Deeper Than the Headlines: Potential Abuse and Neglect at Skilled Nursing Facilities

OIG’s most recent published report determined that an estimated one in five high-risk hospital ER Medicare claims for a treatment provided in the calendar year 2016 were the result of potential abuse or neglect, including injury of an unknown source, of beneficiaries residing in an SNF.

Their report was one in a series of OIG reports addressing the identification, reporting, and investigation of incidents of potential abuse and neglect of vulnerable populations, including the elderly and individuals with developmental Disabilities.

For this particular report, the OIG objectives were to determine:

1. the prevalence of incidents of potential abuse or neglect of Medicare beneficiaries residing in skilled nursing facilities (SNFs) who had a hospital emergency room (ER) Medicare claim in the calendar year 2016 containing a high-risk diagnosis code.
2. whether these incidents of potential abuse or neglect were properly reported by the SNFs.
3. whether CMS and State Survey Agencies reported findings of substantiated abuse to local law enforcement.
4. the extent to which CMS requires incidents of potential abuse or neglect to be recorded and tracked.

The review covered 37,607 high-risk hospital ER claims for 34,820 Medicare beneficiaries residing in SNFs during the calendar year 2016. OIG and the Survey Agencies reviewed supporting documentation for 256 high-risk hospital ER Medicare claims to determine whether the incidents were the result of potential abuse or neglect and if so, reported to the Survey Agencies. They then reviewed incidents that were not included in the sampling frame to determine whether CMS and the Survey Agencies reported findings of substantiated abuse to local law enforcement. They also assessed how CMS tracks all incidents of potential abuse or neglect.

The OIG determined that SNFs failed to report many of these incidents to the Survey Agencies in accordance with applicable Federal requirements. They also determined that several Survey Agencies failed to report some findings of substantiated abuse to local law enforcement. Lastly, OIG determined that CMS does not require all incidents of potential abuse or neglect and related referrals made to law enforcement and other agencies to be recorded and tracked in the Automated Survey Processing Environment Complaints/Incidents Tracking System. According to the OIG, preventing, detecting, and combating elder abuse requires CMS, Survey Agencies, and SNFs to meet their responsibilities. Examples of Findings:

Head Injuries

Of the 51 incidents of potential abuse or neglect, 26 involved head injuries (4 traumatic brain injuries, 3 facial or nasal fractures, 6 lacerations or abrasions, 6 contusions, and 7 unspecified head injuries).

Bodily Injuries

Of the 51 incidents of potential abuse or neglect, 16 involved bodily injuries (12 femur fractures, 3 vertebra fractures, and 1 shoulder dislocation).

Safety Issues

Of the 51 incidents of potential abuse or neglect, 6 involved safety issues (4 poisonings and 2 accidents).

Medical Issues

Of the 51 incidents of potential abuse or neglect, 3 involved medical issues (2 aspiration pneumonia and 1 sepsis).

Example of a Medicare Emergency Room Claim That Potentially Resulted From Abuse or Neglect:

The Survey Agency determined that an incident involving a 72-year-old Medicare beneficiary with a history of throat cancer, recent throat surgery, and a nasogastric tube in place potentially resulted from neglect. The beneficiary was transported to an ER following a postoperative follow-up appointment at the hospital due to productive cough, dehydration, and fatigue and was diagnosed with aspiration pneumonia. At the ER, the beneficiary’s wife expressed concerns regarding the quality of care at the SNF. Specifically, she stated that her husband’s nasogastric tube had not been suctioned well at the SNF, and she believed he was not given all of his scheduled tube feeds. In addition, the SNF records indicated that 5 days prior to the beneficiary was given a meal tray with liquids despite a strict “nothing by mouth” order. The SNF records also indicated that the nursing manager was planning to put steps in place to ensure this type of error did not recur. The beneficiary was admitted to the hospital for 2 days, treated with antibiotics, and then discharged to his home. The combination of the injuries suffered and the allegations made by the beneficiary’s family gave reasonable cause to suspect potential neglect of this beneficiary.

Example of an Incident of Potential Neglect Not Reported by an SNF to the Survey Agency:

An SNF did not report to the Survey Agency an incident of potential neglect involving a 65-year-old Medicare beneficiary with a history of a stroke and diabetes. The beneficiary was brought to a hospital’s ER from the SNF by ambulance. The beneficiary had become extremely lethargic and had breathing difficulties after the SNF had increased the beneficiary’s opioid pain medication several days earlier. The hospital records indicated that the beneficiary was in critical condition with acute metabolic encephalopathy, acute respiratory failure, acute kidney failure, and hypoxemia due to opioid toxicity. The beneficiary improved after receiving an opioid antidote in the ER and was admitted to the hospital for 2 days for further treatment. After the inpatient stay the beneficiary was discharged to the SNF. The SNF records attributed the opioid poisoning to a transcription error. Specifically, an opioid was administered to the beneficiary every 4 hours, but the physician order was for every 6 hours. The SNF records also noted that individualized education was provided to the nurse who incorrectly transcribed the physician order. However, the SNF did not report this incident to the Survey Agency. The Survey Agency determined this incident involved potential neglect because of the combination of the medication error and injuries suffered; accordingly, the SNF should have complied with Federal requirements and reported the incident to the Survey Agency.

Reporting suspected incidents of abuse or neglect should be an essential part of an organization, especially an SNF’s, policies and procedures. Compliance programs are in a unique space to help facilitate such policies and procedures. The OIG’s final recommendations included that CMS take action to ensure that incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs are identified and reported by working with the Survey Agencies to improve training for the staff of SNFs on how to identify and report incidents of potential abuse or neglect of Medicare beneficiaries, clarifying guidance to define and provide examples of incidents of potential abuse or neglect, requiring the Survey Agencies to record and track all incidents of potential abuse or neglect in SNFs and referrals made to local law enforcement and other agencies, and monitoring the Survey Agencies’ reporting of findings of substantiated abuse to local law enforcement.