OIG Expectations–Antipsychotics Back in the Spotlight
The Office of Inspector General (OIG) recently emphasized their continued attention on antipsychotic use in nursing homes based on the identification of several concerning trends. The key takeaway for nursing home leadership was to go beyond an examination of the facility antipsychotic rate and review the clinical systems behind it….let’s break down the OIG findings and overview priority action items.
What Did OIG Find?
OIG reviewed 40 focused nursing home inspections and identified some concerning practices.
Among the findings were residents with dementia receiving antipsychotics to manage behaviors for the benefit of staff, inadequate safeguards for residents receiving these medications, insufficient medical director oversight, consultant pharmacists who did not always identify concerns or recommend dose reductions, and weaknesses in facility policies and procedures.
The companion report raised another concern that has been on the industry’s radar for some time: schizophrenia diagnoses that may not be clinically supported. OIG found examples of residents being inappropriately diagnosed with schizophrenia in ways that masked antipsychotic use and affected publicly reported quality information.
A Diagnosis in the Chart Isn’t the End of the Conversation
When a resident receiving antipsychotics has a diagnosis that excludes them from the quality measure, ask the following questions:
- Where did the diagnosis come from?
- When was it established?
- What clinical documentation supports it?
- Does the resident’s history support the diagnosis?
- Do the physician documentation, psychiatric documentation, care plan, MDS, and medication indication all tell the same story?
That last question is especially important. In many cases, these areas are evaluated in separate silos. Nursing looks at behaviors. Pharmacy reviews medications. MDS considers coding. The physician directs the diagnoses. QAPI tracks the facility’s antipsychotic percentage. But, surveyors are able to connect those dots. Clinical leaders must do the same.
Follow the Clinical Story
For every resident receiving an antipsychotic, the clinical team should be able to follow a clear clinical story:
Diagnosis → Clinical Evidence → Medication Indication → Behaviors/Symptoms → Nonpharmacological Interventions → Monitoring → GDR → Care Plan → MDS
If clarity of the clinical story breaks down at any point, the team should dig deeper, asking questions to determine potential root causes. For example, maybe the resident has an antipsychotic prescribed for “behaviors.” Ask—what behaviors? If the documentation repeatedly states the resident is agitated, combative, or that the behavior continues, is there actually enough information to determine whether the medication is effective?
Perform Root Cause Analysis
What happened immediately before the behavior? What did staff try? Did it work? Is there a pattern? Could pain, toileting, overstimulation, sleep, communication difficulties, hunger, or another unmet need be contributing? Answering these and similar questions allow the interdisciplinary team to make good clinical decisions guided by evidence and focused on person centered care.
Assess the GDR Process
Gradual dose reduction practices should also be on the review list. Most facilities can show that GDR was considered, but that doesn’t necessarily mean the process is effective. Review those residents who have remained on the same antipsychotic for an extended period. Look for repeated documentation that a GDR is “clinically contraindicated” and consider why that is. Is there resident-specific clinical rationale supporting that decision, or has the same statement simply carried forward month after month?
Carefully analyze the resident’s response to a dose reduction and ensure that behaviors and symptoms being monitored closely enough to know whether the reduction was successful. GDR is an important part of the ongoing clinical decision-making process.
Involve the Consultant Pharmacist and Medical Director
Another important takeaway from the OIG findings is the attention given to consultant pharmacist and medical director oversight. Leadership should examine consultant pharmacist recommendations over the last several months and consider the following:
- Are meaningful recommendations being made regarding psychotropic medications?
- Are they being addressed?
- If a recommendation isn’t accepted, is the clinical rationale documented?
- Are the same concerns showing up month after month without resolution?
Involve the medical director into the larger conversation and QAPI goals related to appropriate antipsychotic use in addition to their involvement when there is a question about an individual resident. Establish processes for clinical oversight of facility-level trends such as antipsychotic utilization, new schizophrenia diagnoses, GDR patterns, pharmacy recommendations, and prescribing patterns.
For administrators, DONs, regional clinical leaders, compliance officers, and corporate nurses, outline a response to the OIG reports beginning with a focused review. Pull your current antipsychotic list and ask:
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- Which residents have diagnoses that exclude them from the antipsychotic quality measure?
- Can we validate those diagnoses from the clinical record?
- Do we have schizophrenia diagnoses that appeared for the first time later in life?
- Is there a clearly documented indication for every antipsychotic?
- Can we identify the specific behaviors or symptoms being treated?
- Are individualized nonpharmacological interventions actually being attempted and evaluated?
- Are GDR decisions supported by resident-specific documentation?
- Are consultant pharmacist recommendations being addressed?
- Is the medical director involved in facility-level oversight?
- Do the physician documentation, nursing documentation, care plan, pharmacy review, MDS coding, and quality data tell the same story?
Those questions will tell leadership much more about the strength of the clinical system than simply looking at the facility’s antipsychotic percentage. The bigger message from the OIG work is one we continue to see across many areas of nursing home oversight: a good quality measure doesn’t necessarily mean there is a clinically defensible system behind it, and when the data looks good but the medical record tells a different story, that can actually create even greater facility risk.
Next Steps: Contact Proactive for a comprehensive review of behavioral health clinical systems, care planning, and Antipsychotic/Psychotropic Medication compliance.
Resources
U.S. Department of Health and Human Services, Office of Inspector General. Nursing Homes’ Inappropriate Use of Antipsychotic Drugs Poses a Risk to Residents. March 16, 2026.
U.S. Department of Health and Human Services, Office of Inspector General. Nursing Homes Inappropriately Diagnosed Residents with Schizophrenia to Mask the Misuse of Antipsychotic Drugs. March 16, 2026.
Centers for Medicare & Medicaid Services. Nursing Home Quality Initiative and Long-Stay Antipsychotic Quality Measure guidance.
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