HospitalInspections.org

Based on review of disaster plans, disaster evaluation form, and staff interviews, the facility failed to provide effective communication to a patient, and training to staff to ensure the safety and well-being of patients for tornado disasters. This involves Patient #6 on 6/13/13.

The findings include:

Patient #6 was admitted 6/9/2013 with a right hip fracture after a fall at an assisted living facility. She required a right hip arthroplasty on the evening of 6/10/2013. She had an uneventful recovery, except for requiring maximal assist of nursing and physical therapy staff. She was discharged from the hospital on 6/13/2013 to return to the assisted living facility for further rehabilitation.

On the day of her discharge, her family member recounted a severe weather event in the area of the hospital causing a National Weather Alert of a "Tornado Warning". The hospital sounded a page "Code Orange" alert to the hospital staff. Shortly after the page, a staff member closed the door of Patient #6, but she was not made aware of what was happening. There was no attempt to close the blinds, move her bed from the window, or communicate to her why her door was being shut.

According to the hospital's disaster plan titled "Severe Weather Response" dated 7/12, a Code Orange means that tornados have been cited in the immediate area. The Hospital Incident Command Center will be established anytime a Tornado Warning is sounded for Loudoun or Fairfax County. Requirements for all staff includes:
- pull the orange tool kit (a folder with papers and forms to list patient status and available staff);
- assess the unit;
- assess staffing in their departments and inform the command center;
- all hallways should be cleared at this time.

The disaster evaluation form of the incident 6/13/2013 documented that the initial response was correct per policy, but in retrospect there were some areas that could have improved. The disaster evaluation identfied areas for improvement as: biggest area for improvement is the notification to the patients, so they are informed of the situation, and what hospital staff are doing to protect them Patient blinds should have been shut and patients should have been moved away from the windiows, or later in the hallways for their protection. Also indicated was there was only one phone number for staff to call in their status.

The surgical wing unit director was concerned that the patient room doors were shut without verbal communication from the staff of the reasons why this was done. Also there was some difficulty in filling out the form and communicating that information to the Command Center.

On 8/6/13 at 10:00 a.m. Staff #6 (a nursing tech) stated that if a Code Orange was called, she would close the door and wait for nurse directions. After some hesitation, she said she would go to every room and make sure someone was with the patients. She would probably leave them in the bed, or maybe wheel them out. She was not sure what a Code Orange meant.

On 8/6/13 at 10:20 a.m. Staff #7 (a nursing tech) stated that if a Code Orange was called, she would talk to the patients and reassure them. She started to say she would close all the doors, but then remembered that was for a Code Red. She was not aware of what Code Orange meant.

On 8/6/13 at 10:40 a.m. Staff #8 (a nurse) stated she would go to the file and start to list number of patients who would ambulate, and who must stay in bed. She would try to tell the patients what was happening, close the doors, check on patients, and call the Command Center. She was also not familiar as to what a Code Orange meant, but she would look it up in the orange Disaster File.

According to the the Quality Improvement Director interviewed on 6/5/13, the Emergency Preparedness Committee stated all staff are educated on Disaster Drills once per year. She went on to say that the hospital was aware that the staff on Patient #6's floor did not properly initiate all of the steps of the Tornado Warning, including communicating to the patients who might be concerned.