Change Package to prevent harm
(adverse events, abuse, and neglect)
for nursing home residents

What is the Change Package?
The Change Package is a description and list of successful practices of high-performing nursing homes (i.e., how they prevent harm while honoring each resident’s rights and preferences), organized by overarching themes, and includes strategies to prevent specific adverse events and abuse.

Why is this important?
There is a need to reduce the prevalence of harm with nursing home residents. The Office of Inspector General reported in 2014 that 33% of all residents of skilled nursing facilities experience an adverse event or temporary harm event. The Change Package will be a valuable resource as nursing home staff and providers work with residents and families to prevent, detect, and mitigate harm.

Who can use the Change Package?
The Change Package can be used by nursing home leaders (e.g., administrators, directors of nursing, unit directors/​managers, providers, and owners), residents and families, long term care stakeholders, and anyone with an interest in preventing harm in nursing homes.

How can the Change Package be used?
Ideas for improvement can be generated by reviewing the practices listed and comparing those to practices currently in place. Ideas for improvement can be used for quality improvement purposes in order to improve each resident’s quality of life through safe care.


The links below provide PDFs of the individual sections of the Change Package. Nursing home leaders may choose to focus on one area of harm at a time. The links below allow printing of one section of care practices at a time to review, learn, and implement. Prior to reviewing individual sections, it’s most helpful to review the Change Package as a whole.

- Table of Contents
- Organization and How to Use the Change Package
- Notes on Terminology
- Acknowledgments
Achieving Improved Quality of Life Through Safe Care
Review a model depicting what high-performing nursing homes focus on to achieve the aim of improved quality of life for residents through safe, reliable, quality care.
Foundational Components that Support a Safety Culture
Learn strategies within four foundational components that support a culture of safety and support staff in reliable implementation of timely, quality care practices, while honoring residents’ rights and preferences.
Actions to Prevent All Causes of Harm in Nursing Homes
Each section includes the following components: a) Foundational and Ongoing Education Topics to Consider, b) Pre-Admission Practices, c) Admission Practices, d) Ongoing Care Practices and Monitoring, and e) Resources to Consider.

Events Related to Medication
Includes actions to:
- Prevent medication-induced delirium or other changes in medical condition
- Prevent excessive bleeding due to medication (anticoagulants)
- Prevent falls/​falls with injuries or other trauma with injury secondary to effects of medication
- Prevent constipation, obstipation, and ileus related to medication
Events Related to Resident Care
Includes actions to:
- Prevent fall or other trauma with injury related to resident care
- Prevent pressure and other skin injury such as skin tears
- Prevent exacerbations of preexisting conditions resulting from an omission of care
- Prevent acute kidney injury or insufficiency secondary to fluid maintenance
- Prevent fluid and other electrolyte disorders (e.g., inadequate management of fluid)
- Prevent venous thromboembolism, deep vein thrombosis (DVT), or pulmonary embolism (PE) related to resident monitoring
- Prevent elopement (residents that leave the building without staff knowledge)
Events Related to Infection
Includes actions to:
- Prevention of all types of infections
- Prevent aspiration pneumonia and other respiratory infections
- Prevent surgical site infection (SSI) associated with wound care
- Prevent urinary tract infection associated with catheter (CAUTI)
- Prevent Clostridium difficile infection (CDI)
- Prevent other infection events
Abuse and Neglect
Includes actions to:
- Prevent abuse, neglect, mistreatment, injuries of unknown source, and misappropriation of resident property

Appendix A: Need Ideas for Where to Begin? Focus Here First
Nursing homes participating in the development of this Change Package provided suggestions on the priorities for preventing all cause harm for residents.
Appendix B: Foundational Components that Support Staff in Carrying Out Actions to Prevent Harm (Adverse Events, Abuse, and Neglect) for Nursing Home Residents
Review strategies and detailed actions to build and sustain the four foundational components that support staff in carrying out actions to prevent harm for residents. 
- Leadership
- Resident and Family Engagement
- Committed Staff, Teamwork, and Communication
- Continuous Learning and Improvement
Appendix C: Office of Inspector General (OIG) Report Findings
Review key findings from two reports: 1) Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries and 2) Nursing Facilities’ Compliance with Federal Regulations for Reporting Allegations of Abuse or Neglect.
Appendix D: Team Members to Consider and Resources for Quality Improvement Efforts
When working to improve systems and processes to prevent specific types of harm, review this list to generate ideas for who to involve in quality improvement work in these areas. A list of resources to support effective quality improvement teams is also provided.

This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QINNCC-02171-06/19/18