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Government Report Finds Substandard Care in Nursing Homes

Published on Mar 17, 2014 at 7:44 pm in Nursing Home Abuse.

The federal government has issued an alarming report, finding that up to one in five Medicare patients in skilled nursing facilities experience an adverse medical event within the first 35 days of care.

The report, titled “Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries,” was issued by the U.S. Department of Health and Human Services, Office of Inspector General in February 2014.

The Study

The findings came from what began as a series of studies about hospital adverse events, to determine the extent to which they are preventable, and to measure the cost to the Medicare program. The studies extended into a review of post-acute care in skilled nursing facilities (SNF). Up to 90% of skilled nursing facilities are dually certified as both SNF and nursing homes.

They looked at a sample of 653 nursing home patients who were in the Medicare program and discharged from a hospital to post-acute care at a nursing home for up to 35 days. The period covered was from 2008–2012.

The Findings

The study looked for “adverse events.” In this case, adverse events are defined as harm resulting from medical care. This can include failure to provide needed care, and also errors, and substandard care that leads to harm like infections.

As many as 22% of the residents experienced an adverse event while in nursing home care. That’s one in five.

The adverse events broke down into the follow categories:

  1. Event lead to prolonged SNF stay or transfer to hospital – 80%
  2. Event lead to permanent harm – 0%
  3. Event lead to life-sustaining intervention – 14%
  4. Event lead to death – 6%

According to the DHS report, the events were sorted into three clinical categories: events
related to medication (37%), events related to ongoing resident care (37%), and events related to infections (26%).

Adverse events don’t always involve error or negligence, but doctors who reviewed the files found that 59% of those events were “clearly or likely preventable.” Much of the harm was found to be caused by:

  • Substandard treatment
  • Inadequate resident monitoring
  • Failure or delay of necessary care

The journalism site Propublica reports that, “Patient safety experts told ProPublica they were alarmed because the frequency of people harmed under skilled nursing care exceeds that of hospitals, where medical errors receive the most attention.”

The National Consumer Voice for Quality Long-Term Care (Consumer Voice) is calling for minimum nursing home staffing standards in response to the report.