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Nursing Home Staff Should Be Trained to Identify Possible Adverse Events in Skilled Nursing Facilities

Adverse events in hospitals remain highly prevalent to this day.  From 2008 to 2012, the Department of Health and Human Services conducted a series of studies pertaining to hospital adverse events, which are injurious outcomes from medical care. A Congressionally mandated study was part of this work that sought to identify a national incidence rate for adverse events in hospitals. Researchers developed methods to determine adverse events, as well as the extent to which events are preventable, and measure the cost of events in accordance with the Medicare program. A recent study that is part of that work evaluated post-acute care provided in skilled nursing facilities (SNFs). SNF post-acute care aims to help its patients enhance their health and functioning after a hospitalization and is second only to hospital care among inpatient expenses to Medicare. Not much is known about resident safety in SNFs.

This study approximates the national incidence rate, preventability, and expense of adverse events that occur in SNFs by using a two-stage medical record review to pinpoint events for a sample of 653 Medicare beneficiaries discharged from hospitals to SNFs for post-acute care.

The study found that approximately 22% of Medicare beneficiaries were victims of adverse events during their SNF stays. An additional 11% of Medicare beneficiaries were victims of temporary harm events while staying in a SNF. According to physician reviewers, 59% of these adverse events and temporary harm events were certainly or probably preventable. They deemed much of the preventable harm as a consequence of substandard treatment, inadequate resident monitoring, and untimely or nonexistent necessary care. More than half of the residents who were victims of harm were readmitted to a hospital for treatment, with an approximate expense to Medicare of $208 million in August 2011. This is equivalent to $2.8 billion spent on hospital treatment for harm inflicted in SNFs in FY 2011.

Due to the fact that many of the events that the researchers identified were preventable, their study proves that there is a need and opportunity for SNFs to significantly decrease the incidence of resident harm events. Thus, they recommend that the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) encourage awareness of nursing home safety and seek to decrease resident harm by using methods that the researchers used to foster hospital safety efforts. This would include working together to create and advocate a list of potential nursing home events to assist nursing home staff better identify harm.