Medicaid Pulls Hospital Reimbursement for “Never Events,” Including Severe Bed Sores

By Nursing Home Law Center

Never Events ReimbursementMedicine is an inherently uncertain field; new conditions appear on a regular basis and one patient may suffer from the same ailment as another but display very different symptoms. Individual health factors, genetic traits, and environmental influences all play major roles in individual health, so there is always a reasonable margin of error when it comes to difficult or obscure cases and medical events.

The federal government offers reimbursement to medical providers including nursing homes for the treatment of specific conditions. Included in these provisions are "Never Events," or medical events that in theory should never happen due to their preventability with competent, appropriate care. A recent change in Medicaid laws means that Medicaid will no longer reimburse hospitals and other medical care facilities for Never Events, and bed sores qualify under this distinction.

Why This New Change?

The Medicaid law acknowledges 28 different types of Never Events including preventable medical conditions and injuries from medical errors. With appropriate preventive treatment, it is possible for medical providers to prevent patients from suffering from these ailments. Bed sores are one of the most common afflictions facing nursing home residents in the United States, affecting as many as one in five nursing home residents in the U.S.

Many states already prohibit reimbursement for Never Events and have specific regulations pertaining to qualifying conditions, and the new Medicaid law strives to encourage medical providers to reduce the occurrence of treatment errors and the appearance of preventable medical conditions among patients.

The appearance of a Never Event in a medical facility most often indicates abuse, neglect, or failure to adopt responsible care policies for patients. The financial burden this new Medicaid change potentially imposes should discourage nursing home staff from cutting corners in patient care.

Preventing Bed Sores

Bed sores manifest when a patient spends too much time in one position. Most commonly, bed sores affect nursing home patients confined to bed rest or wheelchair use. Attending caregivers must routinely reposition bedridden patients and lift wheelchair-bound patients to help restore healthy blood flow and prevent the formation of bed sores.

Consistent repositioning prevents blood from pooling in the lowest areas of the body such as the lower back, legs, and feet. The heels are one of the parts of the body most susceptible to developing pressure ulcers.

Some patients suffer from unique medical conditions that require individualized care. For example, a patient who is malnourished or nutrient deficient faces an increased risk of developing bed sores and will have a more difficult time recovering from them.

Patients who undergo surgeries for hip fractures also face an increased risk of developing pressure ulcers, both during and after surgery. The same is true for any necessary surgical procedure; the attending surgical team should ensure the patient does not remain in one position on the operating table for too long at one time.

"Turning" or the repositioning of a bedridden or wheelchair-bound patient should take place no less than every two hours. Many nursing homes and hospitals are adopting a 90-minute policy for turning to further decrease the chances of at-risk patients developing bed sores.

When a patient must undergo a surgical procedure, these events can last for several hours at a time and make repositioning difficult. Attending surgical staff should be sure to reposition surgery patients as necessary and address any risk of pressure ulcers during recovery.

Benefits of the Recent Medicaid Change

The new changes to Medicaid's reimbursement laws for hospitals and nursing homes place a higher duty of care on the staff in these facilities to ensure their patients do not develop bed sores and to treat them quickly and effectively when they do. Ultimately, this means nursing home staff must carefully monitor their patients' bed sores at a minimum once per week to track growth and pain symptoms. However, nursing homes can completely prevent bed sores among their patients with appropriate preventive care such as repositioning and individualized health care plans that address individual patients' medical issues.

When it comes to Never Events, Medicaid has made it clear that the onus of responsibility for preventing these conditions falls to care providers; they must take appropriate steps to prevent their patients from developing these issues and address them promptly with effective treatments when they manifest. Otherwise, nursing homes and other medical facilities face significant financial liability for non-compensable medical procedures.

Ultimately, bed sores are entirely preventable medical incidents with appropriate treatment and patient monitoring practices in place. When hospitals and other medical care facilities allow patients to develop bed sores, this is a clear indication that the facility has failed to provide adequate patient care and is liable for the patient's resulting damages.

A pressure ulcer may require surgical treatment and other significant medical care to prevent infections and other secondary complications, so hospitals and other care facilities must take appropriate measures to prevent these injuries or suffer the consequences under the new Medicaid laws for Never Events.


Related Information

Nursing Home Abuse & Neglect Resources

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