Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
A E S
DVERSE  VENTS IN  KILLED 
 
 
N F :   
URSING  ACILITIES   
 
N I A
 ATIONAL  NCIDENCE  MONG 
M B  
EDICARE  ENEFICIARIES 
 
Daniel R. Levinson   
Inspector General  
 
February 2014 
OEI-06-11-00370   
   
EXECUTIVE SUMMARY:  Adverse Events in Skilled Nursing Facilities:  National 
Incidence Among Medicare Beneficiaries 
OEI-06-11-00370 
 
WHY WE DID THIS STUDY 
From 20082012, we conducted a series of studies about hospital adverse events, defined as harm  
resulting from medical care.  This work included a Congressionally mandated study to determine a 
national incidence rate for adverse events in hospitals.  As part of this work, we developed methods to 
identify adverse events, determine the extent to which events are preventable, and measure the cost of 
events to the Medicare program.  This study continues that work by evaluating post-acute care provided 
in skilled nursing facilities (SNF).  SNF post-acute care is intended to help beneficiaries improve health 
and functioning following a hospitalization and is second only to hospital care among inpatient costs to 
Medicare. Although various health care stakeholders have in recent years paid substantial attention to 
patient safety in hospitals, less is known about resident safety in SNFs.     
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. 
WHAT WE RECOMMEND 
Because many of the events that we identified were preventable, our study confirms the need and 
opportunity for SNFs to significantly reduce the incidence of resident harm events.  Therefore, we 
recommend that the Agency for Healthcare Research and Quality (AHRQ) and the Centers for 
Medicare & Medicaid Services (CMS) raise awareness of nursing home safety and seek to reduce 
resident harm through methods used to promote hospital safety efforts.  This would include 
collaborating to create and promote a list of potential nursing home eventsincluding events we found 
that are not commonly associated with SNF careto help nursing home staff better recognize harm.  
CMS should also instruct State agency surveyors to review nursing home practices for identifying and 
reducing adverse events. AHRQ and CMS concurred with our recommendations. 
 
 
   
   
TABLE OF CONTENTS 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology..............................................................................................12 

Findings......................................................................................................17 

An estimated 22 percent of Medicare SNF residents             
experienced adverse events during their SNF stays .......................17 

An additional 11 percent of Medicare SNF residents             
experienced events during their SNF stays that resulted in 
temporary harm ..............................................................................20 

Physician reviewers determined that 59 percent of adverse           

events and temporary harm events were clearly or likely 

preventable ....................................................................................22 

Over half of the residents who experienced harm went to a 

hospital for treatment, with an estimated cost to Medicare of 

$208 million in August 2011 .........................................................25 
  
Conclusion and Recommendations ............................................................27 

Agency Comments and Office of Inspector General Response.....30 

Appendixes ................................................................................................32 

A: Glossary of Select Medical Terms  ...........................................32 

B: Methodology for Identifying Events and Determining 

Preventability .................................................................................34 

C: Development and Description of the SNF Trigger Tool ..........40 

D: Estimates, Confidence Intervals, and Key Statistics ................42 

E: Rates of Adverse Events and Temporary Harm Events in     

SNFs by Resident Days and SNF Admissions ...............................47 

F: Adverse Events and Temporary Harm Events ..........................48 

G: Agency Comments  ...................................................................59 

 
Acknowledgments......................................................................................65 

 
 
 
   
   
OBJECTIVES 
1. 	  To estimate the national incidence of adverse and temporary harm  
events for Medicare beneficiaries admitted to skilled nursing facility 
(SNF) for post-acute care. 
2. 	  To assess the extent to which adverse and temporary harm events were 
preventable and identify contributing factors. 
3.	   To estimate the costs associated with adverse and temporary harm  
events to the Medicare program.  
BACKGROUND 
The Office of Inspector General (OIG) conducted a series of studies about 
adverse events in hospitals from 20082012.1 This work included a 
Congressionally mandated study of adverse event incidence within 
hospitals.2, 3  OIG found that 27 percent of hospitalized Medicare 
beneficiaries experienced adverse and  temporary harm events, nearly half 
of the events were preventable, and care associated with events cost the 
Medicare program an estimated $4.4 billion a year.  OIG has identified a 
number of problems with the quality of care provided in nursing homes, 
including SNFs. These problems include inadequate discharge planning 
and lack of compliance with CMS standards regarding the use of atypical 
antipsychotic drugs.4,  5  These problems pose risks to individuals and 
increase Medicare costs in the form of hospitalizations.   
Medicare expenditures for SNF care have more than doubled in the last 
decade. Medicare paid $12 billion for SNF care in 2000 and $26 billion in 
2010.6, 7  In fiscal year (FY) 2011, Medicare paid $28.4 billion for SNF 
 
1  OIG released  11 reports regarding adverse events in  hospitals during  2008-2012,  
including reports about the incidence of adverse events, methods for identifying adverse 
events, State reporting systems, and public disclosure of event information.  All reports 
are available at http://oig.hhs.gov/reports-and-publications/oei/a.asp#adverse_care. 
2 Tax Relief and  Health Care  Act of  2006, P.L. 109-432  203.    
3 OIG,  Adverse Events in Hospitals:  National Incidence Among  Medicare Beneficiaries, 
OEI-06-09-00090, November  2010. 

4 OIG,  Skilled Nursing Facilities Often Fail To Meet Care Planning  and Discharge 

Planning Requirements, OEI-02-09-00201, February 2013. 

5 OIG,  Nursing  Facility Assessments and Care Plans for Residents Receiving Atypical  
Antipsychotic Drugs, OEI-070800151, July 2012.   

6 U.S. Department of  Health and Human Services (HHS), Office of the Actuary, National 

Health Statistics Group, SNF Utilization  Chart, 2010, p.  50. 

7 Medicare Payment Advisory Committee (MedPAC), Skilled Nursing Facility Services 

Payment System, updated October 2011, p. 1. 

 
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services provided to 1.8 million beneficiaries.8 Post-acute SNF stays 
which we define for the purposes of this study as SNF stays that began 
within 1 day of discharge from a hospital and lasted 35 days or less 
constitute 70 percent of all Medicare beneficiary stays in SNFs.9    
Adverse Events 
The term adverse event describes harm  to a patient or resident as a result 
of medical care.10  An adverse event indicates harm to the patient as a result 
of medical care, including the failure to provide needed care.  Adverse 
events include medical errors but they may also include more general 
substandard care that results in patient or resident harm, such as infections 
caused by the use of contaminated equipment.  However, adverse events do 
not always involve errors, negligence, or poor quality of care and are not 
always preventable.11,12    
Post-Acute Care in SNFs 
The Social Security Act (SSA) 1819(a) defines a SNF as a facility 
engaged primarily in providing skilled nursing care and rehabilitation 
services for residents who require such care because of injury, disability, 
or illness. Although the term SNF refers to a provider that meets the 
Medicare Part A coverage requirements described above, 90 percent of 
SNFs are dually certified as both SNFs and nursing homes (i.e., long-term 
care providers).13  In 2011, about 20 percent of all hospitalized Medicare 
beneficiaries went to one of the 15,207 SNFs for post-acute care following 
their hospital stays.14  Medicare Part A pays for up to 100 days of care in 
SNFs per benefit period.15, 16  Medicare beneficiaries are eligible for SNF 
stays following a hospital stay of at least 3 days and when a medical 
 
8 Centers for Medicare & Medicaid Services (CMS), 2011 CMS Statistics, Tables III.6 
and IV.6a. Accessed at www.cms.gov/ResearchGenInfo/02_CMSStatistics.asp on   
April 9, 2012. 
9 OIG analysis of 2010 Medicare SNF claims, Standard Analytical File (SAF).  
10 See Appendix  A for a definition of adverse events as well as a list of select clinical 

terms and conditions. 
 
11 R.M. Wachter, Understanding Patient  Safety, McGraw-Hill, 2008, p. 17.   
 
12 OIG,  Adverse Events in Hospitals:  National Incidence Among  Medicare Beneficiaries, 

OEI-06-09-00090, November  2010. 

13 MedPAC, Report to the Congress:  Medicare Payment Policy, Skilled Nursing Facility 

Services, March 2013, p.  161. 

14 Ibid. 

15 A benefit  period is a period of consecutive days  during  which medical benefits  for 

covered services, with certain specified  maximum  limitations, are available to the 

beneficiary.   CMS, Medicare Benefit Policy Manual:  Duration of  Covered Inpatient  

Services, Chapter 3.  

16 CMS, Medicare Benefit Policy Manual:  Coverage of Extended Care (SNF) Services 
Under Hospital Insurance, Chapter 8.  
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  2  
   
   
professional verifies the need for nursing care and rehabilitation related to  
the hospitalization.17   
In 2010, MedPAC described Medicare beneficiaries in SNFs as more 
likely than other Medicare beneficiaries to report poor health status, have 
multiple limitations in their activities of daily living, live in an institution,  
and be disabled.18   Examples of SNF residents include those recovering 
from surgical procedures performed in hospitals (e.g., hip or knee 
replacements) or recovering from acute medical conditions (e.g., stroke, 
pneumonia).19  Examples of care provided to SNF residents include the 
development, management, and evaluation of a resident care plan; 
physical therapy; administration of intravenous feedings; medication 
management; and wound care.   
Medicare Payment to SNFs.  Medicare payment to SNFs is determined by 
rate groups based on the level of care provided and is adjusted for 
geographic and resident population differences.  Each of these 66 rate 
groupsreferred to as resource utilization groups, or RUGsin 
8 categories have weights for nursing and therapy care that are applied to 
the base rates.20  Assignment to a rate group is based on the number of 
minutes of therapy that the resident requires, the need for certain services 
(such as respiratory therapy), the presence of certain conditions (such as 
dehydration), and an index based on the ability of the resident to 
independently perform four activities of daily living (i.e., eating, toileting, 
bed mobility, and transferring).21     
Federal Oversight of Nursing Homes 
CMS oversees nursing home compliance with Federal standards through 
State survey agencies, which monitor SNFs and enforce penalties for 
substandard quality of care.22, 23  Surveys may include medical record 
review and audits of resident assessments or plans of care.24 CMS enters 
into agreements with State survey agencies to conduct onsite surveys of 
 
17 Ibid. 

18  MedPAC, op. cit., p. 162-163. 

19  MedPAC, op. cit., p. 161. 

20 CMS, Resident Assessment Instrument (RAI) Version 3.0  Manual (v. 1.07), ch. 6,  6.3. 

21  Ibid,  ch. 6,  6.6. 
 
22 42 CFR Part  488, Subparts E and F. 

23 CMS, State Operations  Manual, Appendix PP,  Guidance to Surveyors for Long Term 

Care Facilities, Tag F309. 
 
24 42 CFR   488.305(a) and  488.310(b).  

 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  3  
   
   
each nursing home to certify compliance with Federal requirements.25   
When surveyors identify noncompliance with Federal requirements, CMS 
requires nursing homes to submit plans of correction and to correct the 
problems.  If nursing homes do not correct the problems, CMS may take 
enforcement actions, including imposing civil monetary penalties and 
denying payment for new admissions of Medicare residents.26  
CMS requirements regarding resident safety in nursing homes include 
both broad, facility-wide mandates (such as staff training) and 
requirements specific to certain practices (such as treatment of pressure 
ulcers). To establish and oversee quality and safety-related practices, 
CMS requires that nursing homes establish and maintain a Quality 
Assurance and Assessment (QAA) committee composed of a physician 
designated by the facility, director of nursing, and other staff members as 
determined by the facility.27   Tasks of the QAA include identifying and 
addressing quality and safety problems.   To evaluate nursing home quality 
and safety practices, CMS instructs surveyors to review QAA committee 
activities and interview committee members as a part of onsite reviews.28   
Noncompliance with the QAA requirements can result in surveyors citing 
a deficiency specific to the QAA process.29   
Additionally, CMS requires that Medicare- and Medicaid-certified nursing 
homes report alleged instances of mistreatment, neglect, or abuse to State 
survey agencies.30   These instances are to include injuries of unknown 
source as well as misappropriation of resident property.  When allegations 
of such instances are made, the nursing homes must take measures to 
prevent further potential abuse, investigate the allegations, and establish a  
corrective action plan if warranted.31 Federal regulation defines abuse as 
willful infliction of injury and neglect as failure to provide goods and 
services necessary to avoid harm.32  Noncompliance with the reporting 
 
25 42 CFR   488.10 and CMS, Survey and Certification:  General Information, April, 11, 

2013.  Accessed at http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/index.html?redirect=/surveycertificationgeninf
 
o/ on May 15, 2013. 

26  42  CFR  488.402(d), 488.408,  and 488.417. 

27 42 CFR    483.75(o). 
 
28 CMS, State Operations  Manual, Appendix PP, Guidance to  Surveyors for Long  Term  

Care Facilities, Tag F520. 
  
29 Ibid.  

30 42 CFR    483.13(c)(2). 
 
31 42 CFR    483.13(c)(3) and (4). 
 
32 42 CFR    488.301. 
 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  4  
   
   
requirements results in a deficiency citation specific to the reporting 
process.33  
Nursing Home Quality Measures. Medicare- and Medicaid-certified 
nursing homes routinely collect resident assessment data at specific 
intervals during a nursing home stay and maintain the assessment results 
in the Minimum Data Set (MDS).34 CMS converts portions of the MDS 
data into 18 quality measures (QMs), which indicate how well nursing 
homes care for residents.35  Examples of QMs include the percentage of 
residents who develop pressure ulcers, the percentage who develop urinary 
tract infections, and the percentage who experience falls with injury.36   
CMS provides QMs to SNFs for use in quality improvement efforts.   
CMS publicly reports nursing home QMs through the Five-Star Quality 
Rating System and Nursing Home Compare.  CMS gives each Medicare- 
and Medicaid-certified nursing home an overall rating between one and 
five stars. A rating of one star indicates that a nursing home is much 
below average in terms of quality, and a rating of five stars indicates that  
a nursing home is much above average.37 CMS bases the overall 
ratings on the nursing homes performance in three areas:  performance on 
inspection surveys (survey metric), QMs (quality metric), and staffing 
(staffing metric).  
Adverse Event Lists and Reporting. To date, there is no Federal 
requirement that SNFs report adverse events beyond the requirements to 
report instances of mistreatment, neglect or abuse and the discrete 
potential events described in the QMs (e.g., pressure ulcers, falls).  
Additionally, there are no  Federal standards that require States to operate 
adverse event reporting systems.  To help define potential events for 
reporting, the National Quality Forum (NQF) issued guidance in 2011 
expanding its list of hospital Serious Reportable Events (SRE) to SNFs 
 
33 CMS, State Operations  Manual, Appendix PP, Guidance to  Surveyors for Long  Term  
Care Facilities, Tags F223-226.  
34 CMS, RAI Version 3.0 Manual (v. 1.07), ch. 1,  1.2, and ch. 2,  2.6.   
35 RTI [Research Triangle Institute] International, Nursing Home MDS 3.0 Quality 
Measures: Final Analytic Report (Sept. 2012),  1.1 and  1.2.  
36RTI, MDS  3.0  Quality Measures Users Manual (v. 6.0).  Accessed at  
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V60.pdf  
on February  19, 2013.   

37 CMS, Consumer Fact Sheet, December 2008. Accessed at 

http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/Downloads/consumerfactsheet.pdf on  October 

4, 2013. 
  
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  5  
   
   
and other health care settings.38  The NQF SRE list identifies adverse 
events that are serious, largely preventable, and of concern to both the 
public and health care providers.39 The 2011 updated SRE list includes 
24 events applicable to SNF care.  These 24 events largely represent only 
the most egregious potential events such as a patient death or serious 
injury associated with the use of contaminated drugs or devices. 
Resident Safety in Nursing Homes 
Previous studies of adverse events in nursing homes have focused largely 
on medication-related adverse eventswhich are a subset of all adverse 
eventsamong the entire nursing home population.  A 2006 review of 
seven studies measuring the incidence of medication-related adverse 
events in nursing homes revealed that such events are common and that as  
many as half of the events could have been prevented.40  
Research also indicates that patient and resident transfers between 
hospitals and nursing homes can pose problems for medically fragile 
individuals.41  Many transitions from hospitals to post-acute care occur in a 
hurried manner and have limited prior planning, occur during nights and 
on weekends when nursing homes may have fewer and less experienced 
staff, involve clinicians who may not have a relationship with the 
residents, and happen too quickly for nursing home staff to respond well 
and in a timely manner.42  Similarly, hospitalizations of nursing home  
residents increase the risk that residents will experience harm and other 
negative care outcomes.43,  44  The impact on residents during 
hospitalizations can include disruption of their care plans and greater 
 
38  The NQF is a consensus-building organization focused on health care quality  and funded in 
part by grants from HHS.  NQF Mandate  and Call to Action, About NQF, updated January  
2012. Accessed at http://www.qualityforum.org/About_NQF/About_NQF.aspx on March 23, 
2012.  
39  NQF, National Voluntary Consensus Standards for Serious Reportable Events in 
Healthcare, Press Release, August 2011.
  
40 S.M.  Handler, Epidemiology of Medication-Related Adverse Events in  Nursing 

Homes, The American Journal of  Geriatric Pharmacotherapy, 4,  3, 2006, pp. 264-272.   

41 Congressional Research Service, Medicare Hospital Readmissions:  Issues, Policy 
Options and PPACA, Fact Sheet, September 21, 2010. 
   
42 E. Coleman and R.A. Berenson, Lost in  Transition:  Challenges and  Opportunities for 

Improving the Quality of Transitional Care, American College of Physicians, 141,  7, 
 
2004, p.  533.  

43 Assistant Secretary for Planning and Evaluation (ASPE), Hospitalizations of  Nursing  
Home  Residents:   Background and Options, June 2011,  p. 1. 
 
44 J.G.  Ouslander, Reducing Potentially Avoidable Hospitalizations of Nursing Home
  
Residents:  Results of a Pilot Quality Improvement Project, Journal of the American 

Medical Directors Association, 10, 9,  2009, p. 645. 

