Antipsychotics are back in the headlines this week after the Dept. of Health and Human Services Office of Inspector General (OIG) released two reports taking skilled nursing facilities (SNFs) to task for overprescribing antipsychotic drugs and in some cases hiding their use to inflate star ratings.

Nursing experts and the skilled nursing profession answered back that the OIG reports fail to see the positive gains made in curbing antipsychotics use, examine data from years ago, and had a study sample size that cannot measure what is actually happening in SNFs.

The reports come after recent reports said the Centers for Medicare and Medicaid Services (CMS) is reexamining its policies on the use of antipsychotics in nursing homes, possibly setting the stage for a major shift “with the goal of supporting clinically indicated use while continuing to discourage inappropriate prescribing.”

That shift in policy was not at issue in the OIG reports. Instead, inspectors delved into what they determined to be a series of flaws in clinical care and lack of oversight.

“OIG’s comprehensive review of 40 focused nursing home inspections [from 2018 to 2021] 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,” OIG’s report said.

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

Nursing Pro’s Want Perspective

In response to the study, Amy Greer, an RN quality innovative consultant for Zimmet Healthcare Services Group, said OIG “is basing its report off of a rather small sample to indict the nursing home industry on antipsychotic usage. Per the report, it says that these findings are based on a review of only 40 nursing home inspections between 2018 through 2021. How is this enough of a sample to give true data for findings?”

While stating that no one is denying that there are potentially some bad actors, “it is not fair to indict the entire SNF industry and state they are all giving antipsychotic drugs to residents with dementia to manage behaviors.”

There must be a middle ground, Greer said, as “many facilities do diligently work to minimize the amount of antipsychotics prescribed and we have seen many facilities have decreased usage, and they no longer are citing schizophrenia as a new diagnosis for these residents. Again, the actions of some bad apples do not accurately represent the work that SNFs, their medical directors, and clinical staff put into every resident in their facilities.”

Also, of note on these points is that the most recent data from Care Compare (March 2026) shows that of the 15,000 SNFs in the nation, less than 1 percent of nursing homes had their Quality Measure rating impacted by a dementia care or schizophrenia audit.

Relating to Family Concerns

For Amy Stewart, chief nursing officer, AAPACN, one thing that stands out for her from the report is OIG noting that nursing homes use antipsychotics for the "benefit of staff.”

She said “my father had dementia and was on antipsychotics in a nursing home. I have both a nursing perspective and family member one as well. Oftentimes, medication comes as a last resort to help lessen neuropsychiatric symptoms that can be distressing to the patient. This ranges from insomnia to aggression and agitation.”

Stewart said “we lived in fear that my own father's aggression would cause him to hurt someone. Staff or another resident. The medication helped with symptom management. While these medications can be sedating, the dose can often be titrated to a dose that does not cause sedation. Person-centered care should dictate the treatment.”

CMS Balks at Two OIG Recommendations

From the findings in the main report (OEI-02-23-00200), OIG recommended that CMS take the following actions:

1. Further develop resources for nursing homes and increase transparency in order to reduce inappropriate use of antipsychotic drugs and improve dementia care in nursing homes.

   
   

2. Take steps to ensure that nursing home medical directors fulfill their role in reducing the inappropriate use of antipsychotic drugs.

   
   

3. Take steps to ensure that nursing home pharmacists fulfill their role in reducing the inappropriate use of antipsychotic drugs.

   
   

4. Assist nursing homes to improve their policies and procedures pertaining to antipsychotic drug use.

   
   

OIG said that “CMS did not explicitly concur or nonconcur with our first and fourth recommendations. CMS nonconcurred with our second and third recommendations. We added clarification to these recommendations based on CMS’s comments to the draft and encourage CMS to re-examine its position on concurrence in its Final Management Decision.”

The reasons for CMS nonconcurring with OIG’s second and third recommendations to strengthen the accountability of nursing home medical directors and nursing home pharmacists in order to reduce the inappropriate use of antipsychotic drugs were based on regulatory authority.

“CMS stated that its authority is limited to enforcement action against a nursing home found in noncompliance and that it issues a citation against a nursing home if there is evidence that the medical director or pharmacist is found to not be compliant with Medicare and Medicaid requirements,” OIG said.

OIG Cites ‘Masking’

A second review (OEI-02-23-00201 Nursing Homes Inappropriately Diagnosed Residents with Schizophrenia to Mask the Misuse of Antipsychotic Drugs) of the same SNFs studied in the main report tackled issues tied to quality performance measurement and oversight.

In this report, inspectors said their review of nursing home inspections completed by CMS 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.

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

AHCA Cites Positive Progress

In response to the OIG reports, Holly Harmon, senior vice president of quality, regulatory, and clinical services for the American Health Care Association/National Center for Assisted Living, said “nursing homes are committed to continuous improvement and the delivery of high-quality care for all patients and residents, including those with dementia.”

“In fact, nursing homes have been leading the way for more than a decade, working with CMS and other stakeholders through the National Partnership to Improve Dementia Care in Nursing Homes to reduce the unnecessary use of antipsychotics, with remarkable results that improved the lives of tens of thousands of residents,” she added.

Further, nursing homes are working collaboratively with residents, their families, and medical providers to understand and meet the unique needs of every resident. ”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,” Harmon said. 

“We support the appropriate use of medications to meet individual resident needs, with the right medications at the right times. These OIG reports are based on a very small subset of specifically selected nursing homes and are not indicative of national trends. We support continued education about the proper use of psychotropic drugs among nursing home residents and across all parts of the healthcare continuum where these medications are prescribed.”

For the first OIG report, please click here. For the companion report, click here.

Comments or questions? Contact pconnole@parkplacelive.com.