Patient harm during nursing home stay

From a BMJ news report:

A third of Medicare patients who are discharged to a skilled nursing facility for post-acute care are harmed during their stay at the nursing home, says a new report.1

In the study by the Office of Inspector General at the US Department of Health and Human Services, investigators reviewed the records of 653 randomly selected Medicare beneficiaries whose stay at a skilled nursing facility had lasted a maximum of 35 days and had ended in August 2011.

Here is the link to the original report. According to the report 22% of patients experienced serious harm and 59% of the episodes were preventable.

A close look at the methods of the study suggests several cautions in interpreting the findings. The 59% figure is open to question. The determination of preventability was often based on weak circumstantial evidence and unwarranted assumptions. Many of the events that were truly preventable reflected a need for greater vigilance but not error.