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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. Healthcare 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 members who are trained to respond according to policy and procedures. An emergency plan should be documented and available to all staff at all times. 8

According to a study on senior care facility emergency planning, there are three special areas of consideration: 1. 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. 2. 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. 3. Residents who live with some form of dementia may hurt themselves or others because they are no longer in their normal environment. Caregivers must be able to address behavioral challenges, in addition to providing emergency evacuation and care. Dementia affects emergency planning and implementation. 14

The Joint Commission-which accredits more than 21,000 U.S. health care organizations and programs, sets emergency management planning standards in order to confront the specific challenges afflicting senior care facilities and residents. Working with federal and state agencies and first responders, The Joint Commission prioritizes various emergencies based on each emergency s probability and determines each person s specific role. For example, in the case of a hurricane, senior care facilities should communicate with local authorities about road closures in order to prepare for potential emergency evacuations, as well as the acquisition of necessary medical supplies. 15

As a manager, your disaster response preparation should include information from resources available to assist current care. Consulting these resources will improve collaboration between facilities and other providers who must help carry out response measures. There are many resources available for private practitioners to address legal concerns. Practitioners can register for information sharing at the CDC, which provides updates from Federal Emergency Management Agency (FEMA). FEMA also provides online courses that train practitioners to respond effectively during disasters and avoid liability. First and foremost, 911 is the best place to contact, as they can advise what agency can help. Before a disaster strikes, caregivers can take advantage of other resources that can educate and advise. The Red Cross, FEMA, your local Office of Emergency Management, and your local police and fire departments all will be willing to educate you and your community. 16

Each senior care facility s disaster preparedness can vary. Facilities should keep a checklist to ensure preparedness at both the staff and resident levels. The checklist involves assigning duties for when disaster strikes. As part of the checklist, facilities should review evacuation plans at least once a year and post contacts for notification in case of an emergency. They should also have disaster and CPR-trained staff on duty at all times. Additionally, senior care facilities should provide their staff with disaster training from companies like the American Red Cross. They should also have professional counselors available to address the needs of residents and their families. Quarterly staff evacuation drills and bi-annual disaster drills are best practice, and in some states a requirement Monthly updated lists of all residents on each floor should be maintained on a routine basis and include the specific mental and physical disability of each resident and individual relocation needs for that resident in case of emergency. This information is kept in the patient s main chart. 17

Centers for Medicare & Medicaid Services published emergency checklists for health care facilities, state agencies, and long-term care ombudsman programs to follow during disasters. The health care facility checklist includes 70 tasks, one of which should include contacting residents families after the disaster. Communication not only with the residents but with their families reduces possible liability. Other tasks on the list include: ensuring adequate supplies of food and water, and identifying evacuation routes and transportation plans. Additionally, the checklist implores facilities to work with local agencies like local police and fire departments to develop a community emergency plan. The state agency checklist advises collaboration with emergency management agencies. However, this report found that state agency officials primarily focused on enforcing state and federal regulations. The long-term care ombudsman program ensures that all local ombudsmen understand the relevant emergency planning for long-term care facilities. However, following disasters, these ombudsmen had no contact with residents until the disasters ended. 18

In addition to a checklist, assisted living facilities should have emergency supply kits. These kits should 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. Be aware of these items and educate staff to use them in an emergency situation. These items may need routine checks for expiration dates and other storage-related issues. 19

In the case of catastrophic events such as natural disasters, terrorist attacks, or epidemics, healthcare facilities must attend to the most critically ill or injured individuals first. In a worst case scenario, care providers might also have to make decisions about how to dispense limited resources, such as mechanical ventilators, intravenous pumps, and medications. Even staff might be lacking in dire circumstances. The loss of electric power can seem catastrophic, even if just for a few minutes. No facility can anticipate the immense amount of resources that are needed in emergency situations. Evacuation needs to be part of any emergency plan. This includes developing ambulatorybased care, a variety of home health care options, and exploring usage of common areas in hospital settings. Staff must be prepared to carry out these measures on little notice. 20

Knowing the exits of the facility you work in is probably the easiest and most effective way to navigate when dealing with an emergency. When exiting the premises isn t an option, knowing the designated location to safely shelter in place is another measure to ensure safety. Understanding the mobility or cognitive condition of someone you may need to evacuate will allow you to properly mentally and physically prepare. Supplies and assisted devices may be needed in some case, and knowing the residents allows you to make those decisions quickly. Monthly updated lists of all residents on each floor should be updated. List specific mental and physical disability of residents and specific relocation needs for that resident in case of emergency. This information is kept in the 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 have a clearly defined Emergency Preparedness Plan, which should be reviewed with everyone. In the case that a relocation plan falls through, have a list of other potential facilities to evacuate to. This plan should also include evacuation details like modes of transportation. Being prepared will make the process for residents less stressful in an otherwise harrowing situation. 22

