Nursing homes are over-diagnosing patients with schizophrenia in order to conceal the high rates at which they’re prescribing antipsychotic medications, according to a recent report by the New York Times. Schizophrenia diagnoses among nursing home residents have “soared” as much as 70% since the federal government started making public disclosures of antipsychotic drug prescriptions in 2012. These prescriptions factor into nursing homes’ funding and ratings: nursing homes that prescribe them at high rates can receive lower ratings from the government, which in turn can affect their funding.
Linden Center for Nursing and Rehabilitation received 16 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on September 3, 2021. The Brooklyn nursing home’s citations resulted from a total of two surveys by state inspectors. The violations they describe include the following:
1. The nursing home failed to adequately protect residents from infection. Under Section 483.80 of the Federal Code, nursing homes are required to create and maintain a program to prevent and control the development and transmission of disease. A January 2019 citation found that Linden Center for Nursing and Rehabilitation failed to ensure such. The citation states specifically that the facility did not clean or adequately maintain certain areas in its laundry room. State inspectors observed “laundry bins in disrepair,” walls that were “chipped, dirty, in need of painting,” a dirty and clogged water drain, a floor in need of cleaning and sweeping, milk crates filled with dirty used mops, used employee coats and hats in the clean linen area, and overflowing garbage bins. In an interview, the facility’s Director of Housekeeping said that the facility had one housekeeper assigned to the area. A plan of correction undertaken by the facility included the education of laundry and housekeeping staffers.
Rebekah Rehab and Extended Care Center received 10 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on September 3, 2021. The Bronx nursing home’s citations resulted from a total of three surveys by state inspectors. The violations they describe include the following:
1. The nursing home did not implement adequate measures to control infection. Section 483.30 of the Federal Code stipulates that nursing homes must create and maintain an infection prevention and control program to prevent the development and spread of viruses and disease. An August 2017 citation found that Rebekah Rehab and Extended Care Center failed to ensure such. The citation specifically describes a Licensed Practical Nurse who “did not remove gloves, perform hand hygiene and don’t clean gloves” after cleansing a resident’s pressure ulcer. In an interview after the procedure, the nurse stated, “I thought I was washing my hands as needed in regard to washing my hands and changing my gloves.” A plan of correction undertaken by the facility included the re-education of the staffer and the observation of other nursing staffers “to ensure that they were following appropriate wound care techniques.”
A report released last year by New York Assemblyman Ron Kim examined the thousands of deaths from Covid-19 in the state’s nursing homes in an attempt to identify underlying problems that caused the raft of fatalities and what can be done to address those problems. The report, published by Kim’s office in July 2020, is available here.
A new edition of the Long Term Care Community Coalition Elder Justice Newsletter asks a simple question: does providing a nursing home resident breakfast in their soiled bed constitute harm? How about failing to provide a stop date for a resident’s psychotropic medication?
“No Harm” deficiencies refer to citations of rule violations at nursing homes in which health inspectors determined that the violations caused “no harm” to residents. As the LTCCC notes, data provided by the Centers for Medicare & Medicaid Service, which mandate minimum standards of care for nursing homes participating in their programs, show that more than 95% of nursing home health citations describe “no harm” deficiencies. The LTCCC argues, however, that these no harm citations reflect systemic failures to recognize the suffering of nursing home residents, which in turn results in systemic failures to hold nursing homes accountable through financial penalties. “In the absence of a financial penalty,” the newsletter states, “nursing homes may have little incentive to correct the underlying causes of resident abuse, neglect, and other forms of harm.”
The newsletter proceeds to provide instances of health violations in which regulators determined that no harm was done to the resident in question. For example:
Oklahoma’s new elder abuse law cracks down on the use by nursing homes of “chemical restraints” on their patients. According to America Nurse Today, chemical restraints are unnecessary medications used to “restrict a patient’s movement or behavior.” Importantly, these chemical restraints are not a part of a standard approved treatment. Most commonly, nursing homes use antipsychotic medications – powerful psychotropics with a variety of side effects, drug interactions, and risks.
While it is undoubtedly immoral and unethical to force someone without a proper diagnosis to take powerful mind-altering medications just to make them more compliant with nursing staff, the practice is sadly very common. According to Health Affairs, 14 percent of all nursing home patients are on an antipsychotic. The industry watchdog estimates that 83 percent of these prescriptions are for an unapproved or off-label use. A report by the Centers for Medicaid and Medicare Services found that 40 percent of nursing home residents on antipsychotics do not have a diagnosis of psychosis.
To counter the scourge of chemical restraints meant to make elderly residents docile, Oklahoma is cracking down on the nursing homes. Under Oklahoma’s new law, a doctor must conduct a medical exam, diagnose the patient, and obtain informed written consent from the nursing home resident or their caregiver before writing a prescription for antipsychotics. After passing the law, Oklahoma’s governor noted that the state with the most nursing home residents on antipsychotics (20 percent) will now have the toughest law against it.
Senators released a list of 400 nursing homes with a ‘persistent record of poor care,’ according to the federal legislators. These nursing homes are not included in the federal government’s “special focus facilities” a list of nursing homes released by the government each year indicating poor care and unsafe conditions. According to the Senators, the list of 400 facilities is “virtually indistinguishable” from special focus facilities and the elder care facilities are not all lumped together only because a 2014 law imposed a cap on the number of so-called special focus facilities. Consequently, this left 400 facilities subject to heightened government scrutiny without public knowledge.
According to the Centers for Disease Control and Prevention, approximately 1.3 million Americans are nursing home residents at 15,600 facilities across the country. The federal government identified 3 percent of these nursing homes as problematic in April. In New York, these nursing homes include New Roc Nursing and Rehabilitation Center in Rochester, The Knolls in Valhalla, and Cayuga Ridge Extended Care in Ithaca, according to LoHud.com. In addition to these nursing homes, fourteen other New York long-term care facilities were included in the list of 400 released by the Senate.
The federal government fined a Buffalo nursing home $47,827 for erroneously administering insulin to a resident. According to The Buffalo News, the fine against Humboldt House represents the sixth largest in New York for 2018. The newspaper reports that a physician at the nursing home administered insulin to a diabetic resident in February 2018 despite a hospital discharge report warning the nursing home staff to “PLEASE AVOID GIVING THIS PATIENT INSULIN” – in all capital letters.
The nursing home resident, who was not named by the newspaper, was found unresponsive multiple times over the next few days. After reviving the elderly woman with medication and fruit juice, the nursing home finally realized its mistake. Federal officials determined this medication error caused “actual harm” to a patient, the most serious type of violation for a nursing home.
As part of a broader push to deregulate the nursing home industry, the Trump administration has proposed rolling back regulations on antipsychotic use in nursing homes. Under current nursing home regulations, doctors who prescribe antipsychotics to the elderly on an “as needed” basis may only write a prescription for 14 days. At the end of 14 days, the physician must reexamine the nursing home patient and write another prescription, if necessary. The Centers for Medicare and Medicaid Services (CMS) is proposing new regulations that would change the 14-day window to 70 days.
Antipsychotic use in the elderly has remained unnecessarily high and controversial, with public health experts and elder care advocates describing the practice as elder abuse. According to these experts, nursing homes who put their residents on antipsychotics lack a valid medical reason and are simply drugging these patients. Antipsychotics, such as Seroquel and Zyprexa, commonly sedate patients, especially at higher doses. In addition to doping up the residents, these mind-altering drugs also have serious side effects. The medications commonly interact with other drugs and increase the risk of everything from slip and fall accidents to death.