Nursing home safety: updating the new federal rules.
Recommendations will be made, as well, to assist facilities in minimizing possible injuries or losses resulting from incidents on their premises. This will involve attention to the details of physical environment (as opposed to medical practices) that are key factors in maintaining residents' safety.
Prior to October 1, 1990, there were conceptually similar but technically different requirements that governed skilled nursing facilities (SNFs) and intermediate care facilitiesw (ICFs) under the Medicare and Medicaid programs.  The distinctions between SNFs and ICFs, for Medicaid purposes, have now been eliminated under OBRA so that both SNFs and ICFs are now simply referred to as "Nursing Facilities" (NFs). 
As a result of these legislative changes, the Health Care Financing Administration (HCFA) has accordingly promulgated revised regulations governing disaster preparedness for NFs.  The former disaster preparedness conditon of participation requirement for SNFs appearing as 42 C.F.R. Section 405. 1136 has now been removed.  The disaster preparedness requirement for former ICFs that appeared at 42 C.F.R. Section 442.313 has likewise been removed.  Instead, the disaster preparedness requirement for NFs now appears as 42 C.F.R. Subpart B (Requirements for Long Term Care Facilities), section 483.75(o). 
For facilities formerly known as ICFs, the new requirement is generally more stringent than the former standard because, like the former conditon of participation for SNFs, the new rule requires both employee training and the periodic performance of disaster response drills. Under the new disaster preparedness requirement, all facilities are required to have detailed written plans and procedures to meet "all potential emergencies and disasters, such as fire, severe weather, and [a new category] missing residents." Facilities must also "train all employees in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out staff drills using those procedures." 
NFs are also now required to maintain an emergency power system which will at least supply sufficient power to maintain lighting at all points of ingress/egress, as well as to continue operating the fire detection, alarm and extinguishing system and all life support systems. 
None of these requirements formerly pertained to ICFs.
The most common type of disaster is fire. NFs must, as a Level A requirement, comply with the applicable provisions of the 1985 edition of the Life Safety Code of the National Fire Protection Association.  Under the Life Safety Code, facilities are required to develop and maintain a written fire safety plan which must be readily available at either the facility's switchboard or security center. Employees must be instructed in life safety procedures, and the facility must conduct fire drills not less than quarterly on each operating shift (i.e., a minimum of 12 per year). 
Some nursing facilities conduct fire drills more frequently than required under federal and/or state regulations. In fact, monthly drills are becoming increasingly common. While drills of this frequency may seemnigly interfere with the productive time of employees, the extra expense involved may pay intangible dividends in the event of an actual disaster, where appropriate actions and conduct are almost always the result of proper training and frequent repeat training.  A well-prepared facility may not be able to avoid injury or loss of life, but it may certainly mitigate those losses and avoid both the negative public relations and potential legal liability of a staff response that is woefully inadequate or negligent.
The first and foremost concern in any fire is the safety of residents. Residents whose lives may be endangered must immediately be relocated to a place of safety. Afterwards, the fire alarm should immediately be activated and the fire department phoned (one should not rely on an alarm activiation system designed to automatically alert the fire department). Deficiencies in these areas have been a major source of loss of life in adult boarding homes. 
Staff must also evaluate any systems designed to isolate the fire or the dangerous smokes and fumes from the fire. Frequently, facilities utilize magnetic devices which keep fire doors located in long corridors open until the activation of the fire alarm, at which time the doors are to automatically shut. Such systems have been known to fail, and staff must be trained to ensure that fire doors and/or windows remain closed.
Unlike office buildings or schools, evacuation of all occupants of a nursing facility is usually the last resort. Should an evacuation be required, however, residents should be wrapped in blankets. Should there be multiple or extensive injuries, triaging may be necessary prior to resident transport to alternative care centers. As part of its disaster plan, a facility should have both emergent resident transport services and treatment/housing services planned for and available on an emergent basis. After evaluation of injuried residents, staff should again ensure that all doors and windows are closed. 
Fire investigations indicate that a contributor to loss of life involving fires in adult boarding facilities is the lack of proper staff training.  Staff training in these areas is absolutely essential because in an actual emergency, the slightest error may result in undue injuries, fatalities and property losses. Also, residents, to the extent clinically possible, must themselves be trained in fire preparedness and evaculation.
Other disasters which facilities must be prepared to properly address include floods, earthquakes, tornados, and hurricanes. Many of the precautions described above similarly apply to those natural disasters. During advisories or warnings of tornado, hurricane, or flood, residents should be moved away from windows toward the inner corridors of buildings (unless, of course, complete evaculation is indicated).
Utility interruption, whether caused by a natural disaster, fire or otherwise, requires immediate and frequent recontact with utility service representatives to ascertain whether the problem is local or regional in nature. A severe loss of power may warrant the procurement of temporary heating/cooling capabilities, as well as food and water from outside services. Appropriate supervisory personnel may then need to be contacted and requested to report for duty.
