An estimated 22 percent of Medicare beneficiaries experience adverse events during their stays at skilled nursing facilities, according to a just released report from the Department of Health and Human Services' Office of Inspector General. In addition, the OIG found that 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Most significantly, 59 percent of these adverse events and temporary harm events "were clearly or likely preventable," the report concluded.

Much of the "preventable harm" was attributed to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care. And, the report determined that more than 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 and equating to $2.8 billion spent on hospital treatment for harm caused in SNFs in fiscal 2011.

"SNF post-acute care is intended to help beneficiaries improve health and functioning following a hospitalization and is second only to hospital care among inpatient costs to Medicare," stated the report. "Although various health care stakeholders have in recent years paid substantial attention to patient safety in hospitals, less is known about resident safety in SNFs."

Using a two-stage medical record review to identify events for a sample of 653 Medicare beneficiaries discharged from hospitals to SNFs for post-acute care, the study estimated the national incidence rate, preventability, and cost of adverse events in SNFs. The sample beneficiaries had SNF stays of 35 days or less.

"Because many of the events that we identified were preventable, our study confirms the need and opportunity for SNFs to significantly reduce the incidence of resident harm events. Therefore, we recommend that the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services raise awareness of nursing home safety and seek to reduce resident harm through methods used to promote hospital safety efforts," stated the report. "This would include collaborating to create and promote a list of potential nursing home events--including events we found that are not commonly associated with SNF care--to help nursing home staff better recognize harm. CMS should also instruct State agency surveyors to review nursing home practices for identifying and reducing adverse events."

Both AHRQ and CMS concurred with the OIG's recommendations.

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