California Nursing Home Abuse Lawyer Blog
When families place a loved one in a nursing home or assisted living facility, they do so with the expectation that the facility will provide basic safety, dignity, and competent medical care. Unfortunately, that expectation is not always met. In recognition of this reality, the Centers for Medicare and Medicaid Services, known as CMS, identified a category of catastrophic failures in healthcare that should never occur in a properly run facility.
These incidents are known as “never events.”
According to the National Quality Forum, never events are serious medical errors that are clearly identifiable, largely preventable, and result in significant harm or death. Most importantly, they signal a fundamental breakdown in patient safety systems and oversight. In other words, when a never event occurs, it is not bad luck or an unavoidable outcome. It is evidence of negligence.
CMS has identified 28 such events across healthcare settings, including hospitals and long term care facilities. While some of these events apply primarily to surgical or acute care environments, several never events occur far too often in nursing homes and assisted living facilities, particularly those that are understaffed or poorly managed.
The never events most commonly seen in nursing home cases include the development of advanced pressure ulcers after admission.
- Stage three and stage four bedsores are not an inevitable part of aging. They are a sign that a resident was not repositioned, not monitored, and not given appropriate skin care. These wounds are painful, dangerous, and frequently fatal.
- Another devastating never event is patient death associated with falls. Nursing homes are required to assess fall risk, implement safety measures, and provide adequate supervision. When a resident dies following a fall, it often reflects failures in staffing, care planning, or basic monitoring.
- Elopement is another tragic and preventable occurrence. When a resident wanders away from a facility and is missing for hours, the consequences can be severe or deadly. Facilities are required to protect residents with cognitive impairments from leaving unsupervised.
- Medication errors also qualify as never events when they lead to death or serious disability. These errors can involve overdoses, contraindicated drugs, or a complete failure to administer necessary medication.
- The improper use of restraints or bedrails, which can cause suffocation, falls, or severe injury, is another clear violation of care standards. Sexual assault within a healthcare facility is perhaps the most disturbing never event of all, representing a complete failure to protect vulnerable residents.
Because of the seriousness of these events, CMS stopped reimbursing healthcare facilities for costs associated with never events unless the condition was present upon admission. This policy reflects a simple truth. These outcomes are not acceptable.
At Nursing Home Law Group, we have represented families throughout the San Francisco Bay Area in cases involving nearly every one of these never events. Too often, these tragedies are preceded by warning signs buried in facility records and ignored by staff and administrators.
Our firm focuses exclusively on nursing home neglect and abuse cases. We understand how these facilities operate, how corners are cut, and how preventable harm is explained away after the fact. More importantly, we know how to hold facilities accountable under California law.
If your loved one suffered serious harm or died in a nursing home and you were told it was unavoidable, it may not be true. Never events are called that for a reason. They should never happen. When they do, families deserve answers and justice. Nursing Home Law Group is here to help.
