Silent Signals: Unraveling Care Omissions in Nursing Homes

Episode 195
Categories: Neglect & Abuse

Silent Signals: Is neglect lurking in your loved one’s nursing home? Join us as we unravel the often overlooked signs of care omissions, exposing the silent threats to resident safety. In this week’s episode, nursing home abuse attorney Rob Schenk welcomes guest Dr. Harris to talk about understanding, preventing, and addressing care omissions in nursing homes, shedding light on the critical need for vigilance and advocacy in ensuring the well-being of our elderly population.

Silent Signals: Unraveling Care Omissions in Nursing Homes


Hey out there. Welcome back to the podcast. My name is Rob. I will be your host. In this episode, we have a fascinating discussion about what it means for a nursing home to have. An omission of care, what it means like from a philosophical standpoint, what does being hurt mean? What does doing something improper mean?

These types of things, but we’re not doing it alone. We’re doing it with a fantastic individual. Our guest this week is Dr. Yael Harris. I just call her Dr. Harris because I’m sure that I butchered that first name, but Dr. Harris and I are going to have a fantastic conversation about this specific topic.

What is Care Omission? How do we define that? Once we do define it, what does it actually mean and why is it important? All these things are discussed and we’re going to have a link in the show notes. For her article that she helped author a few years ago, About this exact subject. So if you want to read more about that, follow that link and it, cause it’s fascinating, it’s a fascinating paper.

Guest Intro

Let’s get into, let’s get into the substance of the episode, because like I said, this is a fantastic discussion. So again, we don’t do it alone. We have Dr. Harris with us today. Dr. Yael Harris, CEO of Laurel Health Advisors LLC, leads a woman owned small business dedicated to enhancing healthcare access and quality for vulnerable populations.

With nine years at the Centers for Medicare and Medicaid Services, she spearheaded nursing home quality improvement. Dr. Harris champions technology. Particularly telehealth to elevate health outcomes. Her impact contributions extend to diverse organizations such as the American Medical Association, AARP, and the United States Department of Health and Human Services.

Holding a doctorate in public policy and a master’s in public health, her research on nursing home care was funded by the United States Agency for healthcare research and quality. And we are so happy to have her on the show. Dr. Harris, welcome to the show. 

Dr. Harris: 

Thanks for having me. 

How did your research shed light on the specific omissions of care within nursing homes?


So at the beginning of the episode, I talked about an article and that’s how I found you regarding omissions of care in nursing homes. And I was really interested to have you come onto the show and talk about what you found in your research. And Possibly how that can help our listener or our viewer with respect to them having a loved one in a nursing home. So, just if you don’t mind, how did you, how did that paper come to be? How did you come to participate in that? Why did you, what kind of, what spawned that, that research that you conducted? 

Learn more about the study: Omissions of Care in Nursing Homes: A Uniform Definition for Research and Quality Improvement

Dr. Harris: 

Fortunately, I had the privilege of working for the Centers for Medicare and Medicaid Services a while ago and working on nursing home quality, so privilege of working with entities across the country, working directly with ombudsmen, working directly with nursing homes, and advocates for families to find out what’s going on.

What were the quality issues in nursing homes and how could they address them systematically? Were there issues that could really be addressed, not individually, but restructuring processes, etc. I then went private and saw a solicitation from the federal government, the Agency for Healthcare Research and Quality.

Which was looking at this issue of what are omissions of care, and so I was fortunate to be able to do the work with a team of individuals and also bring on a team of national experts to help advise us and the goal of the project really was to standardize the definition of omissions of care. There were so many different understandings and omissions.

Commissions, omissions, neglect. And we were trying to ferret out the differences between the two, because until you really have a definition, you can’t address a quality issue. So that was the main purpose of the paper was to get national experts on agreement. This is what omissions of care means. And in the process, we identified a lot of things. would help nursing homes to improve their care. 

For a related discussion, check out this episode on Overlooked Signs of Nursing Home Neglect.


So just from a broad standpoint, we don’t need a nerd out of the audience, but what was there, was there like a sample size? Was it like we looked at a thousand different nursing homes with 10, 000 different admissions or whatever?

