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This Chartbook on Patient Safety includes a section with results from the National Nursing Home Survey on Patient Safety:
National Healthcare Quality and Disparities Report
This Patient Safety chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (QDR). The QDR includes annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). This chartbook includes a summary of trends across measures of patient safety from the QDR and figures illustrating select measures of patient safety. A PowerPoint version is also available that users can download for presentations.
At the conclusion of the session, the participant will be able to accomplish the following:
Unrecognized spread of germs from healthcare personnel (HCP) contamination occurs every day in healthcare settings, posing a risk to patients and HCP alike. Recent Ebola virus outbreaks demonstrated that the potential for transmission of any pathogen in healthcare settings poses an immediate and serious threat.
Preventing the spread of germs in healthcare is essential to protecting the health of patients and HCP. This International Infection Prevention Week, the CDC Prevention Epicenters Program is pleased to announce a groundbreaking new journal supplement, “Personal Protective Equipment for Preventing Contact Transmission of Pathogens: Innovations from CDC’s Prevention Epicenters Program,” composed of 14 in-depth studies, published in this month’s Clinical Infectious Diseases. This research provides insights from recent personal protective equipment (PPE) work in U.S. healthcare settings. It provides evidence to improve routine use of PPE, and to prevent contact transmission of Ebola and other infectious diseases in healthcare settings.
All healthcare settings can benefit from improvements in PPE use and design. PPE plays an important role in preventing the spread of infectious diseases in healthcare settings, but its optimal design and use need to be informed by dedicated research to achieve the reliability and effectiveness needed to protect patients and HCP.
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
Princeton Place Did Not Always Comply With Care Plans for Residents Who Were Diagnosed With Urinary Tract Infections (A-06-17-02002)
Princeton Place did not always provide services to Medicaid-eligible residents diagnosed with UTIs in accordance with their care plans, as required by Federal regulations. Specifically, Princeton Place staff did not always document that they monitored the residents' urine appearance at the frequencies specified in their care plans. Princeton Place did not have policies and procedures to ensure that its staff provided services in accordance with its residents' care plans. As a result of Princeton Place not following residents' care plans, the residents were at increased risk for contracting UTIs and for incurring complications from UTIs, including requiring hospitalization.
The Department of Health and Human Services Office of Inspector General issued two new reports that address the identification, reporting and investigation of incidents of potential abuse and neglect of our nation's most vulnerable populations, including seniors and individuals with developmental disabilities. OIG issued an early alert in 2017 based on the preliminary findings of this work. Our resulting work, released in June 2019, identify thousands of Medicare claims that indicate abuse and neglect of beneficiaries, including beneficiaries in skilled nursing facilities. If you suspect someone is the victim of abuse or neglect, contact law enforcement immediately.
CMS Could Use Medicare Data To Identify Instances of Potential Abuse or Neglect
Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated
Purpose of Review
To assess adverse events of antidepressants in the treatment of major depressive disorder in adults 65 years of age or older.
In people 65 years of age or older:
Nursing Home Compare Claims-based Measures Technical Specifications, including Five-Star QMs -Update March 2019 plus Appendix
The Immediate Jeopardy Update Training introduces surveyors and non-surveyors to the revised Appendix Q–Core Guidelines to Determining Immediate Jeopardy. The Core Appendix Q focuses on the key components necessary to establish immediate jeopardy (IJ) under the regulations.
These key components are:
The Core Appendix Q also contains information about how surveyors should determine whether IJ exists, and it includes a template that surveyors must use to ensure that sufficient evidence exists for each key component of IJ.
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