It does not take a hurricane to put nursing home residents at risk when disaster strikes.
Around the country, facilities have been caught unprepared for far more mundane emergencies than the hurricanes that struck Florida and Houston, according to an examination of federal inspection records. And these nursing homes rarely face severe reprimands, even when inspectors identify repeated lapses.
In some cases, nursing homes failed to prepare for even the most basic contingencies.
In one visit last May, inspectors found that an El Paso, Texas, nursing home had no plan for how to bring wheelchair-dependent people down the stairs in case of an evacuation. Inspectors in Colorado found a nursing home's courtyard gate locked and that employees did not know the combination, records show. During a fire at a Chicago facility, residents were evacuated in the wrong order, starting with the people farthest from the blaze.
Nursing home inspectors issued 2,300 violations of emergency-planning rules during the past four years. But they labeled only 20 so serious as to place residents in danger, the records show.
In addition, a third of U.S. nursing homes have been cited for failing to inspect their generators each week or to test them monthly. None of those violations was categorized as a major deficiency, even at 1,373 nursing facilities that were cited more than once for neglecting generator upkeep, the records show.
A lack of backup power is being investigated as a factor that could have contributed to the deaths of eight people on Sept. 13 at the Rehabilitation Center at Hollywood Hills, Fla., following Hurricane Irma.
"That's the essential problem with the regulatory system: It misses many issues, and even when it identifies them, it doesn't treat them seriously enough," says Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy. "It's always the same story: We have some pretty good standards and we don't enforce them."
The deaths at the Rehabilitation Center have focused attention on new federal disaster-planning rules, with which nursing homes must comply by mid-November. Those rules were prompted by nursing home and hospital deaths during Hurricane Katrina in Louisiana in 2005.
Dr. David Gifford, senior vice president for quality and regulatory affairs at the American Health Care Association, a nursing home industry group, says facilities have gotten better at handling disasters after each one. Most evacuations go smoothly, he says.
"After each one of these emergencies we've learned and gotten better," Gifford says.
But advocates for the elderly say enforcement of rules remains as great a concern, if not greater.
Dr. David Marcozzi, a former director of the federal emergency preparedness program for health care, says that inspectors — also known as surveyors — should observe nursing home staff demonstrating their emergency plans rather than just checking that they have been written down.
"If you have not implemented and exercised plans, they are paper tigers," says Marcozzi, now an associate professor at the University of Maryland School of Medicine. "The emphasis from the surveyor has to be 'Show me how you do this.' "
But Gifford says preplanning and drills, which are important, go only so far in chaotic events such as hurricanes.
"No matter what planning you might have, what we have learned from these emergencies is these plans don't always work," he says. Nursing homes take surveys seriously and face closure if they do not fix flaws inspectors identify, he added.
Inspection results vary widely by state, influenced sometimes by lax nursing homes or more assertive surveyors, or a combination, according to an analysis of emergency-planning deficiencies.
In California, 53 percent of nursing facilities have been cited for at least one of two deficiencies related to emergency preparation: training employees what to do in an emergency and carrying out unannounced staff drills; or having a detailed written plan for disasters and emergencies, such as fire, severe weather and missing residents. In Texas, one-quarter of nursing homes have been cited. No nursing home in Indiana, Mississippi or Oregon was issued violations for those deficiencies in the past four years.
The danger of high temperatures for elderly residents, which the Hollywood Hills case shows can be disastrous, has been well-known. In a heat wave in 2000, two nursing home residents in a Burlingame, Calif., facility died and six others suffered severe dehydration, heat stroke or exhaustion.
During the past four years, inspectors have cited 536 nursing homes for failing to maintain comfortable and safe temperature levels for residents. Inspectors deemed 15 violations as serious, including two where patients were harmed, records show.
"There is undoubtedly little, if any, enforcement of the laws since we see the same tragedies repeated time and again," says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform.
Asked to explain the rarity of severe citations for lapses in emergency preparation, the federal Centers for Medicare & Medicaid Services, which oversees inspections, referred a reporter to its emergency-preparedness mission statement on its website.
This story was produced as part of a partnership with Kaiser Health News, a nonprofit health newsroom and editorially independent part of the Kaiser Family Foundation.