The HHS Office of Inspector General (OIG) reports that, from 2011 through 2019, about 80% of long-stay nursing home residents were prescribed a psychotropic drug (defined as “any drug that affects brain activities associated with mental processes and behavior,” including anticonvulsants, mood stabilizers, and central nervous system agents). OIG finds that higher rates of psychotropic medication use are correlated with lower rates of registered nurse coverage and higher percentages of poor residents.
For the past decade, the Centers for Medicare & Medicaid Services’s (CMS’s) National Partnership to Improve Dementia Care in Nursing Homes has focused on reducing the inappropriate prescribing of one type of psychotropic drugs – antipsychotic drugs. Facilities’ self-reported reduction in rates of antipsychotic drug use is undermined, if not totally negated, by at least two factors.
First, facilities substituted other psychotropic drugs, particularly anticonvulsants, whose use increased from 28% to 40% of residents in the years studied. Second, when CMS began reporting antipsychotic drug rates on its public website Care Compare, the public reporting excluded residents with schizophrenia from the rates. OIG finds that facilities suddenly identified many residents as having schizophrenia, including “a 194% increase in the number of residents reported in the [resident assessment data] as having schizophrenia” who otherwise lacked any documentation of a schizophrenia diagnosis. In other words, facilities falsified the diagnosis of schizophrenia to improve their star ratings.
CMS identified many of the Inspector General’s concerns itself. In 2014, CMS’s interim report on the Partnership identified “a lack of staff training and lower registered nurse (RN) staffing levels” as possible reasons for antipsychotic drug use. In 2021, it targeted the issue of the inappropriate diagnosing and coding of residents with schizophrenia. However, CMS did not act on these concerns and has continued to describe the Partnership as a success.
OIG finds that even when nursing facilities are cited with psychotropic drug deficiencies, enforcement is rare. Appendix A documents 3,415 psychotropic drug citations in 2011 but only 152 civil money penalties (CMPs) and 4,321 citations in 2019, but only 706 CMPs.
The report is a strong criticism of the Partnership and evidence, once again, of the need for more registered nurses in nursing homes.
- To read the Inspector General’s report, Long-Term Trends of Psychotropic Drug Use in Nursing Homes, OEI-07-20-00500 (Nov. 2022), go to https://oig.hhs.gov/oei/reports/OEI-07-20-00500.pdf.
December 8, 2022 – T. Edelman