Can you just briefly, and just from a large 40, 000 foot view, what, how was the research conducted? 

Dr. Harris: 

Sure, absolutely. We did what’s called a systematic literature review. So we looked through all the literature within a certain timeframe that talked about omissions. It wasn’t just restricted nursing homes.

We looked at omissions in any type of setting to look at the definition. And then we flagged the ones that were specific to nursing homes. And, so that those are more relevant than the other ones. Obviously some things happen to hospitals that the same mission would happen. Sometimes a very different issue.

So we really just want to understand how it’s being defined and used across different types of literature. and then it was an iterative process in terms of developing the definition. So we Went back and forth about the literature, but we also had an expert panel that we consulted with. So we would share with them a draft definition, have a meeting, seek their feedback as a discussion, and then throughout the process, email them.

So we met with them, I think, three times. We also were so fortunate to have a board of stakeholders representing everything from nursing home administrators to. family members to patients themselves to the ombudsman. So really a broad group of people representing national organizations that represent nonprofit nursing homes.

Learn more about this and related regulatory concerns in this comprehensive study on care omissions.

And we met with them at the beginning of the project to explain the nature of the project and see if there was any guidance that they had for us. And at the end of the project, we presented our findings and encouraged them to give us feedback, but also how could they use it? Would it be helpful for them?

And the work they do. We came up with a final definition through that whole process, and the definition is omissions of care in nursing homes encompass situations when care, either clinical or non clinical, is not provided for a resident and results in additional monitoring or interventions or increases the risk of an undesirable or adverse physical, emotional, or psychosocial outcome for the resident.

What does Care Omission mean?


Interesting. So I guess that there was a lot of conflict between them, or not a lot of conflict? What was their conflict with respect to that definition? Like, how hard was it? To get to, and that was, that’s a beautiful, that makes sense to me the definition, but can you just walk me through what was the how do we like, get to that? Was there somebody saying it shouldn’t be, something that’s not clinical or whatever?

Dr. Harris: 

No, that’s a perfect question. Absolutely. That, so that was the issue. One of the first issues was when we talk about missions, are we talking clinical, because if someone has grooming and they expect to, have their grooming happen every day and it’s not happening, that’s care as well.

And then if they’re not getting one on one time that affects psychosocial, so there’s all these factors. And so we said, this is about the resident as a whole, we always focus on person centered care. Sure. And so What does the person need? And it’s not just their clinical care, although that’s critical.

The other issue we thought about is the magnitude of the risk. So there could be an omission that actually doesn’t cause harm. There could be an omission that causes immediate harm with the omission. So I’ll give you an example. If the patient’s supposed, that resident’s supposed to have a vitamin, multivitamin every single day, and the CNA forgets it for a couple of days, it’s unlikely the patient’s going to experience harm, but it’s still an omission.

The clinician has prescribed these medications for the resident because the resident needs these vitamins. However, if the CNA forgets to give them their Coumadin, One single day is a severe magnitude of an interaction. So we wanted to make sure that what we were defining is not the outcome, but the act itself that led to it so it doesn’t necessarily need to lead to harm. It doesn’t necessarily count when or how often the emissions happen. It’s the fact that the person did not receive care. Required for the individual. 

For tips on recognizing signs of neglect, see How Do I Recognize Signs of Nursing Home Neglect.

How is the term neglect different from care omission?


That’s an interesting point because I guess let’s say let’s go back to the first example where someone might come in for respite care, or we’ll talk about grooming or whatever.

And let’s say that personal hygiene isn’t done for a couple of days. So that would be an omission. But there’s no. physical harm from most perspectives. However, I guess you could say that would be a harm to dignity as that’s defined in the regulations dignity and respect of the person.

So there is an injury, but again, I guess it’s just the perspective of how we’re going to, how are we going to define that? And I guess that’s one of the many things that you had to tackle which actually is a segue to, to, I wanted to ask you is. In in, in your view having looked at all this and having tussled with people on how to define these things, which is important what do you think the differences, if any, between omission of care as we, as you’ve described it and what we would typically colloquially think of as negligence, neglect, like what do you think the difference is between those two?