Facilities should also maintain and routinely prepare back-up copies of critical electronic data processing files and programs, should a partial or complete power interruption cause an unintended erasure of critical data. The disaster plan should anticipate alternative means of conducting operations until the electronic information is able to be restored back to normal.
Facilities must also be prepared to respond to a bomb threat, which may ultimately require evacuation. Switchboard personnel should be appropriately trained to handle a bomb threat communicated by phone, and law enforcement officials should be contacted immediately. Appropriate managerial personnel may be required to report so that they may guide officials through their familiar environs in the attempt to locate the alleged bomb. Should the facility require evacuation, any announcement should not mention that the evacuation is due to a bomb threat to avoid the panic that could otherwise ensue.
A system of communications with respect to contacting appropriate public officials, resident families or significant others, and facility personnel should also be a part of the disaster preparedness plan.
Other Safety Requirements
NFs will be required to maintain a water supply in the event the facility's normal source of water is for any reason interrupted. Also, among other new provisions, a section of a NF's dining area will have to be designated as "non-smoking;" handrails will be required to be firmly attached to corridor walls; and all facilities will be required to maintain a pest control program. These requirements have all been incorporated into 42 C.F.R. Section 483.70, effective October 1, 1990.
Residents should be carefully instructed as to which doors they may exit and re-enter and which ones that are to remain secure. Doors that are to remain secured should have "panic bars" designed to simultaneously permit exit and sound an alarm to staff upon engagement. Secured doors should be checked at each operating shift interval. As extra precautions against the potential danger of wandering residents, appropriate fencing should at least be considered, and residents should be photographed upon admission to the facility to assist in their rescue should they wander.
As for residents requiring physical restraints, they must be restrained with "diligent care" and evaluated periodically to ensure they remain safely constrained, and have not compromised their well-being by attempting in some fashion to free themselves. The largest liability verdict known to have been awarded against an elder care faciilty, $39.4 million, was rendered by a Houston jury last year to the family of a resident who was strangulated in a restraining device. 
All risk-involved incidents must be documented and reported to the appropriate managerial person/body within the facility. This require the reporting of situations under which an injury could have occurred, and should not be limited to the mere reporting of incidents in which an injury did actually occur. A data base should be developed so that necessary corrective actions can be implemented after identification of problem areas.
A critical employee safety program deserving mention is the proper training of employees who are engaged in lifting residents. Back injuries are a major source of worker's compensation losses in the nursing home industry, and facilities should consistently and frequently train, monitor and retrain employees in this area.
There are a myriad of other safety-related issues pertaining to the physical environment of the facility, including resident room construction, size, fittings and appropriately designed toilet facilities, the design and maintenance of floors, wheelchairs, beddings and chairs, as well as the use of hot water temperature controls on water heaters. These all merit periodic review.
David A. Verona is Assistant Vice President, Health Care Risk Management, Corroon & Black Corporation, Nashville, TN.
 Health insurance for the aged and disabled (Medicare) is authorized under Title XVIII of the Social Security Act (42 U.S.C. Section 1395 et seq) while grants to states for medical assistance programs (Medicaid, or "Public Aid," or "Medical," depending upon what term any given state uses in its own medical assistance program) is authorized under Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq).
 P.L. 100-203.
 See 54 Federal Register 21 at page 5316 (February 2, 1989).
 Id. at 5359.
 Id. at 5372.
 However, under former standard 42 C.F.R. Section 442.314 applicable to ICFs, facilities wee required to conduct in service staff development programs that included "all aspects of operations."
 See 54 Federal Register 21, p. 5369 (February 2, 1989), as codified at 42 C.F.R. Section 483.70(b). As of October 1, 1990, emergency power provision is a Level B requirement for NFs.
 Id. at 536, as codified at 42 C.F.R. Section 483.70.
 See National Fire Protection Association, Life Safety Code, 1985 edition (Quincy, Massachusetts: ANSI/NFPA 101, February 7, 1985).
 In a fire safety project funded by the U.S. Department of Health and Human Services, David Novak cited facts gleaned from adult boarding home fire investigations which indicated that lack of fire drills was a common factor involved in fires involving multiple deaths of residents. See David W. Novak, Final Report: Transferring Fire Safety Knowledge to the Elderly Via Local Authorities (Quincy, Massachusetts: National Fire Protection Association, 1987), DHHS Grant No. 90AMO136.
 These precautions are only some of the critical aspects of disaster preparedness and facilities should consult additional fire and safety sources for more detailed information.
 Novak, p. 2, citing NFPA fire investigation conclusion.
 The award was made to the family members of a nursing home resident who had died due to strangulation resulting from the patient's attempt to free herself from a restraining device. Baumann et al v. Seven Acres Jewish Geriatric Center No. 86-44019 (Harris County, Texas, 1990). An appeal of this award is now pending.
David A. Verona is Assistant Vice President, Health Care Risk Management, Corroon & Black Corporation, Nashville, TN.
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|Author:||Verona, David A.|
|Date:||Jan 1, 1992|
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