Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

JANET REHNQUIST

Inspector General

november 2001

OEI-02-00-00491

Psychotropic Drug Use 

in Nursing Homes

Supplemental Information - 10 Case Studies
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 
OVERVIEW 

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 individual’s 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; antidepressant; 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies i 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies ii 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 Alzheimer’s 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies iii OEI- 02-00-00491 
TABLE OF CONTENTS 

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

Psychotropic Drug Use in Nursing Homes - Case Studies iv OEI- 02-00-00491 
INTRODUCTION 

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 individual’s 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies 1 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 resident’s 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 antipsychotic 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 onsite. These 10 nursing homes were selected based on five criteria: 

Psychotropic Drug Use in Nursing Homes - Case Studies 2 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 home’s case study individually, we conducted a cross 

case analysis of the inspectios team’s 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies 3 OEI- 02-00-00491 
This inspection was conducted in accordance with the Quality Standards for 

Inspections issued by the President’s Council on Integrity and Efficiency. 

Psychotropic Drug Use in Nursing Homes - Case Studies 4 OEI- 02-00-00491 
10 CASE SUMMARY Vin the main report, our medical record review determined that psychotropic drug use in nursing 

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 team’s 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 psychosocial 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 

Psychotropic Drug Use in Nursing Homes - Case Studies 5 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 

resident’s 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 pharmacist’s 

recommendation to change a medication in order to improve the management of a 

resident’s 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.” 

Psychotropic Drug Use in Nursing Homes - Case Studies 6 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 resident’s 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 antipsychotic 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies 7 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 Alzheimer’s 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.” 

Psychotropic Drug Use in Nursing Homes - Case Studies 8 OEI- 02-00-00491 
INDIVIDUAL CASE STUDIES 

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 Alzheimer’s 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] can’t 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 resident’s 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies 9 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 resident’s 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 redirection 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 

home’s activities by providing training to staff, consulting on aggressive behavior, 

conducting psychological evaluations, and providing therapy for some residents with mild 

Alzheimer’s disease or dementia. 

Psychotropic Drug Use in Nursing Homes - Case Studies 10 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 home’s 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 resident’s 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 

Psychotropic Drug Use in Nursing Homes - Case Studies 11 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 facility’s 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 sister’s 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies 12 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 Center’s 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 resident’s behavior for three days and consult 

the resident’s personal physician. The psychologist from the psychological services team 

reports also providing consultation to the staff and making recommendations for 

medications. 

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Residents on psychotropic drugs are monitored in several ways. Nurses monitor the dayto-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. 

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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 home’s 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 nonpharmacologic interventions are dependent on their knowledge and understanding of the 

Psychotropic Drug Use in Nursing Homes - Case Studies 15 OEI- 02-00-00491 
resident. They describe several approaches to manage a resident’s 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 don’t 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. 

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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 town’s 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 pharmacist’s 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. 

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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 

facility’s 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. 

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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 Alzheimer’s 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 Alzheimer’s 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 resident’s 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.” 

Psychotropic Drug Use in Nursing Homes - Case Studies 19 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. 

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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 Alzheimer’s 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 home’s 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 

corporation’s “Long Term Care Network.” This training is mandatory for all staff, who 

are then tested on program content. 

Psychotropic Drug Use in Nursing Homes - Case Studies 21 OEI- 02-00-00491 
Alternative Interventions 

Mission Nursing and Rehabilitation Center’s policy to avoid the use of psychotropic drugs 

is reflected in the staff’s 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies 22 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 Hospital’s 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 resident’s behavioral symptoms begin after admission. Firstly, the premedication 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 

Psychotropic Drug Use in Nursing Homes - Case Studies 23 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 resident’s 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.” 

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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 shortterm, 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 Alzheimer’s 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 

resident’s 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 

resident’s 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies 25 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. 

Psychotropic Drug Use in Nursing Homes - Case Studies 26 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 nonthreatening 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 resident’s 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 

resident’s 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 

Psychotropic Drug Use in Nursing Homes - Case Studies 27 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 [staff’s] 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.” 

Psychotropic Drug Use in Nursing Homes - Case Studies 28 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. 

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