the supplies and staff they needed in order to ensure that properly trained individuals could provide care to higher acuity patients:

We would not want to take on a lot of acutely ill patients that would prevent us from providing care to our own residents...; we are not staffed or equipped to care for acutely ill patients...; You want to help as much as you can, but then do you dilute the care you are able to provide for your own people?

Most facilities expressed concern about bed availability, though several suggested resourceful ways to create more beds should they become necessary. A few facilities represented would have significant problems accepting transfers because they run at or near full capacity most of the year: "My main limitation would be beds available. I am a 32 bed facility, and usually run 30-31 beds full. It just depends on time of year." Several other facilities suggested they could create makeshift beds by placing mattresses in hallways. One participant remarked, "We would need to scrunch people into the building...; put mattresses down the hallway, put blankets in the lobby."

Participants from facilities located in earthquake-prone regions (California, Washington, and Oregon) voiced concerns about accepting patients if their facility had sustained structural damage. Several participants in these States remarked they would need the building inspected before accepting additional patients: "If the DHS came out and gave us the okay, if the building was okay, then we could accept more patients." A few participants felt their ability to accept patients would be a judgment call at the time of the disaster, even if their facility sustained damage. One participant said he would fit people into the buildings that had not sustained damage rather than trying to transfer all his residents out.

Participants in one State were particularly concerned about the paperwork surrounding transferred residents. They assumed that the electronic medical record system would not function in the aftermath of a disaster and did not know how patient information and billing/reimbursement would be handled. They were concerned whether patients would be transferred with their original records and if they could recoup the costs of patient care.

Nursing homes could provide basic medical care to outside patients.

Most focus group participants suggested their facilities have the staff, supplies, and equipment available to provide basic medical care to community members. One participant remarked that people see nursing homes as "a pseudo-hospital" and expected community members to "try to get in the door" of her facility if they could not get to area hospitals for medical care. Many participants across several of the focus groups agreed with this statement. A few participants reported that the American Red Cross expected their facilities to provide first aid: "The Red Cross told us that they'd expect us to do first aid...; and then move them out." Several participants reported being approached by their local emergency service agency and told they would be asked to "take on people from the community" and provide first aid "at a minimum" during an emergency. Most participants agreed their staff could administer vaccinations or medications without detracting from the care of their residents: "We have staff that could administer vaccinations and medications and that would be a community service that could be provided without necessarily having people move in to your facility."

Many participants suggested their staff could help triage patients even if they could not admit them. Most facilities hold special staff trainings in proper triage techniques and include a section on triage in their emergency manuals. One participant noted:

I could see nursing homes being good triage areas...; we are really well equipped to act in that manner. But I don't think any of our facilities would be able to accommodate large scale acute patient flows.

The question of morgue facilities was brought up independently in three of the six focus groups. Concern was expressed about dealing with deceased residents since transporting them to the county morgue would be problematic during an emergency. One participant reported that the local emergency services agency requested the use of her facility's basement for that purpose: "We have a basement and that basement could be a morgue. Although I'm not sure how that would happen because it's not cold down there."

Nursing homes could provide short-term shelter for community residents.

Most focus group participants reported that their facilities have space to provide shelter for community members but expressed some concerns about providing food and other medical supplies without taking resources from their residents. Participants cited a wide range of spaces available for shelter: therapy rooms, dining rooms, conference rooms and recreation areas. One facility had an auditorium they planned to use in the event of an emergency. Several facilities also suggested local disaster relief agencies could use their grounds: "Next to our facility we have two huge fields...; that would be the perfect space for a Red Cross facility".

Participants in nearly all the focus groups discussed how to prioritize care for residents, staff, families of staff and members of the general population who come seeking shelter. Several participants remarked that facility staff and their families would receive first priority for shelter. According to one participant, "If we have any large areas it would go to our staff...; and then the greater community".

Nursing homes have little excess space and should not be used to store equipment or stockpile drugs.

Nearly all focus group participants agreed that nursing facilities do not have a great deal of excess space and could not provide long term storage facilities for supplies. One participant noted, "I'm sure we could allocate an area if we're not using it for something else...; but as far as open areas, we really don't have an excess of storage." Another participant reported that older facilities were particularly pressed for storage space:

I've never had a building with excess space. There's so many things that we'd like to have room for that we don't have because of space issues...; a true skilled facility, especially one that was built 40 years ago, you just don't have enough s pace.

Participants noted that all nursing facilities have large areas that are routinely used by nursing home residents for activities such as watching television, playing games, dining or arts and crafts. Allocating this space for storage would mean "taking space away from a designated use." Many participants suggested that their facility could provide some short term storage should local emergency response agencies require storage.

