Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
Psychotropic Drug Use 
in Nursing Homes
Supplemental Information - 10 Case Studies
JANET REHNQUIST
Inspector General
november 2001
OEI-02-00-00491 OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's New York regional office prepared this report under the direction of John I. Molnar, 
Regional Inspector General, and Renee C. Dunn, Deputy Regional Inspector General.  Principal 
OEI staff included: 
REGION  HEADQUARTERS 
Demetra Arapakos, Project Leader  Bambi Straw, Program Specialist

Patricia Banta, Lead Analyst

Miriam Gareau, Program Analyst

. 
To obtain copies of this report, please call the New York Regional Office at (212) 264-2000. 
Reports are also available on the World Wide Web at our home page address: 
http://www.hhs.gov/oig/oei  O V E R V I E W  
PURPOSE 
To provide supplemental information to our main report Psychotropic Use in Nursing 
Homes by describing 10 nursing homes use and monitoring of psychotropic drugs. 
BACKGROUND 
This report supplements our main inspection on the use of psychotropic drugs in nursing 
homes, which found that these drugs are generally used appropriately.  The Senate Special 
Committee on Aging requested that the Office of Inspector General look at the extent to 
which psychotropic drugs are being used as inappropriate chemical restraints in nursing 
homes.  Usage rates for these drugs have been increasing since 1995.  A chemical restraint 
is the use of a drug to control an individuals behavior and is legally appropriate only if 
used to ensure the physical safety of residents or other individuals. 
Psychotropic medications are drugs that affect brain activities associated with mental 
processes and behavior.  They are divided into four broad categories: anti-psychotic; anti-
depressant; anti-anxiety; and hypnotic drugs.  The Centers for Medicare & Medicaid 
Services established guidelines for the appropriate use of these drugs in nursing homes. 
We selected 10 different nursing homes for site visits based on their psychotropic drug 
usage rates, geographical variation, facility size, and ownership category.  These facilities 
are in California, Florida, Idaho, Maryland, Massachusetts, Missouri, New York, Ohio, 
Texas, and Wisconsin.  In each nursing home we conducted interviews with administrative 
and direct care staff, toured the nursing home, and spoke with residents.  We present a 10 
case summary and individual nursing home case studies. 
10 CASE SUMMARY 
In the main report, our medical record review determined that psychotropic drug use in 
nursing homes is generally appropriate.  This supplemental information describes nursing 
homes self-reported approaches for managing residents taking these drugs.  It is intended 
to assist the reader in better understanding the findings of the main report and to instruct 
individuals interested in this topic. 
i 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Psychotropic Drug Treatment Protocols 
A drug treatment protocol consists of the general practices used to manage residents drug 
therapy, which are important given that our main report found at least one third of our 
sample nursing home residents entered the facility already on their medication. 
Respondents in all 10 nursing homes describe using similar practices for managing 
residents psychotropic drug therapies, including resident physical and/or psycho-social 
evaluations, behavior monitoring programs, tracking of side effects and adverse reactions, 
and dose reductions.  All 10 nursing homes say they evaluate residents prior to starting 
drug therapy in order to rule out non-psychiatric causes of their behavior; most facilities 
also believe a philosophy of start low and go slow is the best practice.  All 10 facilities 
also report beginning behavior monitoring at the time of admission for residents already 
taking psychotropic drugs.  Finally, many nursing home respondents use the Drug 
Regimen Review conducted by their consultant pharmacist as an important element for 
monitoring psychotropic drug use, and many also use interdisciplinary review committees 
for this purpose. 
Non-Pharmacologic Alternatives 
All 10 nursing homes we visited discuss using alternative non-pharmacologic interventions 
for psychiatric disorders and problem behaviors.  The staff say that they most often try 
interesting the resident in something else (redirecting); providing intensive one to one 
direct care (one-to-one); letting the resident have time alone (time out); talking to the 
resident about what is bothering them (emotional support); removing the resident to a 
different area in the nursing home (relocating); and leaving the resident and returning at a 
later time (re-approaching).  Nursing homes may also get the family involved in  residents 
day to day life at the nursing home and have the same staff person care for the same 
resident in order to establish an ongoing relationship between the two. 
Appropriate Use of Chemical Restraints 
We asked all respondents about the appropriate use of chemical restraints in their nursing 
home.  Overall, respondents express a general reluctance to use a psychotropic drug solely 
as a chemical restraint.  However, eight explain that they may use a psychotropic drug 
when residents behavior is harmful to themselves or to others; the other two say they 
have not had a need to use a restraint.  For example, respondents in one facility say they 
would use a restraint if a resident was striking other residents or staff.  At another facility, 
respondents provide a specific example of using a restraint when a resident was 
continually throwing herself from her bed to the floor. 
ii 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Staff Structure and Training 
All 10 nursing homes have access to psychiatric staff, such as a psych team or 
consultant psychiatrists and psychologists.  Also, in a few homes with specialized units for 
residents with dementia or Alzheimers disease, the nurses and certified nurse aides work 
only in that unit and are often given specialized training to care for these residents. 
Additionally, many nursing homes offer some type of training to direct care staff, such as 
behavior management techniques.  However, some aides say that there is not enough 
direct care staff to care for psychiatric residents. 
AGENCY COMMENTS 
We received comments on the draft report from the Centers for Medicare & Medicaid 
Services.  They believe that the report will contribute to a better understanding of 
psychotropic drug use in nursing homes and in identifying areas for further focus.  The 
CMS also notes that training related to psychotropic drug use and related documentation 
issues is already underway or planned. 
iii 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  T A B L E   O F   C O N T E N T S  
PAGE

OVERVIEW  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   i 

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

10 CASE SUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

INDIVIDUAL CASE STUDIES 
Beloit Health and Rehabilitation Center  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Blair House of Worcester . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Crown Center at Laurel Lakes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Gracewood Nursing Center, Inc.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Macon Health Care Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Manor Care Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  19

Mission Nursing and Rehabilitation Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Mission Terrace Convalescent Hospital  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Mountain View Care and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Park Nursing Home  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

