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.