When participants were asked about using nursing homes to stockpile pharmaceuticals, participants in nearly all focus groups expressed concern about security. Most facilities agreed that they would have space for stockpiled drugs but that doing so would require a facility to "designate a guard for that room, too," because if the space stored pharmaceuticals, they would have to be able to lock and guard it. This theme came up repeatedly:

There's a problem with stockpiling...; If people know that you have a stockpile, are you going to be able to maintain that stockpile? Security is going to be an issue...nursing homes are vulnerable.

I think we have the capacity to do it. The thing that would scare me is the security to do that. We don't have the manpower in our buildings to produce a secure environment. In a disaster people are going to want to care for their families...; and they don't care where they get it...; What scares me about my building, even with the drugs I have on hand, is how do you secure that?

Overall, the majority of participants agreed that nursing homes were not the appropriate place to store supplies, due to a lack of long-term storage facilities, but could provide some short term storage capacity for local disaster relief agencies. In addition, most participants felt that nursing home facilities should not be used to stockpile pharmaceuticals, despite having space available, because they could not keep the drugs secure.

Participants from one focus group felt strongly that nursing homes should not play a large role in disaster response.

The participants were fairly adamant that nursing homes are not equipped to participate in disaster response or recovery activities. According to one participant, "...; a nursing home historically is not part of any disaster plan...; when you think of disaster plans, the community's number one resource is the hospital. Nursing homes are really not part of that equation." Reasons participants gave for this perception included nursing home size, absence of doctors at the sites, and unreliable staff. Several participants suggested that nursing home staff were prone to the mass hysteria surrounding a disaster and would not be a reliable source of support or care for residents: "It's every man for himself."

Two participants added interesting caveats regarding the role of rural nursing homes facilities. One participant from a rural area felt that nursing homes could have an important role in disaster response activities in areas with very few hospitals and several large nursing homes. However, he emphasized that, to date, "These efforts are not coordinated." This point was reiterated by another participant in a different focus group. She suggested that nursing homes would not be seen as area resources in metropolitan regions, but would be more likely play a role in a disaster in more rural areas.

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3.4. Influence of State Regulations on Nursing Homes

Participants were largely unaware of State regulations governing nursing homes during an emergency.

Nearly all focus group participants did not know if regulations governing nursing homes during an emergency existed in their State. Many participants assumed that regulations would be "suspended or loosened" during an emergency, but were not sure if there were legislated rules or regulations to that effect. One participant recommended that "the State...; let LTC facilities know what their stance would be in the case of a disaster." Another participant expressed a similar concern:

One of the fears we have is that the regulations say we can only put 2 patients in a 2 bed room. I'm only licensed for 162 patients, if I have 165 patients in my building...; what really is the result from that? Are they going to look the other way?...Nobody had come back to us and said under these circumstances these are the rules

Several participants suggested that bed licensure or staffing issues would not deter them from providing needed care during an emergency. According to one participant, "I would cast aside...; the regulations for that period of time to accommodate those who are really in need."

Participants from the Oregon focus group said that nursing homes had only recently been involved in State disaster preparedness and planning activities. They all expressed concern about the lack of directives from the State but agreed that no one was going to "suspend the requirements of taking care of their own residents." According to one participant, changes to regulations governing nursing homes during a disaster had not yet been made but:

We just started talking about the suspension of rules and regulations in the event of a disaster where we don't have the capacity to take in any more residents...; If it's not written right into the regulations that that stuff gets set aside, it's going to be a real concern.

In North Carolina, several participants knew that bed licensure regulations are waived if the Governor declares a state of emergency, though one facility was unaware of this regulation. In addition, the North Carolina nursing home association "applies to the State Department of Facility Services on behalf of the facilities" in order to get pre-approval if there is a hurricane warning or some other event. Participants stressed that nursing staff "would still be an issue" because nurses cannot work more than a 16 hour shift and this law "is not exempted in a disaster."

Nursing homes need formal guidance as well as resources and money to develop disaster plans.

Several participants expressed concerns that involving their nursing facilities in disaster preparedness and response activities would require them to develop comprehensive plans for their facilities. All participants agreed that nursing homes do not have the time, staff, training, knowledge, or resources to develop such a plan. One participant suggest that "If regulations are developed that require nursing homes to develop bioterrorism preparedness plans, then resources — money, documents, consultations — should be available to assist us in developing those plans." This theme was reiterated across several focus groups. Several participants said they simply do not have time to do comprehensive disaster planning or "train and drill staff" once a plan is developed. According to one participant:

We've all had disaster plans for decades because it's been required. In light of Katrina and bioterrorism there's this big push, and to be honest I'm feeling overwhelmed because there's basically no resources. I have a business to run and now I have to put a lot of extra time into something I know nothing about...; and everybody's starting to change their expectations -- from the State to the fire marshall who are also getting pressure from the Feds.

