When a record heat wave swept across Europe in the summer of 2003, elderly Parisians were particularly hard hit. “French heat toll almost 15,000,” screamed one BBC headline in September. The cause of death: dehydration and hyperthermia. The diagnosis of the problem: not enough air conditioning, made worse by too many physicians on vacation in August. Across Europe, over 70,000 people died of heat-related causes. We thought we were immune: our nursing homes are air conditioned and we have plenty of nurses, doctors, and regulations. But now we have the disturbing reports of 8 deaths among nursing home residents of a facility in Florida in the aftermath of Hurricane Irma. The nursing home lost power and its back-up generator was useless when a critical component, the transformer, failed. Despite access to an acute care hospital across the street, no one thought to transfer the frail, elderly long term care residents until they were already suffering from severe dehydration and/or hyperthermia. What can we learn from this very sad story?
First, we should drill down and look at the specific facility where the problem occurred. All of the west coast of Florida was affected by the hurricane, after all, but only one nursing home lost patients. The Rehabilitation Center of Hollywood Hills is a Medicare and Medicaid licensed 152 bed facility. It is a for-profit nursing home. And if we consult Nursing Home Compare, the site operated by the Centers for Medicare and Medicaid Services to allow consumers to compare the quality of different nursing homes, we find that the home currently has an overall rating of two stars, or below average. Even more revealing is the further breakdown: in the area of health inspections, it received only one star, or much below average, though in quality it got three stars (average) and in terms of the staff: patient ratio it actually got four stars (above average). So what exactly does this mean?
The problem at Hollywood Hills was not a failure to follow the rules—the facility had a back up generator and supplies for seven days (though their ice collection was presumably not terribly useful if they had no refrigeration). The problem was judgment. Nobody in charge determined that conditions were too dangerous and residents needed to be evacuated. They only figured that out after people began dying, although it takes a couple of days for a lethal degree of dehydration to set in. What our current evaluation system for nursing home lacks is the capacity to measure the ability to respond to novel challenges, to be creative. Perhaps we need to set objective standards, not merely relative standards. If we set the bar high enough, then the lowest performing facilities would still be adequate. That said, it’s striking that the overall rating of the facility was poor. Nursing Home Compare is on to something—we need to have a better way of insuring that the poorer facilities improve.