Adverse Events Identified Among Medicare Skilled Nursing Facilities Residents by Category

Types of Adverse Events Percentage Events Related to Medication 37% Medication-induced delirium or other change in mental status 12% Excessive bleeding due to medication 5% Fall or other trauma with injury secondary to effects of medication 4% Constipation, obstipation, and ileus related to medication 4% Other medication events 14% Events Related to Resident Care 37% Fall or other trauma with injury related to resident care 6% Exacerbations of preexisting conditions resulting from an omission of care 6% Acute kidney injury or insufficiency secondary to fluid maintenance 5% Fluid and other electrolyte disorders (e.g., inadequate management of fluid) 4% Venous thromboembolism, deep vein thrombosis (DVT), or pulmonary embolism (PE) related to resident monitoring 4% Other resident care events 14% Events Related to Infections 26% Aspiration pneumonia and other respiratory infections 10% Surgical site infection (SSI) associated with wound care 5% Urinary tract infection associated with catheter (CAUTI) 3% Clostridium difficile infection 3% Other infection events 5% Source:Office of Inspector General (OIG), Department of Health and Human Services