One-Third of Nursing Home Residents Injured or Killed In Treatment

Photograph by:
 Chalmers Butterfield

A federal study has found that about one-third of nursing home residents receiving skilled care were harmed by the treatment in the facility. The  study, conducted by the Department of Health and Human Services, Office of Inspector General (IG), is entitled, “Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries.” "Adverse events" reported include medical errors and more general substandard care that results in patient or resident harm, such as infections caused by the use of contaminated equipment.   A “skilled nursing” facility (SNF) provides specialized care and rehabilitation services to patients following a hospital stay of three days or more. There are more than 15,000 skilled nursing facilities nationwide, and about 90 percent of them are also certified as nursing homes, which provide longer-term care.

According to the study, an estimated 22 percent of residents experienced at least one adverse event that resulted in a prolonged stay, transfer back to a hospital, permanent harm, a life-sustaining intervention, or death. An additional 11 percent experienced temporary harm while in the nursing home. Physician reviewers determined that 59 percent of these adverse events and temporary harm events were clearly or likely preventable. 

Projected nationally, the study estimated that 21,777 patients were harmed and 1,538 died due to substandard skilled nursing care during one month, August 2011, the month for which records were sampled.  These projections suggest that as many as 261,324 patients are harmed, and 18,456 patients killed, annually, from skilled nursing facility care and treatment.


Federal efforts to strengthen inspections of the nation’s nursing homes are gaining momentum in the wake of the IG's report. According to the Washington Post, Medicare officials became interested in using the IG’s investigative techniques, methods not normally used in measuring nursing home quality, after reviewing a September draft of the IG report.  The IG and  CMS are now working to condense the report’s list of 261 instances of actual harm so that nursing home operators and government inspectors can quickly spot health problems in a medical record that resulted from poor treatment.. The initial list of 261 instances was compiled by a team of physicians, geriatricians and nurse consultants who scoured the selected records to make these determinations on a case-by-case basis. 

Regardless, CMS, the agency responsible for SNF oversight, is developing new rules required by the Affordable Care Act to improve nursing home care by establishing “quality assurance and performance improvement programs.” As part of this effort, the CMS created a website last summer containing resources and training materials that have been used in 5,000 facilities to reduce residents’ pressure ulcers and medication errors, a Medicare spokeswoman said.

In the meantime, however, SNF patients remain at risk.
  
Further complicating the landscape of long term care planning is the inadequacy of public financing for long term care.  The AHCA, earlier this year, released a report by a Medicaid expert demonstrating that long term care services of America’s most vulnerable individuals are significantly underfunded by Medicaid. The report estimates the nation’s highest Medicaid shortfall on record – over $7.7 billion in 2013.

“At a time when Affordable Care Act reforms are fundamentally changing the Medicaid program and the way care is delivered, this report raises a number of challenges facing the nursing center profession,” said Mark Parkinson, President and CEO of AHCA. “With a low operating margin as reported by MedPAC, our profession does not need more cuts to Medicaid.”

The new shortfall number comes at a time when the Medicare Payment Advisory Commission (MedPAC) reports that nursing care centers operate at a margin of 1.8 percent, before sequestration cuts are considered. The report, compiled by Eljay, LLC, also notes that with recent Medicare rate reductions, Medicare no longer fully subsidizes increasing Medicaid shortfalls. 

Highlights from the report, titled A Report on Shortfalls in Medicaid Funding for Nursing Center Care, include:

• The 2013 Medicaid shortfall is expected to exceed $7.7 billion nationally.

• The estimated average Medicaid shortfall for 2013 of $24.26 per Medicaid patient day is 8.6 percent higher than the preceding year’s projected shortfall.

• For a typical 100-bed facility in which 63 percent of residents rely on Medicaid for coverage, this shortfall would mean a loss of more than $550,000 annually.

• On average, Medicaid reimbursed nursing center providers only 88.3 percent of their projected allowable costs incurred on behalf of Medicaid patients. This means that for every dollar of allowable cost incurred for a Medicaid patient in 2013, Medicaid programs reimbursed, on average, approximately 88 cents.

