U.S. Department of Health Adverse Event Reporting Policies for Nursing Homes

Abstract

The objectives of this study were to describe state policies for the frequency of adverse event reporting and follow-up that occurs in U.S. nursing homes, and to identify the health information technology used to facilitate these processes. The study was conducted using a mailed survey to the Departments of Health (DOH) in all 50 states, specifically the department that is responsible for the oversight and regulation of nursing home care. Thirty-two state DOH representatives participated. The primary variables examined were (1) which incidents were most commonly reported to state DOH and (2) whether or not they were followed up with a surveyor visit to the nursing home. There was wide variation in incident reporting processes across all states and lack of a standardized process. Abuse is the only adverse event that almost always is required to be reported to the state DOH and has the highest incidence of follow-up with a surveyor visit. Improving and standardizing adverse event reporting systems is a necessary strategy to enhance patient safety in nursing homes. This study provides an important step by increasing our knowledge base of the current state of adverse event reporting policies and processes at the state level.

Patient safety culture and obstacles to adverse event reporting in nursing homes

“…Due to the high incidence and low reporting rates of adverse events, it has been recommended that adverse event reporting systems should be established to encourage the reporting of adverse events in nursing homes (Wagner, Castle, Reid, & Stone, 2013). However, adverse event reporting systems need to be improved and standardized to reduce obstacles to adverse event reporting and enhance patient safety in nursing homes (Wagner et al., 2013).…”

“…There were many reasons for staff not reporting adverse events, resulting in unreported cases of adverse events (Heard, Sanderson, & Thomas, 2012; Martin, Reneau, & Jarosz, 2018; Tevis, Schmocker, & Wetterneck, 2017). Due to the high incidence and low reporting rates of adverse events, it has been recommended that adverse event reporting systems should be established to encourage the reporting of adverse events in nursing homes (Wagner, Castle, Reid, & Stone, 2013). However, adverse event reporting systems need to be improved and standardized to reduce obstacles to adverse event reporting and enhance patient safety in nursing homes (Wagner et al., 2013).…”

Impact of infection preventionists on Centers for Medicare and Medicaid quality measures in Maryland nursing homes

“…Previous research has cited that, whereas infections are extremely common, outbreaks are reported less often than less frequently occurring events such as abuse. 32 This study identified that NHs with greater FTE support of an IP resulted in better outcomes in some areas. Thus, further research in the role of reporting outbreaks and quality improvement strategies to prevent and track infections in NHs is critical, especially in NHs where minimal support is provided.…”

Nursing home leaders' perception of factors influencing the reporting of elder abuse and neglect: a qualitative study

“…To promote patient safety and prevent abuse and neglect in nursing homes, nursing home leaders need to address both abusive behaviour by individual staff as well as organisational and cultural factors over which individual staff members have no control. A study from the USA, using mail survey to the Departments of Health in all 50 states, found that abuse is the only adverse event that almost always is required to be reported to the supervision authorities; hence, it also has the highest incidence of follow-up with a surveyor visit (Wagner et al , 2011). This shows a need for Norwegian policymakers to establishing clear laws that protect and serve vulnerable adults exposed to mistreatment.…”