Dr. Harris: 

Absolutely. So I think the key distinction is harm. So neglect assumes there was a resulting harm to the patient. Whether it’s, as you mentioned, psychosocial dignity physically, there was actually harm to the patient. And you often think of neglect as intentional. Not just, oh, I forgot by accident, but I didn’t have the time.

I didn’t get to this. Now. There isn’t really a formal definition of neglect. And but with omissions, what we tried to do is define it as it’s not associated with the harm. It’s not associated with the intent it’s associated with did the act happen or not. And so 1 of the things I want to point out is that, omissions of care cannot, it could be a larger issue. When you’re neglecting someone, you’re neglecting a person. You’re not neglecting their care. You’re not neglecting their needs. With an omission, it could be something that is attributable to multiple factors. So let’s go to COVID vaccines.

This was actually developed before COVID, but during the COVID vaccination a patient, a resident, sorry, did not get their vaccine. So there’s a number of reasons for that. The CNA. Or the nurse rather never gave it to the resident, even though the resident requested it, the nurse couldn’t get the vaccine because the provider never authorized the physician ever authorized the patient is safe to get the vaccine.

It could be that the facility itself did not have enough vaccines in stock, they didn’t expect that type of. And then lastly, and this is exactly what happened, it’s system wide in that there was a shortage. so much. Vaccines and we couldn’t get them to the places, even though the providers were saying yes every, unless it contraindicated every single person or should be getting a vaccine.

So again, omissions, the same omission happened. In the end, the resident did not get the vaccine. Hopefully it did not result in a death, but that is the end result of the omission. I did any of those things and what could have been? What can contribute to the omission? And only in one situation is really neglect.

For legal insights into suing for neglect, see this detailed guide on Suing a Nursing Home for Neglect in Georgia.


I see, because I know that it is to the extent that like for coming from where I’m from my perspective as an injury lawyer that negligence in most jurisdictions requires damages. And if you don’t have damage, meaning if there’s no medical bill. If there’s no literally physical injury and we can’t make the argument that there’s an impact on dignity to the extent that it would justify the case, then you don’t have neglect like you don’t from a legal definition, pretty much so that makes sense.

Dr. Harris: 

So in that case, I guess if the individual, the resident didn’t get their vaccination and ended up in the hospital there’d be a reason to sue. However, if this patient didn’t get their vaccination, fortunately COVID was not brought in through, smaller facility, they made proper habits. So you would never even know the patient, the resident didn’t get that because there would be no clinical indication that it caused harm, right?


And some of those instances that you mentioned, you can only have neglect if there is a failure of the center of care. And if there’s a nationwide shortage, that’s outside of the control of the facility. Yeah, okay. All so let me ask this so you’ve crunched all the data that already existed. Was there. Any type of omission that seemed to be prevalent, that seemed to be more common than others. 

Dr. Harris: 

So I would say the late care was one of the most common. And so it was care that was Not thought about at the time, but provided subsequently in a lot of cases, those were not necessarily harmful, but it could have been, like the multivitamin.

If I’d given the multivitamin five hours later, it wouldn’t be harmful. I hadn’t given the coumadin on time. It could be pretty serious. But. These were also attributable to a number of factors. We, these were published articles. We couldn’t go back to the researchers and talk to them. One-on-one, but we did talk to the expert panel who has been working in nursing homes for decades. And so I’ll give you one example. If the person is at risk for pressure ulcer the resident has skin, having skin integrity problems, and they’re not turned. Is that an omission, but is that neglect if the nursing home is short staffed and there’s not enough new certified nurse assistants to manage.

So while they’re supposed to, this patient at this time, they had to go address another resident and meet another residency, so it’s more imperative. And so they turn the resident in two hours. Now that’s enough for someone with really bad skin integrity for the ulcer to form. While there was no mission. It was not neglect. We tried to take the difference, but a lot of times it’s things that were pushed aside because of short resources or competing priorities. 

To learn about workplace safety issues in Georgia nursing homes, visit: Workplace Safety Issues in Georgia Nursing Homes

What are the most common examples of care omissions in your research?