APPENDIX

A: Agency Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  29

iv 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  I N T R O D U C T I O N  
PURPOSE 
To provide supplemental information to our main report Psychotropic Drug Use in 
Nursing Homes by describing 10 nursing homes use and monitoring of psychotropic 
drugs. 
BACKGROUND 
This report supplementals our main inspection on the use of psychotropic drugs in nursing 
homes, which found that these drugs are generally used appropriately.  The Senate Special 
Committee on Aging requested that the Office of Inspector General look at the extent to 
which psychotropic drugs are being used as inappropriate chemical restraints in nursing 
homes.  Usage rates for these drugs have been increasing since 1995.  A chemical restraint 
is the use of a drug to control an individuals behavior and is legally appropriate only if 
used to ensure the physical safety of residents or other individuals. 
Psychotropic Medications 
Psycho-pharmacologic medications are drugs that affect brain activities associated with 
mental processes and behavior.  These drugs are also called psychoactive or 
psychotherapeutic medications.  For clarity, we will refer to this class of drugs 
throughout our study as psychotropics.  Psychotropic medications are divided into four 
broad categories: anti-psychotic; anti-depressant; anti-anxiety; and hypnotic medications. 
Omnibus Budget Reconciliation Acts of 1987 and 1990 
In December 22, 1987, Congress enacted comprehensive nursing home reform with the 
Omnibus Budget Reconciliation Act (OBRA) of 1987 (P.L. 100-203).  As part of OBRA 
1987, Congress passed the comprehensive Nursing Home Reform Act (NHRA).  This Act 
mandates that residents be free from physical or chemical restraints imposed for the 
purposes of discipline or convenience.  It also states that restraints may only be imposed 
to ensure the physical safety of the resident or other residents and only upon the written 
order of a physician that specifies the duration and circumstances under which the 
restraints are to be used.  Further, the nursing Home Reform Act limits the use of as 
needed (PRN) orders and requires efforts to withdraw the drug or decrease dosage be 
made for residents who are receiving psychotropic drugs. 
1 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Additionally, the Omnibus Budget Reconciliation Act (OBRA) of 1990 requires the 
regulation of certain drugs in nursing homes and the establishment of Drug Regimen 
Reviews for nursing home residents.  The provisions of Section 4401 of OBRA 1990 
involve pharmacists more actively in resident care by refocusing pharmacists from a 
product oriented role to one involving clinical practice responsibilities for reducing 
potential drug therapy problems. 
The Centers for Medicare & Medicaid Services Regulations 
To implement the requirements of OBRA 1987, on February 2, 1989, the Centers for 
Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing 
Administration, finalized regulations (42 C.F.R 483.25(1)) on anti-psychotic medications 
and unnecessary drugs.  These regulations were further refined in 1991. The CMS 
regulations state that each residents drug regimen must be free from unnecessary drugs 
and define what is considered an unnecessary drug.  An unnecessary drug is any drug 
used: 
C  in excessive dose; 
C  for excessive duration; 
C  without adequate monitoring or without adequate indications for its use; or 
C	 in the presence of adverse consequences, which indicate the dosage should 
be reduced or discontinued. 
In addition, the CMS regulations state that residents who have not previously used anti-
psychotic drugs should not be given these drugs unless anti-psychotic drug therapy is 
necessary to treat a specific condition as diagnosed and documented in the clinical record. 
Further, the regulation mandates that residents who use anti-psychotic drugs receive 
gradual dose reductions and behavioral interventions, unless clinically contraindicated, in 
an effort to discontinue these drugs. 
In July 1995, the CMS completed the final step in the implementation of OBRA 1987 by 
introducing new tasks into the nursing home survey process.  Further refinements to 
survey procedures and interpretive guidelines were implemented on July 1, 1999.  Some of 
these are specific to psychotropic drug therapy, including: new investigative protocols and 
the incorporation of quality indicators (QIs) based on the Minimum Data Set (MDS) into 
the off-site survey process;  an update to the list of anti-psychotic drugs that can be cited 
as unnecessary or misused under tag number F329; the addition of drug therapy 
guidelines; and a revised definition of medication error. 
Methodology 
We selected a purposive sub-sample of 10 nursing homes in different States to visit on-
site.  These 10 nursing homes were selected based on five criteria: 
2 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  C  geographical location

