NEW YORK (MainStreet) — A U.S. Department of Health and Human Services (HHS) investigation published earlier this year found an alarming number of error-ridden situations even among skilled nurses – nearly 22,000 patients experienced at least one "adverse event" in a single month – resulting from treatment mistakes and poor care. While the study looked at Medicare beneficiaries, most nursing home patients are Medicaid patients, so the numbers of adverse events are likely much higher.

Doctors who reviewed the errors believed much of the preventable harm was due to “substandard treatment, inadequate resident monitoring, and failure or delay of necessary care,” according to the report. Hospital treatment for those patients that month alone cost Medicare $208 million, which equated to $2.8 billion for 2011.

Yet between 2007 and 2012, nursing home enforcement actions decreased by more than 65%, according to numbers compiled by the

Long Term Care Community Coalition

 (LTCCC). This decrease in enforcement actions appears to be the result of the increase in “no harm” labeling of events.

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“In order to prevent bad outcomes for nursing home residents, inspectors must identify poor care, correctly label it in terms of harm, and must penalize nursing home providers with strong sanctions that will encourage them to provide the care we are paying for,” Rudder says. “Currently, a significant number of inspectors are not identifying poor care or are under-estimating the harm that residents are suffering when they do identify poor care. Under-estimating leads to weak or no sanctions. Thus, a significant number of providers have little incentive to give good care."

Families who have loved ones in nursing homes have much to be concerned about but fear retaliation against their loved ones, some of whom cannot speak to tell about their treatment.

"Many residents and their families are afraid to complain,” says Rudder. “Although retaliation is outlawed, many still fear staff taking it out on them or their loved ones. Given that many complaints are not substantiated because of poor investigation by inspectors, one has to be courageous to complain. Nothing will ever change until inspectors are better trained and nursing homes are penalized for the harm they cause."

Attorney and physician Armand Leone, Jr., a partner at Britcher, Leone & Roth in Glen Rock, N.J., notes that “[b]y contacting the ombudsman, the problematic conduct will likely stop and the resident will receive appropriate care – the only employees who will be affected are those who are the problem, and that is the whole point."

Failure to report ongoing wrong-doing allows a terrible situation to continue.

“By not contacting the ombudsman, the problematic conduct will continue with the risk of harm to the patient,” he says.

—Written by S.Z. Berg for MainStreet