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Elder Abuse: “Never Events” – Things that Should Never Happen in a Nursing Home

In an effort to save some taxpayer money and improve patient care at the same time, the Centers for Medicare and Medicaid Services (CMS) has made a list of health conditions that are preventable and should never occur in the nursing home or hospital setting.

According to the National Quality Forum, “never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.

The list of “never event” endorsed by CMS contains 28 negligent events ranging from a surgery performed on the wrong part of the body, to the discharge of an infant to the wrong person. Those listed events that frequently occur in nursing homes are:

● Stage 3 or 4 pressure ulcers or bedsores acquired after admission to a facility.

● Patient death associated with a fall while being cared for in a healthcare facility.

● Patient death or serious disability associated with patient elopement (disappearance) for more than four hours.

● Patient death or serious disability associated with a medication error.

● Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility.

● Sexual assault on a patient within or on the grounds of a healthcare facility.

So serious are these never events that starting October 1, 2008 CMS will not reimburse healthcare facilities for the occurrence of these conditions, unless the condition was present upon admission to the facility.

San Diego Elder Abuse Lawyer

While the list contains many events that have no application to nursing facilities, I can say (sadly) that I have been involved in many lawsuits involving all the “never events” listed above, a few of them more than once.