In the case of natural disasters, terrorist attacks, and epidemics, health care providers must be prepared to make ethical decisions both swiftly and effectively. The Institute of Medicine (IOM) identifies three principles for healthcare providers to follow in order to carry out ethical care: fairness, duty to care, and duty to steward resources. In emergency situations, high ethical standards must always be maintained. Plan for possible reduced staffing during an emergency, as it may be difficult for care workers to get to or access facilities. 23

While preventing a disaster isn t always possible, what managers and direct caregivers do during its first moments could be the difference between life and death. No two situations will ever be the same. Education and training are the best ways to prepare. As manager, you can equip staff with very basic, and mostly free disaster preparedness training. These courses are usually given by local Red Cross locations, or the local Office of Emergency Management. Involve local emergency response teams and consider conducting at least 1 mock evacuation per year. Make evacuation procedures part of new employee orientation. The Joint Commission recommends a minimum of two disaster drills per year; some states require more than 2 drills, up to 1 per month, depending on the health care setting. 24

In addition to the work of The Joint Commission, there has been a national initiative to train long-term care staff for disaster response and recovery. This three-year initiative is called PREPARE, and includes two days of training and conference seminars. The content of the PREPARE program includes eight learning modules: specific vulnerabilities to older adults, psychologic needs, biological and chemical agents, leadership and communication, surveillance and infection control, drills and exercises, state and federal emergency plans, and components of an effective disaster plan. The results of the initiative demonstrated at least a 10% increase in improvement across those eight comprehensive disaster plan areas, as well as increased state and federal agency involvement. Health care facilities should consider using the PREPARE initiative to increase emergency preparedness. 25

Obviously, some things you won t be able to control as manager. All the preparation in the world doesn t account for every variable that you might face in a disaster. The Institute of Medicine s report on medical care in the case of disaster situations didn t advocate for blanket legal liability protections. Despite a strain on resources, disasters aren t an excuse for negligent care and could lead to litigation. As a health care manager, you must study the specific legal protections in your care environment in case of emergencies. Having wider protections will allow you and staff members to make difficult decisions efficiently during disasters. Governments have established standards that immunize Health Care Workers from some negligence claims in declared emergencies. Such decisions may include having to reallocate lifesaving resources among patients. An example includes using mechanical ventilators on residents who are septic or hypotensive instead of to support victims with traumatic brain injury or those undergoing emergency surgery. However, ordinary negligence does not have the same liability protections. Residents can still seek compensation funds for negligence even in an emergency setting. 26

As a response to gaps in health care facility disaster preparation, a Health and Human Services report made several recommendations. The first recommendation was that the Center for Medicare and Medicaid Services revise federal regulations to prepare for things like unreliable transportation contracts or lack of collaboration with emergency planning entities. HHS also recommends that the Center for Medicare and Medicaid Services provide a set standard for state agencies assessing compliance with federal regulations for emergency planning and training. Additionally, the Center for Medicare and Medicaid Services should encourage state agencies and long-term care ombudsman programs to use emergency checklists. Lastly, HHS recommends that the Administration on Aging collaborate with the Center for Medicare and Medicaid Services, long-term care ombudsman programs, and others to develop policies that protect resident health, safety, welfare, and rights after disasters. 27

In emergency cases, the scarcity of resources may leave a facility open to legal challenges. There has been a lack of guidance on how care providers should make decisions in such major emergencies. In the case of disaster, care providers should be aware of the shift in standards relating to a declared state of emergency. 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 also divert an excess number of patients that complies with the Emergency Medical Treatment and Active Labor Act. As part of the coordination effort, managers and 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 implementing an emergency plan, managers should include the legal implications of using volunteer services in an emergency situation. 29

Other legal considerations involve the interests and capabilities of current and incoming residents. In disaster circumstances, care providers should consider a patient s physical and cognitive disabilities, and how they should be accommodated legally during emergency situations. In all circumstances, managers and care providers must also be able to gauge a resident s informed consent. Without the consent of a resident or their family members, you re open to liability, even in emergency settings. Lastly, your health care facility must have the infrastructural preparedness to evacuate atrisk patients in response to emergencies such as natural disasters. Emergency situations don t invalidate normal standards for evacuations. Failure to uphold normal procedure will still be under legal scrutiny. 30

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 (PTSD), 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 CDC, 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. 31

A standard emergency plan should contain information on the following: Communications both internal and external to community care partners, 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 As a manager, make sure your staff can 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 32