OIG REPORT: PSYCHOTROPIC DRUGS AS CHEMICAL RESTRAINTS IN NURSING HOMES*

Psychotropic medications include the anti-psychotic, anti-anxiety, and hypnotic drug categories. Nursing home administration of these agents has increased since 1995. Because of widespread concern that facilities possibly utilize psychotropics to control resident behavior, the United States Senate Special Committee on Aging requested that the Office of Inspector General (OIG) investigate to what extent these potential "chemical restraints" may have become a component of nursing home care.

According to the Omnibus Budget Reconciliation Act (OBRA) of 1987 (P.L. 100-203), and specifically its Nursing Home Reform Act, chemical restraints are appropriate only when used to protect the safety of the nursing home resident and/or other residents. These medications should not be dispensed as a means of resident discipline or for nursing care convenience. OBRA 1990 imposes Drug Regimen Reviews and regulates the use of certain drugs in nursing home populations.

The OIG research methodology incorporated medical record reviews on 485 nursing home residents receiving psychotropic agents, analysis of data from the National Ombudsman Reporting System (NORS) and Online Survey Certification and Reporting System (OSCAR), evaluation of 135 nursing home Drug Regimen Reviews, actual visits to 10 facilities, and interviews with 20 state surveyors and ombudsmen. For study purposes, inappropriate prescriptive practices were predicated on regulation [42 C.F.R. §483.25(1)] of the Center for Medicare & Medicaid Services (1989, revised 1991) that stipulates nursing home residents' drug regimens must exclude unnecessary medications. Excessive dosing or duration of administration, lack of adequate medical monitoring or clear indications for prescription, continued use despite adverse effects, and failure to delineate target behavioral symptoms constitute misuse of psychotropics among nursing home residents.

The final 18-page OIG analysis discovered generally favorable prescriptive practices within the nursing home industry and revealed psychotropic medications were appropriately dispensed in 85% of the study population. Only eight percent (8%) of the nursing home residents evaluated received psychotropic drugs improperly. In the remaining 7% of cases, medical record documentation was inadequate to make an accurate determination.

A 31-page supplement to the main report described practice characteristics in the use of psychotropics across a sample of 10 nursing homes from Ohio, California, Florida, Idaho, Maryland, Massachusetts, Missouri, New York, Texas, and Wisconsin. The institutions varied by size, incidence of psychotropic drug use, and locale (urban versus rural). Ninety percent (90%) were for-profit entities. The supplementary investigation, intended to complement findings of the main report, described the subjects' self-reported approaches for behavioral management of residents requiring psychotropic medications.

This report was prepared by the Office of Evaluation and Inspections (OEI), a branch of the OIG. By P. L. 95-452, the mission of the OIG is to protect the integrity of the Department of Health and Human Services programs, as well as the health and welfare of beneficiaries served by this agency.

Reviewed by:
Elizabeth B. Juliano
James R. Fell

*Department of Health and Human Services, Office of Inspector General, Office of Evaluation and Inspections. Psychotropic Drug Use in Nursing Homes. November 2001. Copies of this report can be obtained by calling the OEI in New York at 212.264.2000 or from the OEI web site at http://www.hhs.gov/oig/oei.

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