 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  6  
   
   
vulnerability for disorientation, stress, and adverse events.45   
Hospitalization rates are seen as a measure of nursing home quality and 
safety and have received attention from OIG and other stakeholders.46,  47  
Federal Efforts To Improve the Quality of Post-Acute Care 
In addition to CMS, other Federal agencies share responsibility for ensuring 
health care quality and safety in nursing homes.  For example, the Agency  
for Healthcare Research and Quality (AHRQ) in HHS leads efforts related to 
research and learning. The Center for Quality Improvement and Patient 
Safety (CQuIPS) within AHRQ provides national leadership in improving 
health care safety.  CQuIPS objectives are to develop a solid evidence base, 
design useful tools, and disseminate information for implementation to all 
health care facilities.48   AHRQ is also required by statute to produce an 
annual report to Congress about health care quality.49    
Patient Safety Organizations. AHRQ maintains responsibility for 
implementing and overseeing the certification process for Patient Safety 
Organizations (PSO) created by the Patient Safety and Quality 
Improvement Act of 2005 (PSQIA).50 PSOs are intended to receive 
adverse event reports from health care facilities and then forward the 
information to a national database from which CQuIPS will analyze 
aggregated data. PSQIA also provides Federal privilege and 
confidentiality protections for information reported to PSOs.51 These 
protections prohibit other entities from accessing adverse event reports, 
including State survey agencies, with providers facing possible penalties 
enforced by the HHS Office of Civil Rights.  Officials at AHRQ and CMS 
indicated in interviews with OIG staff that the PSQIA confidentiality 
provision may be in conflict with CMS compliance requirements that 
allow surveyors access to facility QAA actions and reports. 
To facilitate reporting, AHRQ developed a set of event definitions and 
reporting toolsthe Common Formatswhich PSOs can choose to use 
 
45 E. Hutt, Precipitants of  Emergency Room Visits and  Acute Hospitalization in      
Short-Stay Medicare Nursing Home Residents, Journal of the American  Geriatrics 
Society, 50, 2, 2002, 223224. 
46 OIG,  Medicare Nursing Home Resident Hospitalization Rates Merit Additional 
Monitoring, OEI-06-11-00040, November 2013.   
47 ASPE, op. cit., pp. 812. 

48 AHRQ, Advancing  Patient  Safety:  A Decade of Evidence, Design, and 
 
Implementation, AHRQ Publication  No. 09(10)-0084, November 2009.   

49  Public Health Service Act (PHSA),  913, 42 U.S.C.  299b-2. 

50 The Secretary of HHS delegated authority to AHRQ to certify entities as PSOs, as well 

as to  fulfill other requirements of the PSQIA.  P.L. 109-41  2, PHSA,  924, 42  U.S.C.  
 
299b-24;  73 Fed.  Reg.  70732 (Nov. 21, 2008).   

51  P.L. 109-41  2, PHSA,  924, 42 U.S.C.  299b-24. 
 
 
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and which contain data elements that AHRQ determined are important for 
a complete and useful adverse event report.52 AHRQ designed the 
Common Formats for both the hospital and SNF settings.53  The Patient  
Protection and Affordable Care Act (ACA) provides that, by January 1, 
2015, health plans that participate in insurance exchanges may not 
contract with a hospital of 50 beds or more unless that hospital reports 
patient safety data to a PSO.54  Currently, no such requirement exists for 
SNFs.  
The ACA also mandated HHS to establish a national strategy for quality 
improvement in health care,55 including patient and resident safety,56 and 
increased funding to AHRQ for research grants to explore best practices.57   
As part of this strategy, CMS introduced in 2011 its Partnership for 
Patients, a public/private collaboration to improve health care quality and 
safety, specifically including transitions from acute to post-acute care.58   
HHS also developed the Measure Applications Partnership (MAP), a 
public/private partnership facilitated by NQF and designed to provide 
CMS and other agencies within HHS with input regarding health care 
performance measurement, in order to satisfy a mandate in the ACA to 
seek multi-stakeholder group input.59 MAP recently released a draft set of 
core measure concepts to use in assessing post-acute care by facilities such 
as SNFs, identifying both care coordination and safety as two of six 
high-leverage priority areas.60  
The ACA also requires nursing homes to develop and operate Quality 
Assurance and Performance Improvement (QAPI) programs.61 In June 
2013, CMS released guidance to nursing homes regarding developing and 
 
52 AHRQ, Common  Formats for Patient  Safety Data Collection  and Event Reporting, 

Notice of Availability:  Common Formats Version 1.0, September 2, 2009. 
   
53 AHRQ, Users Guide:  AHRQ Common  Formats for Skilled Nursing Facilities Version  

0.1 Beta Release, February 2011. 
 
54  P.L. 111-148  1311, (h)(1)(A),  i-ii.  

55  P.L. 111-148  3011, PHSA,  399HH, 42 U.S.C.  280j.  

56  ACA,  3011, PHSA,  399HH(a)(2)(B)(vii), 42 U.S.C.  280j(a)(2)(B)(vii). 

57  ACA,  3501, PHSA,  933 and 934, 42 U.S.C.  299b-33  and 299b-34. 
 
58 CMS, Partnership for Patients:  A Common Commitment, April 2011.  Accessed at 

http://www.healthcare.gov/compare/partnership-for-patients/about/index.html on 
  
March 7,  2012. 

59 ACA  3014. 

60 NQF, Input on Measures Under Consideration by HHS for 2012 Rulemaking:  Final 

Report, Measure Applications  Partnership,  February 2012, pp. 99-100. 
 
61  ACA, 6102, Social Security Act,  1128I(c), 42 U.S.C.  1320a-7j(c).  
 
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maintaining QAPI programs.62   This guidance states that QAPI programs 
are to serve as comprehensive plans to both improve routine facility 
practices and to conduct periodic, targeted performance improvement 
projects. It further states that facilities are to continue working within the 
prior Federal requirements, relying on QAA committees to implement and 
oversee QAPI activities.63 CMS provides QAPI tools for identifying and 
addressing quality and safety programs, such as guidance for developing a 
facility mission statement and establishing safety goals.64     
CMS, in its 2012 Nursing Home Action Plan, described several initiatives 
intended to improve resident safety and quality in nursing homes.65 These 
initiatives involve many of CMS nursing home oversight and payment 
tools. Action Plan initiatives include multiple refinements to the existing 
survey and certification process, improvements in data reported through 
the Five-Star Quality Rating System, demonstration projects designed to 
test the effect of payment incentives on nursing home performance and 
quality, and plans to collaborate with Quality Improvement Organizations 
and State survey agencies. 
Measuring Health Care Safety  
Research and policy to improve health care safety and reduce adverse 
events often focus on identifying systemic problems that lead to harm and 
avoid labeling the event as an outcome of negligence or poor quality.  As 
part of this effort to identify problems, researchers and health care entities 
may adopt different standards for distinguishing between degrees of harm  
in defining what constitutes an adverse event.  Thus, entities tracking 
events may find different results depending on the tools used to identify 
and classify events. For example, the National Coordinating Council for 
Medication Errors Reporting and Prevention (NCC MERP) Index can be 
used to classify adverse events by level of harm.  The NCC MERP Index 
was initially developed to categorize the effect of medication errors.  The 
index includes categories for circumstances that presented a risk but did 
 
62 CMS, QAPI  at a Glance:  A Step by Step Guide to  Implementing QAPI in Your Nursing
  
Home. Accessed at http://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/QAPI/Downloads/QAPIAtaGlance.pdf on October 2,  2013. 

63 Ibid. 

64 CMS, Guide for Development Purpose, Guiding Principles, and Scope for QAPI, 
    
June 7, 2013.  Accessed  at http://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/QAPI/Downloads/QAPIPurpose.pdf  on September 5, 2013. 
  
65 CMS, 2012 Nursing  Home Action Plan, 2012. 

 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  9  
   
   
not cause harm (near misses) and those that did cause harm.66   
Table 1 shows the NCC MERP Index for Categorizing Errors. 
Table 1:  The NCC MERP Index for Categorizing Errors 
Level      Description   Event 
A  Circumstances or events occurred that had the capacity to cause error.    
B  Error occurred but did not reach the patient or resident.  
Harm does not 
Error occurred that reached the patient or resident but did not cause  reach patient 
C 
patient or resident harm.  
or resident 
Error occurred that reached the patient or resident and required monitoring 
D 
to preclude harm or confirm that it caused no harm.  
Error occurred that may have contributed to or resulted in temporary harm 
E 
and required intervention. 
Error occurred that may have contributed to or resulted in harm and 
F 
required an initial or prolonged facility stay.  
Harm reaches 
Error occurred that contributed to or resulted in permanent patient or  
G  patient or 
resident harm.  
resident 
Error occurred that required intervention to sustain the patient or residents 
H 
life.  
Error occurred that may have contributed to or resulted in patient or 
I 
resident death.  
Source:  NCC MERP Index for Categorizing Errors,  Medication Errors Council Revises and Expands Index for 
Categorizing Errors:  Definitions of Medication Errors  Broadened, Press Release,  June 12, 2001.  
Researchers have also used the NCC MERP index for measuring and 
distinguishing other types of adverse events.  The Institute for Healthcare 
Improvement (IHI), a nonprofit organization that advises health care 
providers regarding health care quality, uses a modified version of the 
NCC MERP index to measure the degree of harm, regardless of whether 
the harm was the result of error.67  
Identifying Adverse Events. Retrospective medical record review is often 
considered the most definitive method for detecting adverse events, 
because it can provide detail about both the adverse event and the 
circumstances, such as the patients or residents condition prior to and 
following the event.68  Research indicates that identifying adverse events 
retrospectively is a complex and difficult task, requiring extensive clinical  
 
66 AHRQ designed an alternative harm scale for use with the Common Formats.  
According to AHRQ, the AHRQ Harm Scale differs from  the NCC MERP harm scale in 
that it is intended to measure the harm experienced by the beneficiary after the harm is 
ameliorated.   AHRQ, Users Guide:  Version 1.2 AHRQ Common Formats for Patient 
Safety Organizations, 2013. 
67 F.A. Griffin and R.K. Resar,  IHI Global Trigger Tool for Measuring Adverse Events, 
Institute for Healthcare Improvement Innovation  Series, 2009, pp. 45.     
68 E.J. Thomas, D.M. Studdert, and T.A. Brennan, The Reliability of Medical Record  
Review for Estimating Adverse Event Rates, Annals of  Internal Medicine, 136, 11, 
2002, pp. 812816.     
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  10  
   
   
knowledge, adequate documentation, and subjective judgment on the part 
of the researcher.69  
Medical record reviews can be costly, requiring hospitals to make records 
available and substantial effort by physicians or other clinicians to review 
them.  To limit physician medical record reviews to identify adverse events, 
cases can be screened to identify potential events using other methods, such 
as nurse reviews of medical records and analysis of Medicare hospitalization 
claims.  One such method, the IHIs Global Trigger Tool (GTT), uses a 
review of hospital inpatient medical records to identify triggers that could 
signal patient harm and indicate potential adverse events.  A trigger could be 
a description of the harm or a reference that indicates potential harm, such as 
a return to surgery.   The IHI GTT review is designed to be completed by 
nurse reviewers with the results then confirmed or refuted by a physician.  
Another example of a trigger tool is the Nursing Home  Adverse Drug Event 
Trigger Tool.70 Unlike the IHI GTT, which focuses on all aspects of patient 
care in the hospital setting (e.g., medication, surgery, patient care), the 
Nursing Home  Adverse Drug Event Trigger Tool is focused on medication-
related adverse events in  the nursing home or other long-term care settings. 
Determining Preventability.  To provide additional context regarding adverse 
events, researchers have assessed whether events were preventable and 
described the factors contributing to the events.  In a 2010 OIG report about 
adverse events in hospitals, physician reviewers determined that 44 percent 
of events were preventable.71   A 2008 review of eight academic studies found 
a similar result, with an average of 44 percent of events judged preventable.72   
A 2010 study that examined the incidence of adverse events in 10 North 
Carolina hospitals described 63 percent of identified events as preventable.73   
Assessing preventability can provide greater understanding of the causes of 
events, which can be used to develop actionable solutions to the systemic 
problems that lead to events.    
 
69 E.J. Thomas and L.A. Peterson, Measuring Errors and Adverse Events in  Health  
Care, Journal  of General Internal  Medicine, 18, 1, 2003, pp. 6167. 
70 S.M.  Handler, Detecting Adverse Drug  Events Using a Nursing Home Specific 
Trigger Tool,  Annals of Longterm Care, 18, 5, 2010, pp. 17-22.  
71 OIG,  Adverse Events in Hospitals:  National Incidence Among  Medicare Beneficiaries, 
OEI-06-09-00090, November 2010, p.  24. 

72 E.N. De Vries, The Incidence and  Nature of Hospital Adverse Events:  A Systematic 

Review, British Medical Journal  Quality and  Safety in  Health Care, 17, 3,  2008:  pp. 

21623.  

73 C.P. Landrigan, Temporal trends in  rates of patient harm resulting  from  medical care, 

New England Journal  of Medicine, 363,  22, 2010:  212434. 

 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  11  
   
   
METHODOLOGY 
This report estimates the national incidence of adverse events that occurred  
in SNFs using a representative sample of Medicare SNF residents.  Our 
study population includes all Medicare beneficiaries who had Medicare-paid 
SNF stays that met each of the following criteria:   
	   began within 1 day of a beneficiarys discharge from a hospital,  
	   had a length of stay of 35 days or less (rather than the maximum  
100 days allowed by Medicare),74 and 
	   ended in August 2011.   
We included in the estimated national incidence rates all SNF resident harm  
events that occurred during the SNF stays, regardless of whether they were 
preventable. All SNF harm described in this report is attributable to the care 
provided in the SNF.   Additionally, this report provides a physician 
assessment of the extent to which the identified events were preventable and 
an analysis of billing data to estimate the cost to the Medicare program for 
inpatient hospital stays and emergency room visits resulting from  
preventable and not preventable adverse events.  This study largely follows 
the methodology used by OIG in the November 2010 report, which 
estimated the national incidence rate, preventability, and cost of adverse 
events in hospitals.75    
Sample Selection and Profile  
Using Medicare claims data from the National Claims History (NCH) file, 
we selected a simple random sample of 655 Medicare beneficiaries out of 
the 100,771 beneficiaries who had SNF stays that met our 3 sample 
criteria. We excluded 2 beneficiaries because the SNFs they resided in 
were under OIG investigation, which resulted in a review of 653 
beneficiaries SNF stays.  Thirty-seven sample beneficiaries had more than 
1 SNF stay during August (35 had 2 stays and 2 had 3 stays).  Combined, 
reviewed sample beneficiaries had 692 SNF stays that ended in August 
2011; the length of stay averaged 15.5 days. 
The majority (70 percent) of sample beneficiaries entered SNFs following 
hospital stays described by CMS as medical, or nonsurgical, stays.  The 
most frequent medical conditions treated in these stays were septicemia 
 
74 In consultation with CMS, physician reviewers and geriatrician consultants, we limited 
our study  population to  only those stays that  were 35  days  or less because it allowed for  
measurement of  harm in the post-acute care  period.  Additionally, stays that ended on the  
35th  day or earlier constituted the majorityapproximately 70 percentof SNF stays in 
FY 2011.   
75  OIG,  op.  cit., pp. 8-11.   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  12  
   
   
and urinary tract infections.76   The remaining 30 percent of beneficiaries 
entered SNFs following surgical hospital stays (most often for hip or knee 
joint replacements).   
Data Collection 
We requested complete medical records for the sampled beneficiaries  
SNF stays. We received 100 percent of the SNF records we requested.77   
As part of this request, we asked the SNFs to provide the discharge 
summaries and other key medical record documents from the hospital 
stays that preceded the post-acute stays.  In cases when the SNFs were not 
able to provide the hospital records, we requested the records directly from 
the hospitals. We also requested discharge summaries and other key 
medical record documents for any hospital stay that occurred during the 
SNF stay or within 14 days of a beneficiarys discharge from the SNF stay.     
In addition to collecting the medical record documentation, we collected 
billing data for the SNF stays and any associated hospital stays.   We  
collected MDS assessment data associated with the sampled beneficiaries  
Part A SNF stays.  We collected hospital inpatient and outpatient claim data 
associated with sample beneficiaries qualifying inpatient staysas well as 
for any subsequent inpatient or emergency room visitsfrom the National 
Claims History file.   
Identification of Adverse and Temporary Harm Events. We conducted a two-
stage medical record review to identify adverse and temporary harm events.78   
The first stage was a screening process designed to identify sample 
beneficiaries who may have experienced an adverse or temporary harm  
event during their stay(s).  We asked one nurse practitioner and four nurses 
(referred to as screeners) with IHI GTT or SNF experience to review the 
medical records and administrative data associated with the sample 
beneficiaries SNF stays and hospital stays.  They reviewed the medical 
records and administrative data of the hospital stays for evidence of harm 
that occurred during the SNF stays.  They used the OIG-developed SNF 
trigger tool to facilitate and standardize their individual reviews of the SNF 
records.79   The contracted screeners reviewed the records independently and 
each record was reviewed by one screener.  Prior to beginning their reviews, 
 
76 Source:  OIG  analysis of SNF stays for 653 Medicare beneficiaries discharged in  
August 2011. 

77 We did  not request  records for  the two  stays that occurred in  SNFs under OIG 

investigation.  
  
78 See Appendix B for an expanded description of the methodology used to identify  
adverse and temporary harm events.   

79 See Appendix C for description of the development process and a list of SNF Trigger 

Tool triggers. 

