Phony diagnoses conceal druggings
A loophole obscures the true rate of antipsychotic drug use on vulnerable nursing home residents
The handwritten doctor’s order was just eight words long, but it solved a problem for Dundee Manor, a nursing home in rural South Carolina struggling to handle a new resident with severe dementia.
David Blakeney, 63, was restless and agitated. The home’s doctor wanted him on an antipsychotic medication called Haldol, a powerful sedative.
“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”
But there was no evidence that Blakeney actually had schizophrenia.
Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections and other ailments. But understaffed nursing homes often use the sedatives so they do not have to hire more staff to handle residents.
The risks to patients treated with antipsychotics are so high that nursing homes must report to the government how many of their residents are on these potent medications. But there is an important caveat: The government does not publicly divulge the use of antipsychotics given to residents with schizophrenia or two other conditions.
With the doctor’s new diagnosis, Blakeney’s antipsychotic prescription disappeared from Dundee Manor’s public record.
Eight months following his admission with a long list of ailments — and after roundthe-clock sedation, devastating weight loss, pneumonia and severe bedsores that required one of his feet to be amputated — Blakeney was dead.
A New York Times investigation found a similar pattern of questionable diagnoses nationwide, indicating the true rate of antipsychotic drug use on vulnerable residents is being obscured.
The share of residents with a schizophrenia diagnosis has soared 70 percent since 2012, according to an analysis of Medicare data. That was the year the federal government, concerned with the overuse of antipsychotic drugs, began publicly disclosing data by individual nursing homes.
Today, 1 in 9 residents has received a schizophrenia diagnosis. In the general population, the disorder, a±icts roughly 1 in 150 people. It is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive. “It’s used to skirt the rules.”
Some portion of the rise in schizophrenia diagnoses reflects the fact that nursing homes, like prisons, have become a refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also driving the increase. In May, a federal report said nearly onethird of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.
For nursing homes, money is on the line. High rates of antipsychotic drug use can hurt a home’s public image and lower the its score in the Medicare ratings system. Many facilities have found ways to hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors.
One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications.
According to Medicare’s webpage that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.
Unfiltered data obtained by the Times showed that at least 21 percent of nursing home residents — about 225,000 people — are on antipsychotics.
The Centers for Medicare and Medicaid Services, which oversees nursing homes, is “concerned about this practice as a way to circumvent the protections these regulations afford,” said Catherine Howden, a spokesperson for the agency.
“It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve their performance measures,” she said. “We will continue to identify facilities which do so and hold them accountable.”