C  number of residents in November 2000

C  psychotropic drug usage rate in November 2000

C  urban/rural location, and 

C  ownership status

We chose nursing homes in California, Florida, Idaho, Maryland, Massachusetts, Missouri, 
New York, Ohio, Texas, and Wisconsin.  Five of the facilities were large (more than 100 
residents), four were medium (61-99 residents), and one was small (less than 60 
residents).  Also, four of the homes had a high psychotropic drug usage rate (greater than 
34 percent), four had a moderate rate (18 to 34 percent), and two had rates of less than 18 
percent.  Lastly, based on census data, eight of the nursing homes were located in an 
urban area while two were rural.  Nine were for-profit while one was non-profit. 
While on-site at these 10 facilities, we interviewed both administrative as well as direct 
care staff.  Our administrative interviews included discussions with nursing home 
administrators, directors of nursing, medical directors, consultant pharmacists, 
psychiatrists, social workers, and psychologists.  We spoke with these respondents about 
how psychotropic drugs are being used and monitored in their facility.  We also 
interviewed nurses and certified nurse aides in each facility separately from administrative 
staff about how they care for and monitor residents on psychotropic drugs and how they 
handle aggressive residents.  Lastly, while on-site we spoke with and observed the 
residents in our sample and toured the facility, including observing at least one structured 
activity or meal. 
In addition to reporting each nursing homes case study individually, we conducted a cross 
case analysis of the inspectios teams observations and interviews with nursing home staff. 
We used a summary matrix to identify four approaches the nursing homes use to manage 
residents taking psychotropic drugs. These are: psychotropic drug treatment protocols; 
non-pharmacologic alternatives; appropriate use of chemical restraints; and staff structure 
and training.  The results of this cross case analysis are reported in the cross case 
summary. 
Limitations 
This methodology has several limitations.  First, the approaches we describe are based on 
self-reported information that we did not independently validate. This information is based 
primarily on a description of policies and not necessarily of direct practices.  Our intention 
is not to endorse these policies but rather to describe a cross section of nursing home 
approaches to managing residents taking psychotropic drugs.  Finally, we did not examine 
overall quality of care in any of the 10 nursing homes. 
3 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  This inspection was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and Efficiency. 
4 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Vin the main report, our medical record review determined that psychotropic drug use in nursing 
1 0  C A S E  S U M M A R Y
In the main report, our medical record review determined that psychotropic drug use in 
nursing homes is generally appropriate.  This supplemental information describes nursing 
homes self-reported approaches for managing residents taking these drugs.  It is intended 
to assist the reader in better understanding the findings of the main report and to instruct 
individuals interested in this topic. 
Based on the analysis of our interviews and the inspection teams observations, we 
identified four similarities in the 10 nursing homes approaches. These are: 
1.  Psychotropic drug treatment protocols 
2.  Non-pharmacologic alternatives 
3.  Appropriate use of chemical restraints 
4.  Staff structure and training 
Psychotropic Drug Treatment Protocols 
A drug treatment protocol consists of the general practices used to manage residents drug 
therapy.  Such protocols are important given the growing prevalence of psychotropic drug 
use among nursing home residents.  In fact, our main report, Psychotropic Drug Use in 
Nursing Homes, found that at least one third of the nursing home residents in our sample 
entered the facility already on their psychotropic medication.  Also, most of our case study 
respondents say that many residents are already taking a psychotropic drug at their time of 
admission. 
Respondents in all 10 nursing homes describe using similar practices for managing their 
residents psychotropic drug therapy.  These include resident physical and/or psycho-
social evaluations, behavior monitoring programs, tracking of side effects and adverse 
reactions, and dose reductions.  In fact, the results of our medical record review from the 
main report show that nearly all the psychotropic drugs being used by residents in our 
sample are being used without adverse consequences and with adequate monitoring. 
Respondents in all 10 nursing homes say they evaluate residents prior to starting 
psychotropic drug therapy in the nursing home in order to rule out non-psychiatric causes 
of their behavior.  This is supported by the results of our medical record review, that 
found that in most cases, residents behavioral symptoms are not being caused solely by 
environmental stress or medical conditions.  Most respondents mention that they give 
residents a physical work-up when a change in their behavior occurs; respondents say 
identifying what might be precipitating the problem behavior and removing it is important. 
Several respondents also mention assessing residents spiritual, social, and 
5 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  pain status.  When other causes are ruled out and drug therapy is initiated, most facilities 
believe a philosophy of start low and go slow is the best practice.  This means that the 
drug therapy is initiated at the lowest possible dose with incremental increases when 
necessary. 
All 10 facilities say they begin behavior monitoring at the time of admission for residents 
already taking psychotropic drugs.  In three of the 10 homes, respondents say they begin 
behavior monitoring for all new admissions.  Respondents say that behavior monitoring 
allows a more accurate understanding of how residents are responding to their 
psychotropic drug therapy and whether they are appropriate candidates for dose 
reduction.  Some nursing homes document behavior monitoring in the medication 
administration record (MAR) and others have developed specialized behavior monitoring 
sheets. 
Most of the nursing homes use the Drug Regimen Review (DRR), conducted by their 
consultant pharmacist, as an important element for monitoring psychotropic drug use. 
They say that the monthly DRR is helpful for identifying problems or potential problems. 
Some facilities report using the DRR as a tracking tool when monitoring for dose 
reduction, side effects, dosage appropriateness, and adequate documentation in the 
residents medical record. 
The importance attributed to DRRs by our case study respondents is supported by our 
review of all nursing homes DRRs in our main report, Psychotropic Drug Use in 
Nursing Homes.  The DRRs we reviewed for that study include the pharmacists 
recommendation to change a medication in order to improve the management of a 
residents behavioral symptoms, as well as a recommendation to re-evaluate or discontinue 
PRN (when necessary) drug orders.  The DRRs also commonly include a suggestion to 
decrease dosage, a reminder that reduction attempts are past due, or an identification of 
medication errors, such as when inappropriate duplicate drugs are being given. 
Nursing home respondents also report other methods for managing their residents 
psychotropic drug therapy.  These include daily or weekly monitoring in nurses notes, 
periodic psychiatrist assessments, and corporate reviews of psychotropic drug therapies. 
Finally, seven nursing homes report using interdisciplinary review committees to monitor 
the use of psychotropic drugs, including monitoring for side effects and adverse reactions. 
A few of these committees are part of periodic quality assurance team meetings. 
Attendees at these committees can include: the medical director, administrator, director of 
nursing, department heads, consultant pharmacist, MDS RN coordinator, social worker, 
psychiatrist, psychologist, and other direct care staff.  The administrator of a nursing home 
with many mentally ill residents believes a multi-disciplinary approach results in quality of 
care for all residents, saying we focus on a coordination of services. 
6 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Non-Pharmacologic Alternatives 
All 10 nursing homes we visited are using alternative non-pharmacologic interventions for 
residents with psychiatric disorders and problem behaviors.  The staff at all 10 report using 
similar behavior management techniques to care for residents who are acting out, are 
confused or agitated, or who exhibit other behavioral symptoms.  These include 
interesting the resident in something else (redirecting); providing intensive one-to-one 
direct care (one-to-one); letting the resident have time alone (time out); talking to the 
resident about what is bothering them (emotional support); removing the resident to a 
different area in the nursing home (relocating); and leaving the resident and returning at a 
later time (re-approaching).  In fact, during several of our visits, we observed some of 
these techniques, such as individual staff members spending time with residents who 
seemed disturbed or agitated and staff redirecting residents to other activities or locations. 
Nursing home respondents also try other non-pharmacologic approaches.  They may try to 
get the family involved in the residents day-to-day life at the nursing home.  In addition, 
staff also note the importance of having the same staff person care for the same resident in 
order to establish an ongoing relationship between the two.  However, they will also 
consider changing staff if a resident does not get along with that individual.  A few 
respondents also say that for residents whose problem behavior occurs suddenly, it could 
be the timing of an activity or physical care that is causing the problem; a change in timing 
can therefore be helpful.  Several respondents also told us that environmental 
modification, such as keeping the nursing home free of confusing objects, contributes to 
residents emotional wellbeing.  Finally, some nursing homes try innovative approaches 
such as pet therapy, recreational activities, or massage therapy. 
Appropriate Use of Chemical Restraints 
We asked all respondents about the appropriate use of chemical restraints in their nursing 
home.  Overall, respondents express a general reluctance to use a psychotropic drug solely 
as a chemical restraint. However, eight explain that they may use a psychotropic drug 
when residents behavior is harmful to themselves or to others; the other two say they 
have not had a need to use a restraint.  For example, respondents in one facility say they 
would use a restraint if a resident was striking other residents or staff.  At another facility, 
respondents provide a specific example of using a restraint when a resident was 
continually throwing herself from her bed to the floor.  Medical directors and 
administrators at a few nursing homes describe using Risperdal and Zyprexa, two anti-
psychotic medications, as chemical restraints in residents who are extremely combative 
with care or hallucinating. Respondents at other nursing homes say Ativan, an anti-anxiety 
drug, will be given for escalating behaviors. 
7 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Staff Structure and Training 
All 10 nursing homes have access to psychiatric staff, typically on a consultant basis.  For 
example, in one nursing home with a high proportion of mentally ill residents, they 
contract with a company to provide a psych team, whose members could include 
psychiatrists, psychologists, geriatric nurse practitioners, and other geriatric specialists. 
This team evaluates and manages residents.  Other nursing homes may use individual 
psychiatrists and/or psychologists on a consultant basis.  These consultants may assess 
residents taking psychotropic drugs and/or who are enrolled in behavior management 
programs.  Lastly, in all of the nursing homes, residents may also have their own private 
physicians who manage their psychotropic drugs. 
Nursing homes may structure their direct care staffing assignments for residents taking 
psychotropic drugs in different ways.  In a few homes with specialized units for residents 
with dementia or Alzheimers disease, the nurses and certified nurse aides (CNAs) work 
only in that unit and are often given specialized training to care for these residents. 
Additionally, many nursing homes offer some type of training to direct care staff, such as 
behavior management techniques. Further, a few homes provide in-service education to 
nursing staff on psychotropic drug therapy. 
We also asked CNAs about caring for residents taking psychotropic drugs.  A majority of 
CNAs say that when a resident in their care requires full assistance, care duties for other 
residents in their care will be shifted to another CNA.  Some also say that there is not 
enough direct care staff to care for psychiatric residents.  Despite these concerns, 
however, when CNAs were asked what they like most about their jobs, they 
overwhelmingly responded the residents. 
8 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  I N D I V I D U A L  C A S E  S T U D I E S  
BELOIT HEALTH AND REHABILITATION CENTER

