Nursing Homes Inappropriately Diagnosed Residents with Schizophrenia to Mask the Misuse of Antipsychotic Drugs

Why OIG Did This Review

• The misuse of antipsychotic drugs in nursing homes has been a longstanding concern, particularly because these drugs can have a sedative effect and might be used as chemical restraints to control residents’ behavior. In addition, antipsychotic drugs pose an increased risk of death for elderly patients with dementia.
• In response to concerns about misuse, CMS developed a quality measure—the percentage of residents given antipsychotic drugs—to track use of antipsychotic drugs in nursing homes. This quality measure factors into a nursing home’s star rating.
• Residents who have been diagnosed with schizophrenia are not counted toward the quality measure. As a result, nursing homes have an incentive to inappropriately diagnose residents with schizophrenia.
• This is the second in a two-part series assessing antipsychotic drug use in nursing homes.

What OIG Found

OIG’s comprehensive review of 40 nursing home inspections completed by CMS found instances of nursing homes inappropriately diagnosing residents with schizophrenia. Specifically, our review of these inspections found instances in which:

Nursing homes inappropriately diagnosed residents with schizophrenia to mask the nursing homes’ misuse of antipsychotic drugs and to artificially inflate their star ratings.

Medical directors made inappropriate schizophrenia diagnoses to justify prescribing antipsychotic drugs.

Nursing homes also used inappropriate schizophrenia diagnoses to skirt Medicare safeguards intended to protect residents.

By inappropriately diagnosing schizophrenia, nursing homes compromised residents’ care.

What OIG Recommends

OIG recommends that CMS:

1. Build on its efforts to reduce inappropriate schizophrenia diagnoses in nursing homes.
2. Expand its use of data to monitor nursing homes’ use of schizophrenia diagnoses and target oversight.
3. Increase efforts to ensure that nursing home residents and their families are fully informed when antipsychotic drugs are given.

CMS did not explicitly concur or nonconcur with our three recommendations. We encourage CMS to re-examine its position on concurrence in its Final Management Decision.

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