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Richter ShareSource Blog

6 Steps to Reduce Harm in Nursing Homes

Topics: Clinical Consulting, Financial Consulting

Human hand against blue sky background and houseIn December 2018, the Centers for Medicare & Medicaid Services (CMS) and the Medicare Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) released the All Cause Harm Prevention in Nursing Homes Change Package, which was developed as a means to help prevent harm (i.e., adverse events, abuse, and neglect) for nursing home residents. The intended audience of this piece includes nursing homes participating in the National Nursing Home Quality Care Collaborative and anyone interested in improving the quality of life and quality of care for those living in nursing homes.

The following includes answers to some frequently asked questions about the Change Package.

Who could benefit from the use of the Change Package?

The Change Package can be used by nursing home leaders (e.g., administrators, directors of nursing, unit directors/managers, providers, owners), as well as residents and families, long-term care stakeholders, and anyone with an interest in preventing harm in nursing homes. It was developed from a series of nine site visits to nursing homes across the country, and the themes that emerged centered around how these facilities approached prevention of harm while honoring each resident’s rights and preferences, as well as how they carried out their work.

What is in the Change Package?

The Change Package is a description and list of successful practices of high-performing nursing homes (i.e., how they prevent harm while honoring each resident’s rights and preferences). It is organized by overarching themes and includes strategies to prevent specific adverse events and abuse. Nursing homes across the country continue to work to prevent, detect and mitigate certain categories of harm while honoring each resident’s rights and preferences. This Change Package should be a key resource to improve quality of life through safer care for the 1.4 million residents currently residing in a skilled nursing facility. The practices in the Change Package reflect how the nursing home leaders and direct care staff at these sites shared and described their efforts to prevent, detect and mitigate harm. The information applies to both short-stay and long-stay residents.

Where will the Change Package be available?

It is available by using the following link: https://qioprogram.org/sites/default/files/editors/141/C2_Change_Package_20181226_FNL_508.pdf

When will the Change Package be available?

The Change Package is available now.

Why is this important for skilled nursing facilities (SNFs)?

One-third of Medicare beneficiaries experienced temporary harm or adverse events during an SNF stay, and about 60 percent of those instances were preventable, according to previous reports from the HHS Office of the Inspector General.

How do you use the Change Package?

The Change Package is organized by first describing four overarching foundational components that high-performing nursing homes focus on to achieve the aim of improved quality of life for residents through safe, reliable and quality care. The four foundational components are

1) Leadership

2) Committed staff, teamwork and communication

3) Resident and family engagement

4) Continuous learning and quality improvement.

Strong commitment to these four components fosters a culture that allows and supports staff in reliably implementing timely, quality care practices while honoring each resident’s rights and preferences. Detailed strategies and actions to establish the foundation for safe care are described in Appendix B of the Change Package.

The Change Package includes strategies and actions to prevent the specific types of adverse events and harms identified by the 2014 Office of Inspector General reports, which highlighted the need for nursing homes to reduce the incidence of resident harm events and to report allegations of abuse or neglect and investigation results in a timely manner. Any nursing home can choose from these strategies and actions to begin testing for purposes of improving residents’ quality of life through safer care. The strategies and actions range from evidence-based practices to promising practices determined to be worthy of testing by clinical and other long-term care experts in the nursing homes visited.

Foundational Components That Support a Safety Culture

The information below highlights strategies within each of the four components that support a culture of safety and support staff in reliable implementation of timely, quality care practices, while honoring residents’ rights and preferences.

1. Leadership, Committed Staff, Teamwork and Communication:

  • Establish a vision for safe care
  • Set high expectations for staff for customer service and safety minded actions
  • Develop and support a culture of trust, transparency, open communication, respect, teamwork and inclusion
  • Engage the board of directors and corporate leaders in building a culture of safety
  • Select and develop leaders and staff that are accountable for safety
  • Develop a just and fair culture

2. Resident and Family Engagement:

  • Involve resident/ patient/family in goal setting, developing, and updating care plans and daily decisions
  • Promote open communication among the care team and the resident/patient/family
  • Engage residents and families in organizational improvement efforts

3. Committed Staff, Teamwork and Communication:

  • Create a highly effective and collaborative multidisciplinary team
  • Develop an infrastructure that promotes teamwork and communication
  • Provide tools and resources that support teamwork, communication and resident monitoring

4. Continuous Learning and Improvement:
  • Identify staff learning needs to provide safe care
  • Provide orientation and opportunities for ongoing education to support learning
  • Evaluate effectiveness of education
  • Identify and prioritize areas to improve
  • Set organizational goals for safe care by using benchmark data
  • Identify and track measures to understand organizational performance
  • Use a quality improvement process


High-performing nursing homes focused on preventing, detecting and mitigating the following types of harms:

  • Adverse events related to medications, including:
    • Medication-induced delirium or other changes in medical condition
    • Excessive bleeding due to medication
    • Falls, falls with injuries or other trauma with injury secondary to effects of medication
    • Constipation, obstipation and ileus related to medication
  • Adverse events related to resident care, including:
    • Fall or other trauma with an injury related to resident care
    • Pressure and other skin injury such as skin tears and abrasions
    • Exacerbations of pre-existing conditions resulting from an omission of care
    • Acute kidney injury or insufficiency secondary to fluid maintenance, fluid and other electrolyte disorders (e.g., inadequate management of fluid)
    • Venous thromboembolism, deep vein thrombosis (DVT), or pulmonary embolism (PE) related to resident monitoring
    • Elopement
  • Adverse events related to infections, including:
    • Aspiration pneumonia and other respiratory infections
    • Surgical site infection (SSI) associated with wound care
    • Urinary tract infection associated with catheter (CAUTI)
    • Clostridium difficile infection (CDI)
    • Other infection-related events
  • Abuse and neglect, including:
    • Mistreatment, injuries of unknown source and misappropriation of resident property

Interested in learning more about how PDPM will affect your facility? Join us for our Nine Steps to PDPM Webinar Series. Click here to learn more.

Do you have questions about reducing harm in nursing homes, or other clinical challenges? Call Richter’s clinical education consultants at 866-806-0799 to schedule a free consultation. 


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