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About a third of all nursing home patients suffer some sort of harm as a result of their treatment. That's the conclusion of the most comprehensive nursing home safety study ever conducted by the federal government. The study found that most of that harm is preventable, and that it costs taxpayers nearly $3 billion in extra hospitalizations.

NPR's Ina Jaffe explains.

INA JAFFE, BYLINE: On the last day of his life, Charles Caldwell was surrounded by seven members of his family. But no one thought he was dying. He was in a Dallas-area nursing home, recuperating from surgery to insert a feeding tube.

BILL PUTNAM: Because he had Parkinson's and had lost his ability to swallow.

JAFFE: That's Caldwell's son-in-law, Bill Putnam. He says things began to go wrong when a practical nurse gave Caldwell some medication through his feeding tube. She couldn't get it to stay down, so she used three large syringes to force the liquid into Caldwell's stomach. He soon began to choke.

PUTNAM: This medication is traveling up his esophagus and into his lungs, and he can't expel it like you and I could. So within minutes, Dad is thrashing his arms and legs for his last breath. He has no pulse. His eyes are fixed. He is not breathing, and Dad had drowned in front of his family.

JAFFE: Caldwell died in 2008. So while this was not one of the cases examined for the new report, investigators say it's representative of the misjudgment and ignorance that they found over and over again.

RUTH ANN DORRILL: We were surprised at the seriousness of many of our cases.

JAFFE: That's Ruth Ann Dorrill, a deputy regional inspector general in the Department of Health and Human Services. That's the office that conducted the study. She says that a lot of the problems they saw were failures in ordinary, everyday care.

DORRILL: Lack of monitoring and paying attention was definitely a factor, and then what clinicians would call substandard medical care.

JAFFE: Can you give me an example?

DORRILL: For example, a patient was already on 15 medications, and then they were given an additional anticoagulant, like an aspirin; and then they would have a bleed, a fatal bleed.

JAFFE: The study found that about 60 percent of nursing home residents that were harmed found themselves back in the hospital as a result.

DORRILL: And that came to a tune of $2.8 billion to Medicare, in one year alone.

JAFFE: Nursing homes are inspected by state officials, not the federal government. Investigators hope this report will provide guidance for state inspections and improve patient safety. The nursing home industry doesn't dispute the findings of the report. But industry representatives say it doesn't take into account more recent initiatives to improve care. Dr. David Gifford is head of quality and regulatory affairs for the American Health Care Association, which represents about 60 percent of nursing homes.

DAVID GIFFORD: The report reflected care from 2011 and 2012, and it was in 2012 that we started our initiative. And so we've been seeing progress since 2012, but we still have a ways to go.

JAFFE: A very long way, according to Toby Edelman. She's a senior policy attorney with the Center for Medicare Advocacy. She thinks the inspector general's report suggests a simple remedy.

TOBY EDELMAN: The inspector general found that the staff didn't monitor residents, and delayed providing necessary care. Those are staffing issues. We don't have enough nurses in nursing homes providing care to residents.

JAFFE: But for Charles Caldwell's family, it wasn't just the size of the nursing home staff, but what they were trained - or not trained - to do that meant the difference between life and death.

Ina Jaffe, NPR News.

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