OIG Exposes Antipsychotic Drug Misuse in Nursing Homes

WASHINGTON, D.C. — The U.S. Department of Health and Human Services Office of Inspector General released two reports on March 19, 2026, revealing that nursing homes across the country systematically administered antipsychotic medications to dementia patients as a means of chemical restraint, then concealed the practice by adding fabricated schizophrenia diagnoses to residents' medical records, according to multiple news outlets including The Washington Post and STAT News.

The dual investigations, identified as OEI-02-23-00200 and OEI-02-23-00201, examined 40 focused nursing home inspections conducted between 2018 and 2021, according to Skilled Nursing News. Investigators found that facility staff openly acknowledged relying on sedation to manage their workloads rather than providing appropriate dementia care, as reported by STAT News. The findings paint a disturbing picture of an industry that prioritized operational convenience over the welfare of some of its most vulnerable residents.

Among the most troubling cases cited in the reports, a Pennsylvania nursing home administered antipsychotic drugs to a woman over 100 years old because she enjoyed caring for dolls — a common and harmless comfort behavior among dementia patients, according to The Washington Post. In Virginia, investigators found that one man was sedated simply because he preferred to remain in bed, while a woman was drugged after making noise when staff failed to respond to her call light, as reported by The Spokesman-Review. These cases illustrate how normal human behaviors and reasonable complaints were treated as medical problems requiring pharmaceutical intervention.

The scheme to hide the inappropriate prescribing was equally systematic. At one facility, a nurse practitioner added schizophrenia diagnoses to dozens of residents' records in a single day, according to The Washington Post. Staff at some facilities developed electronic health record alerts specifically designed to flag residents who needed false diagnoses added to their charts. Medical directors approved these diagnoses without ever reviewing the patients' actual clinical records, a clear violation of medical standards, as reported by The Spokesman-Review.

The motivation behind the false diagnoses was straightforward: CMS excludes residents with schizophrenia from the antipsychotic quality measure used in Medicare's star rating system. By labeling dementia patients as schizophrenic, facilities could continue sedating them without penalty to their public quality scores.

The scope of the problem is staggering. According to the Center for Medicare Advocacy, OIG found that 249,135 nursing home residents — representing 23 percent of all long-stay residents — had Medicare Part D claims for antipsychotic medications in 2018. Of those, more than 12,000 were not reported in the facilities' Minimum Data Set assessments. Among the roughly 98,000 residents reported as having schizophrenia, more than 29,000 — nearly 30 percent — had no supporting evidence of the diagnosis in their Medicare claims history. Roughly 71 percent of those questionably diagnosed residents were receiving antipsychotic prescriptions.

Toby S. Edelman, senior policy attorney at the Center for Medicare Advocacy, commented on the findings, as reported by both The Spokesman-Review and the Center for Medicare Advocacy. The organization noted that schizophrenia diagnoses in nursing homes nearly doubled after CMS launched its 2012 National Partnership to Improve Dementia Care, which introduced public tracking of antipsychotic use. A prior OIG investigation had previously found that 83 percent of antipsychotic claims in nursing homes were for uses not approved by the FDA.

CMS Inspection History

The OIG reports focused specifically on facilities designated as Special Focus Facilities — nursing homes that CMS has identified as having a history of serious quality problems. Federal regulations prohibit the use of chemical restraints for purposes of discipline or staff convenience, and antipsychotic medications carry an FDA black box warning regarding increased risk of death when administered to elderly dementia patients.

The OIG recommended that CMS strengthen enforcement through higher civil monetary penalties, refer clinicians involved in inappropriate prescribing to state licensing boards, and post inspection findings related to antipsychotic misuse on the Care Compare website, according to Skilled Nursing News. The reports also found that internal safeguards failed at multiple levels: medical directors did not prevent inappropriate prescribing, and consultant pharmacists failed to flag concerns or recommend dosage reductions.

Ownership & Operations

The findings have prompted responses from across the industry. Holly Harmon of the American Health Care Association and National Center for Assisted Living commented on the reports, as reported by The Spokesman-Review and Skilled Nursing News. Jodi Eyigor of LeadingAge and Rani Snyder of The John A. Hartford Foundation also weighed in on the findings, according to Skilled Nursing News.

The American Society of Consultant Pharmacists issued a statement on March 20 supporting quality measure reform in response to the OIG reports, according to PharmiWeb. ASCP argued that the 14-year-old CMS quality metric tracking antipsychotic use had inadvertently incentivized the very inappropriate prescribing and diagnostic fraud the OIG uncovered. The organization advocates for reformed measures that would require concordant documentation on the rationale, efficacy, and safety of prescribed medications.

Meanwhile, according to The Washington Post, CMS faces ongoing pressure from the nursing home industry to relax antipsychotic reporting requirements — a move that critics argue would further reduce transparency at a time when the OIG findings demonstrate the need for greater oversight.

Resources for Families

Families who suspect a loved one may be receiving unnecessary antipsychotic medications or other chemical restraints in a nursing home should contact their state's Long-Term Care Ombudsman program. Ombudsmen advocate for residents and can investigate complaints confidentially.

- National Long-Term Care Ombudsman Resource Center: 1-800-677-1116 - Online resources: [ltcombudsman.org](https://ltcombudsman.org)

Concerns about immediate harm can also be reported to your state's health department survey and certification agency, which is responsible for inspecting nursing homes and enforcing federal standards. Families should document any changes in a resident's behavior, alertness, or medication regimen and request a copy of the current medication list and care plan from the facility.