Many U.S. nursing homes are creating phony schizophrenia diagnoses to hide their use of dangerous antipsychotic drugs to subdue dementia patients, a government watchdog report said Thursday in its sharpest finding yet over a persistent form of alleged abuse.
A diagnosis of schizophrenia allows nursing homes to avoid having the use of the drugs counted against them in government quality measures. It can artificially improve their star ratings on the Medicare consumer website.
Most of the drugs are not approved for patients with Alzheimer’s disease and other forms of dementia because they increase risk of falls, strokes and death. But doctors can prescribe them “off-label,” and caregivers and families regularly resort to them if a patient is violent and poses a threat to themselves and others. Resident advocates have long warned they are overused.
The issue has been surfaced previously in recent years, but the new reportfrom the Office of Inspector General for the Department of Health and Human Services is the agency’s most direct accounting of the alleged deceptive practices.
“We found that nursing homes inappropriately diagnosed schizophrenia to mask their misuse of antipsychotic drugs, artificially inflate their star rating, and skirt established safeguards meant to protect residents,” the OIG report said. “As a result, nursing homes compromised residents’ care.”
In a companion reportreleased Thursday, the OIG said nursing homes resorted to using the powerful medications without first trying non-pharmacological interventions to soothe emotional outbursts and other symptoms of dementia. It said staff admitted to inspectors that they were used to lighten the workload by quieting patients.
The agency cited an instance where an unnamed facility in Pennsylvania gave a woman who was more than 100 years old an antipsychotic because she enjoyed caring for dolls.
It cited instances in Virginia where a man was given the chemical restraints “to calm him down” because he preferred staying in bed to sitting his wheelchair, and where a woman was dosed because she would get upset and make noise when her call light was not answered quickly in the evenings.
“At times, residents with dementia received antipsychotic drugs for exhibiting behaviors that the nursing homes themselves acknowledged were not dangerous or distressing to the resident,” the agency said. “These drugs were used to address harmless behaviors such as repeatedly asking for help or trying to calm themselves.”
Its reports were based on a review of 40 inspection reports by state surveyors.
The OIG’s findings come as the Centers for Medicare and Medicaid Services, which regulates nursing homes, is considering relaxing its reporting standards for antipsychotic use. The Washington Post first reportedthis month that the agency, under lobbying pressure from industry groups and Congress, is reviewing whether nursing homes can stop reporting the use of antipsychotics when the facilities can show they were used appropriately.
None of the OIG investigative findings names individual nursing homes or staff. The American Health Care Association, the lobbying group that represents the nursing home industry in Washington, said that nursing homes have been leading the way as part of a national partnership to reduce the use of antipsychotics.
“These OIG reports are based on a very small subset of specifically selected nursing homes and are not indicative of national trends,” said Holly Harmon, AHCA’s senior vice president of quality, regulatory and clinical services.
“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,” she said. “We support the appropriate use of medications to meet individual resident needs, with the right medications at the right times.”
The organization that represents nonprofit nursing homes, LeadingAge, condemned the practices. “The antipsychotic misuse and masking outlined … are inexcusable,” said Jodi Eyigor, vice president of health policy at LeadingAge. 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.”
Patient advocates called the OIG findings “horrific.”
“The inspector general reports are devastating, confirming that nursing homes continue the decades-long problem of misusing antipsychotic drugs to control residents,” said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy.
The OIG review detailed several ways that nursing homes were allegedly gaming the system. Staff received electronic health record alerts identifying residents given the drugs who lacked schizophrenia diagnoses, prompting nurses to add them. In other cases, staff printed out lists of residents and told clinicians to add diagnoses to the records.
“On a single day at one nursing home, a nurse practitioner added schizophrenia diagnoses to the records of dozens of residents given antipsychotic drugs,” the report said.
Families often were not informed that the facility had entered a diagnosis of schizophrenia, the OIG found. The investigation also pointed the finger at medical directors of some of the facilities, saying they violated professional standards by not following protocols. Some signed off on diagnoses, it said, without reviewing medical records or making sure patients were evaluated.
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