The OIG released a report on March 3, 2014, “Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries,” that examines the national incidence rate, preventability, and cost of adverse events in skilled nursing facilities (SNFs). This report is an outgrowth of a series of studies about hospital adverse events. For purposes of this report, the OIG defined an adverse event as harm to a patient or resident as a result of medical care in a health care setting that resulted in a prolonged SNF stay or hospitalization (including emergency room visit), permanent harm, life-sustaining intervention, or death. Based on a small sample of individuals discharged from hospitals to SNFs with SNF stays that ended in August 2011 (a total of 653 Medicare beneficiaries), the OIG estimates that 22% of Medicare beneficiaries experienced adverse events during their SNF stays and 11% of Medicare beneficiaries experienced temporary harm events during their SNF stays. The OIG’s physician reviewers determined, based on review of the patients’ medical record, that 59% of these adverse events and temporary harm events were clearly or likely preventable. More than half of the residents who experienced harm were rehospitalized, with an estimated Medicare cost of $208 million in August 2011. This equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011 (or roughly 2% of inpatient hospital spending).
The OIG observes that the preventable nature of many of the events it identified indicates an opportunity for SNFs to significantly reduce the incidence of resident harm events. To that end, the OIG recommends that the Agency for Healthcare Research and Quality (AHRQ) and CMS raise awareness of nursing home safety and reduce resident harm through methods the agencies previously used to promote hospital safety. For instance, OIG recommends that the agencies collaborate to create and promote a list of potentially reportable nursing home events to help nursing home staff better recognize and reduce harm (but AHRQ and CMS should specify that they do not require external nursing home reporting of these events). Likewise, the OIG recommends that AHRQ and CMS encourage nursing homes to report adverse events to Patient Safety Organizations. CMS also should include potential events and information about resident harm in future guidance to nursing homes on the development of Quality Assurance and Performance Improvement (QAPI) programs pursuant to the ACA. Finally, the OIG recommends that CMS instruct state agency nursing home surveyors to review facility practices intended to identify and reduce adverse events. AHRQ and CMS concurred with the OIG’s recommendations.