C  Located in Beloit, Wisconsin, a small town in southern Wisconsin

C  For-profit nursing home

C  148 beds (60 Medicare certified, 148 Medicaid certified)

Facility Profile 
Beloit Health and Rehabilitation Center caters to long term residents, most of whom have 
dementia and other mental disorders. These residents also tend to be clinically complex, 
with multiple medical problems requiring intensive daily assistance.  Beloit Health and 
Rehabilitation Center also has a separate Alzheimers Unit, one of the few nursing homes 
in the area to have such a unit.  Despite their high proportion of residents with mental 
disorders, their psychotropic drug use has been decreasing over the past several years. 
Currently, they have a moderate rate of 22 percent. 
Approach to Psychotropic Drug Therapy 
The Beloit Health and Rehabilitation Center follows a start low, go slow protocol for 
their residents use of psychotropic drugs, meaning they will initiate drug therapy on a low 
dose and make gradual modifications.  They will first rule out metabolic causes for 
problematic behaviors before using a drug.  A daily clinical review is conducted for all 
residents on psychotropic drugs and any changes in medication are reviewed by both the 
director of nursing and the case manager before being implemented.  The facility generally 
follows dosage guidelines established by its corporate office; these are more stringent than 
Federal guidelines. 
This nursing home also utilizes a strong interdisciplinary approach in monitoring 
psychotropic drugs.  One staff member, stressing the importance of a team approach, 
states, If [the] pharmacist is the only person tracking drugs, [the drugs] cant be 
effective.  A behavior management program for each resident is established by the case 
manager and team meetings are held at regular intervals to review each residents progress 
and drug use.  These meetings are typically attended by the consultant pharmacist, the 
director of nursing, case manager, and psychologist, as well as other staff members. 
Further, residents are also referred to a geriatric psychiatrist at a nearby hospital for 
evaluation and monitoring. 
9 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Alternative Interventions 
Since staff at Beloit Health and Rehabilitation Center express a strong belief that 
psychotropic drugs should only be used if every other intervention has failed, they use 
various non-pharmacologic interventions for handling problematic behaviors.  They will 
try intensive one-on-ones, in which a staff member is assigned to an individual resident 
for 24 hours a day, until a residents problem behavior is modified or controlled.  Staff at 
the nursing home say they are willing to accept some combative behavior in residents as 
long as the behavior is not dangerous for the resident or others in the facility. In fact, 
during our visit, we observed staff interacting with and comforting residents who were out 
in the hallways and/or appeared distressed by speaking to them in soft, quiet tones and 
trying to re-direct them to their room or some other activity.  Other non-pharmacologic 
interventions used in the nursing home include small group activities, removal or re-
direction of a resident who is displaying problem behaviors, and the assignment of new 
staff to care for a resident.  Lastly, a psychologist is actively involved in the nursing 
homes activities by providing training to staff, consulting on aggressive behavior, 
conducting psychological evaluations, and providing therapy for some residents with mild 
Alzheimers disease or dementia. 
10 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  BLAIR HOUSE OF WORCESTER

C  Located in Worcester, Massachusetts, a small industrial city near Boston

C  For-profit nursing home

C  75 beds (75 Medicare certified, 75 Medicaid certified)

Facility Profile 
Blair House of Worcester cares exclusively for residents with dementia. The residents are 
in various stages of dementia and about 30 to 50 percent have a history of mental illness. 
Since this home is the only one of its kind in the area, it serves residents from both rural 
and urban Massachusetts and Connecticut.  Further, Blair House accepts residents who 
have failed in other nursing homes. 
This nursing home has a higher psychotropic drug usage rate (66 percent) than the others 
in our sample.  One of the homes medical staff explains this rate by saying that, dementia 
is a disease that causes people to act just on raw impulse.  The anti-psychotic drugs slow 
them down and help them to deal with their impulses. 
Approach to Psychotropic Drug Therapy 
Blair House has established a process which staff follow before prescribing a psychotropic 
drug.  For the first 48 hours that residents are in the facility, the staff record their 
behaviors on a standardized behavior monitoring sheet.  Then the social worker develops a 
specialized behavior management plan and monitoring sheet.  If it is needed, they ask the 
psychiatric team, consisting of the psychologist, psychiatric nurse practitioner, and 
psychiatrist, for a consultation which may result in revision of the behavior management 
plan.  If after several weeks the residents behavior has not improved, the psychiatric nurse 
practitioner may prescribe a low dosage of a psychotropic medication. 
When initiating psychotropic drugs as a new therapy or when a change in condition 
occurs, staff at Blair House try to start with a low dosage and gradually increase until the 
resident improves. Staff make it a point to allow time for a new resident to adjust to the 
facility before prescribing medication.  A similar process is followed when a resident 
develops a behavior in the facility.  Staff also rule out physical problems, such as urinary 
tract infections, before using drugs. 
Blair House uses several methods to monitor and minimize psychotropic drug usage. 
Nurses monitor behavior episodes and the side effects of the psychotropic drugs on 
11 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  monitoring sheets. The consultant pharmacist will recommend reductions when the 
resident has exhibited none of the targeted behaviors for three to four months.  Otherwise, 
staff attempt a reduction at least every six months.  In addition, when possible they try to 
prescribe the lowest possible dose of anti-psychotics by combining it with another 
medication, such as an anti-depressant. 
Alternative Interventions 
The facilitys staff use behavior management techniques instead of or in combination with 
psychotropic drugs.  Specifically, the staff use the techniques of redirection and 
reassurance.  For example, a staff member may bring a distraught resident to a quiet place 
for milk and cookies or call a family member to speak to the resident.  In addition, staff 
will redirect disruptive behavior.  They also do not attempt to reorient delusional 
residents.  For example, we observed one resident calling out the name of her sister, who 
had passed away years ago.  The resident wanted her sisters assistance.  Part of the 
behavior management plan for this resident was for staff to tell her that her sister would 
be here soon.  Further, Blair House trains all staff about handling the behaviors of 
residents with dementia.  The administrator believes this training, along with the 
specialized experience of the nurses and certified nurse assistants, is advantageous to the 
residents.  During our site visit, we observed that most of the residents in this facility were 
active; many were walking throughout the hallways and interacting with staff.  Other 
residents were participating in a group activity. 
12 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  CROWN CENTER AT LAUREL LAKE

