How We Did This Study

This study estimates the national incidence rate, preventability, and cost of adverse events in SNFs by 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. Sample beneficiaries had SNF stays of 35 days or less.

What We Found

An estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Physician reviewers determined that 59 percent of these adverse events and temporary harm events were clearly or likely preventable. They 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 equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011.

Source: United States Department of Health and Human Services. (2013). Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries. Retrieved fromhttp://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf(Links to an external site.)

1. Placing yourself in the position of the Nursing Home Administrator, what would you expect CMS to determine SNFs to do as a result of the findings?