 
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we provided training to all screeners on the use of the SNF Trigger Tool.  
The screeners flagged the records of 262 beneficiaries for the second stage 
of the review.  In addition, we randomly selected 100 beneficiaries from 391 
beneficiaries who were not flagged during the screener review to determine 
a screener false-negative rate (i.e., the rate at which the screeners incorrectly 
determined that a beneficiary did not experience an adverse or temporary 
harm event).  See Appendix B for a detailed description of these additional 
reviews. 
The second stage of the medical record review consisted of reviews by five 
contracted physicians of the medical records of the 262 beneficiaries flagged 
by the screening process and the records of the 100 beneficiaries selected for 
the screener false-negative rate review.  The physicians reviewed the records 
independently and each record was reviewed by one physician reviewer.  To  
describe the harm caused by the events, the reviewers used a modified 
version of the NCC MERP harm scale: 
 	  F levelHarm occurred that prolonged the SNF stay or led to a 
transfer to a different SNF or other post-acute facility and/or 
hospitalization (i.e., admission to a hospital observation unit, 
emergency department, or inpatient care). 
 	  G levelHarm occurred that contributed to or resulted in permanent 
resident harm. 
 	  H levelHarm occurred that required intervention to sustain the 
residents life. 
 	  I LevelHarm occurred that may have contributed to or resulted in 
resident death. 
The physician panel included four physicians who participated in the 
2011 OIG study of hospital events (specialists in cardiology, infectious 
disease, internal medicine, and orthopedics) and one geriatrician with 
experience as a Medical Director in SNFs.  To ensure consistency across 
physician reviewers, we facilitated weekly conference calls during which 
physician reviewers discussed cases that either were complex or had possible 
implications for other cases.  Additionally, a contracted geriatric psychiatrist 
provided a secondary review of select events that involved psychotropic 
medications, including falls associated with medications.   
Data Analysis  
We performed analysis and generated estimates about adverse and temporary 
harm events in three categories:  national incidence of events, preventability 
of events, and Medicare cost associated with events.  We included the results 
of the screener false-negative rate review in all of our analyses using 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  14  
   
   
appropriate methodology.  For estimates and corresponding 95-percent 
confidence intervals, see Appendix D. 
Adverse Event Incidence Analysis.   We calculated the estimated national 
adverse event incidence rate as the percentage of Medicare SNF residents 
who experienced at least one adverse event.  We defined adverse events as 
events that resulted in one of the four most serious categories on a modified  
version of the NCC MERP index described above (classified on the index as 
F-I). We projected incidence rates to the population of Medicare 
beneficiaries who had SNF stays that began within 1 day of a beneficiarys 
discharge from a hospital, had a length of stay of 35 days or less, and ended 
in August 2011.   
The overall adverse event incidence rate does not include events that 
physician reviewers identified as temporary harm events, defined as events 
that required intervention but did not cause lasting harm (classified as 
E level harm on the NCC MERP index). We excluded these temporary harm  
events from our overall rate because we determined, in consultation with 
physician reviewers, that the effect of these events was not comparable to 
those of the more serious events (i.e., F level through I level events).  We  
calculated a separate incidence rate for Medicare SNF residents who 
experienced only temporary harm events.   
For beneficiaries in our sample, we also calculated 2 ratios of adverse event 
incidence density: events per 1,000 resident days and events per 100 SNF 
admissions.  These measures are commonly used by providers and medical 
professionals.80  For the resulting metrics and an explanation of the methods 
used, see Appendix E. 
Preventability Analysis. The findings related to preventability are based on  
determinations made by the physician reviewers for each adverse event and 
temporary harm event.  We calculated percentages for each preventability 
classification and for different types of events, the results of which are 
projectable to the population. We also conducted statistical tests to identify 
differences in preventability rates between adverse events and temporary 
harm events and across various categories of adverse events, such as 
medication-related and infection-related events.  
Medicare Cost Analysis.   We estimated the cost to Medicare resulting from  
inpatient hospital stays and emergency room visits.  To determine how much 
Medicare paid for services associated with events, we asked physician 
reviewers to indicate whether the SNF residents were hospitalized because 
 
80 K.M. Arias, Outbreak  Investigation, Prevention,  and Control in  Health Care Settings, 
Second Edition, Jones and Bartlett Publishers, 2009, pp. 330331.   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  15  
   
   
of identified adverse events.  To assist them in their determinations, we 
provided the physicians with summaries of the hospital claims associated 
with each sample beneficiary.   These summaries provided information on the 
hospitalizations that occurred during the SNF stays or within 14 days of the 
sample beneficiaries discharges from the SNFs and the diagnoses codes 
associated with the hospitalizations.   
Using hospital claims data from the NCH file and the results of the 
physicians medical record reviews, we identified the inpatient hospital stay 
or emergency room visit claims associated with the sample beneficiaries  
adverse events. We did this by matching the discharge date of the SNF stay 
with the admission date of the hospital stay or emergency room visit.81   We  
attributed the entire cost of the inpatient hospital stay or emergency room  
visit to the adverse event.  We summed the reimbursements paid by 
Medicare for the hospital and emergency room claims to determine the total 
Medicare paid for the hospitalizations.   
Limitations 
The methodology presents three specific limitations.  First, it is unlikely that 
the study identified all adverse and temporary harm events within the sample 
of SNF residents. To the extent that the study did not identify an event, it 
was likely because documentation in the medical records was incomplete.  
Second, cost estimates do not include all costs of care associated with 
events, including additional SNF stays caused by events but occurring after 
our sample period, additional care beyond the hospitalizations (such as 
physician office visits), and changes in Medicare RUG payments.  Third, our 
sampling methodology limits our findings to beneficiaries who had SNF 
stays that ended in August 2011, began within 1 day of the beneficiaries  
discharges from hospitals, and were 35 days or less.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
 
81 We were not  able to  match  one physician-identified hospitalization  with a Medicare 
claim for an inpatient hospital stay or an emergency room visit.  We included this transfer 
in our transfer rate but imputed the cost as zero dollars.   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  16  
   
   
FINDINGS 
An estimated 22 percent of Medicare SNF residents 
experienced adverse events during their SNF stays    
Approximately one in five Medicare beneficiaries who had post-acute 
SNF stays that were 35 days or less and that ended in August 2011 
experienced at least one adverse event during their stays (22 percent).82   
For this study, an adverse event is as an event that resulted in harm  
equivalent to the four most serious categories (F-I) on our modified 
NCC MERP index (prolonged SNF stay or transfer to hospital, permanent 
harm, life-sustaining intervention, or death).  We estimate that 
21,777 post-acute Medicare SNF residents experienced at least 1 adverse 
event during stays that ended in August 2011.  A small portion of residents 
experienced more than one adverse event (2.6 percent), with a few of these 
residents experiencing as many as three events during a single SNF stay.     
The majority (79 percent) of the adverse events experienced by the 
Medicare SNF residents caused F level harm (see Table 2).  These events 
either extended the beneficiaries stays in the SNFs or resulted in transfers 
from the SNFs to hospitals for acute level care, including both emergency 
department visits and inpatient admissions.  Of the remaining events, 
14 percent required a life-sustaining intervention and 6 percent contributed 
to the residents deaths.   
Table 2: Adverse Events Classified as F-I on OIGs Modified NCC MERP 
Index for Categorizing Adverse Events by Level of Harm  
Percentage of  
Level of Harm  
Adverse Events  
F level: Resulted in prolonged SNF stay, transfer to a different SNF or other  
factor t  post-acute facility, and/or hospitalization (i.e., admission to inpatient      79% 
  care, hospital observation unit, or emergency department)  
G level:  Contributed to or resulted in permanent resident harm*  -- 
H level:  Required intervention to sustain the residents life   14%  
I level:   Contributed to or resulted in resident death   6%  
See Appendix D for confidence intervals.  

*We are unable to reliably project the  weighted point estimate for adverse events classified as G Level harm 

because of the small number  of sample  occurrences.   

 
Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011.
 
We classified the adverse events into three clinical categories:  events 
related to medication (37 percent), events related to ongoing resident care 
(37 percent), and events related to infections (26 percent).  Table 3 lists the 
adverse events within these three categories.  See Appendix F for a list of 
 
82 For this study, we  define post-acute SNF stays as SNF stays that were paid for by 
Medicare Part A under the  SNF benefit, began  within 1 day  of  beneficiaries discharge 
from hospitals, had lengths of stay of 35  days or less, and ended in  August 2011.    
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  17  
   
   
the 148 events with detailed descriptions and level of harm.  While some  
events (such as pressure ulcers and hypoglycemia) have long been of 
concern to post-acute caregivers, we found other events (such as severe 
gastrointestinal bleeding due to anticoagulant overdose) not commonly 
associated with nursing homes.  
Table 3: Adverse Events Identified Among Medicare SNF Residents by  
Category  
Types of Adverse Events   Percentage*  
Events Related to Medication   37%  
   Medication-induced delirium or other change in mental status  12%  
   Excessive bleeding due to medication  5%  
   Fall or other trauma with injury secondary to effects of medication   4%  
  Constipation, obstipation, and ileus related to medication  4%  
  Other medication events  14%  
Events Related to Resident Care     37%  
   Fall or other trauma with injury related to resident care   6%  
   Exacerbations of preexisting conditions resulting from an omission of care   6%  
   Acute kidney injury or insufficiency secondary to fluid maintenance  5%  
   Fluid and other electrolyte disorders (e.g., inadequate management of fluid)  4%  
   Venous thromboembolism, deep vein thrombosis (DVT), or pulmonary  
4%  
embolism (PE) related to resident monitoring  
   Other resident care events  14%  
Events Related to Infections   26%  
   Aspiration pneumonia and other respiratory infections  10%  
   Surgical site infection (SSI) associated with wound care  5%  
   Urinary tract infection associated with catheter (CAUTI)   3%  
   Clostridium difficile infection   3%  
   Other infection events  5%  
Total   100%  
*The percentages for conditions listed within the clinical categories do not sum to 100 percent because of rounding.  

See Appendix D for percentage estimates and  confidence intervals.   
  
See Appendix F for a complete listing  of all adverse events identified by the reviewers. 

Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011. 

Within the sample, physician reviewers categorized some seemingly 
similar events in different clinical categories because the events or factors 
that led to the harm differed.  This was most evident in the categorization 
of resident fall events; physician reviewers categorized about half of 
sample fall events as medication events and the other half as resident care 
events. The fall events categorized as medication events demonstrated 
clear evidence in the medical record that medication was the primary 
cause of the fall, because of delirium and hallucinations caused by 
psychotropic and other medications.  Physician reviewers categorized the 
remaining fall events as resident  care events because the falls and 
accompanying harm were the result of inadequate resident care (e.g., SNF 
staff did not adequately monitor residents who were known fall risks) 
rather than the effects of medication.    
 
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The use of multiple medications often complicated the determination of  
the primary cause of events, particularly when the primary cause was 
related to another medication.  For example, in one case our consulting 
geriatric psychiatrist determined that the overuse of anti-anxiety 
medication might have masked symptoms of hypoglycemia and resulted in 
a delayed diagnosis. 
An estimated 1.5 percent of Medicare SNF residents 
experienced events that contributed to their deaths 
This rate projects to an estimated 1,538 SNF residents who experienced 
adverse events that contributed to their deaths during the study 
month.  Within the sample, events that contributed to deaths  represented a 
wide range of adverse events from each of the three clinical categories.  
Resident care events that contributed to death included blood clots, such as 
deep vein thrombosis (DVT); fluid imbalances; and acute renal 
insufficiency. Medication events included excessive bleeding due to 
anticoagulants and acute hypoglycemia. Most of these residents died at 
hospitals rather than in the SNFs where the harm occurred, having been 
transferred back to the hospitals for higher level treatment as a result of  
the event.  Some of these residents were admitted to hospitals, but others 
died in emergency departments because of the acute nature of their 
adverse events, such as cardiac arrest or excessive bleeding.   
Although no single type of event was prominent within the sample as 
contributing to death, residents who died as a result of events shared 
commonalities. Most had multiple, complex co-morbidities that physician 
reviewers determined made their care more challenging, weakened their 
conditions, or both. For example, one resident who died from a PE had a 
range of other chronic and acute conditions, including a serious infection, 
chronic heart and kidney diseases, a history of blood clots, and dementia.  
Other residents who died had previously experienced multiple instances of  
the types of events that ultimately contributed to their deaths. For 
example, one resident who died of aspiration had suffered multiple prior 
strokes that likely hampered swallowing ability.   
In the case of some resident deaths, physician reviewers found evidence in 
the medical record that the deaths may have been expected by caregivers, 
the residents, or family.  In one such case, the medical record for the 
residents prior hospitalization showed that the hospital physician stopped 
medical intervention and suggested that the resident seek palliative care at 
the SNF.  In another case of an elderly resident, the SNF medical record 
indicated that the residents family requested palliative care shortly before 
the resident died of cardiac arrest.  Most commonly, though, death during 
the SNF stay was likely not an expected outcome, as in the case of a 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  19  
   
   
resident who died of cardiac arrest following progressive kidney failure 
that was not detected until the resident was awaiting discharge from the 
SNF. 
An estimated 4 percent of Medicare SNF residents experienced 
at least one cascade adverse event, wherein multiple, related 
events occurred in succession  
This rate projects to an estimated 3,986 residents who experienced cascade 
events during the study month.  A cascade event is defined as an event 
that included a series of multiple, related events.  We counted cascade 
events as single events.  Within the sample, medication often played a 
secondary role in the cascading harm.  For example, in one sample 
cascade event, a resident with multiple comorbidities, including 
neurological disorders (e.g., tremors, rigidity), and chronic kidney 
insufficiency developed significant gastrointestinal bleeding from  
excessive anticoagulation.  The internal bleeding resulted in hematemesis 
(vomiting blood), which ultimately caused a fatal aspiration.  Also within 
the sample, a number of cascade events began with inadequate resident 
hydration. In at least one sample case, a resident experienced significant 
dehydration followed by an electrolyte imbalance and damage to the 
kidneys because SNF staff did not actively monitor and manage the 
residents fluid intake.   
An additional 11 percent of Medicare SNF residents 
experienced events during their SNFs stays that 
resulted in temporary harm 
Another 11 percent of Medicare SNF residents experienced events 
classified as E level harm on the NCC MERP index (defined as resident 
harm events that required medical intervention but did not cause lasting 
harm).  We estimate that 10,742 post-acute Medicare SNF residents 
experienced at least 1 temporary harm event during the study month.  Of 
these beneficiaries, an estimated 2,154 had more than 1 unrelated 
event. Additionally, 21 percent of beneficiaries who experienced adverse 
events also had temporary harm events during their stays. 
As with adverse events, temporary harm events represented a wide array 
of conditions from the three clinical categories (see  Table 4).  Table F-2 in 
Appendix F contains a list of the 113 temporary harm events identified in 
the sample and provides detailed descriptions.   
 
 
 
 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  20  
   
   
Table 4: Temporary Harm Events Identified Among SNF Residents by  
Category  
Types of Temporary  Harm Events   Percentage*  
Events Related to Medication   43%  
   Hypoglycemic episodes (e.g., low  or significant drop in blood glucose)   16%  
   Fall or other trauma with injury associated with medication  9%  
   Medication-induced delirium or other change in mental status  7%  
   Thrush and other nonsurgical infections related to medication  4%  
   Allergic reactions to medications (e.g., rash, itching)  3%  
  Other medication events  3%  
Events Related to Resident Care    40%  
  Pressure  ulcers   19%  
   Fall or other trauma with injury associated with resident care   8%  
   Skin tear, abrasion, or breakdown  7%  
   Other resident care events  6%  
Events Related to Infections   17%  
  CAUTI   5%  
   SSI associated with wound care   5%  
   Other infection events  7%  
Total   100%  
*The percentages for conditions listed within the clinical categories do not sum to 100 percent because of rounding.  

See Appendix D for percentage estimates and  confidence intervals.   
  
See Appendix F for a complete listing  of all temporary harm events identified  by the reviewers. 

Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011. 

Although many cases of temporary harm within the sample represented 
instances of fairly minor harm to the residents, other temporary harm  
events caused harm that was significant for the residents.  We did not 
classify these events as adverse events because they did not require 
transfer to a hospital or prolong the SNF stays.  Additionally, physician 
reviewers indicated that many sample  temporary harm events could have 
developed into more serious events if SNF staff had not provided a timely 
intervention.  For example, infection events such as Clostridium difficile  
and CAUTIs can quickly escalate from infections to serious, 
life-threatening infections if not diagnosed and treated quickly.83, 84    
 
83 L.A. Mermel, Reducing Clostridium difficile incidence, colectomies, and mortality in  
the hospital setting:  a successful multidisciplinary approach, Joint Commission Journal 
of Quality and  Patient  Safety, 39, 7, 2013:  pp. 298-305.   
84 Centers for Disease Control and Prevention (CDC), Inpatient Care of  Septicemia  or 
Sepsis:  A Challenge for Patients and Hospitals, National Center for Health  Statistics 
Data Brief, 2011.    
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  21  
   
   
Physician reviewers determined that 59 percent of 
adverse events and temporary harm events were 
clearly or likely preventable 
Physician reviewers assessed the extent to which events were preventable 
on the basis of information in the medical records, their clinical experience 
with similar circumstances, research literature about specific events, and 
group discussion to reach consensus.  Combining adverse events and 
temporary harm events, physicians determined that 59 percent were 
preventable and 37 percent were not preventable.  For the 
remaining 4 percent, physicians were unable to make determinations 
because of incomplete documentation in the medical records or extreme 
complexities in the residents conditions or in the care provided.  Table 
5 provides the percentage of events by preventability assessment for 
adverse events, temporary harm events, and both groups of events 
combined. 
Table 5: Adverse and Temporary Harm Events by Preventability  
Determination 
Percentage of  Percentage of  Percentage 
Preventability Assessment  Adverse  Temporary  of All 
Events  Harm Events    Events  
PreventableHarm could have been avoided 
through improved assessment or alternative  69%  46%   59%  
actions   
Clearly preventable   18% 6%   13%  
Likely preventable   50% 40%   46%  
Not preventableHarm could not have been 
avoided given the complexity of the residents  29%  47%   37%  
condition or care required   
Clearly not preventable   11% 12%   11%  
Likely not preventable   18% 35%   26%  
Unable To Determine Preventability*   3%  --  4.2%  
*We are unable to reliably project the  weighted point estimate for temporary harm events classified as Unable to 
 
Determine because of the small  number of  sample occurrences.   

