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Nursing Home Safety – Government Recommendations

Published on Mar 31, 2014 at 8:03 am in Nursing Home Abuse.

nursing home abuse studiesLast year, the federal government undertook a review of care that Medicare patients receive when being discharged from a hospital for post-acute care at skilled nursing facilities. (Up to 90% of skilled nursing facilities are dually certified as both SNF and nursing homes.)

The findings, issued in February, were alarming. Up to one in five residents experienced an adverse event that negatively impacted their health. Worse, up to 69% of those events were found to be preventable.

The report, issued by the U.S. Department of Health and Human Services, Office of Inspector General (OIG), noted that the study replicated the methods used in the 2010 OIG study of hospital adverse events. This report provided the first national incidence rate of adverse events in skilled nursing facilities.

The study found that “22 percent of Medicare beneficiaries experienced adverse events during their SNF stays, resulting in prolonged SNFs stays or hospitalizations, permanent harm, life-sustaining intervention, or death.”

In addition to the alarming concern for patient’s health, the report noted that “hospitalizations necessitated by the events increased costs to Medicare by an estimated $208 million in a single month.”


The OIG found that systemic improvements in patient care at skilled nursing facilities will require a “coordinated response to include both providers and overseers.” The recommended response includes promoting awareness of the common adverse events in nursing homes and educating government surveyors on how to spot problems:

  • Create and promote a list of potential nursing home events – A critical component of the recommended fix is to help providers identify these events and to correct them.
  • Include potential events in federal quality guidance to nursing homes – Guidance should include strategies and best practices for handling common potentially adverse events.
  • Encourage nursing homes to report adverse events – Routine reporting, similar to that urged in hospitals, will help establish event identification in nursing facilities.
  • Instruct nursing home surveyors to review facility practices – Federal regulators should encourage state survey agencies to include an assessment of adverse events in their evaluations.

This approach follows the model used to address adverse events occurring in hospitals. The OIG states that these guidelines for nursing homes can be added to the approach now being taken at hospitals to ensure that safe practices extend to post-acute recovery.