Investigation of Post-Hurricane Irma Nursing Home Fatalities Highlights Importance of Safety Culture

By September 20, 2017 No Comments

The death toll from Hurricane Irma now hovers around 80 people, and estimates say that 1.5 million homes and businesses in Florida remained without power in sweltering heat, five days after the historically strong storm ripped through Florida and the Southeast.

UPDATE: The death toll from this incident has risen to fourteen. More information here.

One of the most tragic stories to emerge out of the wreckage was that of the deaths of eight patients at a Hollywood, Florida nursing home, likely due to heat exposure. It remains unclear why patients were not evacuated sooner, and local officials stated that nursing home staff failed to inform them of the extreme conditions and potential danger.

Three of the victims were found dead at the facility and the others died on the way to the hospital or after they arrived there, according to Hollywood Police Chief Tom Sanchez and as reported by Bloomberg. After getting a call at 4 AM Wednesday that someone had died at the home at Hollywood Hills, police arrived to find it was extremely hot on the building’s second floor. In addition to fatalities, they found other residents who were gravely ill. A criminal probe has been opened and more patients may still succumb to their injuries.

Learning from Tragedy

Reports indicate that the staff at the Hollywood facility tried to keep patients cool with fans ahead of the crisis, but the incident likely reveals a lack of an appropriate chain of command and insufficient facility policies.

We’ve posted before on Commonwealth Insights about how diligence regarding workers’ comp concerns can improve profitability in health care settings. Check that out here. To learn from this case however, it’s important to address the notion of “safety culture.”

What is Safety Culture?

According to the ACNSI Human Factors Study Group, the safety culture of an organization is: “the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.”

The same study group determined that symptoms of poor cultural factors include:

  • widespread routine violations;
  • failure to comply with the company’s own safety management system;
  • and management decisions that appear to put cost or production ahead of safety.

In the Hollywood, Florida patient deaths, management did not inform local officials that they were having trouble dealing with the heat, or that the power had been out for too long. The cost of evacuating the patients may have factored into that decision, and the fact that no one from the staff sought external help indicates a failure to comply with standards for patient safety.

As EHS Today explains in its article “Building the Foundation for the Sustainable Safety Culture,” accountability is key, and management must encourage a distinction between “forward-looking accountability” and “backward-looking accountability.”

Backward-looking accountability is about assigning blame; finding the individual who made the mistake and delivering punishment. Meanwhile, forward-looking accountability identifies changes that need to be made, and assigns responsibility for making those changes. Accountability in a positive safety culture is focused around making changes – building safe habits and a safe physical environment – that will prevent a recurrence, not on punishing those who made the mistake.

Due to the extreme nature of the mistakes made in Irma’s wake at the Hollywood facility, punishment from several sources will need to occur, however, nursing homes and assisted living facilities can learn from this horrible circumstance. Whether it is patient safety, staff safety, or both, empowering employees to speak out can truly prevent tragedy.