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Inspector General's Report Underscores Need for Better Staffing and Better Enforcement of Quality Standards

March 5, 2014 – The Health and Human Services Office of Inspector General (OIG) recently reported that 32% of Medicare beneficiaries who went to skilled nursing facilities (SNFs) and spent an average of 15.5 days in the SNF in August 2011 experienced an adverse event or other harm (Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries, OEI-06-11-00370 (Feb. 2014)). OIG has previously reported deficiencies in hospitals, with 27% of patients in acute care hospitals experiencing adverse events, yet this is the first national study of the much higher SNF rate, which is cause for great concern. The Center for Medicare Advocacy thanks the OIG for bringing attention to the poor care that is preventable but experienced by far too many nursing home residents. 

Physician reviewers working with OIG found that 59% of the adverse events and incidents of harm, including falls, pressure ulcers and medication errors, were preventable. The Inspector General (IG) calculated that 1,538 residents died, 10,742 residents experienced harm and Medicare paid $208 million for hospitalizations of nursing home residents, just in the month of August 2011. “The Inspector General found that many adverse events and harm incidents were caused by staff's failures to monitor residents or provide prompt care, underscoring, once again, that staffing levels in SNFs are grossly inadequate,” said Toby S. Edelman, Senior Policy Attorney, Center for Medicare Advocacy. “More registered nurses and more nursing staff in general are needed to provide residents with the care they need to function at the highest possible level,” Ms. Edelman added.

The Centers for Medicare & Medicaid Services (CMS), which administers the Medicare program, responded to the report by saying that it would incorporate recommendations in new rules for Quality Assessment and Performance Improvement (QAPI) regulations.

"By focusing solely on QAPI, CMS has ignored the need for stronger enforcement of existing federal standards of care," added Ms. Edelman. "Much of the harm identified by the IG – residents' falls, pressure sores, inadequately monitored medications leading to hospitalizations – is the result of facilities' failure to provide care to residents that federal law mandates and has mandated since 1990. CMS needs to step up and fulfill its role as a regulatory agency to ensure, in the words of the 1987 Nursing Home Reform Law, that the Requirements governing care of residents, and enforcement of those requirements, are ‘adequate to protect the health, safety, welfare, and rights of residents and to promote the effective and efficient use of public moneys.'"

The Inspector General’s report confirms what the Center for Medicare Advocacy and other advocates for residents have contended for many years – that enforcement of federal standards of care has not been adequate to protect residents from preventable harm and death.


Please contact Lauren Weybrew at or call 646-214-0514 if you’d like to speak with a representative of the Center for Medicare Advocacy. Learn more about the Center for Medicare Advocacy, Inc. at

The Center for Medicare Advocacy, Inc., established in 1986, is a national nonprofit, nonpartisan organization that provides education, advocacy and legal assistance to help older people and people with disabilities obtain access to Medicare and necessary health care. We focus on the needs of Medicare beneficiaries, people with chronic conditions, and those in need of long-term care. The organization is involved in writing, education, and advocacy activities of importance to Medicare beneficiaries nationwide.

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