According to the Office of Inspector General (OIG) 2017 work plan, rehospitalizations will be under increased scrutiny in the coming year. This focus is rooted in the alarming findings of a 2014 OIG study on adverse events in nursing homes, which found that in just one month Medicare spent nearly $2.8 million on hospital treatments for harm caused by poor nursing care. Even more startling than the cost, many of the adverse events were “clearly or likely preventable” (OIG, 2014, p. 22). The findings have led the OIG to focus its 2017 initiatives on preventing adverse events and avoidable hospitalizations, in addition to improving state survey oversight and bolstering the terms of payment for Medicare residents.


The Cost of Adverse Events and Avoidable Hospitalization

The 2014 OIG study, Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries, looked at Medicare beneficiaries with post-acute SNF stays of ≤ 35 days ending in August 2011 and found that approximately one in five experienced at least one adverse event during their stay, amounting to 22% (p. 17). Disturbingly, an estimated 1.5% of the study group1,538 residents—experienced adverse events that contributed to their deaths (p. 19). An estimated 4%, or 3,986, experienced at least one “cascade” adverse event, wherein multiple, related events occurred in succession. An additional 11% experienced events during their SNF stays that resulted in temporary harm (p. 20). The OIG found that hospitalizations associated with adverse events (including those related to medication, resident care, and infection) totaled over 20,000, costing $207,979,213. The good news is that since this study was conducted, the overall rate of hospitalizations has declined by 13% (Brennan & Engelhardt, 2017).


Preventable Clinical Errors

CMS has identified bacterial pneumonia, urinary tract infections, congestive heart failure, dehydration, and chronic obstructive pulmonary disease as the most common preventable causes of hospitalization. The OIG study found that of the estimated 22% of Medicare beneficiaries who during their SNF stays experienced adverse events and the additional 11% who experienced temporary harm events, 59% of both types of events were clearly or likely preventable. Preventable events were attributed to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care (OIG, 2014, p. 22).


Understanding High Rates of Rehospitalization

The OIG plans to review nursing homes with high rates of patient transfers to hospitals for potentially preventable conditions, in order to determine whether these nursing homes provided services to residents in accordance with their care plans. Prior OIG work indicates that high rates of patient transfers to hospitals could be the result of poor quality of care. For example, in a previous audit, a nursing facility with a high rate of Medicaid resident transfers to hospitals for UTIs was found to often fail to provide UTI prevention and detection services in accordance with its residents’ care plans (OIG, 2017, p. 10). The OIG’s initiative plans to continue to investigate factors contributing to rehospitalization.


The Adverse Event Screening Tool

The SNF Adverse Event Trigger Tool, developed by the OIG with assistance from clinicians at the Institute for Healthcare Improvement (IHI), aims to improve nursing home care by improving staff’s ability to identify harm. CMS defines the tool as “a resource document that can help nursing homes evaluate systems of care around high-risk medications” (Adler, Moore, & Federico, 2015, p. 7). The tool includes a list of 24 potential adverse events in nursing homes, including those related to medication, infections, and resident care, inclusive of falls, pre-existing conditions, and proper fluids. The list also includes issues that are not common to nursing homes (such as severe gastrointestinal bleeding due to anticoagulant overdose) to promote staff awareness. The purpose of the tool is to increase staff recognition of conditions that contribute to adverse events, giving the staff the opportunity to “correct problems and reduce harm as well as to report problems contributing to events” (p. 28). The OIG plans to release the screening tool with written guidance for the purpose of disseminating practical information about the tool for use by those involved with the skilled nursing field (OIG, 2017, p. 9).


State Oversight

In addition to targeting rehospitalization and adverse events, the OIG also plans to focus on state survey oversight. As a follow-up to a 2006 OIG report that found that state agencies did not investigate some of the most serious complaints within required time frames, the OIG will assess these agencies’ investigative time frames, specifically for the most serious nursing home complaints. According to current regulation, all nursing home complaints categorized as immediate jeopardy and actual harm must be investigated within a 2- and 10-day time frame, respectively (OIG, 2017, p. 8).


Verification of Deficiency Corrections

The OIG will determine whether state survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys. Correction plans for deficiencies identified during surveys are required by federal regulation. State survey agencies must verify that corrections have been made through on-site interviews or other evidence. A previous review by the OIG discovered that one state survey agency did not consistently verify corrections as required (OIG, 2017, p. 39).


Abuse and Neglect

The OIG will also assess the incidence of abuse and neglect of Medicare beneficiaries receiving treatment in SNFs, determining whether these incidents were properly reported and investigated in accordance with applicable federal and state requirements. The OIG will also interview state officials to determine whether each sampled incident was reported, if required, and whether each reportable incident was investigated and subsequently prosecuted by the state, if appropriate. The OIG is pursuing this assessment because of ongoing OIG reviews at other settings that indicate the potential for unreported instances of abuse and neglect (OIG, 2017, p. 8).


The recently updated nursing home regulations require facility staff to ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. This reporting should take place no later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury, and no later than 24 hours if the events do not involve abuse or result in serious bodily injury. Reporting should be directed to the facility administrator and to other officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures (483.12, Freedom from abuse, neglect, and exploitation; CMS, 2016).



The OIG’s focus on preventable resident harm; CMS’s increased reporting requirements for resident abuse, neglect, and exploitation; and the Nursing Home Compare Quality Measure for Percentage of short-stay residents who were re-hospitalized after a nursing home admission continue to put the bull’s-eye on improved care outcomes and savings to the Medicare program. Facility leaders who aren’t familiar with the SNF adverse events trigger tool should find out more about it today. It just might help them avoid OIG scrutiny in 2017.




Adler, L., Moore, J., & Federico, F. (2015, November). IHI skilled nursing facility trigger tool for measuring adverse events. Cambridge, MA: Institute for Healthcare Improvement. Available:


Brennan, N., & Engelhardt, T. (2017, January 17). “Data brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents.” The CMS blog. Available:


Centers for Medicare & Medicaid Services (CMS). (2016, November 28). “Advance copy—Revisions to State Operations Manual (SOM), appendix PP—Revised regulations and tags” (S&C-17-07-NH). Available:


Office of Inspector General. (2014). Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries. Available:


Office of Inspector General. (2017). OIG work plan 2017. Available: OIG Work Plan 2017.pdf


Judi Kulus, NHA, RN, MAT, RAC-MT, DNS-CT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.