A review of nursing home inspections by the Office of Inspector General (OIG) found widespread misuse of antipsychotic drugs, especially among residents with dementia, as well as efforts to mask the misdiagnosis of schizophrenia, which helps nursing homes avoid citations.
Dual reports issued Thursday by OIG on antipsychotic use within nursing homes also suggest that these medications were often used to control resident behavior without first attempting non-drug interventions and for staff convenience, despite Food and Drug Administration (FDA) warnings about increased risk of death. Staff admitted that they sometimes relied on them to manage workloads by sedating residents.
The first OIG brief provides an in-depth look at nursing home practices that put residents at risk, while the second brief examines practices used to cover up inappropriate use.
“Nursing homes inappropriately diagnosed residents with schizophrenia to mask the nursing homes’ misuse of antipsychotic drugs and to artificially inflate their star ratings,” OIG stated.
OIG relied on sampled surveys from 40 nursing homes across the nation and assessed compliance related to antipsychotic drugs to draw its conclusions.
“OIG’s comprehensive review of 40 focused nursing home inspections completed by CMS found alarming instances of inappropriate use of antipsychotic drugs and revealed vulnerabilities in care that have implications for the wider nursing home population beyond these examples,” OIG’s brief stated.
Jodi Eyigor, VP of health policy at LeadingAge, the association of nonprofit providers of aging services, including nursing homes, called the examples of misuse noted in the OIG review “inexcusable.”
“Antipsychotics should never be used as chemical restraints and false diagnoses should never be applied to justify inappropriate use of a medication,” Eyigor said. “These issues should be identified and promptly corrected at the individual level and addressed at the systems level to prevent future occurrences of such practices. But the work cannot stop there.”
Practices that put residents at risk
Nursing homes frequently failed to follow required safety measures to protect residents receiving these drugs, the federal watchdog found. Medical directors did not prevent inappropriate use, and pharmacists failed to flag concerns or suggest reducing dosages, the OIG report stated.
OIG’s review points to troubling examples of antipsychotic use, including a dementia resident being given antipsychotics for playing with baby dolls, with other residents getting these medications for similar non-harmful behaviors such as staying in bed, expressing frustration, or repeatedly asking for help. In some cases, facilities acknowledged that the behaviors did not pose risks – even giving antipsychotic drugs to calm residents – but still administered the drugs.
Surveyors also found some nursing homes used antipsychotic drugs as chemical restraints – sedating residents for staff convenience rather than to treat medical symptoms, which violates Medicare rules.
Also, many times facilities failed to monitor residents for side effects such as high blood pressure and interactions with other medications, sometimes defying physician orders.
‘Masking’ misuse of antipsychotics
Currently, the Centers for Medicare and Medicaid Services (CMS) has a quality measure that captures the percentage of residents in the nursing home who receive an antipsychotic drug, which affects a nursing home’s publicly reported star rating on Medicare’s Care Compare. However, those nursing home residents receiving antipsychotics with a diagnosis of schizophrenia, are not counted toward this quality measure.
The OIG’s review alleges that nursing homes frequently misdiagnosed residents with schizophrenia to not only avoid getting cited, but also to inflate their quality ratings. This practice ended up justifying inappropriate use of antipsychotic drugs, allowing the nursing homes to bypass the very safeguards intended to protect residents.
The efforts were deliberate, OIG’s second brief noted.
“Nursing homes developed protocols to ensure that residents given antipsychotic drugs had accompanying schizophrenia diagnoses,” noted the brief. “In some cases, staff described electronic health record alerts that would identify residents prescribed an antipsychotic drug without a schizophrenia diagnosis, prompting nurses to add diagnoses. In other cases, staff printed lists of resident names and told clinicians to add schizophrenia diagnoses to residents’ medical records.”
In the end, the inappropriate schizophrenia diagnoses led to unmet resident needs, with some receiving little or no evaluation and dementia patients treated incorrectly, missing appropriate and non-drug care.
OIG is recommending that CMS strengthen efforts to prevent nursing homes from inappropriately diagnosing residents with schizophrenia. CMS needs to go beyond the updated surveyor guidance and push for referrals of clinicians to state boards, OIG said, and expand enforcement through stronger civil monetary penalties (CMPs), higher fines or faster escalation to serious sanctions like denying payment for new admissions.
CMS should also enhance its audits of schizophrenia reporting and make findings public, such as posting them on Care Compare alongside survey reports, OIG suggests, noting that greater transparency would improve accountability and help residents, families, and consumers make more informed decisions about nursing home quality.
Further clarifying appropriate usage of antipsychotics will also help, sector leaders said.
“[CMS] must focus policies, practices, and metrics on better distinguishing between appropriate and inappropriate use of antipsychotic medications and then target resources to stop the practice,” Eyigor said.
The news comes after CMS told Skilled Nursing News in early March that it was “actively” reviewing federal rules on antipsychotic use for residents in nursing homes, aiming to support clinically appropriate use while discouraging misuse. The CMS review follows a January update designed to improve reporting accuracy, and industry experts say the policy could also be simplified.
Leaders at the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), the nation’s largest nursing home provider association, said nursing homes already work collaboratively with CMS and other stakeholders on dementia management, and have seen to “remarkable results” from initiatives to reduce the unnecessary use of antipsychotics.
However, nursing home residents have complex needs, which complicate clinical decisions.
“Nursing homes work collaboratively with residents, their families, and medical providers to understand and meet the unique needs of every resident. Antipsychotic medications are sometimes deemed necessary and beneficial to certain residents based on their clinical condition and shared decision making with the resident and their medical provider,” said Holly Harmon, SVP of quality, regulatory and clinical services at AHCA/NCAL.
Meanwhile, Rani Snyder, president of The John A. Hartford Foundation, called on improving staffing levels in nursing homes to address the issue.
“For older adults living with dementia who may respond differently to medication, this requires a workforce trained to provide specialized care that prioritizes nonpharmacological approaches, as recommended by national practice guidelines,” Snyder said. “Systemically improving long-term care takes investment in staffing, training and oversight. The public and private sectors share responsibility for identifying solutions that prevent this and all types of elder abuse.”
