SNF adverse event reduction needed, OIG report says

The Centers for Medicare & Medicaid Services (CMS) and the Agency for Health Research and Quality should collaborate and encourage skilled nursing facilities (SNFs) to implement methods used by hospitals to increase safety in their facilities, according to a new report from the U.S. Department of Health and Human Services’ Office of Inspector General (OIG). Also, CMS should instruct state agency surveyors to identify and reduce adverse events in the SNFs they review, the report says.

The OIG says it came to its conclusions after reviewing the medical records of a sample of 653 Medicare beneficiaries who were discharged from hospitals to SNFs for a maximum of 35 days of post-acute care. Twenty-two percent of Medicare beneficiaries who stayed in SNFs for post-acute care experienced adverse events, and an additional 11 percent were temporarily harmed during their SNFs stays, the review found.

When physicians reviewed SNF records, they found that 59 percent of those events likely could have been prevented had it not been for substandard treatment, inadequate monitoring of residents or failure or delay of needed care, claims the report, “Adverse Events in Skilled Nursing Facilities.” More than half of the harmed residents returned to the hospital for treatment, costing Medicare $208 million in August 2011 alone, the OIG says; if extrapolated to a year, the cost of hospital care provided because of harm in SNFs was $2.8 million in 2011.

The report “offers an opportunity for aging services providers to re-examine their own cultures of quality and safety,” Cheryl Phillips, MD, senior vice president of public policy and advocacy for LeadingAge, said in a statement. The organization agrees with the OIG’s recommendation to develop patient safety organizations that would track safety-related events without punishing facilities, she added, because such efforts encourage a “transparent environment of self-reporting."

LeadingAge does not agree with the OIG recommendation that surveyors help reduce adverse events, however, Phillips said. “We have yet to see evidence that a punitive oversight process that is built on fines and punishment is a driver of excellence,” she added.

AMDA issued a statement saying that the OIG report “reinforces that there is still much to be done” in the area of quality of care in post-acute and long-term care settings. The organization called for more data as well as educational and quality measurement tools and noted that it has been working on initiatives to reduce the rate of adverse events.


Topics: Executive Leadership , Medicare/Medicaid , Regulatory Compliance