March 4, 2014 - One-in-three
patients in skilled nursing facilities suffered a medication error,
infection or some other type of harm related to their treatment,
according to a
government report released today that underscores the widespread
nature of the country’s patient harm problem.
Doctors who reviewed the patients’
records determined that
59 percent of the errors and injuries were preventable.
More than half of those harmed had to be readmitted to the hospital
at an estimated cost of
$208 million for the month studied — about 2 percent of Medicare’s
total inpatient spending.
Patient safety experts told
ProPublica they were alarmed because the frequency of people harmed
under skilled nursing care exceeds that of hospitals, where medical
errors receive the most attention.
“(The report) tells us what many of
us have suspected – there are vast areas of health care where the
field of patient safety has not matured,” said Dr. Marty Makary, a
physician at Johns Hopkins Medicine in Baltimore who researches health
The study by the inspector general of the U.S. Department of Health
and Human Services (HHS) focused on skilled nursing care – treatment in
nursing homes for up to 35 days after a patient was discharged from an
acute care hospital. Doctors working with the inspector general’s office
reviewed medical records of 653 randomly selected Medicare patients from
more than 600 facilities.
The injuries and deaths were caused
by substandard treatment, inadequate monitoring, delays or the failure
to provide needed care, the study found. The deaths involved problems
such as preventable blood clots, fluid imbalances, excessive bleeding
from blood-thinning medications and kidney failure.
One patient suffered an undiagnosed
lung collapse because caregivers failed to recognize symptoms. The
patient later had a reaction to medication and a blood clot and had to
be transferred to a hospital.
Projected nationally, the study
21,777 patients were harmed and 1,538 died due to substandard
skilled nursing care during August 2011, the month for which records
Medicare patients “deserve better,”
said Sen. Bill Nelson, D-Fla., chairman of the U.S. Senate Special
Committee on Aging. Nelson said he would push for better inspections of
the facilities. “This report paints a troubling picture of the care
that’s being provided in some of our nation’s nursing homes,” he said.
The report said it is possible to
reduce the number of patients being harmed. It calls on the federal
Agency for Healthcare Research and Quality and the Centers for Medicare
& Medicaid Services (CMS) to promote patient safety efforts in nursing
homes as they have done in hospitals.
The authors also suggest that CMS
instruct the state agencies that inspect nursing homes to review what
they are doing to identify and reduce adverse events.
In its response to the report, CMS
agreed with the findings and noted that the Affordable Care Act requires
nursing homes to develop Quality Assurance and Performance Improvement
programs. The agency’s quality improvement work includes
a website for nursing homes that was launched in 2013.
A “skilled nursing” facility
provides specialized care and rehabilitation services to patients
following a hospital stay of three days or more. There are
more than 15,000 skilled nursing facilities nationwide, and about 90
percent of them are also certified as nursing homes, which provide
John Sheridan, a member of the
American College of Health Care Administrators, which represents nursing
home executives, called the report valuable but noted that it sampled
only a small number of patients. He questioned whether the findings
apply broadly to skilled nursing facilities.
Sheridan also strongly disagreed
with the report’s observation that there’s less known about patient
safety in skilled nursing facilities compared to hospitals. He said
Medicare has robust inspections of nursing homes it certifies – they
take place annually or when there are complaints and are usually
conducted by state contractors. Medicare also keeps detailed data on the
violations, he said. (ProPublica’s
Nursing Home Inspect makes it easy to search and view Medicare
Sheridan agreed that skilled
nursing facilities could improve, but said the caregivers face a
daunting task and work diligently despite low reimbursements Medicare
pays to the facilities.
“They don’t go to work every day to
cause an adverse event,” Sheridan said of the providers. “They do it to
care for the residents there. They do it with sacrifice and love.”
Dr. Jonathan Evans, president of
the American Medical Directors Association, a group focused on nursing
home care, said while he doesn’t dispute the estimates in the inspector
general’s report, they are typical of problems that exist throughout the
health care sector.
Evans said that patients receiving
skilled nursing care are leaving hospitals sooner and that many are not
medically stable and have more intensive needs. Nursing homes,
originally designed for long-term patients who did not need intensive
care, and have been slow to adapt, Evans added.
“You have a system of long-term
care that’s trying to retrofit to be a system for post-acute care,” he
said. “The resources to care for them and commitment from those sending
them from one facility to another haven’t kept pace.”
Evans called the study significant
and said he hopes it raises awareness and sparks improvements.
Makary, the Johns Hopkins’ doctor,
said the patient safety movement has been more focused on problems at
hospitals than in nursing homes.
A 2010 report by the HHS inspector
general estimated that
180,000 patients a year die from bad hospital care, and
other estimates have been higher. The patient safety research
community has focused on reducing bloodstream infections and surgical
errors at hospitals but has done less to address issues specific to
nursing homes, Makary said.
Developing metrics to track
improvement would be more effective than annual inspections, which don’t
do a good job of capturing a facility’s everyday performance, Makary
Patient advocates said the study
verifies what they’ve heard from skilled nursing patients and their
families. Richard Mollot, executive director of New York’s Long Term
Care Community Coalition, said he was “flabbergasted” by medication
errors, bedsores and falls that were identified in the report.
They are prominent problems that
nursing homes should be “well versed” to address, he said.
Mollot said the report should have
more forcefully called for better enforcement of the existing standards
in nursing homes.
States inspect nursing homes on
behalf of Medicare every year and when there are complaints, he said,
but some inspectors are tougher than others. Medicare’s current
standards of care are good, he said, and “if they were enforced we
wouldn’t have these widespread problems.”
About 40 percent of people over age
65 will spend time in a nursing home at some point, Mollot said.
Hopefully, he said, the inspector general’s report will help the public
see that care needs to improve.
“They are dangerous, dangerous
places,” he said.
>> For comments,
updates and more about this report go to
ProPublica. This story was first published by ProPublica,
March 3, 2014, 9:47 a.m.
ProPublica is an independent, non-profit newsroom that produces
investigative journalism in the public interest. The work focuses
exclusively on truly important stories, stories with “moral force.” It
reports to do this by producing journalism that shines a light on
exploitation of the weak by the strong and on the failures of those with
power to vindicate the trust placed in them.
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