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 care quality.
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 doctors found that 22 percent of patients suffered events that caused lasting harm,
and another 11 percent were temporarily harmed. In 1.5 percent of cases the patient died because of poor care, the report said. Though
many who died had multiple illnesses, they had been expected to survive.
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 estimated
that 21,777 patients were harmed and 1,538 died due to substandard skilled
nursing care during August 2011, the month for which records were sampled.
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 longer-term care.
As hospitals have moved to shorten
patient stays, skilled nursing care has grown dramatically. Medicare spending
on skilled nursing facilities more than doubled to $26 billion between 2000 and 2010. About one-in-five Medicare patients who were hospitalized in 2011 spent time
in a skilled nursing facility.
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 inspection reports.)
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 said.
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.
—
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