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In Superstorm Sandy's wake, health experts and regulators are warning that thousands of nursing homes nationwide are still ill-prepared for a natural disaster.
The late October storm was the latest in a string of disasters to reveal gaps in emergency planning, despite an industry-wide effort to improve preparedness in the years since Hurricane Katrina.
Even in New York City, where disaster readiness has been a way of life since 9/11, seaside nursing homes and assisted living centers struggled to evacuate 6,300 residents from their flooded or powerless buildings in the days after the storm.
Some changes could be in the works. The federal Centers for Medicare and Medicaid Services said it expects to issue new disaster planning requirements for nursing homes this year, with an aim toward avoiding the types of problems seen in Sandy.
"They seem to do quite well with food, water, transportation, but once you get beyond that, they aren't so great," said University of Pittsburgh researcher Nicholas Castle, who published a study of more than 2,000 nursing home evacuation plans in 2008.
In New York, there was confusion at many homes about where patients should be sent. Some sat for hours aboard unmoving ambulances as the drivers waited for orders, only to be taken to the wrong place. Some facilities accepting evacuees wound up overloaded with more patients than they were prepared to handle. With the phones knocked out, relatives struggled to learn where loved ones had been taken. Medical records that were supposed to accompany displaced residents never arrived.
State and city health officials say that, by one important measure, the evacuations were a success because no patient died during transport. But that statistic doesn't include patients like Grigoriy Grodzenskiy.
The 95-year-old was on the fifth floor of the Sea Crest Health Care Center, in Brooklyn, when Sandy's surge swept over the beach at Coney Island and inundated the nursing home's ground floor.
Grodzenskiy, a retired scientist who fought for Russia in World War II, spent a frigid day in the heatless building, then nearly six hours aboard ambulances before he was taken to a nursing home in the Bronx — a facility so overcrowded with evacuees that he was soon moved again. After that second trip, Grodzenskiy's health deteriorated. He died eight days after the storm.
"His final days were so difficult for him," said his daughter, Tatiana Vishnepolsky.
Experts have been warning for years that the evacuation plans at many nursing homes need improvement.
The inspector general of the U.S. Department of Health and Human Services said in a report last year that while most facilities had evacuation plans that complied with federal law, they were often woefully insufficient.
Many had no plan for how to communicate if their phones went down. They lacked procedures for making sure records and medications accompanied patients. They often hadn't worked out a system with local authorities to determine when to have patients shelter in place, rather than evacuate.
After that report, Medicare and Medicaid officials pledged changes. One possibility is a new requirement that nursing homes to model their evacuation plans around a federally authored checklist.
"We have been actively soliciting input to determine appropriate ways for nursing home facilities to be adequately prepared for disasters and coordinate with other local and national emergency preparedness systems," the agency said in a statement.
Joseph Donchess, who leads the Louisiana Nursing Home Association and is chairman of a disaster planning committee at the American Health Care Association, said the industry has come a long way since 2005's Katrina, but he said Sandy and other storms have shown there is room for improvement.
Speaking by phone Wednesday from a health care association meeting in Washington, D.C., where the Sandy experience was being discussed, he said there should be better systems for tracking displaced patients and making their medical files available electronically to the facilities that receive them.
He also said there needs to be better regional planning for catastrophic emergencies, in which multiple facilities are scrambling for scarce beds and resources.
The Sandy evacuation in New York City was complicated by a decision by public health officials not to order patients moved from low-lying homes in advance of the storm, as they had a year earlier for Tropical Storm Irene.
They hesitated for good reason. Medical experts say evacuations can push frail patients into a sudden decline. Death rates among nursing home patients often spike in the 30 to 90 days after an evacuation.
But the delay upended planning at places like Sea Crest. The home's executive director, Michael Schrieber, said that his staff had drilled for evacuations, but that the detailed plan assumed patients would be removed before a storm, not during a power outage.
"Everything that I had called for an elevator," he said, but the lifts were knocked out by flooding. Staff members were carrying patients out down flights of stairs and were so exhausted that National Guard troops were brought in to help.
In some states where hurricanes are more common, including Louisiana and Florida, nursing homes are required to have detailed plans specifying where their patients will be taken in an evacuation, but there is no such requirement in New York.
That meant that when Sandy struck, placements were done on the fly. In several cases, patients stayed put for many hours, or even days, while officials at a command center in Brooklyn figured out which facilities could take them.
"It was a struggle to find beds," New York City Health Commissioner Dr. Thomas Farley said in testimony before city council members last month.
Sea Crest's disaster plan called for it to send up to 40 patients to the Workmen's Circle MultiCare Center, in the Bronx, but in the confusion, bus and ambulance drivers took 99 patients there, leaving the facility scrambling to find extra cots and mattresses, which were lined up on the floor.
Workmen's Circle's director, Larry Abrams, said the home's staff made a heroic effort to make the newcomers comfortable, but administrators also decided keeping so many extra people wouldn't be safe. They spent the next day finding alternative placements for almost all the evacuees.
"I can only imagine how they felt," he said of the patients.
With phone service out at damaged nursing homes, some relatives had problems tracking where residents had been taken.
Sherri Gonzalez said she made frantic phone calls for two weeks from her home in Miami before her family was able to locate her 90-year-old father, Morris Markowitz, who had been evacuated from the flooded Shoreview Nursing Home to the Crown Nursing and Rehabilitation Center in Brooklyn.
"I kept calling the place. Nothing. The phone just rings," she said.
New York State Department of Health spokesman Bill Schwarz said that overall, the evacuations were a success, but he promised all aspects of the operation would get a thorough review in coming months.
"We protected a lot of people in dire circumstances ... but no, it wasn't perfect," Schwarz said.