Wednesday July 23, 2014
The Office of the Inspector General recently released their
findings of a study they conducted from 2009-2011. In this study
they found an estimated 22 percent of Medicare beneficiaries
experienced adverse events during their SNF stays. An additional 11
percent of Medicare beneficiaries experienced temporary harm events
during their SNF stays. Physician reviewers determined that 59
percent of these adverse events and temporary harm events were
clearly or likely preventable. They attributed much of the
preventable harm to substandard treatment, inadequate resident
monitoring, and failure or delay of necessary care. Over half of
the residents who experienced harm returned to a hospital for
treatment, with an estimated cost to Medicare of $208 million in
August 2011.
Because many of the events that were identified were
preventable, their study confirms the need and opportunity for SNFs
to significantly reduce the incidence of resident harm
events.
Therefore, the OIG recommended that the Agency for Healthcare
Research and Quality (AHRQ) and the Centers for Medicare &
Medicaid Services (CMS) raise awareness of nursing home safety and
seek to reduce resident harm through methods used to promote
hospital safety efforts. This would include collaborating to create
and promote a list of potential nursing home events-including
events that were found that are not commonly associated with SNF
care-to help nursing home staff better recognize harm. The OIG
stated that CMS should also instruct State agency surveyors to
review nursing home practices for identifying and reducing
adverse events. AHRQ and CMS concurred with our
recommendations.
