Nursing Homes Falsely Diagnose Patients as Schizophrenic to Sedate Them, Report Says

Nursing home staff overdiagnoses their dementia patients with schizophrenia so they can prescribe antipsychotics in order to make the patients easier to manage, a report from the HHS Office of Inspector General (OIG) 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,” the authors wrote in the report released on Thursday. “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.”

In addition, the report noted, “In response to concerns about the use of antipsychotic drugs, CMS [the Centers for Medicare & Medicaid Services] developed a quality measure that captures the percentage of residents in the nursing home who receive an antipsychotic drug. This quality measure factors into a nursing home’s star rating, which reflects the home’s overall performance” and can be found on Medicare’s website.

But residents on antipsychotics are not counted toward the CMS quality measure if they have schizophrenia, which gives the facilities an incentive to label such patients as schizophrenic to improve their star rating, according to the report.

“Notably, OIG found that nursing homes’ reporting of schizophrenia diagnoses increased following the introduction of the quality measure,” the authors wrote.

The report was based on 40 survey reports focused on dementia care or schizophrenia that CMS conducted from 2018 through 2021. “These types of surveys specifically address the use of antipsychotics, including the accuracy of schizophrenia diagnoses for residents given antipsychotics,” the authors noted. “We selected the sample using a range of criteria including recency of the survey; type of survey; and citations related to the inappropriate use of antipsychotic drugs, which involved inappropriately adding schizophrenia to resident records.”

The survey review focused on several key areas, including the addition of schizophrenia diagnoses to resident records; the impact on nursing homes’ star rating; company policy regarding the use of these diagnoses; and the role of the medical director, the authors wrote.

“We also reviewed the survey reports to describe the various ways resident care was impacted by the addition of schizophrenia diagnoses,” they added. “These survey reports often include statements from interviews that the surveyors conducted with staff, residents, and family members.” Limitations of the report included the fact that it was based on a purposive sample of surveys and therefore the extent of inappropriate schizophrenia diagnoses by all nursing homes could not be determined. In addition, the authors did not independently verify the accuracy of the information included in the surveys.

The authors recommended that although CMS already has instructed its surveyors to consider referring clinicians to their state board if they inappropriately diagnose residents with schizophrenia, the agency “should expand these efforts and consider imposing additional remedies on nursing homes when they are found by surveyors to have inappropriately diagnosed residents with schizophrenia.” Those might include increased civil money penalties “or even stronger remedies, such as a denial of payment for new admissions.”

In addition to the report on inappropriate schizophrenia diagnoses, the OIG also released a report on antipsychotic overprescribing in nursing homes more broadly. Similar to the other report, this report — which appeared to be based on the same 40 surveys — found that nursing homes give antipsychotics to residents to manage their behavior, despite the risks to residents’ health. It also found that “Inadequate nursing home policies and procedures undermined safeguards meant to protect residents.”

The report recommended that CMS:

• 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
• Take steps to ensure that nursing home medical directors fulfill their role in reducing the inappropriate use of antipsychotic drugs
• Take steps to ensure that nursing home pharmacists fulfill their role in reducing the inappropriate use of antipsychotic drugs
• Assist nursing homes to improve their policies and procedures pertaining to antipsychotic drug use

CMS “did not explicitly concur or non-concur with our first and fourth recommendations,” the report authors wrote. “CMS non-concurred 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.”