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Series: In-Depth Review of Nursing Home Citations Related to the Use of Antipsychotic Drugs

Announced on  | Last Modified on  | Series Number: SRS-E-26-006
Status
Completed
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

The potentially inappropriate use of antipsychotic drugs among nursing home residents remains concerning despite efforts to decrease their use over the last decade. Antipsychotic drugs were developed to treat schizophrenia—a serious mental disorder that is generally diagnosed before the age of 30. These powerful drugs are known to have severe side effects, particularly among elderly individuals with dementia. In 2008, the Food and Drug Administration issued a boxed warning against the use of all antipsychotic drugs among elderly individuals with dementia because of the increased risk of death. OIG has raised concerns about the high use of antipsychotic drugs among nursing home residents. In response, CMS took steps to discourage the use of these drugs by, for example, developing publicly reported quality measures related to the use of antipsychotic drugs among nursing home residents. More recently, OIG has raised concerns about the potential falsification of schizophrenia diagnoses to make the use of antipsychotic drugs appear appropriate and avoid Federal attention. We will conduct an in-depth review of survey reports to: (1) examine the nature of nursing home citations related to the use of antipsychotic drugs and (2) identify vulnerabilities that contribute to the inappropriate use of these drugs.

There are 2 projects in this series.

COMPLETED PROJECTS IN THIS SERIES (2)

In-Depth Review of Nursing Home Citations Related to the Use of Antipsychotic Drugs

Project OEI-02-23-00200 • Completed on March 16, 2026

In-Depth Review of Nursing Home Citations Related to the Use of Antipsychotic Drugs

Project OEI-02-23-00201 • Completed on March 16, 2026

TIMELINE

  • February 15, 2023
    Series Number SRS-E-26-006 Assigned
  • February 15, 2023
    Projects Announced

    In-Depth Review of Nursing Home Citations Related to the Use of Antipsychotic Drugs - OEI-02-23-00200

  • In-Depth Review of Nursing Home Citations Related to the Use of Antipsychotic Drugs - OEI-02-23-00201

  • March 16, 2026
    Project Complete - OEI-02-23-00200

    In-Depth Review of Nursing Home Citations Related to the Use of Antipsychotic Drugs complete. Report Published

  • March 16, 2026
    Project Complete - OEI-02-23-00201

    In-Depth Review of Nursing Home Citations Related to the Use of Antipsychotic Drugs complete. Report Published

  • March 16, 2026
    Series Complete

    In-Depth Review of Nursing Home Citations Related to the Use of Antipsychotic Drugs complete.

2 REPORT PUBLISHED

Nursing Homes’ Inappropriate Use of Antipsychotic Drugs Poses a Risk to Residents (OEI-02-23-00200)

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.

Recommendations are updated each month and may not immediately be available for recently completed projects.

Nursing Homes Inappropriately Diagnosed Residents with Schizophrenia to Mask the Misuse of Antipsychotic Drugs (OEI-02-23-00201)

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.

Recommendations are updated each month and may not immediately be available for recently completed projects.
Work Plan Type
Office of Evaluation and Inspections
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Quality of Care
Target Groups
Elderly
Financial Groups
Medicare A