HHS OIG: Nursing Homes Misuse Antipsychotics on Dementia Residents

HHS OIG Reports & Publications

Published March 16th, 2026

Detected March 19th, 2026

Summary

The HHS Office of Inspector General (OIG) issued a report finding that nursing homes inappropriately administer antipsychotic drugs to residents with dementia, often to manage behavior for staff benefit, despite FDA warnings of increased mortality risk. The report recommends CMS develop resources and increase transparency to reduce misuse and improve dementia care.

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What changed

The HHS OIG has released a report detailing the inappropriate use of antipsychotic drugs in nursing homes, particularly affecting residents with dementia. The report, based on a review of 40 nursing home inspections, found that these drugs were administered to manage resident behavior for staff convenience, disregarding FDA warnings about increased mortality risks for dementia patients. Furthermore, nursing homes failed to implement required protective steps, medical directors did not prevent misuse, pharmacists did not identify medical concerns or recommend dose reductions, and inadequate policies undermined resident safeguards. The report identifies this as the first in a two-part series on the misuse of antipsychotic drugs.

While CMS did not fully concur with all recommendations, the OIG urges them to re-examine their position. The OIG recommends that CMS develop resources for nursing homes, increase transparency, ensure medical directors and pharmacists fulfill their roles in reducing inappropriate antipsychotic drug use, and assist in improving nursing home policies and procedures. These findings highlight significant vulnerabilities in dementia care and the need for improved oversight and intervention to protect vulnerable residents from potentially harmful medication practices.

What to do next

Review current policies and procedures regarding the use of antipsychotic drugs for dementia patients.
Ensure medical directors and pharmacists are actively involved in preventing inappropriate antipsychotic drug use.
Develop and implement enhanced training for staff on dementia care and behavioral management alternatives.

Source document (simplified)

Nursing Homes’ Inappropriate Use of Antipsychotic Drugs Poses a Risk to Residents

Issued on

03/16/2026

| Posted on

03/19/2026

| Report number: OEI-02-23-00200

Report Materials

Why OIG Did This Review

Antipsychotic drugs present a risk to nursing home residents, particularly those with dementia. These drugs are not approved to treat dementia, and the Food and Drug Administration (FDA) has warned that they may increase the risk of death for these individuals.
The inappropriate use of antipsychotic drugs in nursing homes has been a longstanding concern for Congress and others. The drugs can have a sedative effect, raising concerns that nursing homes may use them to control residents’ behavior.
This is the first of a two-part series addressing inappropriate use of antipsychotic drugs in nursing homes.

What OIG Found

OIG’s comprehensive review of 40 focused nursing home inspections completed by CMS found alarming instances of inappropriate use of antipsychotic drugs and revealed vulnerabilities in care that have implications for the wider nursing home population beyond these examples. Our review found:

Nursing homes gave antipsychotic drugs to residents with dementia to manage their behavior for the benefit of staff, despite FDA’s warning that these drugs may increase the risk of death.

Even though antipsychotic drugs pose risks to residents’ health, nursing homes did not take required steps to help protect residents who were given these drugs.

Medical directors failed to prevent inappropriate use of antipsychotic drugs.

Nursing home pharmacists failed to identify medical concerns and did not recommend dose reductions.

Inadequate nursing home policies and procedures undermined safeguards meant to protect residents.

What OIG Recommends

OIG recommends that CMS:

Further develop resources for nursing homes and increase transparency in order to reduce inappropriate use of antipsychotic drugs and improve dementia care in nursing homes.
Take steps to ensure that nursing home medical directors fulfill their role in reducing the inappropriate use of antipsychotic drugs.
Take steps to ensure that nursing home pharmacists fulfill their role in reducing the inappropriate use of antipsychotic drugs.
Assist nursing homes to improve their policies and procedures pertaining to antipsychotic drug use. CMS did not explicitly concur or nonconcur with our first and fourth recommendations. CMS nonconcurred with our second and third recommendations. We added clarification to these recommendations based on CMS’s comments to the draft and encourage CMS to re-examine its position on concurrence in its Final Management Decision.

Report Type Evaluation HHS Agencies Centers for Medicare and Medicaid Services Issue Areas Quality of Care Target Groups Elderly Financial Groups Medicare A