 
Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011.
 
Physicians determined that a larger percentage of adverse events was 
preventable (69 percent) than temporary harm events (46 percent).85 If we 
were to include only preventable events in the estimated incidence rate of  
adverse events among Medicare beneficiaries, the adverse event rate 
would be 15 percent (rather than 22 percent) and the rate of additional 
beneficiaries experiencing temporary harm events would be 5 percent 
(rather than 11 percent).  Physician reviewers determined that 66 percent 
of medication events were preventable, 57 percent of resident care events 
 
85 The ratio of preventable adverse events to adverse events was statistically higher than  
the ratio of preventable temporary harm events to temporary harm events at the 
95-percent confidence level. 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  22  
   
   
were preventable, and 52 percent of infection events were preventable.  
Table 6 provides the percentage of preventable events by clinical category.       
Table 6: Percentage of Preventable Adverse and Temporary  Harm Events 
by Clinical Category  
Percentage of Preventable 
Types of Adverse and Temporary Harm Events   Adverse and Temporary  
Harm Events (n = 155)  
Events Related to Medication  66%  
Events Related to Resident Care   57%  
Events Related to Infections  52%  
 
Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011. 
Within the clinical categories, physician reviewers often gave the same  
preventability assessment to events with similar circumstances.  In making 
preventability determinations for specific cases, physicians factored in 
both the residents condition and the adequacy of SNF monitoring and 
interventions. For example, all cases of hypotension in the sample were 
considered preventable because all the residents developed the condition 
because of insufficient monitoring.  Similarly, all allergic reactions  
identified in the sample were considered not preventable because the 
residents medical records lacked historical information about allergies.   
In other cases, similar events had different preventability determinations, 
often because of variation in the health of SNF residents involved.  For 
example, reviewers described pressure ulcers as preventable when the 
resident was generally healthy and able to comply with pressure ulcer 
precautions (e.g., frequent rotation of the resident) but received inadequate 
evidence-based pressure ulcer precautions.  They described pressure ulcers 
as not preventable when they found evidence that the resident received 
evidence-based preventative pressure ulcer care but developed the ulcers 
because of comorbidities that greatly increased their risk of developing 
pressure ulcers. Physician reviewers reported that these comorbidities 
made it difficult for SNF staff to provide the type of care typically used to 
prevent such ulcers. As another example, among sample cases of 
aspiration pneumonia, physicians determined preventability on the basis of  
resident conditions that may not respond well to treatments, such as 
chronic dysphagia (difficulty in swallowing).  Among hypoglycemic 
episodes, physicians determined similar cases as preventable on the basis 
of factors such as the residents past experience with wide variance in 
blood glucose levels and staff use of appropriate insulin dosing regimens. 
 
 
 
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Factors that contributed to preventable adverse and temporary 
harm events included substandard treatment, inadequate 
resident monitoring, and failing to provide treatments 
Physician reviewers selected one or more rationales to support each 
preventability determination from a list developed by the physician panel.  
To make these selections, physicians gleaned information from medical 
records, such as staff actions, environmental factors, and resident 
condition unrelated to the event. Among preventable events, 37 percent 
involved inadequate monitoring of the residents and 25 percent involved 
failure to provide necessary treatments.  One sample resident suffered an 
undiagnosed pneumothorax (collapsed lung) because of SNF staff failure 
to recognize symptoms of shoulder pain and shortness of breath.  The 
resident later had two additional events, a reaction to medication and a 
blood clot, both requiring transfer to a hospital.  Table 7 provides 
preventability rationales for events within the preventable and not 
preventable assessment categories.  
Table 7: Adverse and Temporary Harm Events by Preventability 
Rationales  
Adverse and Temporary Harm Preventability Rationale   Percentage* 
Preventable Events  
Appropriate treatment was provided in a substandard way  56%  
The residents progress was not adequately monitored   37%  
Necessary treatment was not provided  25%  
Error was related to medical judgment, skill, or resident management  14% 
Resident care plan was inadequate   11%  
Care plan was incomplete or not sufficient in describing residents condition   7%  
The residents health status was not adequately assessed   4%  
Not Preventable Events  
Resident was highly susceptible to  event because of health status  59%  
Event occurred despite proper assessment and procedures followed   32%  
Residents diagnosis was unusual or complex, making care difficult   27%  
Care provider could not have anticipated event given information available   20%  
*Percentages do not add to 100 because physician reviewers often selected more than one rationale.  

See Appendix D for confidence intervals. 

 
Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011.
 
Not preventable events involved residents who were highly 
susceptible or otherwise at risk for experiencing harm despite 
efforts by staff to avoid harm 
In these cases, physicians determined that the care provided was sufficient 
and appropriate and that there was no evidence of errors or other 
problems.  In some of these cases, necessary treatment resulted in harmful  
side effects.  For example, one elderly resident in our sample experienced 
delirium from needed pain medications given following surgery and 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  24  
   
   
another experienced gastrointestinal bleeding from anticoagulants 
prescribed for a heart condition.  In other cases, resident care decisions 
made in the prior hospitalization resulted in harm during the SNF stay.  In 
one case, a resident developed a full body rash several days into the stay 
that was an allergic reaction to an antibiotic that had been prescribed in the 
preceding hospitalization and was continued in the SNF. In other cases of 
not preventable adverse events, the SNF residents or families contributed 
to the events by not complying with staff recommendations.  For example, 
one sample resident with Alzheimers-related dementia fractured his hip 
while attempting to stand without assistance and another resident pulled 
out his feeding tube, ultimately causing an infection at the insertion site.            
For 59 percent of the not preventable events, physician reviewers found 
that residents comorbidities or health status made them highly susceptible 
to the events.  Within our sample, aspiration pneumonia events were a 
prominent example.  Many of the sample beneficiaries who experienced 
these events were highly susceptible to aspiration because they had 
comorbidities that made it difficult for them to swallow.  In one such case, 
a resident with significant difficulty swallowing because of neurological 
disorders (tremors, rigidity) aspirated despite a thorough evaluation and 
with aspiration precautions in place (substituting liquid food for solid).86   
Over half of the residents who experienced harm went 
to a hospital for treatment, with an estimated cost to 
Medicare of $208 million in August 2011 
Adverse events that occurred in post-acute SNF stays of less than 36 days 
ending in August 2011 resulted in an estimated 20,393 resident transfers to 
hospitals and an estimated $208 million in Medicare expenditures for 
these hospitalizations.87  Of the estimated $208 million spent on all 
hospitalizations, $136 million was spent on hospitalizations associated 
with preventable events.  The estimate of $208 million spent on care 
associated with all adverse events equates to 2 percent of the $10.2 billion 
that Medicare spent on inpatient hospital stays in August 2011.88   
 
86 The study methodology did  not include an analysis of end-of-life care issues, such as 
instructions from residents and  families to not resuscitate residents in the event of a poor 
condition.  However, when these factors were present in the medical record, physician  
reviewers considered them in  determining  preventability.  For example, when the SNF 
record included a signed order to provide only palliative care or included notes regarding  
a discussion  of such care with the resident  or family, physician reviewers weighed that  
obligation  against any inadequacies in the provision of care leading up to the harm event.   
87 For this study, we define hospitalization  as any transfer to a hospital for an inpatient  
admission, emergency  department visit, or  observation unit stay. 

88  The August 2011  Medicare inpatient cost figure  is from  OIG analysis of August 2011 
 
Medicare hospital claims, NCH file. 

 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  25  
   
   
Assuming that the rate of Medicare spending on hospitalizations due to 
adverse events in SNFs remained constant throughout the year, 2 percent 
of the $140 billion Medicare inpatient expenditures equates to $2.8 billion 
spent in FY 2011 on hospitalizations associated with preventable and not 
preventable adverse events that occurred in SNFs.89   
Of the estimated 32,519 Medicare SNF residents who experienced at least 
1 adverse or temporary harm event, an estimated 19,470 (60 percent) were 
hospitalized at least once as a result of the events.  The hospitalized 
residents constitute 19 percent of all Medicare beneficiaries in SNF stays 
that were 35 days or less and that ended in August 2011.90  Because some  
SNF residents were hospitalized more than once, the total number of  
hospitalizations resulting from adverse events was 20,393.  Within our 
sample, infection-related events resulted in the fewest hospitalizations 
among the three clinical categories but incurred the highest cost per 
hospitalization (see Table 8).    
Table 8: Costs of Hospitalizations Associated With Adverse Events  
Estimated  Estimated  Estimated 
Hospitalization Type   Number of   Average  Total  
Hospitalizations   Costs   Spending  
Hospitalizations for medication events   7,203  $8,372  $57,729,935 
Hospitalizations for resident care events  7,511  $8,967  $67,350,098 
Hospitalizations for infections events  5,679  $14,599   $82,899,180  
Hospitalizations Associated With All Events   20,393  $10,276   $207,979,213  
Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011.  
Within the sample, certain types of events frequently led to 
hospitalizations. For example, all sample aspiration pneumonia events led 
to hospitalization. For most of these sample events, the medical records 
indicated that SNF staff hospitalized the residents  because the care needed  
to ameliorate the respiratory distress caused by the aspiration exceeded the 
level of care they could provide. 
The full costs associated with these events are likely greater than our 
estimate.  Our cost estimate is a projection of reimbursements paid by 
Medicare Part A for the hospitalizations associated with the identified 
adverse events and by Medicare Part B for emergency room visits.  It does 
 
89 The annual cost estimate of $2.8  billion is 2  percent of the $140  billion Medicare 
inpatient costs for FY  2011,  which assumes the same proportion of costs for adverse 
events for the other 11 months that  we found in  August  2011.   Annual Medicare inpatient 
cost figure is from CMS, 2011 CMS  Statistics Book, Table III.6, Office of Research, 
Development, and Information,  CMS Pub. No. 03504, June 2011, p.  30.      
90 The remaining Medicare SNF residents either did not experience adverse events  or 
temporary harm events, experienced events that did not lead to hospitalization,  were 
hospitalized for other  reasons,  or died during their SNF stays.  
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  26  
   
   
not include any other costs paid by Medicare or by other payers 
including beneficiariesfor medical care needed as a result of the adverse 
events or temporary harm events. 
CONCLUSION AND RECOMMENDATIONS 
The ACA mandated HHS to establish and follow a national strategy for 
quality improvement in health care, including patient and resident safety.  
Post-acute care in SNFs is intended to help beneficiaries improve health 
and functioning following a hospitalization and is second only to hospital 
care among inpatient costs to Medicare.  While health care stakeholders 
have in recent years given substantial attention to patient safety in 
hospitals, less is known about resident safety in SNFs.   
Replicating the methods we used in the 2010 OIG study of hospital 
adverse events, this report provides the first national incidence rate of 
adverse events in SNFs. Twenty-two percent of Medicare beneficiaries 
experienced adverse events during their SNF stays, resulting in prolonged 
SNFs stays or hospitalizations, permanent harm, life-sustaining 
intervention, or death. An additional 11 percent experienced temporary 
harm events.  This 32-percent total harm rate is similar to what OIG found 
in its 2010 hospital report, which stated that 27 percent of Medicare 
beneficiaries had experienced adverse and temporary harm events during 
their hospital stays.  Also, 59 percent of events in SNFs were preventable, 
and hospitalizations necessitated by the events increased costs to Medicare 
by an estimated $208 million in a single month, suggesting potential 
savings from reducing the incidence of adverse events that occur in SNFs. 
Because more than half of the adverse events that we identified were 
preventable, our study confirms the need and opportunity for SNFs to 
significantly reduce the incidence of events.  This reduction in events and 
improved safety for post-acute residents would require a coordinated 
response to include both providers and overseers.  A number of agencies 
within HHS share responsibility for addressing this issue, most  
prominently AHRQ as a coordinating body for efforts to improve health 
care quality and CMS as the Nations largest health care payer and an 
oversight entity.  
Therefore, we recommend the following: 
 
 
 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  27  
   
   
AHRQ and CMS should raise awareness of adverse events in 
post-acute care and seek to reduce harm to nursing home 
residents through methods used to promote hospital safety  
In response to recent OIG recommendations to reduce adverse events in 
hospitals, AHRQ and CMS are collaborating to create a list of potentially 
reportable adverse events for hospital staff education and facility 
measurement.  CMS also developed hospital surveyor training to assist 
hospital overseers in assessing safety practices, and AHRQ has refined the 
process for submitting event reports to PSOs.  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 period of post-acute recovery.91   Agency 
response to this recommendation should include the following:     
 	  AHRQ and CMS should collaborate to create and promote a 
list of potential nursing home events 
Staff identification of resident harm is critical to the success of  
resident safety efforts, giving them the opportunity to correct problems 
and reduce harm as well as to report problems contributing to events.  
Our physician review of medical records found that many events were 
the result of failure by SNF staff to monitor residents or staff delay in 
providing necessary medical care.  AHRQ and CMS should ensure 
that nursing home staff are able to identify resident harm events to 
prevent harm or worsening.  Additionally, we found events not 
commonly associated with nursing homes that therefore may not have 
been included in staff training efforts. 
To inform nursing homes about the range of potential adverse events, 
AHRQ and CMS should collaborate to create and promote a list of 
potentially reportable events for nursing homes.  The list would 
educate SNF staff about the full range of resident harm.  The list 
should go beyond the conventional SNF care issues and include a 
comprehensive range of possible resident harm.  Events could include 
those identified in this report and by other researchers, recognizing the 
unique challenges of the SNF setting rather than duplicating lists of  
hospital events. AHRQ and CMS should be clear that they do not 
require external nursing home reporting of these events, but provide 
the list to broaden and improve staff understanding.   
 
 
91  We  specify that these efforts should  be  directed to all nursing homes rather than  only to  
post-acute care in SNFs, given that  AHRQ and CMS guidance and CMS oversight  
authority extend to all nursing home stays.  
 
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 	  CMS should include potential events and information about 
resident harm in its quality guidance to nursing homes      
Under the ACA, nursing homes must develop QAPI programs to 
address quality problems and improve facility performance.  In 2013, 
CMS began to provide new guidance to nursing homes to encourage 
effective QAPI development and implementation.  The initial 
guidance, released in July 2013, focused on core elements needed to 
improve practices, such as goal-setting.  CMS has indicated that 
subsequent materials to be released in 2014 will provide information 
specific to clinical care and resident safety.  CMS should ensure that 
the guidance includes elements similar to what it has promulgated to 
hospitals, including a definition of adverse events, a list of potential 
adverse events for staff education on the range of harm that residents 
can experience, strategies for detecting and measuring adverse events, 
and best practices for improving staff recognition and reporting of 
adverse events. Issuing similar guidance to both hospitals and nursing 
homes may improve communication and collaboration regarding 
shared safety concerns and care transitions as prescribed in the ACA.  
 	  AHRQ and CMS should encourage nursing homes to report 
adverse events to Patient Safety Organizations  
Nursing home reporting to PSOs would enable the post-acute 
community to gain from the structure already in place for the hospital 
community.  Routine reporting by nursing homes could help establish 
the process of event identification within facilities, and the resulting 
PSO analysis of nursing home events would provide much-needed 
information that would be useful in quality and safety improvement 
efforts.  Analysis of events across facilities assists providers in 
directing resources to the areas of greatest need, setting clear goals for 
improvement, assessing the effectiveness of specific strategies, 
holding nursing homes accountable, and gauging progress in reducing 
incidence.   
Encouraging nursing home reporting to PSOs will require efforts on 
the part of both agencies to adapt processes to the nursing home setting 
and to reduce barriers to reporting.  AHRQ has designed PSO 
reporting formats for the nursing home setting, and a number of PSOs 
accept adverse event reports from post-acute care providers.  AHRQ 
and CMS should build on these initial steps by conducting outreach to 
nursing homes about event reporting, promoting the reporting of 
adverse events by nursing homes to PSOs, and gaining knowledge 
about the nature and type of information and assistance that would be 
most helpful to nursing homes.   AHRQ and CMS should also 
collaborate to resolve any barriers to nursing home reporting due to 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  29  
   
   
possible conflicts between QAPI provisions that require nursing homes 
to share event information with State agency surveyors and PSO 
provisions that require confidentiality of reported information.      
CMS should instruct nursing home surveyors to review facility 
practices for identifying and reducing adverse events      
Federal requirements regarding resident safety in SNFs include both 
broad, facilitywide mandates, as well as requirements specific to certain 
practices.   These requirements are tied largely to nursing home QAPI 
programs and governed by the facilities QAA committees. CMS should 
instruct State survey agencies to include an assessment of adverse event 
identification and reduction in their evaluations of QAPI and QAA  
compliance and link related deficiencies specifically to resident safety 
practices. This link would provide an incentive to nursing homes to 
develop strategies to reduce adverse events.   To facilitate State agency 
assessment of QAPI programs, QAA committee activities, and other 
nursing home activities related to adverse events, we recommend that this  
guidance include information about how surveyors should assess nursing 
home adverse event collection efforts and should include the list of 
potentially reportable events to be developed by AHRQ and CMS.  
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
We received comments on the draft report from AHRQ and CMS. 
AHRQ. AHRQ concurred with our recommendations.  AHRQ stated that 
the information presented in the report will help improve the care provided 
to an especially vulnerable patient population.   
In response to our sub-recommendation that AHRQ and CMS collaborate 
to create and promote a list of potential nursing home events, AHRQ 
stated that it will use information about the 261 events identified in our 
report as it develops the next version of the Common Formats.   
In response to our sub-recommendation that AHRQ and CMS encourage 
nursing homes to report adverse events to PSOs, AHRQ stated that it will 
increase its emphasis on this organizational priority.  In particular, AHRQ 
will conduct outreach to organizations representing nursing homes to 
increase awareness of PSOs.  AHRQ also noted that it is working with 
CMS on the 11th Scope of Work for Quality Improvement Organizations, 
specifically to resolve issues related to nursing home event reporting.     
CMS. CMS concurred with our recommendations.  CMS stated that it 
recognizes the importance of identifying adverse events among nursing 
home residents as a way to improve resident quality of life and medical 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  30  
   
   
care. In its comments, CMS provided details about current activities and 
future plans to improve nursing home resident safety. 
In response to our recommendation that AHRQ and CMS raise awareness 
of adverse events in post-acute care and seek to reduce harm to nursing 
home residents through methods used to promote hospital safety, CMS 
agreed that helping nursing homes better understand what constitutes an 
adverse event could reduce preventable harm.  CMS also agreed that it 
would be instructive to review methods used by hospitals to reduce 
adverse events. CMS indicated that activities underway to establish 
specific QAPI requirements for nursing homes may raise awareness of 
adverse events. These activities include CMS development of technical 
guidance on QAPI and release of the guidance to nursing homes.   
In response to our sub-recommendation that AHRQ and CMS collaborate 
to create and promote a list of potential nursing home events, CMS stated 
that it will work with AHRQ to develop a common definition and 
description of adverse events. CMS also stated that it intends to use the 
results of the OIGs review to build a list of potential adverse events.   
In response to our sub-recommendation that CMS include potential events 
and information about resident harm in its quality  guidance to nursing 
homes, CMS stated that it will include guidance on adverse events and a 
list of potential events in its QAPI technical assistance and make this 
available through the nursing home QAPI Web page.   
In response to our sub-recommendation that AHRQ and CMS encourage 
nursing homes to report to PSOs, CMS concurred conditionally.  CMS 
stated that while it believes PSOs can help nursing homes improve their 
performance improvement capabilities, it is concerned that the 
confidentiality and privilege protections outlined in the legislation that 
created the PSOsthe Patient Safety and Quality Improvement Act of 
2005could make it difficult for surveyors to adequately assess nursing 
home QAPI programs.  Therefore, CMS stated that in implementing the 
sub-recommendation, it would work with  AHRQ to ensure preservation of 
both the survey and certification function and the confidentiality and 
privilege protections afforded by PSOs.   
In response to our recommendation that CMS instruct nursing home  
surveyors to review facility practices for identifying and reducing adverse 
events, CMS stated that activities underway to establish QAPI 
requirements for nursing homes will include guidance for surveyors on 
how to evaluate nursing home efforts to identify and reduce adverse 
events. 
For the full text of AHRQ and CMS comments, see Appendix G.   
 
