Senior Care Policy Brief: A System Designed to Hide the Problem

The HHS Office of Inspector General (OIG) released two reports raising serious concerns about the continued inappropriate use of antipsychotic (AP) medications in nursing homes. These findings – combined with investigative reporting and longstanding LTCCC research – underscore a troubling reality: despite more than a decade of federal initiatives, inappropriate drugging of nursing home residents remains widespread, underreported, and largely unchecked.

• One OIG report found that too many nursing home residents continue to be prescribed AP drugs without adequate clinical justification, exposing them to significant risks, including stroke, falls, and death, particularly for residents living with dementia.
• A second OIG report found that nursing homes “inappropriately diagnosed residents with schizophrenia to mask the nursing homes’ misuse of antipsychotic drugs and to artificially inflate their star ratings.”
• These findings reinforce a major 2021 New York Times investigation which documented how nursing homes have systematically added questionable schizophrenia diagnoses to residents’ records.
  • The Times investigation, using LTCCC data, found that at least 21% of nursing home residents were receiving AP drugs, significantly higher than publicly reported rates.
  • At the same time, schizophrenia diagnoses among nursing home residents increased dramatically despite the condition being rare and typically diagnosed before the age of 40.

• Federal reporting rules exclude residents with schizophrenia and certain other diagnoses from publicly reported AP rates. In the absence of strong oversight, this loophole creates an incentive for facilities to reclassify residents rather than reduce drug use.
  • As a result, official data significantly understate the true prevalence of AP drugging, obscuring risks to residents and misleading consumers and policymakers.
• In 2012, CMS launched the National Partnership to Improve Dementia Care, pledging to reduce unnecessary AP use in nursing homes. While official data suggest progress, LTCCC’s research shows that most of these gains are illusory.
  • Apparent progress since 2012 is driven in significant part by reporting exclusions, diagnostic gaming, and shifting prescribing practices, rather than meaningful reductions in inappropriate drugging.
  • LTCCC’s “A Decade of Drugging” found that, had CMS set and achieved an annual reduction goal of 20%, an estimated 1.1 million residents could have been spared from dangerous AP drugs.
• At the same time, understaffing continues to drive reliance on chemical restraints, as facilities use drugs to manage “behaviors” that require time, training, and direct care.

Bottom line: CMS’s and the nursing home industry’s efforts have not addressed the root causes of inappropriate drugging and have allowed facilities to circumvent accountability while residents remain at risk.