C  Located in Hudson, Ohio, a suburb of Cleveland

C  Non-profit nursing home

C  75 beds (75 Medicare certified, 0 Medicaid certified)

Facility Profile 
Crown Center at Laurel Lakes is part of a larger campus that offers assisted and 
independent living to its residents.  The nursing home shares services, such as  recreational 
activities and physical therapy, with the assisted living unit.  About 75 percent of the 
nursing home residents come from the assisted or independent living units.  The nursing 
home has a mix of both short-term and long-term residents with a variety of needs.  In 
addition, residents from the independent living and assisted living volunteer in the nursing 
home by visiting and sometimes sitting with an upset resident.  According to the staff, the 
nursing home residents in this facility are of a higher socio-economic class, education 
level, and have higher family involvement than average. 
Crown Center has a drug usage rate of 25 percent, which is moderate in comparison to the 
other homes in our sample.  The medical director attributes this rate to standing as 
needed orders for sleeping medications that are rarely used.  He explains that many of the 
residents in the home are privately funded and pay for their own sleeping medication; 
therefore, the nursing home is hesitant to cancel the order, even when the drugs are not 
used regularly. 
Approach to Psychotropic Drug Therapy 
Crown Centers policy is to encourage safe and effective  drug therapy.  They use 
psychotropic drugs for both short-term and long-term treatment.  According to staff, 
these drugs are used in the short-term to treat psychological problems due to: illness (such 
as a stroke), the death of spouse or roommate, or depression when first coming to the 
nursing home.  Staff also report that for long-term therapies, psychotropic drugs such as 
anti-anxieties are sometimes used in conjunction with anti-depressants to treat depression. 
Also common in this facility are as needed orders for residents who need occasional 
sleep aids.  According to staff, if a resident comes to the facility already using a 
psychotropic drug and the diagnosis is appropriate, we continue [the drug].  If a new 
problems arises, the nursing staff chart the residents behavior for three days and consult 
the residents personal physician.  The psychologist from the psychological services team 
reports also providing consultation to the staff and making recommendations for 
medications. 
13 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Residents on psychotropic drugs are monitored in several ways.  Nurses monitor the day-
to-day effectiveness of the drugs with a  standardized behavioral monthly flow chart. 
On this chart, nurses record during each shift the frequency of behavior episodes and side 
effects.  They also record the type of behavior and the intervention as well as the type of 
side effect and the action taken.  The MDS RN coordinator performs a test for side-effects 
on all residents taking anti-psychotic medications.  In addition, the consultant pharmacist 
reports recommending appropriate dose reductions. 
Alternative Interventions 
Staff at Crown Center at Laurel Lake also use various behavior management techniques. 
The administrator reports that psychotropics are not the first route to go.  When a 
resident is acting out aggressively, staff report trying to calm the resident by diverting or 
redirecting them.  They may call the family to come in or ask a volunteer to sit with the 
resident.  They may give them food, a book of pictures they like, or massage therapy.  One 
nurse remarked that if you are with a patient every day you can figure out what they 
want.  Staff here take steps to modify behavior.  Lastly, the nursing home also contracts 
with a psychological consulting company for psychotherapy and behavior management 
advice. 
14 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  GRACEWOOD NURSING CENTER, INC.

C  Located in Pinellas Park, Florida, a suburban retirement community

C  For-profit nursing home

C  120 beds (120 Medicare certified, 120 Medicaid certified)

Facility Profile 
At the time of our visit to Gracewood Nursing Center, Inc. a transfer of ownership was in 
progress.  This nursing home has plans to add a specialized orthopedic rehabilitation unit 
but presently most of the residents are long-term care and 65 and older.  Many are bed 
bound, others are wheelchair bound, and few are ambulatory. A few younger residents 
with chronic disabling conditions also live at the home.  Previous to the change in 
ownership, the facility had received many deficiency citations in the last three surveys, 
including a G level in the most current survey.  An interim administrator has been hired 
by the corporation during the transition to improve conditions. Gracewood Nursing 
Center has a moderate psychotropic drug usage rate of 18 percent. 
Approach to Psychotropic Drug Therapy 
Gracewood Nursing Center, Inc., has instituted new guidelines and protocols for all 
residents who come into the facility already taking one or more psychotropic medications 
and for residents who begin such therapy after admission.  First, they will rule out a 
medical cause for problematic behaviors and evaluate residents for other unmet needs such 
as dietary dislikes and personality clash with care-givers or roommates.  Then, a behavior 
monitoring program is initiated.  For those residents taking anti-psychotics, a bi-annual 
Abnormal Involuntary Movement Scale (AIMS) test is given. 
The nursing homes new guidelines include interdisciplinary strategies to maintain 
residents at an optimum behavioral level and to monitor the use of psychotropic drugs. 
Bi-monthly behavior management meetings are conducted during which eight residents are 
selected for a full medical record review.  A monthly pro psychoactive drug review is 
conducted by RN staff who partner with the consultant pharmacist and gerontologist in an 
effort to reduce dosage when appropriate and/or taper dosage with a goal to discontinue 
the drug.  As one RN respondent says, We rely heavily on the drug regimen review to 
identify any problems. The consultant pharmacist also meets with the director of nursing 
bi-monthly to review charts. 
Alternative Interventions 
The staff at Gracewood Nursing Center, Inc. have a strong belief that alternative non
pharmacologic interventions are dependent on their knowledge and understanding of the 
15 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  resident. They describe several approaches to manage a residents behavioral symptoms as 
supportive of the resident, especially when an acute and sudden onset of a behavior 
occurs.  If the resident is aggressively acting out they generally will use one-to-one 
monitoring.  The director of nursing emphasizes that staff are instructed to talk to the 
resident in an effort to determine what might be upsetting to them [and] thereby triggering 
the behavior.  One CNA says if the behavior occurs in the first week of admission, we 
usually dont consider this a real change in condition but will continue to monitor [the 
behavior].  Other alternative interventions used in the nursing home include small group 
day trips outside the facility, touch therapy, and counseling by a member of the clergy. 
We noted little activity at this nursing home except for a smoking area in an open center 
courtyard, where a few of the younger ambulatory residents gather to smoke. During the 
five hours we were at the nursing home we did not see any planned activities for residents 
in the multi-purpose common room.  One resident, a woman in her early forties who has 
been living in the home for  twelve years and was one of the three residents randomly 
selected for a medical record review, complained about the care she receives, claiming that 
the staff is slow to respond to residents needs and requests. 
16 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  MACON HEALTH CARE CENTER

