A Guide to Crisis Management in Long Term Care Facilities

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his article provides LTC managers with guidance on how to prepare for crises in advance and the steps to take when such situations arise. It then explains what to do after crises, when a crisis management team will reassess its process. 

After a debrief of her team’s immense success in managing the Texas power outage of February 2021,  Melissa Orth, the president and CEO of The Legacy Senior Communities in Plano, Texas, decided that they had the proper system in place. Still, they decided that even more could be done. “We all felt that we need to be doing more of that proactive planning in case something crazy happens again,” she said. Orth talked to Peter Murphy Lewis on the LTC Heroes podcast about the planned and unplanned elements of crisis management in LTC.

What is Crisis Management 

Crisis management means making plans before an emergency strikes in the form of any disrupting event, ranging from impending viral pandemics to small-scale office equipment malfunction. Essentially, crisis management is the art of minimizing the damage done to organizations and their stakeholders by sudden, unplanned events. It is a process of managing the perception, response, and impact of an event that has the potential to negatively affect your reputation. 

While it might seem that crises are rare, the reality is that 69% of organizational leaders experienced at least one corporate crisis from 2014 to 2019, with the average number of crises experienced being three. 

In long term care, crises are related to unexpected events that have a negative or disruptive influence on resident life, quality of care, staffing, or even profit margins. Examples of such unexpected events include losing employees and residents to casualties, natural disasters, the spread of infection within the facility, and food poisoning.

A good crisis management strategy can help prevent emergencies from happening in the first place. And if an unexpected event does occur in your facility, your team’s crisis management team can mitigate the damage done. To get a better idea of what an emergency plan is, take a look at the components listed for emergency preparedness plans in the state of Virginia as organized by the JSI Research & Training Institute: 

• Setting the context for emergency preparedness planning
  • Identifying essential functions
  • Identifying critical resources
  • Hazard vulnerability assessment
  • Facility profile
  • Coordination with local and state level emergency management partners
• Critical emergency planning areas
  • Establishing chain of command and roles for an emergency
  • Setting up redundant communications systems
  • Human resources: staffing in an emergency
  • Planning for sheltering in place
  • Planning for evacuation

The Importance of Crisis Management and Crisis Prevention in LTC 

Imagine a regular day at your facility. The RN nurses clock in for their early morning shift and begin their rounds of administering oral medication. You have a yoga hour planned at two in the afternoon. The kitchen was checked thoroughly just yesterday for an upcoming survey. And then, a resident drops her metal bowl of food on the ground, breaking a floor tile. By the time a nurse shows up, another resident has already fallen, bruised himself on the tile, and is bleeding. 

Crisis prevention and management’s answer to this problem would not be to keep a nurse alert at all times nor to store extra tiles. Rather, it would be to use paper utensils. This is just one example of how crisis management in an LTC setting can be unpredictable and call for unexpected measures. 

The benefits of crisis management and crisis prevention In LTC

Long term care environments are tense due to problems with staffing, cultural differences, functional isolation from visitors and families, safety and infection issues, limited visiting hours and pandemic restrictions, and communication breakdowns between staff and residents with cognitive impairment. 

Residents are generally vulnerable, have comorbidities, and need constant care and attention, meaning even a minute of inattention can mean the loss of life. Hence the high-stakes nature of nursing homes makes them conducive environments for crises. 

Fortunately, some LTC facilities have been able to improve employee morale and increase the quality of care provided by implementing disaster drills and CERT Training. Further, a crisis strategy that puts residents at less of a risk could likely increase the satisfaction levels of both residents and employees; crisis management benefits the entire facility, as it translates to fewer injuries among residents, which makes the jobs of your staff easier and more manageable. 

Properly implementing preventative strategies will also help with the turnover rate of your staff. Those who pursue the career path of becoming a long term care nurse want to help people. But they do not expect that to include the stress of facing emergency situations unaccompanied by leadership. Losing just one nurse will cost a facility thousands of dollars. Elaborate protocols for crisis management will alleviate emergency-related concerns and, thus, could be instrumental in solving the staffing problem in LTC. 

Crisis management will benefit your facility in that: 

• Your staff may be able to handle a crisis before it is necessary to call in outside agencies. Prevention and preparedness are better than damage control.
• There may be a lower turnover rate among your staff members, who now find their work more fulfilling and safe. As you know, the turnover rate has only worsened following the outbreak of the COVID-19 pandemic, though more flexible schedules, mentorship, and training resources are methods you can use to reverse that trend at your facility. 

• Quality care will not be compromised. By quickly discovering an issue internally, you will prevent it from emerging in the form of complaints or lawsuits. You can prevent fines, litigations, and penalties with proper crisis management. Use this surveyor checklist to grade your facility’s emergency preparedness and get ahead of potential disaster. 
• Your residents and family members will feel reassured knowing that management is doing all that they can to keep them and their loved ones safe. That means a better reputation for your facility and more referrals from hospitals. 
• A crisis will have less of a negative impact on your facility. That is great for the longevity and sustainability of your facility
• There will be an increase in occupancy rates and the need for fewer staff members since the ones currently employed are adequately trained.

