Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated

This audit report is one of a series of OIG reports addressing the identification, reporting, and investigation of incidents of potential abuse and neglect of our Nation's most vulnerable populations, including the elderly and individuals with developmental disabilities. Our objectives were to determine (1) the prevalence of incidents of potential abuse or neglect of Medicare beneficiaries residing in skilled nursing facilities (SNFs) who had a hospital emergency room (ER) Medicare claim in calendar year 2016 containing a high-risk diagnosis code, (2) whether these incidents of potential abuse or neglect were properly reported by the SNFs, (3) whether the Centers for Medicare & Medicaid Services (CMS) and State Survey Agencies (Survey Agencies) reported findings of substantiated abuse to local law enforcement, and (4) the extent to which CMS requires incidents of potential abuse or neglect to be recorded and tracked.