C  Located in Macon, Missouri, a rural farming community in northeastern Missouri

C  For-profit nursing home

C  120 beds (52 Medicare certified, 50 Medicaid certified)

Facility Profile 
Macon Health Care Center is located near the towns community hospital, which accounts 
for its emphasis on long term specialized care.  Many residents require a high level of 
skilled care, such as tube feedings, tracheotomy care, and intravenous drug therapy.  Other 
specialities include stroke rehabilitation as well as mental illness and advanced dementia. 
Accordingly this nursing home has a high psychotropic drug usage rate of 46 percent. 
Additionally, many of the residents have a diagnosis of psychosis, schizophrenia, or 
retardation.  Within their parent corporate organization, Macon Health Center is one of 
nine facilities in Missouri that cares for residents with mental illnesses. These residents are 
meshed into the general nursing home population. 
Approach to Psychotropic Drug Therapy 
Respondents at Macon Health Care Center describe residents taking long term 
psychotropic drugs as having been admitted into the nursing home from a psychiatric 
institution with a prior history of such drug therapy.  However, the administrator says the 
admission protocol for all residents requires a full physical assessment by the MDS RN 
coordinator, and,  if admitted on a psychotropic drug, an assessment of appropriateness 
for reduction is also done.  If a behavior develops after admission several steps are taken 
before initiating drug therapy.  If the behavior is aggressive, one-to-one care is started. 
Staff evaluate the resident for pain and a full medical work-up follows.  When these steps 
do not indicate the reason for the behavior, the resident is given a psychological 
evaluation. 
At Macon Health Care Center, monitoring of residents drug therapies includes quarterly 
and annual assessments by the MDS RN coordinator.  The medical director or nurse 
practitioner reviews these assessments.  Also, the nursing home has weekly 
interdisciplinary behavior team meetings and monthly quality assurance meetings that most 
attending physicians and all department heads attend. Additionally, the director of nursing 
has developed a tracking system using the consultant pharmacists DRR to follow trends 
and dosage for residents on all categories of psychotropic drugs. The regional consulting 
nurse also conducts a corporate review of residents on psychotropic drug therapy. 
17 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Alternative Interventions 
All direct care staff interviewed describe staff education as an important piece in the 
successful behavioral management of residents with mental illness. Additional special 
sessions for staff working in the Special Needs Unit address the challenge of working with 
this resident population, as does an alternative program that sends direct care staff to the 
facilitys regional office for training.  Nursing home staff say this training keeps their 
behavior management skills up to date. 
Approaches to moderate resident behaviors include innovative and creative strategies. For 
example, the facility has instituted pet therapy - birds, rabbits, cats and a dog, are 
wonderful diversions for the residents, says one RN.  In fact, during our visit, we 
observed residents happily greeting a dog that was scampering through the hallways.  The 
administrator credits the social worker and nursing staff as a limitless source of creative 
thinking. 
18 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  MANOR CARE HEALTH SERVICES

C  Located in Silver Springs, Maryland, a suburb of Washington D.C.

C  For-profit nursing home

C  130 beds (28 Medicare certified, 130 Medicaid certified)

Facility Profile 
The majority of residents at Manor Care Health Services are long term care residents, 
many of whom have dementia and other chronic illnesses.  The nursing home also has a 
separate Alzheimers Unit.  This facility has a psychotropic drug usage rate of 38 percent. 
Many residents at Manor Care come from an assisted living center that is adjacent to the 
nursing home, particularly as their Alzheimers disease or dementia becomes more severe. 
Approach to Psychotropic Drug Therapy 
Manor Care Health Services will generally start residents on low psychotropic drug 
dosages when beginning a new drug therapy. They also generally obtain pharmacist and 
psychiatrist input when initiating or making a change in psychotropic drug medication. 
They will try to monitor new residents for at least one week before prescribing a 
psychotropic drug, although the staff may use a psychotropic drug on a short term basis 
to control a residents agitation and yelling, especially if the resident is a new admission. 
Each resident in the facility also has a behavior tracking chart that is periodically updated, 
and a psychologist and psychiatrist are also available for ongoing consultation. 
Manor Care Services has a psychotropic drug committee that meets monthly to monitor 
how the drugs are used.  This committee is comprised of the director of nursing, unit 
manager, consultant pharmacist, and social worker.  During their meetings, the members 
discuss the residents behavior, response to the drugs, and possible side effects.  The social 
worker at the facility stresses the importance of such monitoring since there are more 
patients with psychiatric problems in nursing homes today than ever before.  In fact, we 
observed several residents in the hallways and common rooms that appeared confused 
and/or were yelling and moaning.  Staff comforted these residents by speaking to them in 
quiet tones or holding their hands; in some cases, they redirected the resident to another 
location. 
The staff express a belief that decisions on when and how to use drugs are unique to each 
individual and his or her needs.  The director of nursing states, [We] treat patients on an 
individual basis. 
19 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Alternative Interventions 
Staff at Manor Care Services attempt various non-pharmacologic approaches to handle 
behavioral issues.  These include: redirecting residents to new activities or locations; 
changing roommates if that is an issue; changing the timing of direct care activities (such 
as bathing); talking to residents about their care; and assigning the same staff person to 
care for the same resident.  One of the CNAs we spoke with says that when residents act 
out aggressively, she may leave them for a short period of time or ask them what is 
bothering them.  Her approach was typical of the care we observed while touring the 
facility. 
20 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  MISSION NURSING AND REHABILITATION CENTER

C  Located in Mission, Texas, a large suburban town in the Rio Grande Valley

C  For-profit nursing home

C  120 beds (30 Medicare certified, 67 Medicaid certified)