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APPENDIX A 
Glossary of Select Medical Terms92  
Adverse eventHarm to a patient or resident as a result of medical care 
or in a health care setting. For purposes of calculating an incidence rate 
for this study, we defined adverse events as events that resulted in one of  
the four most serious categories on our modified version of the NCC 
MERP Patient Harm Index (classified on the index as F-I):  prolonged 
SNF stay or hospitalizations (including emergency room visit), permanent 
harm, life-sustaining intervention, or death.  
AnticoagulantA drug that hinders blood coagulation, typically used to 
prevent or treat blood clots. 
AspirationAccidental inhalation of foreign material into the lungs, such 
as food and/or gastric contents. 
Aspiration pneumoniaAn infectious process caused by the inhalation 
of oropharyngeal secretions (food, liquid, or gastric contents) that are 
colonized by pathogenic bacteria. 
Blood clotA coagulated mass that can occlude an artery or vein.  
ComorbidityThe presence or effect of one or more diseases or 
disorders in addition to a primary disease or disorder.  
Chronic kidney insufficiencySlow loss of kidney function over time. 
Deep vein thrombosis or DVTA condition marked by the formation of 
a thrombus (blood clot) within a deep vein (as of the leg or pelvis) that is 
potentially life threatening if dislodgment of the thrombus results in 
pulmonary embolism blocking the pulmonary (lung) artery. 
Fluid and electrolyte balanceMinerals in the body that have an electric 
charge and are in body fluids, such as Sodium (Na+) and Potassium (K+).  
Maintaining the right balance of electrolytes helps maintain normal 
biochemical and physiological functions.   
Gastrointestinal (GI) bleedingBleeding from one or more areas of the 
digestive or GI tract. 
HypertensionAbnormally high arterial blood pressure that typically 
results in a thickening of arterial walls and is a risk factor for various 
 
92 Clinical definitions adapted  from the National Institutes of Health, U.S. National 
Library of Medicine, Medline Plus Medical Dictionary. Accessed at 
http://www.nlm.nih.gov on May 5, 2013. 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  32  
   
   
pathological conditions or events (such as heart attack, heart failure, 
stroke, end-stage renal disease, or retinal hemorrhage).  
HypoglycemiaAn abnormal decrease in blood sugar in the blood. 
HypotensionAbnormally low blood pressure. 
IleostomyThe bottom of the small intestine (ileum) attached to the 
stoma; bypasses the colon, rectum, and anus. 
IleusHypomotility of the gastrointestinal tract in the absence of  
mechanical bowel obstruction; specifically, a condition that is commonly 
marked by a painful distended abdomen, vomiting, toxemia, and 
dehydration when intestinal contents back up. 
KetoacidosisA condition in which the body cannot use sugar (glucose) 
for energy because there is no insulin or not enough insulin; fat is used for 
energy instead.  During ketoacidosis, ketones build up in the blood and 
urine. In high levels, ketones are poisonous and potentially life 
threatening. 
Pressure ulcerAn ulceration of tissue deprived of adequate blood 
supply by prolonged pressure; also called decubitus ulcer and bedsore. 
SepsisA systemic response typically to a serious, usually localized, 
infection (in the urinary tract or lungs), especially of bacterial origin. 
SepticemiaPresence of virulent microorganisms, such as bacteria, virus, 
or fungi from an infection accompanied by acute systemic illness.  
Temporary harm eventPatient or resident harm event that required 
intervention but did not cause lasting harm, a prolongation of medical stay, 
or death or require a life-sustaining intervention; classified as E level of  
harm on the NCC MERP index. 
ThrushYeast infection that causes white patches in mouth, in the GI 
tract, and in other mucocutaneous junctions. 
Urinary tract infection (UTI)An infection of the tract through which 
urine passes and which consists of the renal tubules and renal pelvis of the 
kidney, the ureters, the bladder, and the urethra. 
   
 
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APPENDIX B 
Methodology for Identifying Events and Determining 
Preventability 
We conducted a two-stage medical record review to identify adverse and 
temporary harm events.  In the first stage, a nurse practitioner and four 
registered nurses (referred to as screeners) identified sample beneficiaries 
who were likely to have experienced adverse and temporary harm events 
during their SNF stays.  In the second stage, physicians identified adverse 
and temporary harm events in the records of the subset of beneficiaries who 
were determined by the screeners as likely to have experienced adverse or 
temporary harm events and in the records of those selected as part of an 
assessment of the screener efficacy.   
Screening for Beneficiaries Who Likely Experienced Harm Events. To  
identify beneficiaries who were likely to have experienced adverse and 
temporary harm events during their SNF stays, contracted screeners 
reviewed the following:  complete medical records from the SNF stays; 
resident assessment data (i.e., Minimum Data Set) collected during the SNF 
stay; discharge summaries, lab results, and other key documents from the 
medical records of the hospital stays that preceded the SNF stays; discharge 
summaries, lab results, and other key documents from the medical records of 
the hospital stays or emergency room visits that occurred during the SNF 
stays or within 14 days of the SNF discharge dates; and administrative and 
billing data from the preceding and subsequent hospital stays.  From the 
SNF resident assessment data, we extracted information about each 
residents health status during the stays, any chronic illnesses, rehabilitation 
progress, and possible medical concerns (e.g., risk of falling, developing a 
pressure ulcer). From hospital claims  data, we extracted administrative data 
(e.g., admission and discharge dates), diagnosis and procedure codes, and 
information on the reimbursements paid by Medicare for the hospital stays.  
The screeners reviewed the documents and data from the preceding and 
subsequent hospital stays to look for evidence of events that occurred during 
the SNF stays. A beneficiary was considered likely to have experienced an 
adverse or temporary harm event if the screeners found at least one potential 
event during any of the beneficiarys hospital stays.  Of the 653 beneficiaries 
in the sample, the screeners flagged 262 beneficiaries (40 percent) records 
for physician review.   
To standardize their review, we required the screeners to use an 
OIG-developed protocolthe SNF Trigger Toolto identify triggers in the 
medical record.  These triggers are indicators of possible adverse and 
temporary harm events.  If the screeners found a trigger,  they explored the 
 
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record further to determine whether events occurred and, if so, documented 
the level of harm.   
The screening process enabled us to reduce the number of cases requiring 
second-level review of the full medical records by a physician.  The 
physician reviewers indicated that the results of the screening methods 
helped them to readily identify potential adverse and temporary harm events 
for consideration. 
Determining a Screener False-Negative Rate. In addition to reviewing the 
records associated with the 262 beneficiaries flagged by the screeners, the 
physicians also reviewed the records of 100 beneficiaries randomly selected 
from 391 beneficiaries who were not flagged by the screeners.  The 
physicians reviewed these records to determine the rate at which the 
screeners failed to identify beneficiaries who likely experienced adverse or 
temporary harm events.  The physician reviewers found harm events not 
otherwise found by the screeners in 7 of the 100 randomly selected 
beneficiaries records.  These events are noted in Appendix F.    
Physician Identification of Events Within SNF Records. Five contracted 
physicians independently reviewed the medical records of the 
362 beneficiaries flagged by either the screening method or selected as part 
of the screener false-negative rate review.  The physician reviewers 
represented a variety of specializations and experience:  an infectious disease 
specialist, a cardiologist, an orthopedic surgeon, an internal medicine 
specialist, and a geriatrician with extensive experience as a SNF medical 
director.  All five had many years of clinical experience, and four had prior 
experience in detecting adverse and temporary harm events in retrospective 
medical record review.  Four of the five served as physician reviewers for a 
2010 OIG study of adverse events in hospitals. 
To identify adverse and temporary harm events experienced by the SNF 
residents during their SNF stays, the physicians reviewed all the information 
made available to the screeners as well as the results of the screeners  
reviews. In addition to reviewing the SNF records, the physicians reviewed 
the documents and data from the preceding and subsequent hospital stays to 
look for evidence of events that occurred during the SNF stays. 
Over 20 weeks, the physician reviewers examined the records of the 362 
beneficiaries. Each case was reviewed by one physician.  Physician 
reviewers used a structured medical review protocol that required them to 
describe each adverse event, list the parts of the medical record that 
contained evidence of the event, and specify the level of harm experienced 
by the patient. Harm was categorized in accordance with a modified version 
of the NCC MERP Index of Categorizing Medication Errors.  The modified 
version of the NCC MERP index is in Table B-1.   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  35  
   
   
Table B-1: Modified Version of the NCC MERP Index for Categorizing 
Errors Used in the OIG study of Adverse Events in SNFs  
Level    Description   Category  
Temporary 
E  Harm occurred that caused temporary harm that required intervention. 
Harm Event 
Harm occurred that prolonged the SNF stay  and led to a transfer to a 
different SNF or other post-acute facility and/or hospitalization 
F 
(i.e., admission to a hospital observation unit, an emergency  department, or 
inpatient care).  
Adverse 
G  Harm occurred that contributed to or resulted in permanent resident harm.   Event
H  Harm occurred that required intervention to sustain the residents life. 
I  Harm occurred that may have contributed to or resulted in resident death.  
Source:  Modified version of  the NCC MERP Index for Categorizing Errors,  Medication Errors Council Revises and 
Expands Index for Categorizing Errors:  Definitions of Medication Errors  Broadened, Press Release,  June 12, 2001.  
We recorded all harm events identified by the physician reviewers as 
occurring during the SNF stays and attributable to SNF care.  We excluded 
all harm events that occurred before the beneficiary entered the SNF and all 
events attributable to the care provided in the preceding hospitalization.  
When an initial event caused a series of related and dependent events, we 
collapsed the events into a cascade event and counted it as a single event.93   
When a resident experienced a specific type of event more than once during 
a stay (e.g., two episodes of hypoglycemia), we counted them as a single 
event if the second event reoccurred within 7 days of the first event and 
occurred under the same circumstances.  We counted them as separate events 
if the second event reoccurred more than 7 days after the first event or the 
circumstances that led to the event were substantially different.    
Determining Preventability for Each Event. The physician reviewers 
included an assessment of the extent to which events were preventable and 
factors that contributed to events. They used a five-point response scale:   
	   Clearly PreventableResident harm could definitely have been 
avoided through improved assessment or alternative actions. 
	   Likely PreventableResident harm could have been avoided through 
improved assessment or alternative actions. 
	   Likely Not PreventableResident harm could not have been avoided 
given the complexity of the residents condition or the care required.  
	   Clearly Not PreventableResident harm could definitely not have 
been avoided given the complexity of the residents condition or the 
care required. 
 
93 On the basis of OIG interviews  with IHI staff, a cascade event is defined as an initial 
event that causes a series of related events for the same patient and  results in collapsing  
these into a single event.    
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  36  
   
   
   Unable To DeterminePhysicians were unable to determine 
preventability because of incomplete documentation or case 
complexity.  
Assessing an event as clearly preventable or  clearly not preventable required 
a greater degree of certainty on the part of the reviewer.  The expanded scale 
enabled physicians to make more precise determinations, while our primary 
statistics collapse clearly and likely. Physician reviewers used a uniform  
method to improve consistency in making preventability determinations.  We  
worked with the reviewers to develop a decision algorithm during practice 
reviews consisting of a series of questions that led the reviewers to a 
suggested response. Questions addressed issues such as whether there was a 
medical error, whether the event could have been anticipated, and how 
frequently the event occurred given proper care.  Physicians did not 
automatically accept the suggested response, but determined whether it was 
appropriate in the particular case.  Figure B-1 on the next page illustrates the 
review process for determining preventability.  
To make distinctions about the circumstances in each case, physicians used 
their clinical experience and judgment.  They considered all evidence in the 
medical records, including staff actions and the residents condition.  
Physicians also used information about accepted standards of care, the 
frequency with which certain events occurred despite appropriate assessment 
and care, the physicians individual clinical experiences, guidance developed 
during the review process, and group discussion of cases.  Using a list of 
contributing factors gleaned from prior research and experience in prior OIG 
studies of adverse event incidence, physicians indicated the rationale for 
each determination and provided a narrative description for each case.  
The list of contributing factors included broad concepts from the decision 
algorithm, such as errors, but also more nuanced factors, such as whether the 
resident was monitored or was susceptible to the event.  To identify the 
factors that contributed to the events and assess preventability, physicians 
relied on information provided in the medical record about the residents  
conditions and actions of health care providers, supplemented by their own 
clinical expertise. Physician reviewers used published research and policy 
guidance regarding evidence-based guidelines and associated standards of 
care.  
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  37  
   
   
Figure B-1:  Physician Review Process for Determining 
Preventability 
 
Consistency Discussions and Review. Throughout our medical records 
review, we facilitated 17 conference calls during which the physician 
reviewers discussed the review protocol and sample cases that either were 
complex or had possible implications for other cases.  The goal of these calls 
was to reach consensus on difficult and complex cases and to establish 
consistency between reviewers. On the calls, the physicians solicited the 
opinions of the other panelists and used the conclusions of their discussions 
to make determinations on difficult cases.  We required that physicians 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  38  
   
   
discuss all clearly preventable determinations and events that potentially 
contributed to a residents death during the weekly conference calls, and we 
encouraged them to bring other cases for discussion if they had difficulty or 
felt the cases would inform other determinations.  Physicians also often 
brought cases to group discussion if they involved care specific to a 
specialization of another physician.  We documented the discussions and 
conclusions made during these weekly calls, continually revising a written 
physician guidance document to further promote consistency.   The 
physicians reviewed or discussed the majority of the identified events as 
well as possible events, which the group ultimately determined did not meet 
the study threshold. 
Following the medical records review, we analyzed the identified events,  
harm-level determinations, and preventability determinations to identify any 
inconsistencies and discussed these with physician reviewers.  This process 
resulted in changes to the initial determinations of some events.   
 
 
   
   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  39  
   
   
APPENDIX C 
Development and Description of the SNF Trigger Tool 
In preparation for this study, OIG built a trigger tool for screening SNF 
medical records.  We refer to this tool as the SNF Trigger Tool.  For 
studies of adverse events in hospitals in 2008 and 2010, OIG used a 
modified version of the IHIs GTT.  The IHI GTT is a 20-minute review 
of medical records that identifies triggers signaling possible resident 
harm and then identifies adverse and temporary harm events on the basis 
of evidence in the records.  A trigger could be a description of the harm  
itself or a reference that indicates harm occurred (such as a return to 
surgery). The IHI GTT is to be completed by nurses.  The results are then 
to be confirmed or refuted by a physician.  The IHI GTT is designed to be 
specific to acute care medical records.   
OIG developed a SNF Trigger Tool to apply the concept of the acute care 
IHI GTT to post-acute SNF care.  OIG staff and contracted physicians 
developed the instrument in consultation with experts in trigger tool 
development, geriatricians, a geriatric pharmacist, and nurses employed in 
SNFs.  The development process included reviewing triggers against 
findings of published research, clinical expertise, and two rounds of 
practice SNF record reviews.  The development team used a seven-step 
modified Delphi Method to identify and refine SNF triggers (see 
Table C-1).94  The Delphi method facilitates group decision making by 
prioritizing key issues for discussion and consensus.   
    Table C-1: OIG Modified Delphi Method for SNF Trigger Tool Development 
Step 
Step Name   Step Description  
Number  
1  Facilitator  Facilitator serves as a moderator throughout all rounds.  
2  Panel  Convene panel of experts in the SNF setting.  
3  List   Create preliminary list of SNF triggers. 
Respond to triggers with five-point scale and comment section to 
4  Survey  
select level of agreement that the trigger would lead to harm.  
Compile responses for each trigger by clustering into Agree, Neutral, 
5  Analysis 
and Disagree. A mean was calculated for each of the groups.  
6  Feedback   Calculate de-identified feedback and discuss.  
7  Modifications  Modify SNF trigger list according to discussion. 
Source:  SNF Trigger Tool development process. 
The resulting SNF Trigger Tool worksheet includes 49 triggers that the 
nurses used to screen cases for physician review (see Table C-2).  The 
worksheet divides triggers into three clinical categories: resident care, 
medication, and procedures. 
 