That’s an interesting point. So you mentioned delayed care, and you gave an example of delayed care, the turning repositioning. So would you say that your research showed you that. One of the primary drivers of delayed care was shortage of staffing or some other more systemic cause or not. 

Dr. Harris: So this is personal verses from the literature itself, but having spent a long time working For the federal government to understand quality.

I think there’s two key challenges. And you’ll see high quality nursing homes have this issue. One is having sufficient staff to meet the needs of the resident and not blaming the nursing home. There’s a lot of turnover all over the industry right now, not just in medical care. But that’s a challenge.

The residents need care. They need around the clock care. They wouldn’t be in a nursing home. And so making sure that there’s sufficient staff to meet their needs. But then I know for a while the government talked about staffing ratios and they put in a certain cap. I don’t think that’s enough because if you have a new person come in every three months, you’re really Spending all that time training them.

They’re not proficient. And especially when you look at the psychosocial, they don’t know the resident. It’s really important. This is a person you interact with every single day. You live in that nursing home. This is someone who’s part of your daily life. You want a relationship with that person.

You want that person to know your preferences. Like I really like to sleep in and then get bathed and showered at 10, as opposed to seven in the morning. Like you want that person to know your preferences. If they, even if they have enough. sufficient staff. And, but that staff is turning over every two, three months.

You don’t have that relationship. You don’t have that collaboration. And there’s things that don’t go into your care plan, but that make part of your life. Someone asked me, they’re like, what if someone came in and brushed your teeth when you didn’t want it just, it’s very invasive.

So you really want that relationship going. And so it doesn’t matter if it’s done at the same time every day, it’s not an omission, but it’s really not person centered care. So there’s an interplay there. 

Additional examples and signs of neglect can be explored in Three Signs of Atlanta Nursing Home Neglect.

What key factors contribute to the occurrence of care omissions?


Sure. So I guess what I hear you say is that, um, in your experience that staffing, whether it be turnover training, not enough, these are the things that typically would lead to omissions versus somebody intentionally just not wanting to turn in repositions or things like this. It’s not as though in your experience, people are just bad people. Its resources are stretched or there’s not the opportunity to provide person centered care. In other words, 

Dr. Harris: I like to think that actually, as I, as always say, When you’re working in a nursing home, you could make more money working at McDonald’s where they will actually fund your school care as well.

So staff don’t go to the nursing homes to work there because, is a job, but they make a decision that they want to be in, in a field that’s helping people. It’s not an easy job. It doesn’t pay any more than a daycare worker. So to some extent, you’ve gotta start by thinking these people are not ill-intentioned.

That doesn’t say everyone, but for the most part, no one goes into the situation being ill-intentioned, and part of the turnover rate is related to, it’s a very tough job. They may not get the support. I think one of the key things, and I’m glad you brought this up, is it’s about the system itself and the support that the team needs.

So when I was, for Medicare and Medicaid services, we always talked about person centered care and holistic care and consistent assignment. And by that we meant I have the same nurse CNA working with me daily. I’ll be sexist and say she knows my needs, knows my understanding, we have a relationship and understanding.

If she forgets something, it’s because she’s distracted, like she has ill intent that I’m not gonna say that happens all the time. But the big issue is if she forgets something, there’s a blame and accusatory, negative implications, whereas it could have been. It’s an omission.

It’s not an intentional omission, in which case the good nursing homes are learning institutions. They’re always looking at how we can improve. What did we do that we could do better? And so this is true in hospitals too. If you have an open policy where people can report omissions without getting penalized, and in some ways almost, not applaud them for the omission, but applaud them for their honesty, it allows you to look at are there systematic issues going on?

For details on whether you can sue a nursing home for UTIs, check out this discussion: Can You Sue a Nursing Home for UTIs?

For example, I couldn’t get there because of that. I had ten patients to take care of when I’m only supposed to have eight. Then we know that’s a consistent problem. This is happening over and over again. It’s an issue that the nursing home can address. If it’s an issue where, the nurse gets distracted, how do we help?