Facility Profile 
Mission Nursing and Rehabilitation Center admits mostly long term residents and recently 
discharged hospital patients requiring highly skilled care.  Additional specialties include 
dementia care, orthopedic rehabilitation, and a 20 bed Alzheimers Unit (the second such 
unit in the area for which there is usually a waiting list for beds.)  Because of a forced 
closure of a nearby psychiatric nursing facility and this nursing homes reputation for 
specialized psychiatric care, many recent referrals have a history of mental illness. Despite 
a high proportion of residents with mental disorders, this nursing home has a low 
psychotropic drug rate of 16 percent.  Many of the residents are Spanish speaking, as are 
the staff who care for them. 
Approach to Psychotropic Drug Therapy 
Respondents at Mission Nursing and Rehabilitation Center believe their low psychotropic 
usage rate is reflective of a policy to avoid the use of such drugs if possible.  The 
pharmacological approach for all residents admitted into the facility already taking a 
psychotropic drug includes initiation of behavior monitoring and a consultant pharmacist 
check for appropriate psychiatric diagnosis and dosage suitability. Behavior monitoring is 
also initiated for all new admission to help direct care staff develop an understanding of 
the resident. 
In an effort to ensure the effectiveness of drug therapies, this facility conducts daily 
interdisciplinary reviews of all residents who have experienced a change in condition or 
medication.  All department heads are required to attend. The director of nursing also 
conducts daily medication order reviews.  Behavior management programs are developed 
by an in-house psychology team, to which all staff may refer a resident.  This team is made 
up of a clinical nurse geriatric specialist, psychologist, and psychiatrist.  The consultant 
psychiatrist is also available to assist staff on an as-needed basis. 
Staff also describe a corporate belief in specialized training.  All staff receive annual 
psychotropic drug training and satellite training sessions are broadcast via the 
corporations  Long Term Care Network.  This training is mandatory for all staff, who 
are then tested on program content. 
21 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Alternative Interventions 
Mission Nursing and Rehabilitation Centers policy to avoid the use of psychotropic drugs 
is reflected in the staffs commitment to try alternative interventions for a resident whose 
onset of behavioral symptoms begin after admission. These alternative interventions 
include: emotional support of the resident, encouragement of the resident to verbalize 
what is wrong, time out, and redirection. To manage aggressive residents, staff use 
calming techniques such as a decrease in sensory stimulation, redirection (especially if the 
resident is confused), bringing the resident into his/her room, encouraging the resident to 
verbalize what is bothering him or her, and activity therapy.  If none of these methods are 
successful, the physician is called.  Residents whose behavior poses a threat to self or 
others and who cannot be maintained with either pharmacologic or non-pharmacologic 
treatment, are transferred to a local psychiatric facility for evaluation and treatment. 
22 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  MISSION TERRACE CONVALESCENT HOSPITAL

C  Located in Santa Barbara, California, a city in southern California

C  For-profit individually owned nursing home

C  138 beds (138 Medicare certified, 0 Medicaid certified) 

Facility Profile 
Mission Terrace Convalescent Hospitals specialties include orthopedic and medical 
rehabilitation, wound care, and hospice care. According to the administrator, who owns 
this facility as well as a sister facility with assisted living, the nursing home is becoming 
more of a rehabilitation center and less a long term setup; she also says she avoids a 
dementia speciality.  The director of nursing describes the resident population as having 
more family involvement and a higher socio-economic class and education level than most 
other nursing homes. 
Mission Terrace Convalescent Hospital has a moderate psychotropic drug usage rate of 33 
percent.  The director of nursing says that  although few residents have psychiatric 
diagnoses and/or dementia., many hospice patients require anti-anxiety drug therapy as 
part of end of life care. [Additionally], many transitional patients, such as the robust 65 
year old who has just undergone hip replacement, usually want a sleeping pill while they 
are here. 
Approach to Psychotropic Drug Therapy 
This nursing home has developed separate procedures for residents coming into the 
nursing home already taking a psychotropic drug and for residents whose drug therapy 
begins after admission.  The MDS RN coordinator says, for residents admitted and 
already taking a psychotropic [drug] we determine the behavior [necessitating the drug 
therapy], monitor and calculate, then work toward reduction.  She also describes the 
steps taken when a residents behavioral symptoms begin after admission.  Firstly, the pre-
medication behavior is identified and a medical work-up is done.  Then a behavior 
management program is started.  The MDS RN coordinator believes that: perhaps as 
many as 80 percent of the time [the work-up] rules out and diverts the use of a 
psychotropic drug, especially for urinary tract infections, which can cause aberrant 
behaviors in the elderly, such as agitation, aggression, confusion, and hallucinations. 
At Mission Terrace Convalescent Hospital, the consultant pharmacist monitors 
psychotropic drugs by reviewing the drug treatment plans and reporting to the director of 
nursing monthly.  These reports are also placed in the residents medical record. Residents 
who take more than one psychotropic medication or who are undergoing 
23 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  dosage reduction are followed by a psychiatrist, while others are managed by the attending 
physician. 
The nursing staff also utilizes a behavior management program developed by the director 
of nursing. This system is color coded by behavior type and includes a daily tally of 
behavior episodes observed in the resident and any circumstances that appear to be related 
to the behavior.  This account is kept in the residents medical record and reviewed by the 
director of nursing as part of her weekly assessments. Additional discussions about 
residents taking psychotropic drugs occur at weekly rehabilitation meetings attended by 
the administrator, medical director, department heads, and other direct care staff. 
Alternative Interventions 
Mission Terrace Convalescent Hospital will generally attempt alternative interventions for 
residents with behavioral disturbances. They first rule out medical causes for the behavior 
and assess the resident for spiritual, social, dental needs, and for the presence of pain. 
Staff say they utilize one to one, redirection, emotional support, and other behavior 
management techniques.  One registered nurse we interviewed, who is the staff trainer, 
says we underestimate the impact of life altering scenarios... these patients feel very 
threatened over the loss of control. The usual response is to give [the resident] a pill. 
The director of nursing believes: for the resident who wanders, or is anxious and 
confused about where they are and why they are here... a loss of independence is too often 
overlooked by nursing home care-givers.  We encourage all of our staff, from 
housekeepers to RNs, to offer emotional support to the patient to reduce their [residents] 
anxiety.  Similarly, a charge nurse says, We try to find other methods, other than 
drugs. 
24 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  MOUNTAIN VALLEY CARE AND REHABILITATION

C  Located in Kellogg, Idaho, a small town in rural Northwestern Idaho

C  For-profit nursing home

C  68 beds (68 Medicare certified, 68 Medicaid certified)

