OIG Report: Adverse Events in SNFs


In February 2014, the Office of Inspector General (OIG) released a report evaluating post-acute care provided in skilled nursing facilities (SNF). The conclusion was that an estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays resulting in prolonged SNF stay periods or hospitalizations, permanent harm, life-sustaining intervention, or death. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Physician reviewers determined that 59 percent of these adverse and temporary harm events were clearly or likely preventable. The OIG 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, which equates to $2.8 billion spent on hospital treatment for harm caused in SNFs during 2011.

Defining Adverse Events

An adverse event indicates harm to the resident as a result of medical care, including the failure to provide needed care. Adverse events include medical errors but they may also involve more general substandard care that results in resident or resident harm, such as infections caused by the use of contaminated equipment. However, adverse events do not always involve errors, negligence, or poor quality of care and are not always preventable.

Categorizing Adverse Events

The OIG categorized the causes of adverse events into three (3) event-classes:

  • Common adverse events related to medication (37%)

    • Delirium or other change in mental status (e.g. over-sedation); excessive bleeding; falls or other trauma with injury; and constipation.

  • Common adverse events related to resident care (37%)

    • Falls or other trauma with injury; exacerbations of preexisting injuries resulting from an omission of care; and fluid or electrolyte disorders.

  • Common adverse events related to infection (26%)

    • Aspiration pneumonia and other respiratory infections; Catheter-Associated Urinary Tract Infection (CAUTI); and Clostridium difficile infection.

Preventing Adverse Events

More than one-half of all adverse events are preventable. Medication-related events (66%), resident care-related events (57%), and infection-related events (52%) all have high preventability, and yet still show high rates of recurrence. For example, almost 3 million healthcare-associated infections (HAIs) strike nursing home residents every year, contributing to nearly 400,000 deaths annually. Two-thirds of Urinary Tract Infections (UTIs) in long-term care settings are catheter-associated (CAUTI), which are highly preventable.

The Agency for Healthcare Research and Quality (AHRQ) recommends the following best practices for preventing adverse events:

  • Matching health care needs with service delivery capability;

  • Facilitating information transfer and clear communication;

  • Focusing on infection control;

  • Increasing safe medication use;

  • Preventing residents from falling; and

  • Preventing bed sores.


Centers for Medicare and Medicaid Services (CMS) has stated that activities are underway to establish Quality Assurance Performance Improvement (QAPI) requirements for nursing homes and will include guidance for surveyors on how to evaluate nursing home efforts to prevent adverse events. Facilities are continuing to work within the prior Federal requirements, relying on QAA committees to implement and oversee QAPI activities. In addition, facilities should consider instituting a Performance Improvement Plan (PIP) focused on prevention of adverse events.



Department of Health and Human Services. Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries

AHRQ Safety Program for Long-Term Care: Preventing CAUTI and Other HAIs http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/index.html

On-Time Quality Improvement Manual for Long-Term Care Facilities http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/ontimeqimanual/ontimeqimanual.pdf