What do you need? What tools do you need to make sure that all these care happen? So I’m not saying it’s not There are no malicious intentions, there could be, but for the most part, I think people who go into nursing homes want to do the right thing, and they need to be able to not be afraid to share when they need help identifying how to improve their processes.

How can nursing homes best prevent care omissions?


What do you think are the results of Your research on this paper, like what were the implications or what did you intend the implications to be? And do you think that they were met? In other words, like, all right, we have the definition of omission. Now what what’s the, what are the next steps?

Once we have, okay, we’ve decided that intention is important, it’s just whether or not this care was left out, et cetera, et cetera. What are the next steps? 

Dr. Harris: 

That’s a great question. I think the initial reason the federal government funded this was to have a standardized definition to evaluate issues in nursing homes.

The real goal was to have a standardized definition so that you could separate action from And inaction from the outcome, and you also could destigmatize omissions so they can be better detected. So omission is not neglect and omission is, something that could be addressed or some, was inadvertent or could be advertised.

And you can also use this definition to conduct root cause analysis. So as I talked about earlier, I’m finding out if there’s really a pattern. And so having a standardized definition helps you. To get here. The other thing that I really found that I really enjoyed working on which aligns with my passion is trying to identify omissions and also taking into account identifying care.

What is care, is it the care plan? No, it’s not always documented in the care plan. It’s not just clinical care. There’s more harm psychosocial harms are pretty expensive. This is their home. They live there. There needs to be a matter of respect and dignity and accommodating preferences.

And so that is still part of an omission if that’s. neglected. Someone says, I need help getting dressed and the help doesn’t come. That’s still an omission. And then the other issue that we talked about was commission versus omission. Someone got the wrong med, is that neglect is an omission.

For further reading on this topic, consider this article on How Can I Tell if My Loved One Is Being Neglected or Abused?.

And we define that as a commission. So in other words, there was no mission in that the person didn’t get the right med, but getting the wrong med was not an omission. It was a commission. So I think it really helped us distinguish from, as you said, neglect to omission. So rather than going into nursing homes, assuming bad actors, it allows you to go in and look at what processes can be improved and how do we measure differences across nursing homes? So it’s the glass half full versus glass half empty approach. And without that standard definition, it’s easy to just assume everyone Is a bad actor. 


So it’s right. I guess if this is this would make theoretically the copy process, the quality assurance performance review process somewhat more efficient, somewhat more able to respond to the specific issues they’re having if we’ve defined, okay, this is what’s going on and even specifically to your points of okay, we, you might not have done this, your mens rea might not have been intentional, but, Is this systemic?

Is this just nurse Jane Smith doing this? Like how can we approach this from a facility wide level and change things? That makes a lot of sense. Dr. Harris, this has been a fantastic conversation and I really very much appreciate you coming on. And talking to us about this is, it’s almost like I said, at the top of the show, it’s almost like a philosophical discussion.

For additional resources and legal perspectives, explore Who Can You Sue for Nursing Home Neglect?.

This is like a philosophy: what does it mean to have been harmed? What does clinical care mean for us? But these are all important questions because it drives what we are going to do. In the real world. So I really appreciate you coming on. 

Dr. Harris: 

Thank you. And thank you to all of your listeners for the work they do. It’s very important that we take into account our, our older adults for the most part, and that we’re recognizing their needs and meeting their needs. There are very important parts of our community. And so thank you for doing this. 


Excellent. All right. I hope that you enjoyed the content of this episode. 

A new episode of the nursing home abuse podcast is published every single Monday. We are back to a once a week schedule after, I don’t know, a couple of year break. So hope that you’re enjoying cobwebs off. All this is new. The world has changed in the two or three years since we’ve been doing this. So hopefully we’re just getting the kinks out and getting our sea legs for lack of a better word.

And with any luck, the episodes will get better and better, but who knows, maybe not. And if not, Hey, go listen to the Joe Rogan podcast or something. Just kidding. But not kidding. That’s, I guess it’s good. I don’t know. I haven’t watched that in a while. Anyway, with that, everybody, we’ll see you next week.