Several other participants stated they do not have people on staff knowledgeable in disaster planning and coordination nor do they have the money to hire outside consultants to assist them. In light of this lack of knowledgeable people, many participants indicated a need for "some level of government" to provide them with guidelines related to handling contamination during a bioterrorist event or infectious disease outbreak because it would be "too hard to develop plans around this with no experience and limited resources". 

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3.5. The Role of the Red Cross and the Effects of Hurricane Katrina

Nursing homes are uncertain about the role of the Red Cross in a disaster.

The role of the Red Cross was discussed in the majority of the focus groups. Focus group participants universally described the Red Cross as a valuable organization. A few facilities mentioned having worked with them to train/certify their staff on CPR and first aid procedures or to provide community first aid in their facilities. One facility that had previously been unsuccessful in working with its local government in emergency planning ultimately sought coordination with other entities and received a very helpful response from the Red Cross.

It became clear that most nursing homes do not plan on getting needed support from the Red Cross during an emergency. According to one participant:

The Red Cross and community support is probably not going to be focused on nursing homes because they are going to assume that [we] have more resources than the rest of the community to take care of ourselves. There is going to be such a rationing of support if there is a major disaster that I wouldn't expect that the Red Cross would be helping out nursing homes.

Not only did participants not expect help from the Red Cross, some nursing homes are concerned that they may be asked to provide support to the Red Cross. One participant that had recently learned that the Red Cross had been dedicated a large space on their property to establish a shelter in an emergency had the following to say:

They're not there for our benefit. They are still asking that we be able to defend in place or work through the needs that we have. They may ask us to help augment them. Like, maybe if we have a couple of nurses that can help with triage or nursing wounds...; not helping us. They would be asking us for someone to come over and assist in something.

Several participants in this focus group agreed that the Red Cross would not provide support to nursing homes and may actually seek their help. Another facility in a different State also reported having space on their campus designated as a potential Red Cross shelter. Participants in that State's group voiced concerns that their local Red Cross is failing financially, resulting in staff and office reductions.

Hurricane Katrina provoked fears of liability and judgment, decreased confidence that the government will be a source of support in an emergency, and resulted in changes to the duration of time for which nursing homes think they need to be self-sustaining in an emergency.

In the two focus groups that were held after Hurricane Katrina, fears of being judged for their actions during a disaster were pervasive:

I think the biggest fear is that we will try to do everything right, but if we fail...; we'll be judged...; we'll be on the front page of the news...; In my heart, I believe that a lot of those folks down in Katrina did everything they could. It's so easy to judge after the fact how things were done wrong when there are no resources to provide assistance to do things right.

Everybody has a fear of how, not so much the government responds to you, but how the political situation and press respond to you...; We have created an environment...; either you did wonderful and you are a hero or you did terrible and you are a goat...; A lot of people are very fearful of any kind of disaster for this very reason.

In addition to judgment from the political and media realms, a number of participants were worried about being held liable for their actions in a disaster because the United States has become such a "litigation society:"

Sometimes, too, you get really caught up in the regulations and legality part to the point that you are paralyzed...; You can go a little bit overboard.

There's a little flexibility, but I think it could create a lot of hesitancy to do certain things if we're concerned that when this is all over, somebody will be unhappy about what we did, we'll get sued, or we'll lose our license...;

So much of what we are judged on is our documentation. In a disaster, does that go out the window?...; I wonder about the folks that were in Katrina and how they handled that. The litigation that's going on now really isn't fair if they weren't able to document everything that they were doing like they would in a normal day.

At one of these two post-Katrina focus group sites, there was a prevailing lack of confidence that the government would be there to help their facilities during an emergency. They voiced the expectation that they will have to "fend for themselves". One participant added:

I don't think it's realistic that they're going to be there at the door to help us. Even if they choose to be and want to be...; It's not that they don't want to be. They just can't be everywhere.

Participants in one State explained that Hurricane Katrina had prompted them to take steps to increase the amount of time for which they could be self-sufficient in an emergency. According to one participant:

The residents aren't going anywhere. They need patient care. You try to provide that the best you can for a 72 hour minimum period...; Nowadays, when we do disaster preparedness, we're training to be prepared for 7 days. For a skilled nursing facility, that's going to be hard to do. Your shelves are only so big for food. Keep an open mind that it may be more than 72 hours. That's the reality...; That is directly a result from Katrina. Everything changed after Katrina. Everything went to 7 immediately.

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