Meanwhile, the consequences of neglecting to put a crisis management strategy in place range from:

• Being fined by the government due to lack of compliance
• Putting residents’ lives in danger
• Risking your facility being shut down due to irrecoverable losses and public disgrace

Thus, it is always best to be prepared for an upcoming crisis by taking the time to formulate an effective and thorough plan. 

Implementing a Crisis Management Strategy at Your LTC Facility

Implementing a crisis management strategy requires that you dedicate a sizable portion of your resources to devising a crisis management plan that flows in accordance with the stages of crisis, which can be reduced to the following four main stages:

1. Prodromal: This is the pre-crisis stage, the calm before the storm. At this point, nothing has really happened yet, and you may not even be aware of what is to come. This is the green zone, where you should be working on your protocols and strengthening your crisis management team. Any and all preparation done in this stage can be the determinant of how a crisis will affect your facility. To start preparing, you will need two things: a crisis management team and a detailed protocol.
2. Acute: This is when a crisis occurs. It is sudden, but only disastrous if you are completely unprepared. Remember, a crisis can only turn disastrous if you let it. Not everyone can turn it into an opportunity, but it’s best to be prepared.

3. Chronic: This is the clean-up stage. This is where the storm has passed leaving behind remains. The former step required resilience, but this is where the real work starts.
4. Resolution: This is the recovery phase and occurs post-crisis. At this point, you will either return to the prodromal stage or remain stuck in the acute or chronic stages depending on how well your staff handles a given crisis and how quickly your facility recovers from it.

A Checklist for the Prodromal Stage of Crisis Management and Crisis Prevention in Long Term Care 

The prodromal stage is an opportunity for you and your team to mitigate or even prevent a crisis before it occurs. It is the most impactful stage of the entire process and requires serious dedication and decisive leadership. The two key things to do at this stage are build a team and develop protocols that can be strictly followed. 

Creating a crisis management team

Ideally, crisis management team (CMT) members should be drawn from throughout the organization and across roles to ensure that personnel with varied qualifications are available for action. The steps needed to build a team that can prevent crises will vary from facility to facility depending on the health of residents, the number and qualification of staff, and available resources. Still, some elements are shared. Regardless of the particular situation of your facility, you will want to: 

1. Organize a strong team: The composition of the crisis management team should be decided on by participating co-directors and nursing leaders. Emphasis should be placed on a need for at least one RN who is trained in CPR and first aid and has both leadership skills and experience. Once selected, this individual will be asked to serve as a liaison when communicating with members of the board of directors or the public.

2. Establish staff awareness: It is essential that all members of a crisis management team are aware of the steps that were involved in devising a crisis plan as well as the emergency procedures your leadership team chooses to adopt. By making sure that all are aware of the expectations at your facility, team members will know what to do before a situation gets out of hand. Unfortunately, only 26% of organizations have crisis plans that are “well known” by their CMT. Make sure yours is not one of them. 
3. Establish resident awareness: All residents need to be made aware of the plan to both provide assurance and get them better prepared as well. Staff should be able to answer any questions the residents may have. Further, the staff should encourage residents to be involved in developing a crisis plan.
4. Facilitate regular training: Annual training will most likely be needed. At the start of each year, all team members should review what they learned the previous year in relation to their position on the CMT. 

After forming a well-equipped crisis management team, you will need to provide them with protocols that determine the responsibilities of each member so that they can take swift action at the time of a crisis.

Creating prevention protocols

Crisis management protocol is a series of steps to follow in the event that an accident or emergency occurs. It is crucial for LTC facilities and home health care agencies to have such systems in place so that the role of each team member is clear and actionable. Each facility must develop unique protocols appropriate for their situation with the help of professionals. The following are some guidelines you will want to follow to get started:

1. Conduct situation analysis: Intelligence-gathering is your first priority. You must have sufficient information on hand to guide staff appropriately. Jot down every single scenario you can think of going wrong – from an elevated heart rate to a worldwide pandemic to a financial crunch – and then organize it appropriately. 

2. Draw commonalities: With all the bad scenarios in front of you, it is now time to figure out what each will require and group items together when possible. For instance, a financial crunch and a worldwide pandemic will both need hefty monetary resources. A resident’s elevated heart rate and the pandemic will both need great communication between your team and the ability to lead. And a pandemic and financial crunch both require the ability to think out of the box and ration resources. 
3. Reassess: Based on these commonalities, list the number of things – not the number of disasters – for which you need to be prepared. This is because potential disasters are innumerable and hence beyond control. Of course, certain circumstances will require their own protocols. For instance, if your facility is on a fault line, you will want to keep an earthquake kit ready and make sure every single person on the team knows the protocol. 
4. Draft Protocol: Consider seeking the counsel of a professional or outsider in drafting a protocol. The CDC and a number of NGOs have various checklists available for download of protocols that account for probable disasters and crises. If you decide to use a template, make sure to tweak it for your facility.
5. Communicate: Once your protocols are ready, go over them every quarter with your team. Practicing a few days a year will ensure that everyone remembers to do their job in a high-pressure situation. New staff members need to be trained as soon as they join your facility. Display these protocols and your floor plan on your facility’s notice board. You should also ask a few healthy residents to volunteer to teach their peers. 