94  B.B. Brown,  Delphi Process:  A Methodology Used for the Elicitation of Opinions of 
Experts, RAND Corporation, September 1968.  
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  40  
   
   
Table C-2: SNF Trigger Tool Worksheet 
Care Module Triggers   Medication Module Triggers  
C1  Acute mental status change  M1  Abnormal electrolytes  
C2  Aspiration  M2  Abrupt medication stop 
C3  Call to physician or family members  M3  Anti-emetic use 
C4  Code or Emergency Medical Services (EMS)  M4  Diphenhydramine (Benadryl) use  
C5  Death  M5  Elevated INR  
C6  Drop in hemoglobin/hematocrit  M6  Epinephrine use  
C7  Studies for emboli:  PE or DVT   M7  Glucose <50, Glucagon or Dextrose supplement  
C8  Fall  M8  Abrupt onset hypotension 
C9  Family complaint  M9  Naloxone (Narcan) use  
C10   Any infection  M10  Sodium Polystyrene (Kayexalate administration) 
C11   New or increased diuretics  M11  Abnormal drug levels 
C12   High or low body temperature   M12  Thrombocytopenia 
C13   In (SNF) stroke or TIA   M13  Total WBC < 3000 
C14   New onset of incontinence  M14  Vitamin K administration (Aqua-Mephyton)  
C15   Insertion or use of urinary catheter   M15  Antibiotics started in SNF  
Significant Change in Status Assessment 
C16   M16  Increasing pain medication needs 
in MDS (SCSA) 
C17   Resident incident or accident  M17  Administration of parenteral fluid 
C18   Pressure ulcer   M18  Rising ALT/AST liver function test 
C19   ED visit   M19  Medication-Other  
Transfer to acute care hospital or observation 
C20  
(OBS) unit  Procedure Module Triggers  
C21   Restraint use  
C22   Rising serum creatinine  P1  Postoperative/post-procedure complication  
C23   Urinary retention   P2  Procedure reintubation/BiPAP/new CPAP 
C24   New onset diarrhea   P3  Procedure-Other  
C25   Prolonged constipation  --  -- 
C26   Diagnostic radiology or imaging studies  --  -- 
C27   Care-Other   --  -- 
Source:  OIG,  Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  
 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  41  
   
   
APPENDIX D 
Estimates, Confidence Intervals, and Key Statistics 
Table D-1: Beneficiary Level Estimates, Confidence Intervals, and Key Statistics  
95-Percent  95-Percent  
Confidence  Confidence  
  Interval   Interval  
Sample  Lower  Upper  Lower  Upper 
 
Size (n)  Percentage  Bound  Bound  Frequency    Bound   Bound  
Event Experiences for All Beneficiaries    
Experienced at least  one adverse  event   653  21.7%   18.3%   25.4%   21,777   18,213   25,342   1 
Experienced at least  two adverse  
653  2.6%  1.6%  4.1%   2,615   1,407   3,824   2 
events  
Experienced at least  one temporary  
harm event and didnt experience an   653  10.7%  8.3%   13.7%   10,742   8,073   13,410   3 
adverse event  
Experienced at least  one adverse  event 
653  32.4%  28.7%  36.2%   32,519   28,746   36,292   4 
or at least one temporary  harm event  
Experienced only  preventable adverse 
653  15.4%  12.4%  19.0%   15,483   12,212   18,755   5 
events  
Experienced only  preventable 
temporary  harm events and no adverse   653  4.9%  3.5%  6.8%   4,923   3,317   6,530   6 
events  
Experienced adverse events that 
653  1.5%  0.8%  2.8%   1,538   598   2,479   7 
contributed to death   
Experienced transfer to a hospital  
653  19.4%  16.1%  23.1%   19,470   15,930   23,010   8 
because of an adverse event 
Experienced a cascade  adverse event   653  4.0%   2.5%   6.2%   3,986   2,183   5,789   9 
Beneficiaries Who Experienced at Least One Adverse Event or One Temporary Harm Event    
Experienced at least  one hospitalization 
that was the result of an adverse event   191  59.9%  52.0%  67.3%   19,470   15,930   23,010   10 
or a temporary harm event  
Beneficiaries Who Experienced at Least One Adverse Event    
Experienced temporary harm in addition  
127  21.2%  15.0%  29.1%   4,615   3,053   6,178   11 
to adverse  events   
Beneficiaries Who Experienced Temporary Harm Events and No  Adverse Events    
Experienced multiple temporary harm 
64  20.1%  12.0%  31.6%   2,154   1,050   3,257   12 
events and no adverse events  
Source:  OIG analysis of SNF stays and Medicare claims for 653 Medicare beneficiaries discharged in August 2011.   
 
   
   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  42  
   
   
 
Table D-2: Estimates, Confidence Intervals, and Key Statistics 
95-Percent  
Confidence  
Interval  
Sample  Lower   Upper 
  Size (n)  Percentage  Bound  Bound 
   
OIGs Modified  NCC MERP Index for Categorizing Adverse Events by  Level of  Harm 
Harm F   148  78.5%   70.8%   86.3%   13 
Harm G*  148  --  --  --  14 
Harm H   148  13.5%   6.6%   20.4%   15 
Harm I   148  6.2%   2.4%   9.9%   16 
Clinical Category for All Adverse Events    
Medication adverse events    148  37.4%  28.0%   46.8%   17 
Resident  care adverse events   148  36.8%  27.6%   46.0%   18 
Infection  adverse events   148  25.8%  18.0%   33.6%   19 
Adverse Events Related to Medication    
Delirium or other change  in  mental  status, e.g., over-sedation    148  11.6%   4.2%   18.9%   20 
Excessive bleeding    148  4.9%   1.2%   8.7%   21 
Fall or other trauma with injury     148  3.7%   0.8%   6.6%   22 
Constipation, obstipation, and ileus   148  3.7%   0.8%   6.6%   23 
Other medication-related  adverse events   148   13.5%   7.1%   20.0%  24 
Adverse Events Related to Resident Care     
Fall or other trauma with injury related to resident care   148  5.5%   2.0%  9.1%  25 
Exacerbations of preexisting conditions resulting from an omission  
148  5.5%   0.3%  10.7%  27 
of care   
Acute kidney injury or insufficiency secondary to fluid maintenance     148  4.9%   1.2%  8.7%  26 
Fluid and other electrolyte disorders  (e.g.,  inadequate management  
148  3.7%   0.8%  6.6%  28 
of fluid)  
Venous thromboembolism, DVT, or  PE related to resident 
148  3.7%   0.3%  7.0%  29 
monitoring    
Other resident care events    148  13.5%   6.8%  20.1%  30 
Adverse Events Related to Infections    
Aspiration pneumonia and other respiratory infections    148  9.8%   3.8%   15.8%   31 
SSI associated with wound care    148  4.9%   1.6%   8.3%   32 
CAUTI   148  3.1%   0.4%   5.7%   33 
Clostridium difficile infection   148  3.1%   0.4%   5.7%   34 
Other infection-related adverse events    148  4.9%   1.5%  8.3%  35 
Clinical Category for All Temporary Harm Events    
Medication temporary harm events    113  42.8%   33.5%   52.2%   36 
Resident care temporary harm events   113  40.3%   30.9%   49.7%   37 
Infection temporary harm events   113  16.8%   10.0%   23.7%   38 
 
Continued on next page. 

*We are unable to reliably project the  weighted point estimate for adverse events classified as G Level harm because of the small number of 

sample occurrences.   

Source:  OIG analysis of SNF stays and Medicare claims  for 653 Medicare beneficiaries discharged in August 2011. 

   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  43  
   
   
Table D-2: Estimates, Confidence Intervals, and Key Statistics (Continued)  
95-Percent  
Confidence    
Interval  
Sample  Lower   Upper 
  Size (n)  Percentage   Bound  Bound   
Temporary Harm Events Related to Medication    
Hypoglycemic episodes (e.g., low or significant drop in blood  
113   16.0%  9.3%   22.7%   39 
glucose) 
Fall or other trauma with injury associated with medication   113   9.2%  1.9%   16.5%   40 
Medication-induced delirium or other change in mental  status   113   6.7%  2.3%   11.1%   41 
Thrush  and other nonsurgical infections related to medication   113   4.2%  0.6%   7.8%   42 
Allergic reactions to medications (e.g., rash, itching)   113   3.4%  0.1%   6.7%   43 
Other temporary harm events related to medication   113   3.4%   0.1%   6.6%   44 
Temporary Harm Events Related to Resident  Care    
Pressure ulcers   113   19.3%  10.8%   27.8%   45 
Fall or other  trauma with injury associated with  resident care   113   8.4%  3.4%   13.5%   46 
Skin tear, abrasion, or breakdown   113   6.7%  2.2%   11.3%   47 
Other resident care events   113   5.9%  1.7%   10.1%   48 
Temporary Harm Events Related to Infections    
CAUTI    113   5.0%  1.1%   9.0%   50 
SSI associated with wound care   113   5.0%  1.1%   9.0%   51 
Other temporary harm events related to infections   113   6.7%  1.8%   11.7%   52 
Preventability Classification  for All Adverse Events and Temporary Harm Events   
  Preventable events   261   59.2%  52.7%  65.8%  53 
o  Clearly preventable events   261   13.1%  8.2%   18.0%  54 
o  Likely preventable events   261   46.1%  39.4%   52.8%  55 
  Not preventable events  261   36.5%  30.2%   42.8%  56 
o  Clearly not preventable events   261   11.0%  7.3%   14.7%  57 
o  Likely not preventable events   261   25.5%  19.7%   31.3%  58 
  Unable to determine  261   4.2%  0.9%   7.5%  59 
Preventability Classification  for Adverse Events    
  Preventable adverse events   148  68.7%  60.7%   76.6%  60 
o  Clearly preventable adverse events   148   18.3%  10.7%   26.0%  61 
o  Likely preventable adverse events   148   50.3%  41.5%   59.2%  62 
  Not preventable adverse events  148  28.9%  21.1%   36.6%  63 
o  Clearly not preventable adverse events   148   10.5%  5.5%   15.4%  64 
o  Likely not preventable adverse events   148   18.4%  11.4%   25.4%  65 
  Unable to determine adverse events   148  2.5%  0.05%   4.9%  66 
Continued on next page. 
  
Source:  OIG analysis of SNF stays and Medicare claims  for 653 Medicare beneficiaries discharged in August 2011. 

 
   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  44  
   
   
 
Table D-2: Estimates, Confidence Intervals, and Key Statistics (Continued) 
95-Percent    
Confidence  
Interval  
Sample  Lower   Upper   
  Size (n)  Percentage  Bound  Bound 
Preventability  Classification for Temporary Harm Events  
  Preventable temporary harm events   113  46.3%  36.3%   56.3%  67 
o  Clearly preventable temporary harm events   113   5.9%  1.7%   10.1%  68 
o  Likely preventable temporary harm events  113   40.4%  30.5%   50.3%  69 
  Not preventable temporary  harm events   113  47.1%  36.9%   57.2%  70 
o  Clearly not preventable temporary harm events   113   11.8%  6.0%   17.6%  71 
o  Likely not preventable temporary harm events   113   35.3%  25.3%   45.3%  72 
  Unable to determine temporary  harm events*   113  -- --  -- 73 
Preventable Adverse and Temporary Harm Events Within Each Clinical Category    
Medication adverse and temporary harm events   103  66.1%  56.0%   76.1%   75 
Resident care  adverse  and temporary harm events   99  56.5%  46.0%   66.9%   74 
Infection adverse and temporary harm events   59  51.7%  37.6%   65.7%   76 
Physician Rationale for All Preventable Events    
Appropriate treatment was provided in a substandard way   155   55.7%   46.9%   64.5%  77 
Residents progress was not adequately monitored   155   36.5%   28.2%   44.8%  78 
Necessary treatments were not provided  155   24.5%   16.5%   32.4%  79 
Error related to medical judgment, skill, or resident management 
155  14.3%   8.1%   20.6%  80 
occurred 
Resident care  plan was inadequate   155   11.3%   5.4%   17.3%  81 
Care plan was incomplete or not sufficient in describing resident 
155  7.2%   3.3%   11.1%  82 
condition or  care  
Residents health status was not adequately assessed   155   4.2%   1.2%   7.2%  83 
Physician Rationale for All Not Preventable Events    
Resident was highly susceptible to event because of health  status   97   59.2%   48.0%   70.5%  84 
Event occurred despite  proper assessment and procedures  
97  31.9%   21.1%   42.8%  85 
followed 
Residents diagnosis was unusual or complex, making care difficult   97   27.1%   16.5%   37.8%  86 
Care provider could not have anticipated event given information  
97   20.4%  12.2%   28.6%  87 
available  
*We are unable to reliably project the  weighted point estimate for adverse events classified as G Level harm because of the small number of 
  
sample occurrences.   

Source:  OIG analysis of SNF stays and Medicare claims  for 653 Medicare beneficiaries discharged in August 2011. 

 
 
 
 
 
 
 
 
 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  45  
   
   
Table D-3: Point Estimates and Confidence Intervals for Total and Average Additional 
Medicare Costs Associated With Adverse Events 
95-Percent  
Confidence  
Interval  
Sample  Lower   Upper 
 
Estimate Description   Size (n)   Total  Cost   Bound   Bound  
Costs Associated With Adverse Events in SNFs    
Increased cost because of hospitalizations  from adverse events that 
148  $207,979,213   $150,589,933   $265,368,492  88
occurred during SNF stay  
Costs Associated With Preventable Adverse Events in SNFs    
Increased cost because  of  hospitalizations from  preventable adverse  
100  $135,548,133   $84,361,921   $186,734,346  89
events that occurred during SNF stay  
Source:  OIG analysis of SNF stays and Medicare claims  for 653 Medicare beneficiaries discharged in August 2011.    
 
Table D-4: Projections and Confidence Intervals for Total and Average Additional 
Medicare Costs Associated With Adverse Events Within the Clinical Categories  
95-Percent   95-Percent   95-Percent    
Confidence  Confidence   Confidence  
Interval   Interval   Interval  
Category of  
 
Adverse  Lower  Upper  Lower  Upper  Mean  Lower  Upper  
Events  Frequency    Bound  Bound  Total Cost   Bound  Bound  Cost   Bound  Bound 
Hospitalizations 
and costs 
associated with  7,203  4,716  9,691   $57,729,935  $29,686,945   $85,772,925   $8,372   $5,418   $11,326  90 
medication 
events 
Hospitalizations 
and costs 
associated with  7,511   4,998  10,024   $67,350,098  $39,029,148   $95,671,047   $8,967  $7,064   $10,870  91 
resident care 
events 
Hospitalizations 
and costs 
5,679  3,621  7,736   $82,899,180  $38,018,755   $127,779,605   $14,599   $9,386   $19,811  92 
associated with 
infections  
Hospitalizations 
and costs 
associated with  20,393  16,688  24,097   $207,979,213  $150,589,933   $265,368,492   $10,276  $8,241   $12,312  93 
all events in 
SNFs 
Source:  OIG analysis of SNF stays and Medicare claims  for 653 Medicare beneficiaries discharged in August 2011.    
 
   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  46  
   
   
APPENDIX E 
Rates of Adverse Events and Temporary Harm Events in SNFs 
by Resident Days  and SNF Admissions 
Health care facilities, particularly hospitals, commonly measure adverse 
events by incidence density, which takes into account the period during 
which residents are observed. For example, incidence density is often 
used in measuring hospital-acquired infections because risk can increase 
with the length of exposure to the health care environment.95 IHI, a 
nonprofit advisory group to hospitals, cites advantages to using incidence 
density metrics over standard incidence rates that measure the number of 
events per resident.96  IHI reports that measuring total events by resident  
days or hospital admissions enables hospitals to count multiple events 
experienced by the same beneficiary.   
The sample of 653 Medicare beneficiaries discharged during August 2011 
included 692 total SNF stays (admissions) and a total of 10,759 days in the 
SNF (resident days). We calculated resident days by subtracting the 
admission date for each SNF stay from its discharge date.  Table E-1 
provides ratios for adverse events and temporary harm events in the 
sample per 1,000 resident days and per 100 admissions. 
Table E-1:  Rates of Adverse and Temporary Harm Events in the Sample by  
Resident Days and SNF Admissions  
Per 1,000   Per 100 
Category  
Resident Days   Admissions  
Adverse events  14  21 
Temporary harm events   11  16 
Adverse and temporary  harm events combined   24  38 
 
Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011. 
 
 
 
 
95 K.M. Arias, Outbreak  Investigation, Prevention,  and Control in  Health Care Settings, 

Second Edition, 2009, Jones and Bartlett Publishers, pp. 330331. 

96 IHI,  IHI Global Trigger Tool for Measuring Adverse Events, Second Edition,  2009, 

p. 13. 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  47  
   
   
APPENDIX F 
Adverse Events and Temporary Harm Events 
Tables F-1 and F-2 contain information about adverse events and 
temporary harm events identified in the sample, including description, 
harm level, and preventability.  Table F-1 contains information about 
adverse events (148 adverse events).97   Table F-2 contains information 
about temporary harm events (113 events).   
 
