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OIG Investigation Reveals Failure to Report Abuse: Consumer Voice Calls for Comprehensive CMS Action

June 17, 2019

A new report from the US Department of Health and Human Services Office of Inspector General (OIG) shows a disturbingly high level of potential abuse and neglect in skilled nursing facilities, and failures at every level of the system designed to protect vulnerable nursing home residents.  The report, Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated, found that 1in 5 high-risk hospital emergency room Medicare claims for treatment in 2016 were the result of potential abuse or neglect of residents in a skilled nursing facility. Equally disturbing, nursing homes failed to report the majority - 84% -of these claims to state survey agencies as required by federal law and regulation, and state survey agencies failed to report 67 of 69 claims - 97%- to local law enforcement as required.  In turn, the Centers for Medicare and Medicaid Services (CMS) did not track these incidents.

What do these failures mean to residents?  They mean that the resident who is the target of abuse or neglect continues to suffer and experience harm, sometimes fatally, and many other residents may also be harmed.   They mean that incidents of abuse and neglect go uninvestigated, unsanctioned, unprosecuted and undeterred.  
Such a significant breakdown of the system calls for a strong response. Unfortunately, the OIG recommendations to CMS are insufficient. The recommendations include training of nursing home staff; clarification of guidance on definitions of abuse and neglect; requiring state survey agencies to record and track all potential abuse/neglect and referrals to local law enforcement; and monitoring those referrals.  Yet, while these steps should certainly be taken, they fall far short of the level of action needed.  

Consumer Voice calls on CMS to use its authority to hold nursing homes, the state survey agencies, and itself accountable for doing the job the public entrusts - and pays them - to carry out.  For instance, whenever a nursing home fails to report abuse/neglect to the survey agency or law enforcement, the survey agency should assess this violation as seriously endangering or being likely to seriously endanger one or more residents and impose a significant monetary penalty. CMS should also alert the public to the facility’s failure to report on Nursing Home Compare.  

There is much more that CMS can and should do to address not just reporting, but also detecting, investigating and preventing abuse and neglect.  Protective measures include:

  • Ensuring that people with certain criminal convictions are not hired to work in nursing homes
  • Requiring surveyors themselves to report potential abuse/neglect to law enforcement when conducting a survey
  • Mandating adequate staffing levels so front-line staff are not stretched so thin that it becomes impossible to provide quality care

CMS should also take action against abuse and neglect perpetrated by corporations – situations where corporations, often with records of poor care, are permitted to take over facilities and then cut budgets to the point where quality and residents suffer.

There is agreement among all stakeholders that there should be zero tolerance of nursing home abuse and neglect, and that no incidents are acceptable. CMS has a major role to play in achieving that goal, and indeed, a duty to do so. Consumer Voice calls on CMS to immediately develop and implement a comprehensive public plan to make the residents’ right to be free from abuse and neglect a reality.

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