Dec 18 2025 | Adverse Event Disclosure

Adverse events happen; while companies and their staff work hard to minimize the likelihood of an adverse event occurring, absolute avoidance is an unachievable goal. It’s best, then, to plan for adverse events so prompt and efficient response can mitigate additional risk.

Adverse events is defined by the US Department of Health and Human Services as “an event in which care resulted in an undesirable clinical outcome – an outcome not caused by underlying disease – that prolonged the patient say, caused permanent patient harm, required life-saving intervention, or contributed to death.”

Adverse events can be mild or severe; they can also be “near misses,” meaning if the event is not addressed to minimize future incidents, it could very well lead to harm should it occur again.

Examples of adverse events include but are not limited to medication errors, missing residents, resident falls, and pressure injuries.

Facility leadership staff should receive training regarding the appropriate and timely disclosure of adverse events. Some recommendations, according to the 2024 Aging Services Claim Report, include:

PREPARE IN ADVANCE. Before starting a conversation about an adverse event with anyone, gather all relevant data about the event. Include details of what occurred, action steps taken by the facility, and any ongoing steps being taken to address the situation. Prepare to answer questions depending on the situation and the person/people with whom you are speaking.
CHOOSE THE RIGHT SETTING. Meet, in person, in a private and comfortable setting where both parties can speak openly without distractions or interruptions. Consider inviting a neutral third party, such as a social worker, to provide support and facilitate the conversation if necessary.
BE HONEST AND TRANSPARENT. Begin by acknowledging the seriousness of the situation and expressing concern for the resident and family. Offer clear and factual information about the adverse event, including when it occurred, who was involved, and the impact on the resident. Do not downplay, make excuses, or minimize the severity of the event – this can erode trust and credibility.
ACTIVELY LISTEN. Allow the person plenty of time to express thoughts and feelings about the situation, and to ask questions. Demonstrate empathy and understanding; validate feelings and concerns. Do not interrupt. Reassure that their feelings and emotions are valid and taken seriously.
OFFER SUPPORT AND ASSISTANCE. Reiterate that the resident’s safety and well-being are of top priority to the facility. Outline steps being taken to address the situation and ways you plan to prevent future occurrences. Provide ongoing updates and communication as the situation progresses, maintaining transparency and accountability throughout the resolution process.

Adverse events should be reported to a clinical supervisor and the administrator as well as a risk manager per the facility’s policies and procedures, and an incident report should be completed promptly. Adverse events include incidents involving one or more of the following:

A resident is harmed or sustains an injury
An outcome has potential clinical significance
An outcome differs from anticipated results
An unexpected safety crisis

For more information on resident safety and responding to adverse events, the 2024 Aging Services Claim Report authors recommend consulting with the following resources:

Posted in Skilled Nursing Facilities, Survey & Regulatory