Nursing Homes’ Inappropriate Use of Antipsychotic Drugs Poses a Risk to Residents

Report Materials

• Full Report (PDF, 1.5 MB)
• Report Highlights (PDF, 261.2 KB)
• Companion Report

Why OIG Did This Review

• Antipsychotic drugs present a risk to nursing home residents, particularly those with dementia. These drugs are not approved to treat dementia, and the Food and Drug Administration (FDA) has warned that they may increase the risk of death for these individuals.
• The inappropriate use of antipsychotic drugs in nursing homes has been a longstanding concern for Congress and others. The drugs can have a sedative effect, raising concerns that nursing homes may use them to control residents' behavior.
• This is the first of a two-part series addressing inappropriate use of antipsychotic drugs in nursing homes.

What OIG Found

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. Our review found:

Nursing homes gave antipsychotic drugs to residents with dementia to manage their behavior for the benefit of staff, despite FDA's warning that these drugs may increase the risk of death.

Even though antipsychotic drugs pose risks to residents' health, nursing homes did not take required steps to help protect residents who were given these drugs.

Medical directors failed to prevent inappropriate use of antipsychotic drugs.

Nursing home pharmacists failed to identify medical concerns and did not recommend dose reductions.

Inadequate nursing home policies and procedures undermined safeguards meant to protect residents.

What OIG Recommends

OIG recommends that CMS:

1. Further develop resources for nursing homes and increase transparency in order to reduce inappropriate use of antipsychotic drugs and improve dementia care in nursing homes.
2. Take steps to ensure that nursing home medical directors fulfill their role in reducing the inappropriate use of antipsychotic drugs.
3. Take steps to ensure that nursing home pharmacists fulfill their role in reducing the inappropriate use of antipsychotic drugs.
4. Assist nursing homes to improve their policies and procedures pertaining to antipsychotic drug use.

CMS did not explicitly concur or nonconcur with our first and fourth recommendations. CMS nonconcurred with our second and third recommendations. We added clarification to these recommendations based on CMS's comments to the draft and encourage CMS to re-examine its position on concurrence in its Final Management Decision.