Nursing facilities often fail to report serious cases of potential abuse and neglect of Medicare beneficiaries, according to two new reports from HHS' Office of Inspector General (OIG).
About the reports
For one report, auditors at OIG examined Medicare billing records from 2016 to identify instances in which potential neglect and abuse had resulted in such severe injury that patients were taken directly to the emergency department. For example, they considered billing codes for fractures, gangrene, head injuries, patients swallowing foreign objects, and shock as red flags of potential abuse or neglect. The auditors then asked state investigators to review a sample of the cases and determine which cases warranted reporting to federal authorities.
The report focused on nursing facilities that provide skilled nursing and therapy services to Medicare beneficiaries recovering from surgeries or hospitalization. Many of the facilities also provided long-term care.
The second report was broader in scope, looking for unreported instances of potential abuse or neglect in any setting, not just nursing homes.
In total, the researchers identified 37,600 total cases that raised red flags, involving 34,800 Medicare beneficiaries. Based on the state investigators' feedback, they estimated about 6,600 cases involving 6,200 patients suggested cases of potential neglect or abuse that went unreported.
Gloria Jarmon, deputy inspector general for audit services, said her team discovered nursing home facilities failed to report one in five cases of potential abuse or neglect.
For example, the auditors highlighted a case in which a 65-year-old woman was transported to the ED in critical condition. According to the report, the patient had opioid poisoning because a nurse at the facility wrote down the wrong doctor-prescribed dosage. The patient was treated and sent back to the same nursing facility, and the nurse received additional training. However, the facility never reported the incident to CMS.
The auditors wrote that cases of abuse or neglect in nursing homes often go unreported because older individuals are in a vulnerable position and may be afraid to alert friends or family. In other cases, the auditors wrote, a medical condition may mask the abuse.
The auditors separately raised concerns about how infrequently state nursing home inspectors raised concerns about abuse or neglect to local law enforcement. They examined a sample of 69 cases across five states in which a state auditor confirmed that nursing facility patients had experienced neglect or abuse, finding that only two had reported the cases to local law enforcement.
When the auditors looked beyond just nursing homes, they estimated health care providers failed to report nearly 33% of the more than 30,000 potential cases or abuse or neglect to law enforcement or Adult Protective Services, even though the law requires them to make such reports.
The auditors outlined several recommendations for CMS, including:
- Providing nursing facilities with clearer guidance about what kinds of episodes must be reported;
- Improving training for facility staff; and
- Requiring state nursing home inspectors to record and track potential abuse as well as incidents reported to law enforcement.
In addition, the auditors said CMS should periodically examine Medicare billing data to identify signs of potential abuse or neglect.
CMS largely agreed with the auditors' recommendations. However, the agency did not concur with the billing code data recommendation. CMS said that billing code data may not be the best way to identify potential abuse in real time because it can take up to a year for claims to be filed.
CMS Administrator Seema Verma said the agency already is taking steps to improve nursing home oversight.
David Gifford, VP for quality at the American Health Care Association, said that it would "fully support more transparent reporting." The group said Medicare's current definition of neglect "is vague and creates confusion about what should be reported" (Alonso-Zaldivar, AP/ABC News, 6/12; Kounang, CNN, 6/12; Jaffe, "Shots," NPR, 6/12).
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