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Inspector General’s Report Says Nursing Home Abuse Largely Underreported

In a perfect world, when a family entrusts their loved one to a nursing home’s care, the staff would always take care of them. Unfortunately, that is not always what happens.

A recent report from the Office of the Inspector General (OIG) found that nursing home abuse is prevalent and remains widely underreported.

Findings From the Inspector General’s Report

Advocates have been saying for decades that more abuse happens in nursing homes than is widely known. The report from the OIG confirms this sad truth.

The OIG determined roughly 1 in 5 high-risk visits to the emergency room by Medicare beneficiaries (primarily Americans 65 years and older) were potentially the result of abuse or neglect.

Furthermore, many homes didn’t report incidents to the proper protective agencies even though they are required by federal law.

The OIG also discovered that some Survey Agencies (state-level health inspectors) did not report proven incidents of abuse to local law enforcement.

Finally, the OIG also realized Centers for Medicare & Medicaid Services (CMS) does not require referrals to law enforcement for situations of potential abuse or neglect to be recorded in their Incident Tracking System or other survey systems.

If calls to law enforcement don’t get recorded, it skews the data in Medicare’s nursing home rating systems, making the home seem better than it is.

Furthermore, a lack of recorded law enforcement calls prevents homes from improving because their staff doesn’t receive the training they need to better handle escalating situations. If the staff can’t improve their skills, more residents will be put at risk of abuse.

Nursing Homes Not Reporting Abuse

The main takeaway from this report is that nursing home abuse is widely underreported and mishandled. Under CMS regulations, nursing homes are required to report abuse to inspectors, and those inspectors are required to report their findings of abuse to CMS and law enforcement.

Nursing homes are failing to comply with these regulations and it’s putting vulnerable people at continued risk if these facilities aren’t held accountable.

Agencies Failing to Respond to Reports of Abuse

According to the report, not only are the homes not reporting abuse, but when they do report abuse, the applicable protective agencies are also dropping the ball.

From the report’s findings, when nursing homes do report incidents of abuse, CMS officials and health inspectors don’t always follow proper protocol, which is to record and track the incidents.

Since there’s no requirement for the inspectors to track referrals to local law enforcement, the issue of nursing home abuse seems less common or severe than it is.

Inspector General Recommendations to CMS

Once the abuse comes to light, steps can be taken to prevent it from happening again. The OIG report had several recommendations for CMS to ensure potential abuse and neglect are reported.

The Inspector General’s report recommended:

  • CMS should work with the Survey Agencies (health inspectors) to improve staff training so they can better identify and report potential abuse and neglect.
  • CMS needs to clearly define what abuse or neglect looks like so that staff members know what to report.
  • Survey Agencies need to record and track all situations of potential abuse and neglect.
  • Survey Agencies also need to record whenever a call gets made to local law enforcement and other protective services.
  • CMS needs to monitor whether or not the Survey Agencies are reporting proven incidents of abuse to local law enforcement.

Holding Nursing Homes Accountable to Prevent Abuse

Nursing home abuse is preventable. It’s up to everyone to hold nursing homes accountable for committing, enabling, and covering up abuse. This includes the staff, family members, law enforcement, and the agencies put in place to protect residents.

If you or a loved one have suffered nursing home abuse, it’s critical to take action. Contact the Nursing Home Abuse Center if you or a loved one has been the victim of abuse. Our legal team can answer questions and review your case for free.

Nursing Home Abuse Support Team

The Nursing Home Abuse Center (NHAC) was founded to bring justice to those affected by nursing home and elder abuse. Our mission is to educate and empower victims of abuse and their families to take a stand against this unlawful mistreatment. We work to return dignity back to those who have been broken down by nursing home abuse and neglect.

Lauri, J.F. (2019, June 27). Nursing Home Neglect and Abuse Incidents are Largely Unreported. The National Law Review. Retrieved from

Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated. (2019). Retrieved from