Antipsychotic use in nursing homes is once again receiving increased federal attention.
Antipsychotic use in nursing homes is once again receiving increased federal attention.
In June 2026, the Department of Health and Human Services Office of Inspector General added a nationwide analysis of antipsychotic drug use in nursing homes to its active work plan. The review will examine antipsychotic use among Medicare beneficiaries in nursing homes, including the extent to which residents receiving these medications have a diagnosis of dementia.
The announcement follows two related OIG reports issued on March 16, 2026. One examined inappropriate antipsychotic use and weaknesses in facility safeguards, while the other addressed unsupported schizophrenia diagnoses used to mask antipsychotic use. OIG specifically called attention to the responsibilities of medical directors, consultant pharmacists, prescribing practitioners, and facility leadership.
At the same time, other organizations have warned that pressure to lower antipsychotic rates may lead to clinically necessary treatment being discontinued or replaced with other psychoactive medications not captured by the quality measure.
The challenge for facilities is to prevent inappropriate use without allowing the measure itself to override individualized clinical judgment.
Appropriate Use Requires a Coordinated Process
Antipsychotic oversight cannot rest with nursing alone. It requires coordinated involvement from nursing staff, prescribing practitioners, the consultant pharmacist, the medical director, direct-care staff, residents, and their representatives.
For each resident receiving an antipsychotic, the clinical record should support:
- A clear diagnosis or clinical indication
- Specific, observable target symptoms
- Individualized non-pharmacological interventions
- Monitoring for effectiveness and adverse effects
- Timely practitioner and consultant pharmacist review
- Resident or representative involvement in treatment decisions
- Consideration of gradual dose reduction when clinically appropriate
- An individualized rationale when continued use remains necessary
Behavior monitoring should provide enough information to determine whether the medication is producing the intended benefit. General references to “behaviors” or check marks alone may not adequately describe the target symptoms, triggers, interventions attempted, or whether they were effective.
Facilities must also monitor for adverse effects such as sedation, reduced intake, falls, movement changes, altered alertness, and decreased participation or function.
The consultant pharmacist should evaluate the medication’s indication, dose, duration, effectiveness, adverse effects, interactions, and opportunities for gradual dose reduction, with recommendations tracked through resolution.
The medical director should become involved when broader patterns emerge, including unsupported diagnoses, unclear target symptoms, delayed practitioner responses, possible adverse effects, or overdue reviews. These patterns should also be addressed through QAPI.
The Other Side of the Debate
In November 2025, Project PAUSE released a white paper questioning whether CMS’s long-stay antipsychotic quality measure adequately distinguishes inappropriate prescribing from clinically necessary treatment. The white paper argued that pressure to lower rates may interfere with individualized decision-making or contribute to the substitution of other psychoactive medications not reflected in the measure.
That concern deserves consideration.
Antipsychotics should not be used for staff convenience, as a substitute for adequate care, or without a valid clinical indication. However, regulatory pressure should not drive the discontinuation of treatment that is clinically necessary and beneficial.
A low antipsychotic rate does not necessarily demonstrate strong medication management, just as a higher rate does not automatically establish inappropriate use. The percentage should prompt review, not replace clinical judgment.
The goal is fewer inappropriate antipsychotics while preserving access to necessary treatment.
A Personal Experience That Shapes My Work
Balanced oversight is not theoretical for me. My professional focus on psychotropic medication management is shaped by a personal experience that showed me how quickly medications can complicate an already serious decline when they are not promptly reassessed.
My mother was 64 and fully cognitively intact. Despite significant health challenges, she was caring for my father as he fought a glioblastoma and helping care for six children they had adopted later in life.
After she was hospitalized following a serious illness, she developed delirium and became confused, paranoid, and at times aggressive. As her condition worsened, I reviewed her medications and discovered that an antipsychotic had been added and another medication with similar potential effects later followed.
We asked the medical team to discontinue both and manage the delirium with supportive care, close monitoring, and family presence. Within hours of the last dose, she began to improve. Within a week, only mild confusion remained, and she was discharged to inpatient rehabilitation. Within a month, she returned home and resumed her previous level of function.
I have often wondered what her outcome might have been if I had not known to request the medication list, question the new prescriptions, and advocate for reassessment.
That experience is one reason hospital-initiated antipsychotics are among the first areas I examine when assisting clients with psychotropic medication management. Even with the longstanding focus on antipsychotic use, our consulting team continues to identify low-dose medications started during hospitalization that remain in place well into the post-acute or long-term care stay.
The concern is not that facilities should disregard hospital orders. It is that a medication prescribed for delirium, acute confusion, agitation, or another temporary symptom may become part of the resident’s ongoing regimen without timely clinical review.
Medication reconciliation should therefore include more than accurately entering the discharge orders. The receiving team should clarify why the medication was started, whether the original symptoms remain, what effects and adverse consequences will be monitored, and when the practitioner will reassess continued need.
A low dose does not eliminate the need for a clear indication, individualized monitoring, and timely reevaluation.
What Facilities Should Do Now
In response to the renewed federal focus, and more importantly to protect resident function, safety, and quality of life, facilities should review current antipsychotic use, with particular attention to new orders, hospital-initiated medications, possible adverse effects, unsupported diagnoses, and delayed follow-up.
For each resident, the team should be able to answer:
Why was the medication started, is it still needed, is it helping, and could it now be contributing to decline?
OIG’s nationwide analysis makes this a timely regulatory concern. The potential impact on residents makes it a clinical priority.
Polaris Group’s clinical consultants can help facilities strengthen psychotropic medication oversight through focused reviews, medication reconciliation processes, care planning, QAPI support, mock surveys, and ongoing clinical consulting.
