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In its first analysis of adverse events in skilled nursing facilities (SNFs), the Department of Health and Human Services' Office of Inspector General (OIG) reports that care is poor and dangerous for many residents.  OIG reports that nearly one in three Medicare beneficiaries who went to SNFs for 35 days or fewer in August 2011 (and who spent an average of 15.5 days in the SNF) experienced an adverse event or other harm, for example falls, avoidable infections, pressure sores, improper medication dosing, hospitalizations, and death.[1]  OIG determined that

  • 22% of residents experienced an adverse event during their stay in the SNF[2] and that an additional 11% of residents experienced events leading to "temporary harm," [3] totaling 32% of residents.
  • 59% of the adverse events and incidents of temporary harm were preventable[4] and "many events were the result of failure by SNF staff to monitor residents or staff delay in providing necessary medical care."[5]   
  • "Factors that contributed to preventable adverse and temporary harm events included substandard treatment, inadequate resident monitoring, and failing to provide treatments."[6]
  • More than half of the residents who experienced harm were hospitalized, "with an estimated cost to Medicare of $208 million in August 2011."[7] 
  • "[A]n estimated 1.5 percent of Medicare SNF residents [1,538 individuals] experienced events that contributed to their deaths" in August 2011. [8]  For most of the residents who died, death was "likely not an expected outcome."[9] 

Adverse events were related to

  • Medication (37%), including medication-induced delirium or other change in mental status (12%)
  • Resident care (37%), including fall or other trauma with injury related to resident care (6%), and
  • Infections (26%), including aspiration pneumonia and other respiratory infections (10%)[10]

Temporary events under the same three categories included

  • Medication (43%), including hypoglycemic episodes (e.g., low or significant drop in blood glucose) (16%)
  • Resident care (40%), including pressure ulcers (19%), and
  • Infections (17%).[11]

Physician reviewers found that 59% of the adverse events and harm incidents were preventable.[12]   (69% of adverse events were preventable; 46% of temporary harm events were preventable. [13])  The physicians determined, more specifically, that

  • 66% of medication events were preventable
  • 57% of resident care events were preventable
  • 52% of infection events were preventable[14]

OIG suggested that its study may have underestimated both the number of residents who were harmed and the costs to the Medicare program.[15]

The evaluation was based on a simple random sample of 655 Medicare beneficiaries (out of 100,771 beneficiaries) who met three criteria: they began their SNF stay within one day of discharge from a hospital, they stayed in the SNF for 35 days or fewer, and their SNF stays ended in August 2011.[16]  The average length of stay for residents in the sample was 15.5 days.[17]

Nurses performed an initial screening and referred 262 cases to physicians for review.  The physicians determined that 32% of the 655 Medicare residents experienced an adverse event or temporary harm, according to the classification system of the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) Index.[18]


Many of the adverse events and instances of temporary harm were caused by staffing failures – "failure by SNF staff to monitor residents or staff delay in providing necessary care."[19]  But as the Center recently reported in its analysis of staffing deficiencies in nursing facilities, very few deficiencies in staffing are cited and even the most serious deficiencies – those identified as causing residents "immediate jeopardy" – are frequently not sanctioned in any way.[20]

In a News Release discussing the OIG's report, the Center for Medicare Advocacy criticized the Centers for Medicare & Medicaid Services' (CMS') response to the report,[21] which focused solely on the plan to incorporate the OIG's recommendations in new rules that the agency intends to promulgate for Quality Assessment and Performance Improvement (QAPI) programs.[22]  Since many of the specific failures in care identified by the OIG report (such as falls, pressure sores, and inadequately monitored medication) reflect failure to comply with existing requirements of federal law, the Center called on CMS to "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."[23]


Unfortunately, the Inspector General's report confirms what the Center and many other residents' advocates have reported for years – that enforcement of federal standards of care has not been adequate to protect residents from preventable harm and death.

[1] OIG, Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries, OEI-06-11-00370 (Feb. 2014).  OIG used the classification system of the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) Index:
F     Error occurred that may have contributed to or resulted in harm and required an initial or prolonged facility stay.
G      Error occurred that contributed to or resulted in permanent patient or resident harm.
     H      Error occurred that required intervention to sustain the patient or resident's life.
      I      Error occurred that may have contributed to or resulted in patient or resident death.
Id. 10, Table 1.  OIG defined temporary harm events, according to NCC MERP, as
     E      Error occurred that may have contributed to or resulted in temporary harm and required intervention.
[2] Id. 17.
[3] Id. 20.
[4] Id.22.
[5] Id. 28.
[6] Id. 24.
[7] Id. 25.
[8] Id. 19.
[9] Id.
[10] Id. 18, Table 3.
[11] Id. 21, Table 4.
[12] Id. 22.
[13] Id.
[14] Id. 22-23.
[15] Id. 16.
[16] Id. 12.
[17] Id.
[18] Id. 10.  The NCC MERP categories are identified in note 1, supra.
[19] Id. 28.
[20] See CMA, "Staffing Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned," (Weekly Alert, March 7, 2014),
[21] CMA, "Adverse Events in Nursing Facilities Outpace Hospitals; Inspector General's Report Underscores Need for Better Staffing and Better Enforcement of Quality Standards" (News Release, March 5, 2014),
[22] 42 U.S.C. 11281(c), added by section 6102 of the Affordable Care Act.
[23] See note 22, supra.


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