By Robert A. Belflower, Ph.D.
Faculty Member, Emergency and Disaster Management, American Military University

The U.S. population is aging. There are currently over 50 million U.S. residents age 65 or older. That population is expected to increase to over 70 million by 2030. Yet the percentage of seniors residing in nursing homes is decreasing because more seniors are choosing to live at home or in assisted living facilities.

At the same time, the total number of seniors residing in nursing homes is increasing. An estimated 96% of seniors residing in nursing homes have disabilities that limit their mobility or are suffering from Alzheimer’s disease or another chronic illness. These special needs persons require careful handling and treatment.

Many of these nursing homes are located in southeastern or Gulf Coast states. Unfortunately, these are the regions that are most exposed to annual hurricanes between June and November. That makes nursing home residents especially vulnerable during hurricane season.

For example, 35 residents drowned in St. Bernard’s Parish in Louisiana when Hurricane Katrina flooded the St. Rita’s Nursing Home in 2005. Hurricane Irma caused the heat-related deaths of eight residents of a Hollywood, Florida, nursing home in 2017. If residents are liable to die or be severely injured during hurricanes, why do nursing homes opt for shelter-in-place protocols during these deadly storms?

Evacuation Challenges

There are many reasons why nursing homes often opt not to evacuate their residents in the face of impending danger. Some of the more commonly given reasons are: it is too expensive; we don’t have the transportation; and we don’t have anywhere to go.

What Decisions Come into Play Whether to Shelter in Place or Evacuate?

I interviewed nursing home administrators all around Louisiana to hear directly from them what drove their decisions to shelter in place or evacuate during hurricanes. None of their answers were reasons not to evacuate.

While transportation during evacuations was an additional cost, it was offset by the extra cost for additional staff and overtime pay during shelter-in-place operations. Whether the nursing home sheltered in place or evacuated, there were extra costs to stockpile food, water, medical supplies and daily care products. In the end, there was no appreciable cost difference either way.

Transportation Is Not a Factor in Evacuations

Most Louisiana nursing homes are owned by corporations with many facilities around the state.  Each nursing home owns several multi-passenger vans with wheelchair lifts used for transporting residents to daily doctor appointments. During evacuations, the corporations pool these vans to transport residents confined to wheelchairs.

The vans are supplemented by transportation contracts with commercial bus companies and in some cases with public school districts to evacuate mobile residents. The nursing homes also have contracts with ambulance services to transport residents who are connected to life-saving medical devices. So transportation is also not a factor.

Nowhere to Go Is Not a Factor in Evacuations

During an evacuation, residents are transported from one nursing home to another in a safer location owned by the same corporation. Additionally, many of these corporations have negotiated mutual aid agreements with each other. If residents cannot be evacuated to another nursing home owned by the same corporation, they can be evacuated to a mutual aid nursing home. Nowhere to go is also not a factor.

Residents’ Health Is the Foremost Danger

The nursing facility is the residents’ home. Some residents have been there for many years. They have friends there among the other residents or staff. They may even have relatives living there too. The nursing home is their place of security. Their physical and mental health will likely deteriorate during evacuations.

The nursing home administrators I spoke with described these deteriorating resident conditions:

• “You’re taking very acutely ill patients with so many co-morbidities out into the heat, to load them up on the vans that they’re going to sit in for several hours before they get to their host facilities. Most of these patients are incontinent. You’re looking at a host of problems that moving them creates [such as] skin tears; some are obese. During Katrina, you know, when you have a 400-pound patient, getting them onto a transportation vehicle is a nightmare.”
• “You’re dealing with frail, elderly patients. The actual transportation problem, where they’re at [their] comfort zone is in their room, where they’re safe and they’re taken care of. Now emotionally, they’re lifted up out of that spot, taken to an unknown place, where people they don’t know are taking care of them. They don’t know what’s going on. They don’t know that … they don’t have a good feeling. A lot of those things, anxiety alone, will cause issues to the elderly that are disruptive to multiple areas of their body — mentally, physically, everything. So, psychologically it will take them down, and everybody understands the depressive aspect in the elderly. Once that failure to thrive kicks in, it’s hard to stop it. You don’t want them to think, ‘Ah, I’m leaving, this must be the end.’ And now emotionally they are done, they’re detached.”
• “It was very hard on all of the residents, emotionally, physically, mentally. Being with like 30 something patients for those 14 days [the residents had been evacuated to another nursing home], it was like, ‘You’re not going to leave me; you’re not leaving me.’ The patients themselves, it took a real toll on them. Some of them, after the transfer and the transfer back, you saw a great physical decline. I’d say within a two- or three-month period, we lost patients. So [the relocation] was very profound for them, and they did not understand. Where is my family? Why are they not here? It’s very hard.”
• “Evacuation of a facility and staff, unless it’s absolutely necessary, creates more problems than benefits. Patients deteriorate. Our patients are in a condition that don’t need to be trucked all over the countryside, particularly when there’s an evacuation going on and it’s not routine traffic.”

Why Nursing Home Administrators Prefer to Shelter in Place

Nursing home administrators in Louisiana prefer to shelter in place during hurricanes. Not because it is cheaper, or easier, or because of poor prior planning. It is because they care deeply about the health of the residents. They know from first-hand experience that nursing home residents suffer mentally and physically during evacuations, and those ailments might lead to an untimely death.

If a city or parish emergency manager directs an evacuation, the nursing home administrators obey the order. Even if no evacuation order is given, an administrator will evacuate the nursing home if he or she believes the home is directly threatened by flooding, sustained hurricane force winds, or other physical threat. But given a choice, Louisiana nursing home administrators prefer to shelter in place during hurricanes to preserve the physical and mental well-being of their residents as much as possible.

About the Author

Robert A. Belflower, Ph.D., served on active duty in the U.S. Army for six years before joining Northrop Grumman Corporation for a 32-year career as a program manager. Most recently, he has four years’ experience in higher education as an administrator and faculty member. Decision-making during stress is his research interest. He was a coach at the U.S. Army’s Leaders Training Program that trained brigade and battalion commanders and their staffs during an intense seven-day simulated combat environment.

He was the deputy exercise director for a series of emergency management and consequence management exercises conducted for large school districts, military installations, foreign nations and the U.S. Northern Command. His doctoral dissertation examined the decisions made by nursing home administrators during the approach of a hurricane.