Nurse with elderly woman in hospital

Never Events in Nursing Homes

When a nursing home resident suffers serious injury and/or wrongful death in a nursing home entrusted with his or her care, it can be devastating. Our most vulnerable members of society deserve to be treated with the highest quality of care, but unfortunately that does not always happen. Serious injuries and death can happen in nursing homes, especially when they are chronically understaffed. The National Quality Forum (NQF) started a list of "Never Events" in 2001 that should never happen in a healthcare setting, including at skilled nursing facilities (SNFs).

Never Events are devastating, with over 70% of reported events in the last 12 years causing death. These types of medical events can cause very serious injuries and are often preventable. In 2008, the Centers for Medicare and Medicaid Services (CMS) began refusing payment for treatment involving certain Never Events, such as pressure ulcers, or "bed sores." In a skilled nursing setting, neither Medicare nor Medicaid will pay for care required by/as a result of the following Never Events:

  • Pressure ulcers (also called "bed sores") stages III and IV due to failure to reposition

  • Preventable falls and trauma

  • Surgical site infections

  • Vascular-catheter associated infections

  • Catheter-associated urinary tract infections

  • Administration of incompatible blood

  • Air embolism

Other events in the skilled nursing field deemed by the NQF as a Never Event include:

  • Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person

  • Patient death or serious disability associated with patient elopement (disappearance)

  • Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)

  • Patient death or serious injury associated with a fall

  • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances

  • Patient death or serious injury associated with the use of restraints or bedrails

  • Abduction of a patient/resident of any age

  • Sexual abuse/assault on a patient

  • Death or significant injury of a patient or staff member resulting from a physical assault

Nursing homes seem to have a reputation for a poor safety culture, and injuries and deaths are much more likely when nursing home residents are not cared for properly. If you or a loved one has experienced a serious injury or death in a skilled nursing facility or hospital, contact Daniel Pleasant Holoman LLP. We have attorneys licensed in North Carolina, Kentucky, Tennessee, and Georgia who have vast knowledge and experience helping families with cases against nursing homes for injury and wrongful death. There is no cost to speak to someone about your case, and we offer contingency fee arrangements so that we only receive money if we successfully recover money in the case.

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