Table F-1: Adverse Events by Clinical Category,  Harm Level, and Preventability (n=148)  
Harm 
Adverse Event   Preventability   
Level  
 
Events Related to Medication (55) 
Medication-induced delirium or other change in mental status (13)    
1. Delirium and agitation secondary to psychotropic and pain medications resulting in 
F  CNP  196 
hospitalization  
2. Delirium, hallucinations, and respiratory failure secondary to pain and anti-anxiety medications 
F  CP  67 
(opioids and benzodiazepines) resulting in hospitalization  
3. Confusion, delusions, and continuing episodes of disorientation secondary to pain medication 
F  LNP  106 
(opioids and benzodiazepines) resulting in hospitalization  
4. Delirium, disorientation, and hallucinations secondary to inappropriately prescribed anti-anxiety  
medication (lorazepam) and other medications (acetaminophen and hydrocodone,  F  LP  142 
cyclobenzaprine Hcl) 
5. Cascade in which disorientation and hallucinations due to multiple medications 
(acetaminophen, hydrocodone, cyclobenzaprine Hcl, and lorazepam) led to a fall with resultant  F  CP  143 
skin tear and rib fracture, which led to pneumonia resulting in hospitalization  
6. Acute change in mental status due to inadequate hydration therapy that was exacerbated by  
F  CP  190 
multiple medications 
7. Acute change in mental status secondary to medication  F  LNP  1239 
8. Cascade event in which confusion and somnolence secondary to medications led to 
F  LP  60 
dehydration because of decreased fluid intake  
9. Delirium secondary to multiple pain medications (opioids) resulting in hospitalization   F  LP  199 
10. Delirium secondary to psychiatric medications (hydrocodone)   F  LP  1241 
11. Confusion secondary to beta blocker (metoprolol) with sinus bradycardia  F  LP  1242 
12. Episode of unresponsiveness secondary to psychiatric medication (lithium)*  F  CP  1245 
13. Lethargy and altered mental status secondary to medication*  F  LP  1250 
*Event identified during screener false-negative rate review.  
 
Continued on next page. 
 
   
 
97 The harm level is classified according to the modified  version of the  NCC  MERP  
Index for Categorizing Errors (EI).  Preventability determination is reflective of the 
physician review index:  CP = clearly preventable, LP = likely preventable, LNP = likely 
not  preventable, CNP = clearly not  preventable, and UTD = unable to  determine. 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  48   
   
Table F-1: Adverse Events by Clinical Category,  Harm Level, and Preventability (n=148) 
(Continued) 
Harm 
Adverse Event   Preventability   
Level  
 
Events Related to Medication (55) (continued) 
Excessive bleeding due to medication (8)    
1. Cascade event in which hematemesis (gastrointestinal bleeding) from an anticoagulant 
I  LP  9 
(warfarin) led to aspiration, which resulted in death  
2. Epistaxis (significant bleeding through nose) due to anticoagulant (warfarin) resulting in 
H  CP  16 
hospitalization  
3. Gastrointestinal bleeding due to anticoagulation treatment (aspirin) resulting in hospitalization   F  LNP  38 
4. Cascade event in which hemoptysis (coughing up blood) associated with anticoagulant led to 
I  LNP  50 
aspiration, cardiac arrest, anoxic encephalopathy  and contributed to residents death 
5. Cascade event in which anticoagulant (warfarin) toxicity led to hematemesis (gastrointestinal 
H  LNP  90 
bleeding) with resultant hypotension and kidney  insufficiency resulting in hospitalization 
6. Coumadin toxicity led to gastrointestinal bleeding resulting in hospitalization   F  LP  92 
7. Anticoagulant overdose led to hematemesis and subdural hematoma   H  CP  127 
8. Gastrointestinal bleeding secondary to anticoagulants resulting in hospitalization   F  CNP  194 
Fall or other trauma with injury  secondary to the effects of medication (6)    
1. Fall associated with atypical antipsychotic (quetiapine) led to right hip fracture resulting in 
G  LNP  95 
hospitalization  
2. Fall associated with inappropriately prescribed atypical antipsychotic (quetiapine) resulting in 
F  LP  115 
femur fracture resulting in hospitalization  
3. Fall associated with appropriately  prescribed antipsychotic medication (haloperidol decanoate) 
F  CNP  146 
resulting in injury to hand  
4. Fall associated with appropriately  prescribed atypical antipsychotic (olanzapine) and 
F  LNP  164 
antidepressant (escitalopram) that caused a hip fracture resulting in hospitalization  
5. Fall associated with inappropriately prescribed opiates for pain (hydromorphone, 
F  LP  1206 
hydrocodone/APAP, tramadol) resulting in rib fracture  
6. Fall associated with inappropriately prescribed antipsychotics (haloperidol decanoate and 
F  LP  1210 
risperidone) resulting in hematoma 
Constipation, obstipation, and ileus related to  medication (6)    
1. Inadequate bowel care led to significant constipation secondary to opiates resulting in 
F  LP  89 
hospitalization  
2. Severe constipation due to pain medications (opioids)  F  LP  126 
3. Significant ileus secondary to narcotics resulting in hospitalization   F  CNP  1207 
4. Significant constipation secondary to opiates resulting in hospitalization  F  LNP  1223 
5. Significant ileus secondary to opiates and inadequate bowel care resulting in hospitalization   F  LP  1240 
6. Abdominal distention with ileus secondary to opiates   F  LP  2001 
Hypoglycemic events related to medication (5)    
 
1. Hypoglycemic episode characterized by blood glucose of 31   H  LP  93 
 
2. Hypoglycemic episode characterized by blood glucose of 34   H  LP  94 
3. Hypoglycemic episode characterized by blood glucose of 32   H  LP  111 
4. Hypoglycemic episode characterized by blood glucose of 38 resulting in hospitalization and 
I  LP  213 
contributing to the resident's death 
5. Hypoglycemic episode characterized by a blood glucose of 20 resulting in hospitalization and 
I  LP  1232 
contributing to the resident's death 
Continued on next page.   
 
   
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  49   
   
Table F-1: Adverse Events by Clinical Category,  Harm Level, and Preventability (n=148) 
(Continued) 
Harm 
Adverse Event   Preventability   
Level  
 
Events Related to Medication (55) (continued) 
Medication-induced allergic reaction (4)   
1. Cascade event in which antibiotics (levofloxacin) given for an infected incision site caused an 
F  CNP  12 
unanticipated allergic reaction characterized by  pruritic rash over most of resident's body 
2. Rash secondary  to anticoagulant  F  CNP  134 
3. Rash secondary  to antibiotic  F  CNP  145 
4. Rash secondary  to antibiotics  F  CNP  147 
Ketoacidosis, hyperosmolar coma, and other complications of diabetes related to insulin management (3)    
1. Failure to provide adequate insulin care led to diabetic ketoacidosis resulting in hospitalization   F  CP  98 
2. Cascade event in which hyperosmolar diabetic coma characterized by somnolence and 
I  CNP  100 
vomiting led to aspiration resulting in hospitalization and contributing to the residents death 
3. Diabetic ketoacidosis due to insufficient administration of insulin resulting in hospitalization  F  LP  151 
Anemia and other blood count problems secondary to medication  (2)    
1. Cascade event in which provision of antibiotics led to pancytopenia, angina, and pneumonia 
F  LP 
resulting in hospitalization   107 
2. Anemia due to inadequate administration of epoetin alfa (anemia medication) in resident with 
F  LP 
chronic kidney failure resulting in hospitalization   1209 
Hypotension secondary to medication (2)    
1. Syncope with atrial fibrillation and hypotension secondary to overdose of levothyroxine and 
F  LP 
liothyronine resulting in hospitalization  51 
2. Hypotension secondary to ACE inhibitor resulting in hospitalization   F  LP  123 
Nausea and vomiting secondary to  medication (2)   
1. Digoxin toxicity led to nausea   F  LP  133 
2. Nausea and vomiting secondary to antibiotic  F  LP  184 
Other medication events (4)    
1. Acute kidney injury due to inadequate diuretic therapy characterized by hyperkalemia resulting 
H  LP  119 
in hospitalization 
2. Stroke because of a failure to provide anticoagulants resulting in hospitalization   G  LP  6 
3. Hyperkalemia and severe dehydration due to ACE inhibitor (lisinopril) resulting in hospitalization  H  CP  47 
4. Seizure secondary to inadequate monitoring of antiepileptic medication resulting in 
F  CP  78 
hospitalization  
Events Related to Resident Care (54)    
Fall or other trauma with injury  related to resident care (9)  
 
 
1. Fall resulting in chest hematoma   F  LP  10 
2. Fall with injury resulting in hospitalization   F  LNP  24 
3. Fall with large hematoma on head resulting in hospitalization   F  LP  33 
4. Fall with nasal fracture resulting in hospitalization   F  LNP  72 
5. Fall with injury resulting in hospitalization   F  LNP  75 
6. Fall resulting in effusion and hematoma on knee resulting in hospitalization   F  LNP  155 
7. Fall resulting in multiple skin tears  F   LP  159 
8. Fall resulting in hematoma on head resulting in hospitalization   F  LNP  215 
9. Ankle fracture due to unwitnessed trauma in SNF   F  UTD   1215 
Continued on next page.   
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  50   
   
Table F-1: Adverse Events by Clinical Category,  Harm Level, and Preventability (n=148) 
(Continued)  
Harm 
Adverse Event   Preventability   
Level  
Events Related to Resident Care (54) (continued)  
Dehydration and related electrolyte disorders associated with resident care (8) 
1. Cascade event in which substandard monitoring of resident with known obstructive kidney  
disease resulted in progressive kidney failure, hyperkalemia (electrolyte abnormality  I  CP  5 
characterized by  high potassium), and cardiac arrest, which contributed to the residents death 
2. Cascade event in which failure to adequately  hydrate resident with dysphagia led to 
hypovolemia, hypernatremia (electrolyte abnormality characterized by high sodium), 
H  CP  87 
hypotension, paroxysmal atrial tachycardia, need for cardioversion, non-STEMI myocardial 
infarction, and acute kidney injury  resulting in hospitalization  
3. Cascade event in which failure to recognize postoperative delirium led to poor oral intake, 
F  LP  101 
hyperkalemia, and hypernatremia resulting in hospitalization  
4. Severe hypernatremia due to inadequate hydration resulting in hospitalization   F  LNP  109 
5. Hyponatremia with increased lethargy  and change in mental status due to free-water  
F  LP  112 
gastrostomy tube flushes resulting in hospitalization  
6. Change in mental status due to electrolyte disorder caused by multiple free water gastrostomy  
tube flushes in a resident with a recent history of syndrome of inappropriate antidiuretic  F  LP  114 
hormone secretion (SIADH)  
7. Cascade event in which insufficient monitoring of ileostomy led to leaking, excoriation around 
H  LP  165 
insertion site, significant dehydration, acute kidney  injury, and high potassium 
8. Significant dehydration due to inadequate hydration resulting in hospitalization   F  LP  256 
Acute kidney injury  or insufficiency secondary to fluid maintenance  (6)    
1. Cascade in which acute kidney injury due to inadequate hydration led to high potassium and 
F  LP  58 
uremia characterized by significant lethargy  resulting in hospitalization 
2. Acute kidney injury characterized by severe hyperkalemia due to inadequate monitoring of 
H  LP  76 
electrolytes and serum creatinine resulting in hospitalization  
3. Acute kidney insufficiency and confusion due to inadequate hydration therapy resulting in 
F  LP  83 
hospitalization  
4. Acute kidney injury due to poor monitoring of hydration and inadequate diuretic therapy  
F  LP  118 
complicated by antipsychotics used to treat associated delirium 
5. Cascade event in which inadequate hydration led to acute kidney insufficiency, hypotension, 
F  LP  1229 
and obtundation  
6. Acute kidney injury due to progressive dehydration resulting in hospitalization and contributing 
I  LP  1231 
to the residents death  
Venous thromboembolism, DVT, or PE related to resident monitoring (6)    
1. DVT due to insufficient DVT prophylaxis resulting in hospitalization and a PE that contributed to 
I  UTD   36 
the residents death 
2. PE due to inadequate resident monitoring that resulted in a hospitalization and contributed to 
I  CP  43 
the residents death 
3. Delay in recognition of pneumothorax resulting in hospitalization   F  LP  183 
4. DVT and pulmonary embolism due to inadequate monitoring resulting in hospitalization  F  CNP  185 
5. DVT due to a failure to provide adequate DVT monitoring and prophylaxis resulting in 
F  LP  212 
hospitalization  
6. Significant DVT due to failure to provide sufficient DVT monitoring and prophylaxis resulting in 
F  LNP  234 
hospitalization  
Continued on next page.   
 
 
 
 
 
 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  51   
   
Table F-1: Adverse Events by Clinical Category,  Harm Level, and Preventability (n=148) 
(Continued) 
Harm 
Adverse Event   Preventability   
Level  
Events Related to Resident Care (54) (continued)  
Exacerbations  of preexisting conditions resulting from an omission of care (6)  
1. Suicide attempt by resident at risk for suicide characterized by self-inflicted cuts on wrists 
resulting in hospitalization due to inadequate compliance with a care plan that was not sufficient  F  LP  161
for the resident 
2. Failure to properly assess resident in SNF and in preceding hospital stay, which led to delay in 
F  CP  170
recognizing hip fracture resulting in hospitalization  
3. Jaundice, low hemoglobin, and lethargy due to a delay in recognition of acquired autoimmune 
F  CNP  214
hemolytic anemia resulting in hospitalization  
4. Hydronephrosis due to delay in needed post-hospital followup care for resident with significant 
F  LP  227
urinary tract obstruction 
5. Failure to provide appropriate intervention for increasing hypothyroidism and monitoring of 
increasing heart failure, which led to episode of exacerbated heart failure resulting in  F  LP  240
hospitalization  
6. Reduction in diuretics and failure to adequately monitor increased weight gain (anasarca) 
associated with congestive heart failure and cirrhosis resulting in hospitalization and contributing   H  LP  1244
to the residents death*  
Respiratory issues (other than infections below) (4)    
1. Hypoxia and respiratory distress due to insufficient pulmonary suction resulting in hospitalization  H  CP  19 
2. Delay in diagnosis of pneumothorax and inadequate monitoring, which led to significant 
H  LP  136
worsening of condition characterized by difficulty breathing resulting in hospitalization  
3. Failure to provide adequate tracheostomy care resulted in acute respiratory failure   H  LNP  246
4. Cascade event in which delay in treatment for pleural effusion led to worsening of hypoxia 
F  CP  1243
(inadequate oxygen in blood) resulting in hospitalization for chest tube, drainage, and intubation* 
Excessive  bleeding related to resident care (3)    
1. Excessive bleeding from infection site resulting in hospitalization   F  LP  68 
2. Excessive bleeding around  wound vacuum pump site resulting in hospitalization   F  LNP  160
3. Hematuria secondary to Foley catheter resulting in hospitalization   F  UTD   205
Displacement of feeding tubes related to resident monitoring (2)    
1. Feeding tube displacement due to lack of monitoring resulting in hospitalization   F  LP  20 
2. Feeding tube displacement due to lack of monitoring resulting in hospitalization   F  LP  77 
Hypotension related to resident care (2)    
1. Cascade event in which dehydration due to inadequate monitoring led to hypotension, sinus 
F  LP 
tachycardia, and atrial fibrillation resulting in hospitalization   31 
2. Hypotension and hematuria due to inadequate monitoring of Foley catheter resulting in 
F  CP 
hospitalization   249
Stage III or IV pressure ulcers (2)    
 
1. Stage III pressure ulcer on sacrum and stage II pressure ulcer on buttocks  F  CP  59 
 
2. Stage III pressure ulcer on heel   G  LP  254
Other resident care events (6)    
 
1. Clogged arteriovenous shunt (dialysis access device) due to excessive blood clotting   F  LP  203
 
2. Significant constipation resulting in hospitalization   F  LNP  55 
3. Cascade event in which failure to provide adequate skin care caused a skin friction abrasion that     
F  LP  1228
progressed to a  stage II pressure ulcer and developed cellulitis resulting in hospitalization 
4. Omission of care, which led to progressive weakness and decreased bowel and overall functional     
F  CP  61 
status resulting in hospitalization  
 
5. Substandard urinary catheter care, which led to urinary retention resulting in hospitalization   F  LP  73 
6. Cascade event in which pulmonary fluid overload led to decreased oxygenation, respiratory 
H  LP  166
failure, atrial flutter, and significant lethargy  resulting in hospitalization  
*Event identified during screener false-negative rate review.
  
 
Continued on next page. 

Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  52   
   
Table F-1: Adverse Events by Clinical Category,  Harm Level, and Preventability (n=148) 
(Continued) 
Harm 
Adverse Event   Preventability   
Level  
Events Related to Infections (39) 
Aspiration pneumonia and other respiratory  infections (13)  
1. Aspiration pneumonia due to inadequate aspiration precautions and monitoring of resident 
F  CNP  22 
with history of dysphagia 
2. Aspiration pneumonia due to failure to monitor resulting in hospitalization   F  LP  71 
3. Cascade event in which dysphagia and vomiting led to aspiration pneumonia, associated with 
hyperglycemia (with diabetic ketoacidosis or hyperosmolar coma) and hyponatremia, resulting  F  CNP  84 
in hospitalization 
4. Several episodes of emesis, which led to aspiration pneumonia resulting in hospitalization  F  CNP  116
5. Aspiration pneumonia resulting in hospitalization   F  LP  135
6. Aspiration pneumonia resulting in hospitalization   F  LNP  188
7. Cascade event in which aspiration pneumonitis led to respiratory failure resulting in 
H  LP  207
hospitalization  
8. Aspiration pneumonitis resulting in hospitalization   F  CNP  210
9. Aspiration pneumonia characterized by tachypnea, dyspnea, and chest congestion resulting in 
I  CNP  220
hospitalization and contributing to the residents death 
10. Emesis associated with lung infiltrate resulting in hospitalization   F  CNP  1224
11. Recurrence of pneumonia due to incomplete treatment of prior pneumonia resulting in 
F  UTD   1234
hospitalization  
12. Cascade event in which aspiration pneumonitis led to respiratory failure, which exacerbated 
H  CP  1236
residents COPD resulting in hospitalization for needed BIPAP treatment 
13. Aspiration pneumonia resulting in hospitalization*   F  LNP  1254
SSI attributable to wound care (8)    
1. Superficial infection around surgical incision site on lower back  F  LP  4 
2. Superficial infection around surgical incision site for recent knee arthroplasty   F  LP  11 
3. Superficial infection around surgical incision site on hip    F  LP  45 
4. Superficial infection around surgical incision site on leg resulting in hospitalization   F  LP  53 
5. Superficial infection around surgical incision site for recent toe resection resulting in 
F  LP  54 
hospitalization  
6. Cellulitis at surgical site resulting in hospitalization   F  LP  149
 
7. Cellulitis at PEG tube placement site resulting in hospitalization  F  LNP  150
 
8. Cellulitis at site of skin graft resulting in hospitalization  F  LNP  217
CAUTI (5)    
 
1. Urinary tract infection associated with urinary catheter resulting in hospitalization   F  LP  99 
2. Cascade in which a partial obstruction due to Foley catheter placement led to a urinary tract     
F  LP  187
infection. 
 
