Why Nursing Homes Are Missing Critical Safety Events—and What Compliance Leaders Must Do Next

Nursing homes are facing a new level of scrutiny. Not just around billing or staffing, but around whether critical safety events are being captured, investigated, and reported. 

Recent findings from the Office of Inspector General (OIG) revealed that nursing homes failed to report 43% of falls resulting in major injury or hospitalization. For facilities already stretched thin, this is more than a data point: it’s a warning sign. 

Because when serious events aren’t reported, it’s a patient safety failure and a compliance risk with real consequences. 

Where the Pressure Is Coming From

1. OIG Guidance and FallsWithMajor Injury 

The OIG has reinforced that nursing homes must have systems in place to: 

• • Identify adverse events 
  • Ensure accurate and timely reporting 
  • Investigate root causes 
  • Implement corrective actions 
  • Prevent recurrence 

Yet the 43% underreporting rate for serious falls highlights a major disconnect between policy and practice. 

The problem is that many don’t have reliable, repeatable processes to make reporting consistent across shifts, staff, and departments. 

Pro Tip: Compliance Manager from Healthicity helps you document, track, and streamline every investigation in a centralized system. 

2. Medicare Patients Leaving Against Medical Advice (AMA)

AMA discharges create another high-risk area for nursing homes. 

When Medicare patients leave against medical advice, facilities must be able to document clearly: 

• • Clinical risks communicated to the patient 
  • Who provided the education 
  • Why the patient chose to leave 
  • Follow-up steps attempted 
  • How continuity of care was addressed 

Inconsistent or incomplete AMA documentation can lead to: 

• • Disputes around reimbursement 
  • Increased liability exposure 
  • Survey deficiencies 
  • Gaps in continuity of care documentation 

AMA events don’t happen frequently in every facility, but when they do, they demand precision and consistency. 

3. Patient Safety Organization (PSO) Participation Challenges

PSOs are meant to support learning, not become another administrative burden. But for many nursing homes, PSO participation introduces challenges such as: 

• • Difficulty classifying which events qualify for PSO protection 
  • Lack of standardized event categorization 
  • Trouble pulling reliable data for PSO reporting 
  • Inconsistent documentation practices across departments 
  • Limited ability to see trends or generate meaningful insights 

Without organized safety data, nursing homes lose one of the biggest benefits of PSO participation: the ability to drive real system improvement. 

The Underlying Problem: Process Gaps, Not Effort Gaps

In most nursing homes, staff are committed and doing their best; however, the core challenge is not effort, but infrastructure.  

When event reporting depends on paper forms, spreadsheets, email chains, staff memory, and informal handoffs, critical safety data becomes fragmented and inconsistent. This fragmentation limits visibility, delays timely response, and increases the organization’s exposure to compliance and regulatory risk. 

Watch On-Demand: We have a two-part webinar series focused on the OIG’s Nursing Facility ICPG, designed to break down key standards and help you stay updated on regulatory requirements. 

What Stronger Nursing Home Compliance Looks Like

Facilities that reduce risk and improve reporting consistency tend to have a few things in common: 

• Clear workflows for reporting serious events 
• Standardized documentation for AMA discharges 
• Consistent categorization of safety events 
• Centralized data for internal review and PSO reporting 
• Leadership visibility into trends, not just individual incidents 

When those elements are in place, compliance stops being reactive and starts becoming part of how the organization functions every day. 

Where Tools Like Compliance Manager Fit In

While policy and training matter, sustainable compliance requires structure. 

Organizations are using platforms like Compliance Manager to help operationalize what OIG guidance and PSO requirements demand, including: 

• Standardizing incident reporting workflows 
• Centralizing documentation  
• Supporting organized, defensible data collection 
• Providing leadership with visibility into compliance and safety trends 
• Eliminating reliance on disconnected tools and manual processes 

Nursing homes operate at the intersection of patient vulnerability and increasing regulatory scrutiny. Challenges such as the underreporting of serious falls, inconsistent documentation of discharges against medical advice, and fragmented Patient Safety Organization data are not merely compliance gaps; they represent significant patient safety risks.  

Facilities that invest in standardized, well-designed processes, supported by appropriate tools and infrastructure, are better positioned to reduce regulatory exposure, strengthen patient protections, improve survey and inspection outcomes, and support staff rather than overwhelm them. Ultimately, these efforts contribute to building and maintaining trust with regulators, residents, and the families who depend on them for safe, reliable care. 

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