Deeper Than the Headlines: OIG Testimony on Nursing Homes

Everyone has a boss they answer to, even the OIG. The OIG is frequently reporting to their ultimate boss(es), the U.S. Congress and they often do so via the testimony they provide to various committees and subcommittees.

In early September, Ruth Ann Dorrill, Regional Inspector General for the OIG provider her testimony, “Examining Federal Efforts to Ensure Quality of Care and Resident Safety in Nursing Homes” to the United States House of Representatives Committee on Energy and Commerce, Subcommittee on Oversight and Investigations.

Of course, many nursing homes provide excellent care and are diligent in protecting their residents. But Ms. Dorrill testified that an alarming number of residents are subject to costly medical harm, unsafe conditions, and abuse and neglect, much of it preventable with better practices and oversight. The OIG found that one in 3 three Medicare residents in skilled nursing facilities experienced harm from the care provided, and half of these harm events were preventable.

The adverse events OIG identified in nursing homes resulted in a range of harmful outcomes for residents, including extended stays in the skilled nursing facility (SNF), transfers to hospital emergency departments, and the need for life-sustaining intervention. For 6 percent of the adverse events, the harm contributed to residents’ death. Over half of the residents who experienced harm returned to a hospital for treatment, incurring millions of dollars in additional Medicare expenditures.

Some adverse events involved medical errors such as supplying incorrect medication, but most preventable harm resulted from daily substandard care, such as inadequate resident monitoring and failure or delay of necessary care. For these adverse events, residents and families may not know that they were harmed, thinking instead that the residents’ suffering and decline were the result of their illness or conditions and inevitable. Nursing home staff also failed to identify harm in some cases; for example, several adverse events started with dehydration, which can quickly result in kidney damage. One nursing home resident died of cardiac arrest after progressive kidney failure that was not detected until the resident was awaiting discharge from the SNF.

Most nursing home residents who died or were harmed by adverse events had multiple, complex comorbidities that made their care challenging. OIG found a wide range of adverse events not typically associated with nursing home care, such as internal bleeding due to medication. While some events are widely recognized as risks for patients in nursing homes, such as falls and pressure ulcers, fewer nursing home staff may be aware of the risks posed by aspiration and blood clots, both of which harmed numerous patients in the OIG’s study sample. When the OIG reviewed CMS guidance, they noted a tendency to focus narrowly on a subset of the most extreme harm events, many of which are rare, while missing the broad range of possible, more common harms that cause patient declines.

Ms. Dorrill testified that a shift in thinking about the care provided in nursing homes is needed. OIG’s work identifying adverse events in nursing homes and other settings showed that nursing home residents often had care needs like patients in hospitals, with residents sometimes seriously ill and impaired. The hospital community has focused keenly on patient safety and, while still experiencing high harm rates in some categories, has made substantial changes in the provision of patient care and safety systems. OIG feels sustained improvements in nursing homes will require a cultural shift that recognizes clinical harm and elevates reduction of harm as a priority for nursing home care.

The foundation of OIG’s recommendations to reduce harm is that CMS (and the Agency for Healthcare Research and Quality) raise awareness of adverse events in nursing homes (and other post-acute-care settings) with the same methods used to promote hospital safety. Broadening these and other patient safety improvement efforts to include the nursing home environment would ensure that safe care practices promoted in acute care hospitals extend to the critical periods of post-acute recovery and long-term care.

Reporting of abuse was also an issue Ms. Dorrill raised in her testimony. She stated the OIG has documented serious deficiencies in reporting of abuse and neglect of nursing home patients dating back several years and continuing in their recent and ongoing work. OIG found that, in 2012, nearly one in four nursing facilities did not have policies for reporting allegations of abuse or neglect and the subsequent results of an investigation, and facilities reported only half of allegations and investigation results as federally required. In response to OIG recommendations that CMS ensure nursing homes maintain policies for reporting allegations of abuse or neglect and report allegations in a timely manner, CMS revised the State Operating Manual (SOM) in 2017 to instruct State Agency surveyors to assess facility policies and practices. Yet concerns about unreported abuse and neglect remain. OIG reviewed hospital emergency room records from 2015 and 2016 for SNF residents sent to hospitals whose injuries may have been the result of potential abuse or neglect in the SNF. In preliminary work, OIG found 134 such incidents across 33 States. They further found that many of these incidents may not have been reported to law enforcement. Pending completion of the full review, OIG alerted CMS that it had inadequate procedures to ensure that incidents of potential abuse and neglect at SNFs are properly identified and reported. OIG made immediate suggestions for improvement, including that CMS analyze Medicare claims (including matching claims for emergency room services to claims for SNF services) to identify incidents of potential abuse and neglect and take specific steps to enhance its ability to impose civil monetary penalties for reporting failures. Other areas included in the testimony were emergency preparedness for SNFs and State Agency Enforcement.

In concluding her testimony, Ms. Dorrill emphasized the need for future improvement. She said, “the problems I present today are not new, and they may seem daunting and intractable given the challenges and complexities of nursing home care. But change is possible and essential. Nursing home care will always be a deeply challenging enterprise, but with dedicated attention and focus, CMS, States, and providers can do better.”

If you are involved in providing nursing home care, it might be wise for you to review the testimony in its entirety.

Questions or Comments?