3. Urinary tract infection associated with urinary catheter   F  LP  216
4. Urinary tract infection associated with urinary catheter characterized by acute change in     
F  CP  255
mental status resulting in hospitalization 
5. Cascade event in which urosepsis led to dehydration, hypotension and paroxysmal     
F  LNP  1225
supraventricular tachycardia  
Clostridium difficile infection (5)    
1. Clostridium difficile infection resulting in hospitalization  F  LP  74 
2. Clostridium difficile infection   F  LP  158
3. Clostridium difficile infection associated with significant weight loss resulting in hospitalization   F  CP  218
4. Clostridium difficile infection resulting in hospitalization  F  LNP  229
5. Clostridium difficile infection resulting in hospitalization  F  LP  242
*Event identified during screener false-negative rate review.
  
Continued on next page. 
  
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  53   
   
 
Table F-1: Adverse Events by Clinical Category,  Harm Level, and Preventability (n=148) 
Harm 
Adverse Event (Continued)   Preventability   
Level  
Events Related to Infections (39) (continued) 
Sepsis (3) 
1. Urinary tract infection associated with urinary catheter characterized by acute change in 
F  CP  39 
mental status and somnolence resulting in hospitalization  
2. Sepsis due to progression of inadequately treated pneumonia resulting in hospitalization  H  CP  88 
3. Failure to provide adequate care for urinary tract infection, which led to sepsis resulting in 
F  LNP  167
hospitalization  
Vascular-catheter associated infection, e.g., PICC line, central line (3)    
1. Port site infection resulting in hospitalization   F  LP  86 
2. Infection (MRSA) around dialysis insertion site resulting in hospitalization  F  LNP  182
3. Cascade event involving DVT and catheter-associated central line infection    F  LP  243
Soft tissue or other nonsurgical infection (2)    
1. Cellulitis on legs resulting in hospitalization   F  LNP  69 
2. Progressive infection characterized by rash, sloughing, and necrosis resulting in 
F  CP  140
hospitalization  
Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011.   
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  54   
   
Table F-2: Temporary Harm Events by Clinical Category and Preventability (n=113)  
Temporary Harm Event   Preventability   
 
Events Related to Medication (48) 
Hypoglycemic episodes (e.g., low  or significant drop in blood glucose) (19)    
1. Multiple hypoglycemic episodes characterized by lowest blood glucose of 24   CP  224 
2. Hypoglycemic episode characterized by blood glucose of 32   LP  25 
3. Multiple hypoglycemic episodes characterized by lowest blood glucose of 35   CP  34 
4. Multiple hypoglycemic episodes characterized by blood glucose of 55 and unresponsiveness  CP  70 
5. Hypoglycemic episode characterized by blood glucose of 43   LP  82 
6. Hypoglycemic episode characterized by blood glucose of 59 and lethargy   LP  91 
7. Hypoglycemic episode characterized by blood glucose of 39   LNP  96 
8. Hypoglycemic episode characterized by blood glucose of 49   LP  125 
9. Hypoglycemic episode characterized by blood glucose of 49 and diaphoresis (excessive sweating)   LNP  148 
10. Multiple hypoglycemic episodes characterized by lowest blood glucose of 66 and diaphoresis   CP  153 
11. Hypoglycemic episode characterized by significant drop in blood glucose from baseline  LP  163 
12. Hypoglycemic episode characterized by shaking and heart palpitations  LP  171 
13. Hypoglycemic episode characterized by blood glucose of 48   LP  173 
14. Hypoglycemic episode characterized by a significant drop in blood glucose  LP  244 
15. Cascade event in which hypoglycemic episode characterized by  blood glucose of 53 resulted in fall  LP  245 
16. Hypoglycemic episode characterized by symptoms and blood glucose of 57   CNP  15 
17. Multiple hypoglycemic episodes characterized by blood glucose of 54 and 48   LP  252 
18. Hypoglycemic episodes characterized by significant drop in blood glucose and trembling  LP  1208 
19. Multiple hypoglycemic episodes characterized by lowest blood glucose of 20   CP  1211 
Medication-induced delirium or other change in mental status (8)    
1. Delirium secondary to pain medication (hydrocodone)   LP  7 
2. Delirium and hallucinations due to pain medication (opioid)   LP  13 
3. Delirium and hallucinations secondary to polypharmacy   LP  17 
4. Delirium secondary to pain medication (opioid), which caused resident to pull IV tube   LP  66 
5. Confusion and anxiety secondary  to pain medication (oxycodone)   LP  79 
6. Lightheadness and vertigo due to  pain medication (opioids)  LNP  130 
7. Confusion secondary to pain medication (opioids)  LP  178 
8. Episode of diaphoresis and dizziness due to pain medication (oxycodone and paracetamol)   CNP  200 
Fall or other trauma with injury  associated with medication (8)    
1. Fall associated with inappropriately prescribed anti-anxiety  medication (clonazepam) resulting in 
LP  27 
injury to head  
2. Fall associated with appropriately  prescribed anti-anxiety medication (lorazepam) resulting in 
LNP  154 
abrasions 
3. Fall associated with anti-anxiety medications (lorazepam and escitalopram) and inappropriately  
LP  157 
prescribed atypical antipsychotropic medication (risperidone) resulting in abrasion  
4. Multiple falls associated with inappropriately prescribed antidepressant (fluoxetine) and anti-anxiety  
medications (selective serotonin reuptake inhibitor and lorazepam) resulting in skin tears and  LP  168 
abrasions 
5. Fall associated with poor diabetes management  (multiple episodes of hypoglycemia and 
LP  1213 
hyperglycemia) resulting in abrasions 
6. Fall associated with inappropriately prescribed anticholinergic (amitriptyline and perphenazine) 
LP  1235 
resulting in skin tear on forearm  
7. Delirium and disorientation secondary to opiates for pain (oxycodone) resulting in multiple falls 
LNP  1252 
without injury*  
8. Fall associated with psychotropic medications (alprazolam and risperidone) resulting in abrasions  LP  122 
* Event identified during screener false-negative rate review.
  
 
Continued on next page. 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  55   
   
Table F-2: Temporary Harm Events by Clinical Category and Preventability (n=113) 
(Continued) 
Temporary Harm Event   Preventability    
Events Related to Medication (48) continued   
Thrush and other nonsurgical infections related to medication (5)    
1. Oral thrush secondary to antibiotics  CNP  35 
2. Candida vaginitis secondary to antibiotics  CNP  40 
3. Oral and pharyngeal thrush secondary to antibiotic  CNP  46 
4. Pharyngeal thrush secondary to antibiotic  CNP  49 
5. Candida vaginitis and oral thrush secondary  to antibiotics  LNP  241 
Allergic reactions to medications (e.g., rash, itching) (4)    
1. Allergic reaction to medication (fluroquinolone antibiotic) characterized by itching  CNP  30 
2. Rash in groin area due to immunosuppressant (methotrexate)   LNP  176 
3. Skin rash on abdomen and legs associated with medication  CNP  186 
4. Pruritus associated with narcotics  CNP  230 
Constipation, obstipation, and ileus (2)    
1. Significant constipation secondary to pain medication (opioids)   LNP  18 
2. Significant constipation secondary to pain medication (opioids) and inadequate bowel care  LP  108 
Other medication events (2)    
1. Seizure in resident with history of seizures during period of inadequate levels of anti-epileptic 
LNP  121 
(phenytoin)  
2. Significant and unanticipated diarrhea secondary to laxative  LP  2 
Events Related to Resident Care (45)    
Pressure ulcers (20)    
1. Stage I pressure ulcer  UTD   28 
2. Progression of stage I pressure ulcer to stage II pressure ulcer  LP  52 
3. Stage I pressure ulcers on heels  LP  63 
4. Progression of stage I pressure ulcer to a stage II pressure ulcer   LNP  81 
5. Stage I pressure ulcers on buttocks and heel  LP  104 
6. Stage II pressure ulcer on buttocks  LP  110 
7. Stage I pressure ulcer on coccyx  LP  124 
8. Stage I pressure ulcer  LP  156 
9. Stage II pressure ulcers on thigh and stage I pressure ulcers on buttock and coccyx  LNP  169 
10. Progression of stage I pressure ulcers on coccyx and heels to stage II ulcers  LNP  195 
11. Progression of pressure ulcer on buttocks from stage I to stage II   LNP  209 
12. Stage I pressure ulcer on heel  LNP  223 
13. Stage I pressure ulcer on heel  LNP  225 
14. Progression of stage I pressure ulcer to stage II   LP  239 
15. Multiple stage I pressure ulcers on heels, elbow, scapula, and toe   CNP  250 
16. Stage II pressure ulcer on heel  CP  1226 
17. Stage I pressure ulcer on coccyx*   UTD   1248 
18. Unstagable pressure ulcer on left heel  LNP  132 
19. Unstagable pressure ulcer on right heel  LP  1233 
20. Stage III pressure ulcer on hand   LNP  57 
* Event identified during screener false-negative rate review.
    
Continued on next page. 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  56   
   
Table F-2: Temporary Harm Events by Clinical Category and Preventability (n=113) 
(Continued) 
Temporary Harm Event   Preventability    
Events Related to Resident Care (45) continued    
Fall or other trauma with injury  associated with resident care (10)    
1. Fall resulting in skin tear   LP  1 
2. Fall with injury to head   LP  29 
3. Fall with skin tear   LNP  37 
4. Trauma while in bed characterized by abrasions on temple and elbow  LNP  85 
5. Fall resulting in abrasions on face and elbow  LNP  198 
6. Fall resulting in elbow fracture   LNP  211 
7. Multiple falls resulting in skin tear on hand and elbow  LNP  232 
8. Fall resulting in multiple skin tears on appendages and bruising on head   LNP  236 
9. Fall from motorized wheelchair resulting in multiple scrapes and abrasions  CNP  247 
10. Fall resulting in hematoma on head   LNP  1230 
Skin tear, abrasion, or breakdown (8)    
1. Skin tears on arm and leg   LNP  97 
2. Skin tear on leg  LNP  141 
3. Multiple skin breakdowns above the coccyx  LNP  162 
4. Skin tear on elbow  CNP  179 
5. Pressure wound on leg associated with cast   LP  181 
6. Abrasion on forearm caused by collision with railing  LNP  231 
7. Skin tear on right forearm   LNP  1220 
8. Multiple skin excoriations  UTD   1222 
Other resident care events (7)    
1. Acute urinary retention  LNP  105 
2. Multiple day  delay in appropriate treatment of excessive swelling in a resident recovering from a hip 
LP  80 
fracture, which resulted in difficulty breathing  
3. Hypotension due to inadequate hydration therapy  LP  65 
4. Failure to monitor resident, which led to dislodged enteral feeding tube requiring multiple 
LNP  3 
replacement attempts 
5. Cascade event in which inadequate monitoring led to severe dehydration with associated confusion 
LP  120 
leading to falls with minor injuries 
6. Blistering caused by medical tape   LP  14 
7. Acute kidney injury secondary to inadequate monitoring of urinary  retention  LNP  253 
Events Related to Infections (20)    
CAUTI (6)    
1. Multiple catheter associated urinary tract infections secondary to multiple catheterizations.  LP  21 
2. Recurrent urinary tract infections associated with urinary catheter   LP  102 
3. Urinary tract infection associated with urinary catheter   LP  113 
4. Urinary tract infection associated with urinary catheter   CP  128 
5. Urinary tract infection associated with urinary catheter   LNP  177 
6. Urinary tract infection associated with urinary catheter   LP  226 
Continued on next page.   
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  57   
   
Table F-2: Temporary Harm Events by Clinical Category and Preventability (n=113)  
Temporary Harm Event   Preventability    
Events Related to Infections (20) continued    
SSI attributable to wound care (6)    
1. Superficial infection at surgical incision site   LNP  174 
2. Superficial infection at surgical incision site   LNP  180 
3. Cellulitis at surgical site   LP  206 
4. Cellulitis at surgical site   LP  208 
5. Superficial infection at surgical incision site for a lower leg fracture   LP  238 
6. Superficial infection at surgical incision site for recent knee replacement  UTD   1219 
Soft tissue or other nonsurgical infection (4)    
7. Conjunctivitis on eye   LNP  103 
8. Fungal skin infection on abdomen   LNP  129 
9. Blepharitis (swelling of the eyelids)  LNP  131 
10. Bacterial conjunctivitis  UTD   193 
Clostridium difficile infection (2)    
11. Clostridium difficile infection following treatment with broad spectrum antibiotic  CNP  23 
12. Clostridium difficile infection   LP  228 
Other infections (2)    
13. Sepsis resulting from urinary tract infection  LNP  1246 
14. Aspiration pneumonia  CNP  1212 
Source:  OIG analysis of SNF stays for 653 Medicare beneficiaries discharged in August 2011.   
 
 
 
 
   
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  58   
   
APPENDIX G 
Agency Comments:  AHRQ 
 
 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  59 
 Also related to this recommendation, AHRQ is now working with CMS on their 11th Scope of Work 
are 
for QIOs, and in particular we  working to resolve issues and to communicate guidance related to 
nursing home reporting ofadverse events. 
We look forward to following up with yoU: regarding our activities related to the above 
recommendations, as well as to collaborating as appropriate with our colleagues at CMS. 
We believe that your previous reports on adverse events in hospitalized Medicare patients have 
provided valuable information to the public and to Federal and private-sector healthcare leaders. This 
report promises to do the same by addressing a new and especially vulnerable patient population. 
Ifyou or yout staff has any questions, please feel free to contact Dr. Bill Munier, Director, Center for 
Quality Improvement and Patient Safety at William.munier@ahrq.hhs.gov or 301-427-1921 
Richard Kronick, Ph.D. 
Attachment 
I 
...  .....  .  .  ... 
Adverse Events in Skilled Nursing Facilities:  National incidence Among Medicare Beneficiaries (OEI-06-11-00370)  60   
   
 
 
 
 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  61  Agency Comments:  CMS 
(.,~~r_~ 	
5  DEPARTMENT OF HEALTII & HUMAN SERVICES  Centers lor Medicare & Medicaid Services 
Administrator 
Washington, DC 20201 
DATE:  DEC Z3  2013 
TO: 	 Daniel R. Levinson 
Inspector General 
FROM: 	 Ma~l'lwenner 
Administrator 
SUBJECT: 	 Office oflnspector General (OIG) Draft Report: "Adverse Events in Skilled Nursing 
Facilities: National Incidence among Medicare Beneficiaries" (OEI-06-11-00370) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the above subject OIG draft report. This is another study in a series ofremarkable 
OIG reports on adverse events. Through a significant investment in original research generating 
new information not otherwise available, each such report has made important contributions to 
our understanding ofthe nature and prevalence ofadverse events in hospitals and nursing homes. 
01G objectives for this report were to--(1) Estimate the national incidence ofadverse and 
temporary harm events for Medicare beneficiaries in skilled nursing facility (SNF) post-acute 
care; (2) Assess the extent to which adverse and temporary harm events were preventable and 
identify factors contributing to these events; and (3) Estimate the costs associated with adverse 
and temporary harm events to the Medicare program. 
CMS fully concurs with OIG on the importance ofidentifying avoidable adverse events among 
nursing home residents and improving the quality oflife and care for nursing home residents. 
OIG recommendations and CMS responses to those recommendations are discussed below. 
OIG Recommendation 
The OIG recommends that AHRQ and CMS should raise awareness ofadverse events in post
acute care and seek to reduce harm to nursing home residents through methods used to promote 
hospital safety. 
CMS Response 
The CMS concurs with this recommendation. We agree that helping nursing homes to have a 
better understanding ofadverse events and an awareness ofthe preventable events that often lead 
to resident harm could reduce preventable i~ury and harm to residents. We also agree that 
reviewing those methods for promoting hospital safety would be valuable in the development of 
nursing home information. Section 6102 (c) ofthe Affordable Care Act also established specific 
requirements for nursing homes to develop Quality Assessment and Performance Improvement 
(QAPI) activities, and required CMS to develop technical assistance materials in advance ofa 
new QAPI regulation to help establish standards and distribute best practices for meeting these 
standards. CMS launched the nursing home QAPI website in summer of2013 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  62   
   
 
 
 
 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  63   
   
 
   
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  64   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Kevin K. Golladay,  
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office; Ruth Ann Dorrill, Deputy Regional Inspector General; and 
Blaine Collins, Deputy Regional Inspector General.   
Jeremy Moore served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the Dallas regional office 
who contributed to the report include Maria Balderas and Nathan Dong.  
Central office staff who provided support include Heather Barton, Mandy 
Waltz Brooks, Kevin Farber, Althea Hosein, Sandy Khoury, Berivan 
Demir Neubert, and Diane Reinke. 
 
Adverse Events in Skilled Nursing Facilities:  National Incidence Among Medicare Beneficiaries (OEI-06-11-00370)  65   
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.