Facility Profile 
Mountain Valley Care and Rehabilitation is one of only two nursing homes in the local 
area. Most of the residents in this nursing home are long-term, although some are short-
term, requiring orthopedic and stroke rehabilitation.  The majority of the residents are 
over 70 years old and only a very limited number are independent.  This nursing home has 
a low drug usage rate of 9 percent. 
Approach to Psychotropic Drug Therapy 
According to the administration, most of the residents on psychotropic medications came 
to the facility already taking the drugs.  Occasionally an in-house resident may be 
prescribed a psychotropic drug, such as a resident with Alzheimers disease who begins to 
hallucinate.  However, before medication is prescribed, the staff takes several steps.  They 
assess the resident for medical problems to determine if the behavior is being caused by 
pain or another physical problem, such as a urinary tract infection.  Also, staff record each 
residents behavior, noting the type of behavior, the time of day, and what precipitated the 
behavior.  The charge nurse explains that, We try to establish what behaviors they 
[residents] demonstrate and develop interventions before we start medications.  If none 
of these interventions work, they will consult the psychiatrist and start a medication. 
The nursing home staff reports monitoring residents taking psychotropic medications in 
several different ways.  The charge nurse explains that once [the resident is] on the 
med[ication] we do behavior monitoring sheets and continue to look for interventions. 
The nurses also record any side effects they observe by placing side effect stickers in the 
residents medical chart.  Once a month, the consultant pharmacist reviews the 
medications.  The psychotropic drug group, consisting of the psychiatrist, director of 
nursing, MDS RN coordinator, and social services, meets monthly to review charts and 
behavior sheets and to assess whether or not the drug is effective. 
Alternative Interventions 
In an interview, the medical director told us that he is the personal physician of  most of 
the residents in the facility and that he has an aversion to these drugs.  He explained that 
he is concerned about the side effects of psychotropic drugs as well as the regulations 
surrounding their use.  Instead, he advocates alternatives, such as behavior management. 
25 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  Staff also explain that the consulting psychiatrist has made this easier with his ideas for 
alternative treatments and his experience with using the different drugs. 
The nursing home uses several non-pharmaceutical techniques to control residents 
behavior.  As described above, staff monitor and record the circumstances of residents 
targeted behaviors.  They graph these behaviors over time and record in the chart which 
interventions were successful in order to identify what precipitates the behavior and 
remove it.  For example, we met one resident who had been acting out aggressively 
towards other residents until staff discovered it was because he felt territorial of the space 
in front of his door.  To alleviate some of his anxiety, the staff placed a small rug in front 
of his door to remind other residents not to stand there.  The nursing home also uses pet 
therapy (cats, birds, and dogs) to calm residents.  In addition, they have allowed a local 
child day care center to build a playground on their grounds.  Staff say the nursing home 
residents enjoy watching the children play. 
26 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  PARK NURSING HOME

C  Located in Rockaway, New York, in the borough of Queens, New York City

C  For-profit nursing home

C  196 beds (196 Medicare certified, 196 Medicaid certified)

Facility Profile 
Park Nursing Home has a high proportion of mentally ill residents.  The age range of the 
entire resident population is from 36 to 90, with an average age between 60 and 70 years. 
Most are long term care and many have a long standing diagnosis of schizophrenia or 
advanced dementia. As soon as the inspection team entered the facility, we observed 
intense activity and noise levels, with some confused residents wandering throughout the 
facility. However, the staff used a firmly directive yet gentle approach that was non-
threatening and non-confrontational to guide residents. 
Park Nursing Home actively seeks out residents with a history of mental illness.  The 
administrator credits a contract with the New York State Mental Health Authority as 
keeping the facility competitive while also providing a much needed public service to a 
marginal population; he explains that State psychiatric institution closures have displaced 
many patients. 
Approach to Psychotropic Drug Therapy 
Park Nursing Home uses a highly systemized approach for residents taking psychotropic 
drugs, starting with an automatic psychiatric consultation for all residents coming into the 
nursing home already taking psychotropic medications.  Staff attempt to discontinue the 
drugs for these residents.  Whether or not the resident is newly prescribed or has a history 
of taking such drugs, the drug therapy plan is developed by the psychiatrist, who 
determines a pharmacologic versus behavior modification approach, or a combination of 
the two.  The director of nursing believes that only by individualizing the residents plan 
of care with input from a multi-disciplinary team, can there be a successful outcome. 
Further, the medical director conducts weekly chart reviews for those residents who have 
had a change in condition and physically examines any newly admitted resident.  Beyond 
the monthly DRR, a consultant pharmacist also reviews three to eight medical records a 
week and makes necessary recommendations to the physician of record. 
Quality control for all residents taking a psychotropic drug includes a behavior monitoring 
record, weekly RN psychotropic drug notes, interdisciplinary notes evaluating the 
residents current behaviors and response to all interventions, and a weekly psychiatrist 
note that includes an assessment for side effects and efficacy of continued treatment. 
When a resident experiences a change in condition or behavior, an automatic 
27 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  psychiatric consult is stimulated. Finally, all residents with a mental illness diagnosis are 
seen by the psychiatrist once a year or if not stable, every three months.  Because of the 
high proportion of residents with mental illness, Park Nursing Home maintains 24 hour 
and 7 day psychiatric consultation coverage. 
Alternative Interventions 
The Park Nursing Home administrator believes the first step to successful alternative 
management is to observe all new admissions into the facility on a one to one basis. They 
also use activities therapy and psychiatric therapy and an innovative redirection approach 
that places diversionary objects in common areas.  For example, a dresser with its drawers 
filled with fabrics and other safe objects allows the residents the opportunity to open the 
drawers, pull out the fabric, and begin unfolding and re-folding the material. 
Continuity of care staff is also cited by all nursing home staff as integral to modifying 
residents behavior. The administrator describes staff retention as extremely important to 
us;  we try to accommodate [staffs] personal needs as much as possible.  Almost all of 
the CNAs at this nursing home are long term employees who have established 
relationships with both the residents and their families. The charge nurses in the care units 
make every effort to resident assignments unchanged from day to day. The three CNAs 
we interviewed say that the change in the nursing home resident population over the last 
two years has been a difficult adjustment for them.  As one stated, These patients are a 
lot of work. As soon as you finish giving care to one, get them bathed and dressed, and 
you move on to the next, the first has already taken off his clothes and you have to start all 
over. 
28 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  APPENDIX A 
Comments on the Draft Report 
In this appendix, we present in full the comments from the Centers for Medicare & 
Medicaid Services. 
29 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  30 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491  31 
Psychotropic Drug Use in Nursing Homes - Case Studies  OEI- 02-00-00491