OIG Knocks CMS for Failing to Monitor Antipsychotic Drug Use in Nursing Homes

The Office of Inspector General (OIG) of the U. S. Department of Health and Human Services (HHS) has criticized the Centers for Medicare & Medicaid Services (CMS) for its laxity in monitoring nursing home compliance with resident assessments and care plans for residents given antipsychotic drugs.

The OIG is the law enforcement division of HHS. The CMS is federal agency that administers the Medicare and Medicaid programs.

The Importance of Resident Assessments and Care Plans
To ensure quality of care for residents, federal nursing home regulations require that Medicare- and Medicaid-certified nursing facilities provide residents with the services they need to achieve the highest practicable level of well-being. To identify these services, nursing facility staff must assess each resident’s functional capacity upon admission to the facility and periodically thereafter. Staff must then specify in a written care plan, based on these assessments, the services that each resident needs.

Many elderly nursing home residents receive "atypical antipsychotic" drugs. Often called "second generation antipsychotics," atypicals are a group of antipsychotic tranquilizing drugs used to treat psychiatric conditions, such as schizophrenia, bipolar disorder, depression, and psychotic features.

Common atypical antipsychotic drugs include olanzapine (tradename: Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal).

Federal regulations impose extra protections for nursing home residents receiving antipsychotic drugs, in part due to an increased risk of death associated with them.

In an earlier study, OIG found that when nursing home residents received these drugs, about half of the drugs were not given for medically-accepts indications as required by Medicare and one-fifth were not given in accordance with federal standards to protect residents from unnecessary anti-psychotic drug use.

For a follow up report published today, the OIG reviewed nursing home records for evidence of compliance with the rules regarding resident assessments, documentation of decisions made by the nursing home staff, and care plan development and implementation.

The Four-Step Assessment Process
The resident assessment and care plan process involves four steps.

The first step is the Assessment itself. For example, the facility staff notes antipsychotic drug use in the last seven days and unsteady gait. These items trigger the Resident Assessment Protocol (RAP) for psychotropic drug use.

The second step is Decisionmaking. The nursing staff will note in the RAP summary: "Antipsychotic drug use may contribute to unsteady gait. Proceed to care plan."

The third step is Care Plan Development. Thus, it will list this problem: "The resident is at risk of side effects of antipsychotic drug use, especially unsteady gait."

The fourth step is Care Plan Implementation. It will list this intervention: "Monitor resident for drug side effects and efficacy. Evaluate for gradual does reduction."

Eighteen percent of records OIG reviewed did not contain evidence to indicate that planned interventions for antipsychotic drug use—the fourth step—actually occurred.

Overall, 373 of the 375 records OIG reviewed for elderly nursing home residents receiving atypical antipsychotic drugs during the first 6 months of 2007 lacked evidence to indicate that they met all federal requirements for nursing facility resident assessments and care plans.

For example, although the participation of the resident, family, or legal representative in developing care plans is required only “to the extent practicable,” 91 percent of records did not contain evidence that the resident, the resident’s family, or the resident’s legal representative participated in the care plan process; and almost two-thirds of all records did not document why such participation did not occur.

The burden lies with CMS, the OIG observed, to ensure that nursing homes take actions to provide high-quality care to elderly residents.

OIG opined that CMS fell short of its legal duties in three areas:

(1) The detection of noncompliance with federal requirements for resident assessments and care plans for residents receiving antipsychotic drugs,

(2) Taking appropriate action to address noncompliance with these requirements, and

(3) Providing methods for nursing homes to enhance the development and usefulness of resident assessments and care plans. 

U. S. Office of Inspector General, HHS, "Nursing Facility Assessments and Care Plans for Residents Receiving Atypical Antipsychotic Drugs" (OEI-07-08-00151), July 2012, http://go.usa.gov/wpX.

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