The most important step in the protocol procedure is communication. In order to properly convey what needs to be done, your protocol should be simple and efficient. Too many details will make your protocol hard to remember and unlikely to be followed correctly. Of course, unprecedented circumstances, like the COVID-19 pandemic, require added attention and some improvisation. “I have found that the best way to manage and lead with COVID is to be as informed as you can,” Orth said. At the same time, there comes a certain point where you will have to act based on instinct. “You have to just trust your gut since there is no manual.”

You can use the detailed checklist provided by the Centers for Medicare & Medicaid Services (CMS) to get ideas about everything from evacuation plans to transferring residents.

A Checklist for the Acute Stage

This is the most challenging phase of a crisis, as it involves:

1. Implementation of the protocol: If you have taken the necessary steps to prevent, mitigate and recover from the crisis, this stage is a lot easier. All safety precautions must be made beforehand. If a protocol is well-designed, your facility will be impacted minimally. Supervisors should know what to do when an emergency occurs. If, however, the plan derails or the crisis is unprecedented and impossible to handle in-house, supervisors should notify their staff, other managers on duty, and their regional emergency coordinator immediately. 
2. Communication: Communication within the crisis management team is absolutely crucial at this point. Have your electronic devices handy and keep a human count of your team members, even if there are only five of them. You will not have the time to look for, call upon, or call your team members. 
3. Resilience: To put it simply, if you follow the protocol and inform the stakeholders, all you can really do is wait it out. Remaining calm in the eye of the storm takes a great deal of strength, especially knowing that you will have to deal with the ramifications when it has blown over.

It takes great leadership to implement these steps effectively. Orth is a prime example of such a leader in long term care settings. She attributes this ability to her being put in challenging situations in a variety of contexts. “The types of decisions you have to make grow over time. As you learn things at each place, they collectively make you more prepared for the next event or decision,” Orth said in her interview.

During the Texas power outages of February 2021, Orth used her past experiences and knowledge to aid her decision-making process. While the freezing weather was disastrous for many, the battle-tested Orth was able to make life-changing decisions to keep all of the residents at numerous facilities safe from the cold. And she did so while preventing the spread of COVID-19 from one campus to another.

A Checklist for the Chronic Stage

This is the cleanup stage in disaster management and involves:

1. Communication: This is where you will have to make a lot of calls and inform stakeholders of all the happenings and assure them of the results. Each person on the CMT team, your staff members, families of the residents, supervisors, senior management, and even government officials need to know what happened during the crisis.
2. Reporting: All data, quantitative and qualitative, needs to be collected and analyzed. You will have to prepare charts, give press releases, and release the report for the stakeholders to view and form questions. Remember, the report is not only about the disaster but also an assessment of how your facility handled it, the protocols in place, and the lasting impact of the crisis. It is completely possible that you may not be able to report all findings or have incomplete data. However, it is best to document everything as much as possible.

If you did not have a strong CMT or the proper protocols in place, the chronic stage can be the lengthiest. This is because it might then include damage control, paying fines, and issuing apologies. Handling this stage well requires a good deal of resilience and discipline, and it should only be carried out under the guidance of a leader or the head of the CMT.

Sometimes such damage control will be necessary even if you took the steps to properly prepare your facility. This could be because team members were not on the same page at the time of crisis or simply unforeseen circumstances. “You can put all the protocols in place, but you don’t always have the answer as to how someone becomes infected, or how that spread happens,” Orth said. “Sometimes you can trace it back and say, ‘Oh, you know, these protocols weren’t being followed, and we need to tighten them.’ But other times, it’s just a mystery and remains a mystery.” 

A Checklist for the Crisis Resolution Stage

In the last stage in crisis management, everything is back to normal and there are, again, no signs of an impending crisis. This means that you are back to the prodromal stage only with better protocols in place. As such, this stage consists of reflection and further preparation in the form of: 

Reassessment, documentation, and edits: Based on the reports gathered in the previous stage, your facility’s staff and the CMT need to decide how you failed, what went right, and where things can be improved. You must then make changes to your protocols in accordance with the conclusions drawn. Changes can mean more thoroughly preparing your team, establishing better communication, or editing the entire process. 

Summary

Crisis management preparation is a challenging and time-consuming process. However, putting the proper protocols in place is worth the effort, as proper planning will help your organization recover from an incident more quickly and efficiently. 

The key components of crisis management plans include creating a team that will carry out tasks during crises and establishing clear roles and responsibilities. You must also establish the procedures for reporting what happened during a crisis so that your staff knows what information needs to be shared publicly or internally. 

By heeding this advice and making preparations in advance, you will be able to avoid chaos should disaster strike. While there is no one-size-fits-all process for long term care facilities, the steps outlined here will give you a head start on finding what works for you. 

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