According to a federal report titled “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries,” one in three nursing home residents experienced harm during their stay at a facility. The study, authored by the Office of Inspector General (OIG) in February 2014, investigated adverse incidents in nursing homes from 2008 through 2012. Of those who experienced hard, 59 percent of the incidents were “clearly or likely preventable.”
Among the findings, the report concluded that “Physician reviewers…attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care. Over half of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011. This equate to $2.8 billion in hospital treatment for harm caused in SNFs [Skilled Nursing Facilities] in FY 2011.
Of the harmful incidents that occurred, two-thirds of them were considered serious and one-third were considered temporary. Serious incidents include those that required a longer nursing home stay or hospitalization; incidents that caused permanent injury; incidents that required life-sustaining intervention, or incidents that resulted in death, which occurred in six percent of the adverse events. Temporary harm includes pressure sores, falls that resulted in minor injuries, and medication-induced delirium resulting from misuse of atypical antipsychotic drugs. Moreover, the study revealed that “[a]n estimated 4 percent of Medicare SNF residents experienced at least one ‘cascade’ adverse event, wherein multiple, related events occurred in succession.”
According to Richard Mollot, executive director of the Long Term Care Community Coalition, an organization dedicated to improving the quality of care in nursing homes, the OIG’s findings show a need for more oversight and enforcement of government standards in nursing facilities. He stated, “These findings clearly show that lax enforcement of the minimum safety standards is taking a toll on our most vulnerable citizens, with tragic results. This report should serve as a wake-up call to state legislators and Congress: something has gone terribly wrong with our oversight system…What is the purpose of having standards if they are not enforced?”
In light of the OIG’s study, Mollot also pointed out that his organization recently discovered that the number of financial penalties imposed on nursing homes has been declining. In cases where a nursing home is not meeting quality-of-care standards, the government can impose a fine upon the facility. According to Mollot, the number of financial penalty citations recently fell 33 percent from 3.094 to 1,909 nationwide.
Mollot said, “It is difficult to understand why, in the face of persistent nursing home abuse and neglect, our survey system increasingly shuns enforcement…”