Skip to main content

Nearly All Nursing Homes Fail Federal Rules on Anti-Psychotics

 |  By cclark@healthleadersmedia.com  
   July 13, 2012

The improper use of anti-psychotic drugs in nursing homes is much worse than previously reported, according to another report in a series on the topic from the federal Office of Inspector General, which says that 99.5% of sampled records fail to meet all federal requirements.

"Overall, 373 of the 375 records reviewed for elderly nursing facility residents receiving atypical antipsychotic drugs during the first six months of 2007 lacked evidence" that they met requirements for resident assessments and care plans, the report says.

Additionally, nearly half (48%) of these patients' records did not meet two or more federal requirements.

The issue has ramifications for the entire healthcare industry because use of anti-psychotic drugs is associated with a higher rate of death in patients living in skilled nursing facilities, who are frequently readmitted to hospitals.

The report sats that increased scrutiny of the failure by state licensing inspectors on behalf of the federal government may result in findings of immediate jeopardy declarations that require immediate corrective action "because of actual or potential serious injury, harm, impairment, or death to a resident."

A year ago, the OIG, which is a branch of the U.S. Department of Health and Human Services, published a report saying that about half of anti-psychotic medications given to Medicare beneficiaries in nursing homes  were not for medically accepted indications, and one in five were not given in accordance with federal safeguards to protect residents from unnecessary use.

The latest report takes the investigation one step further by looking at whether all four requirements in the process of determining appropriate use of those anti-psychotics in nursing homes were met.

The OIG recommends that the Centers for Medicare & Medicaid Services should do more to improve the process, specifically by modifying the survey "to target a small subsample of residents receiving anti-psychotic drugs focusing on the quality of care for these particularly vulnerable residents."

Also, CMS could require that nursing facilities document any efforts “to include the participation of residents, their families, or their legal representatives" in developing care plans.

CMS concurs with the recommendations, according to the report. CMS also recently initiated efforts to reduce the use of anti-psychotic drugs in skilled nursing home residents by 15% by the end of this year. CMS plans to work with hospitals as well, because anti-psychotic use may originate in acute care settings prior to the patient being transferred to a nursing home facility.

The four levels of requirement for anti-psychotic drug use that were not met are:
1. Nursing facility staff must prepare a comprehensive assessment upon admission, whenever there is a significant change in the resident's physical or mental condition, and at least once a year. A registered nurse is required to conduct or coordinate each assessment with the participation of other health professionals.

One-third of the reviewed records failed to meet this requirement.

2. Attention to "triggering conditions" that may alter decision-making in the care plan. For example, the OIG report indicates that if a resident taking an atypical antipsychotic drug experiences periods of lethargy, that observed state should trigger a resident assessment protocol (RAP).

About 4% of the reviewed records failed this requirement.

3. Nursing facilities must develop a care plan for each resident within seven days after the completion of the comprehensive assessment. These plans must include objectives and timeframes to meet residents' physical, mental, and psychosocial needs. These plans are supposed to be completed by an interdisciplinary team with participation, to the extent practicable, of the resident's family or legal representative.

Nearly all, or 98.9%, of records failed to meet this requirement.

4. Implementation of the care plan requires, for example, that the nursing home attempt gradual dose reductions of antipsychotic drugs at least once per quarter, monitor resident for side effects of these drugs, and document that the implementation actually occurred.

About 17.9% of the reviewed records failed to meet this requirement.

The report also says that a psychiatrist, geriatrician, or psychologist should be involved in developing care plans. "However, only two (out of the 375) care plans involved such practitioners," the report says. And 20% of the records indicated that an RN, a social worker, or a licensed practical nurse was solely responsible for developing the plan.

Tagged Under:


Get the latest on healthcare leadership in your inbox.