The HHS Office of Inspector General’s (OIG) two recent Issue Briefs on antipsychotic drugs and nursing homes – Nursing Homes’ Inappropriate Use of Antipsychotic Drugs Poses a Risk to Residents, OEI-02-23-00020 (Mar. 2026) and Nursing Homes Inappropriately Diagnosed Residents with Schizophrenia to Mask the Misuse of Antipsychotic Drugs, OEI-02-23-00201 (Mar. 2026) – provide detailed descriptions of the serious misuse of antipsychotic drugs by 40 nursing homes nationwide that were specifically surveyed by the Centers for Medicare & Medicaid Services (CMS) to focus on antipsychotic drug use. OIG describes “alarming instances of inappropriate use of antipsychotic drugs” at the 40 facilities that “revealed vulnerabilities in care . . . for the wider nursing home population beyond these examples.” Antipsychotic drugs, which the Food and Drug Administration warns can be life-threatening for residents with dementia, are one of three priority areas for OIG’s work.
The first Issue Brief describes staff administering antipsychotic drugs to manage residents’ behavior “for the benefit of staff” and failing to monitor residents taking antipsychotic drugs, as required by federal regulations. It describes nursing homes administering antipsychotic drugs without a clinical rationale: “Staff at one nursing home in New York described a resident as “never aggressive,” yet gave him antipsychotic drugs. This resident was quiet, had no behavioral symptoms directed toward others, did not disrupt his living environment, and stayed in his room. The nursing home could provide no reason why he was given antipsychotic drugs.”
The second Issue Brief describes nursing homes admitting that they added “schizophrenia diagnoses to resident records for the purpose of improving the nursing homes’ star ratings,” nurses reporting that “company policy” required them “to add schizophrenia diagnoses to residents’ records,” and more. At one facility, staff “systematically add[ed] schizophrenia diagnoses to residents’ records,” so that its recorded antipsychotic drug rate dropped from more than 80% to 5%.
April 23, 2026 – T. Edelman