The Office of the Inspector General (OIG) issued its report entitled “Incidents Of Potential Abuse And Neglect At Skilled Nursing Facilities Not Always Reported And Investigated” in June 2019 in which the OIG stated, in part: “We determined that an estimated one in five high-risk hospital ER Medicare claims for treatment provided in calendar year 2016 were the result of potential abuse or neglect, including injury of unknown source, of beneficiaries residing in a SNF. We determined that SNFs failed to report many of these incidents to the Survey Agencies in accordance with applicable Federal requirements. We also determined that several Survey Agencies failed to report some findings of substantiated abuse to local law enforcement.”
The OIG report stated that in 2008, 1 in 10 elderly persons reported emotional, physical, or sexual abuse or potential neglect in the previous year. However, many cases are not reported because the elderly are afraid or unable to tell protective services, police, friends, or family.
There were approximately 2.7 million skilled nursing facility (SNF) admissions involving approximately 1.9 million Medicare beneficiaries in calendar year 2016.
The OIG review covered 37,607 high-risk hospital ER Medicare claims nationwide, which involved 34,820 of the approximate 1.9 million beneficiaries residing in SNFs during calendar year 2016. The beneficiaries associated with these claims were transported to the ER directly from a SNF during 2016. These claims were 27,127 hospital outpatient and 10,480 inpatient claims, totaling $163,207,281, and contained at least 1 of 580 diagnosis codes consisting of outpatient principal diagnosis codes and inpatient admitting diagnosis codes that OIG determined to be high risk for potential abuse or neglect.
The 580 diagnosis codes included head injuries, bodily injuries, and safety and medical issues. OIG selected these codes to identify incidents of potential abuse or neglect that were not specifically coded by the treating medical providers on the associated Medicare claim as involving potential abuse or neglect. OIG selected a sample of 256 high-risk hospital ER Medicare claims (160 outpatient and 96 inpatient) from 8 States.
OIG obtained the medical records and other supporting documentation associated with these Medicare claims and reviewed them with Survey Agency officials to determine whether the injuries or illnesses that required treatment were the result of incidents of potential abuse or neglect. OIG then determined whether the SNFs properly reported these incidents of potential abuse or neglect in accordance with applicable Federal requirements.
The OIG’s Findings
Of the 256 sampled high-risk hospital ER Medicare claims, 51 were the result of incidents of potential abuse or neglect that were reportable to the Survey Agencies under Federal requirements. Based on OIG’s sample results, OIG estimated that 7,831 of the 37,607 high-risk hospital ER Medicare claims were the result of incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs.
Of the 51 sampled high-risk hospital ER Medicare claims that were the result of potential abuse or neglect, 43 were not reported by the SNFs to the Survey Agencies. On the basis of these sample results, OIG estimated that 6,608 high-risk hospital ER Medicare claims were associated with incidents of potential abuse or neglect that were not reported by the SNFs to Survey Agencies during calendar year 2016.
Five Survey Agencies did not report findings of substantiated abuse to local law enforcement for 67 of 69 incidents outside of OIG’s sampling frame involving 34 SNFs.
Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness (42 CFR § 488.301).
Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish (42 CFR § 488.301).
Injuries of unknown source: An injury is classified as an “injury of unknown source” when both of the following conditions are met: (1) the source of the injury was not observed by any person or could not be explained by the resident and (2) the injury is suspicious because of its extent or location (e.g., the injury is located in an area not generally vulnerable to trauma) or because of the number of injuries observed at one time or the number of injuries over time (“CMS State Survey Agency Directors’ Letter,” (S&C-05-09), December 16, 2004).
The OIG report concluded: “Because many incidents of potential abuse or neglect were not reported to the Survey Agencies, CMS and the Survey Agencies were not always able to pursue legal, administrative, and other appropriate remedies to ensure the health, safety, and rights of Medicare beneficiaries residing in these SNFs. In addition, CMS’s and the Survey Agencies’ failure to report 67 of the 69 incidents of substantiated abuse to local law enforcement may have led to significant delays in the investigation of these incidents or subsequent prosecution of the perpetrators, as appropriate. Finally, CMS does not require certain information about incidents of potential abuse or neglect to be entered into ACTS. Preventing, detecting, and combating elder abuse requires CMS, Survey Agencies, and SNFs to meet their responsibilities.”
If you or a loved one suffered injuries (or worse) while a resident of a nursing home in the United States due to nursing home neglect, nursing home negligence, nursing home abuse, nursing home understaffing, or the nursing home failing to properly care for a vulnerable adult, you should promptly find a nursing home claim lawyer in your state who may investigate your nursing home claim for you and file a nursing home claim on your behalf or behalf of your loved one, if appropriate.
Click here to visit our website to be connected with medical malpractice attorneys (nursing home claim attorneys) in your U.S. state who may assist you with your nursing home claim, or call us toll-free in the United States at 800-295-3959.
Turn to us when you don’t know where to turn.