• Between the time periods covered by the cost reports used in the study and 2013, the study projects costs will increase an average of 3.8 percent, while rates increased an average of 2.9 percent.

The study 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. This equated to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011.  

One patient suffered an lung collapse the facility failed to diagnose, because caregivers failed to recognize symptoms. The patient later had a reaction to medication and a blood clot and had to be transferred to a hospital.  The reported deaths involved problems such as preventable blood clots, fluid imbalances, excessive bleeding from blood-thinning medications and kidney failure. 

Many patient advocates are calling for better staffing of SNFs.  The Consumer Voice, for example, issued  a statement calling on federal legislators to pass a law requiring minimum staffing standards in nursing homes, urging Congress to use the "wasted $2.8 billion spent on hospital treatment" for harm caused to patients to instead fund additional nursing staff "so that residents are cared for instead of harmed."

The failure of the federal government to cite facilities with staffing deficiencies under existing regulations, however, is not helping residents, according to the Center for Medicare Advocacy (CMA), which points out that 90 percent of nursing facilities do not have sufficient staff to meet resident's needs. The CMA finds that even if a staffing deficiency is cited, the nursing home is often not sanctioned, and the group warns that the federal enforcement system will not be effective in improving care if it is not used.  

Dr. Jonathan Evans, president of the American Medical Directors Association, speaking to ProPublica, attributes the OIG’s results to the fact that patients are leaving hospitals sooner, before they are medically stable:  

You have a system of long-term care that’s trying to retrofit to be a system for post-acute care. The resources to care for them and commitment from those sending them from one facility to another haven’t kept pace.

As hospitals have moved to shorten patient stays, skilled nursing care has grown dramatically. According to ProPublica, "Medicare spending on skilled nursing facilities more than doubled to $26 billion between 2000 and 2010. About one-in-five Medicare patients who were hospitalized in 2011 spent time in a skilled nursing facility." 

The Washington Post explained how these changes may affect SNFs: 

These strategies may help nursing home inspectors detect problems that do not emerge during typical inspections that focus on “what’s happening to residents today,” said Jane Straker, a research scholar at the Scripps Gerontology Center at Miami University in Ohio.

Routine inspections — as opposed to inspections prompted by complaints — often take three days and occur every 9 to 15 months, said Robyn Grant, policy director for the National Consumer Voice for Quality Long-Term Care, a Washington-based national advocacy group. Inspectors look at the medical records of as many as 30 residents, depending on the size of the facility, and also check a range of other services, from housekeeping and food preparation to required social activities and protection of residents’ rights. They also assign a severity level to any violation of Medicare rules that determines whether the facility will be fined, and if so, how much.

And their arrival may not come as a surprise, Grant said. The predictable schedule of inspections may give nursing homes a rough idea of when to expect the next one. She said residents and their families have reported improvements in staffing and other preparations before an inspection.

Kaiser Health News, reported that the American Health Care Association (AHCA), which represents 12,000 nursing homes and other long-term-care facilities, is still reviewing the IG report findings, but stated that nursing homes have already taken steps to continue to improve quality of care by, for example, reducing hospital re-admissions and off-label use of antipsychotic medications, and increasing the time nursing staff spends with patients, according to Dr. David Gifford, the association’s senior vice president of quality and regulatory. 

"Medicaid funding for nursing centers continues to be inadequate in most states even as state economies improve,” said Joe Lubarsky, President of Eljay, LLC. “It is likely that state rebalancing efforts and transitions to managed care will only exacerbate the problem; all at a time when emphasis on quality has never been higher."

To read the OIG report, click here.  

To read the CMA's findings on nursing home staffing, click here. 

To read ProPublica's article on the report, click here.
To read the Washington Post article, click here.  
To read the Kaiser Health News article, click here.  
To read the AHCA Releaset, click here. 
To read the Report on Shortfalls in Medicaid Funding for Nursing Center Care, click here.