59% of Adverse & Temporary Harm Events during SNF Stays Preventable, OIG Finds

In a February 2014 report, “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries,” the Office of the Inspector General (OIG) details its study to estimate the incidence rate, preventability and cost of adverse events that occur at skilled nursing facilities. This report reviewed Federal oversight of nursing homes, including looking specifically at adverse event lists and reporting requirements. The OIG found that there are no federal requirements in place to report adverse events and that there are no Federal standards that require States to have reporting systems in place for adverse event monitoring and has provided recommendations to correct those issues. Let’s take a look at some of the report’s findings:

Overall, the OIG’s report found that 22% of sampled beneficiaries experienced adverse events during their SNF stays and 11% experienced temporary harm events.

In this study, adverse events were broken into 3 clinical categories (totals do not equal 100% due to rounding):

  1. Medication-related events – 37% of adverse events in sample
  2. Ongoing resident care-related events – 37% of adverse events in sample
  3. Infection-related events – 26% of events in sample

To review the medical records, reviewers used a modified version of the NCC MERP Scale, putting beneficiary claims into four areas. Nearly 80% of the adverse events experienced were found to be at the F level. Of the approximately 1.5% of SNF residents that had an adverse event that contributed to their deaths, there was no single type of event that could be shown as a major contributing factor. However, the study found that most of the residents had multiple, complex co-morbidities that reviewers found “made their care more challenging, weakened their conditions, or both.”

Harm Level Description Percentage of Adverse Events
F Level Harm occurred that prolonged the SNF stay or led to a transfer to a different SNF or other post-acute facility and or/hospitalization 79%
G Level Harm occurred that contributed to or resulted in permanent resident harm
H Level Harm occurred that required intervention to sustain the resident’s life 14%
I Level Harm occurred that may have contributed to or resulted in resident death 6%


In addition to looking at adverse and temporary events, the cost of care for preventable events also had to be determined, and was found to cost Medicare $4.4 billion. The physician reviewers determined preventability by breaking down the events as per these guidelines:

  • A preventable event includes one where harm could have been avoided through improved assessment or alternative actions
  • A not preventable event is one where harm could not have been avoided given the complexity of the resident’s condition or care required
  • Unable to determine preventability – this occurred only in a small subset of the sample

The reviewers found that substandard treatment, inadequate resident monitoring and failure to provide treatments led these otherwise preventable incidents to happen. Specifically,

  • 66% of medication events were preventable
  • 57% of resident care events were preventable
  • 52% of infection control events were preventable

Read the full report along with the OIG’s recommendations to CMS and the AHRQ here.

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