Medication Overuse, Chemical Restraints & Antipsychotics in Rhode Island Nursing Homes

What is a chemical restraint?

A chemical restraint generally involves medication used to control behavior or restrict a resident's freedom of movement when the medication is not being used appropriately as treatment for the resident's medical or psychiatric condition.

Current CMS survey guidance treats unnecessary psychotropic medication and chemical restraint concerns together under F605. CMS specifically explains that “convenience” can include medication used to cause sedation or reduce the effort staff must provide to meet a resident's needs.

Rhode Island protections against inappropriate medication use

Rhode Island nursing-facility regulations define “mistreatment” to include inappropriate use of medications, isolation, or physical or chemical restraints as punishment, for staff convenience, as a substitute for treatment or care, contrary to a practitioner's order, or in quantities that inhibit effective care or treatment and harm or are likely to harm a resident.

Rhode Island also states that nursing home residents must be free from chemical restraints and, except in emergencies, physical restraints. Residents retain rights to participate in treatment decisions and to voice grievances without restraint, coercion, discrimination or reprisal.

What are psychotropic medications?

Federal nursing-home rules define psychotropic drugs broadly to include medications that affect brain activities associated with mental processes and behavior. They commonly include:

• Antipsychotics.
• Antidepressants.
• Anti-anxiety medications.
• Hypnotics and other medications used for sleep.

These medications may be appropriate when a resident has a diagnosed condition and the drug's expected benefits outweigh its risks.

Antipsychotics and dementia

Antipsychotic medication can sometimes be used for severe symptoms when clinically appropriate, but use in residents with dementia deserves careful evaluation because these medications can carry significant risks and should not simply be used to make a resident easier to manage.

Families can ask exactly which symptom is being treated, what risks and benefits were considered, and what non-drug interventions have been attempted.

Residents have a right to participate in treatment decisions

Current CMS guidance emphasizes that before initiating or increasing a psychotropic medication, the resident must be informed and have the opportunity to participate in treatment decisions, including the right to accept or decline the medication, subject to applicable clinical and legal circumstances.

Rhode Island nursing-home regulations likewise state that residents are to participate in the planning and selection of medical treatment and care.

Gradual dose reduction

Federal nursing-home rules require residents using psychotropic drugs to receive gradual dose reductions and behavioral interventions unless clinically contraindicated, in an effort to discontinue the drugs.

A gradual dose reduction does not mean medication must always be stopped. If reducing the dose causes symptoms to return or creates other clinical problems, the practitioner may determine that continued treatment is appropriate. The rationale should be documented.

PRN psychotropic and antipsychotic orders

PRN means medication given “as needed.” Federal rules limit PRN psychotropic orders because open-ended as-needed medication can create a risk of unnecessary use.

• PRN psychotropic medication orders are generally limited to 14 days.
• For non-antipsychotic psychotropics, an order may be extended when the prescribing practitioner documents the rationale and duration.
• PRN antipsychotic orders are limited to 14 days and cannot simply be renewed without the practitioner first evaluating the resident and determining that a new order is appropriate.

Non-drug approaches to behavioral symptoms

When a resident with dementia is agitated, wandering, calling out, resisting care or displaying other behavioral symptoms, staff should consider potential causes and individualized interventions.

Possible contributors include:

• Pain.
• Hunger or thirst.
• Infection or delirium.
• Constipation.
• Need to toilet.
• Overstimulation or noise.
• Fear or unfamiliar caregivers.
• Sleep disruption.
• Medication side effects.
• Changes in routine.

Non-drug interventions can involve changes in staff approach, environment, activities, routines, communication, comfort measures and addressing the underlying trigger.

Warning signs of possible medication overuse

Possible warning signs include:

• A previously alert resident becoming persistently sleepy.
• Difficulty waking the resident for meals or activities.
• New falls after a sedating medication is started or increased.
• A major decline in mobility or interaction without another explanation.
• Medication being given repeatedly for behaviors without clear assessment of the cause.
• Family members being unable to obtain a clear explanation of the indication.
• Long-term psychotropic use with no apparent review or dose-reduction consideration.
• PRN medication being used frequently without reassessment.

These findings can have medical explanations unrelated to inappropriate medication use. Sudden sedation, confusion or functional decline deserves clinical evaluation.

Medication overuse and falls

Sedating medications can increase dizziness, impaired balance or reduced alertness in some residents. When falls begin after a medication change, the medication regimen should be considered as one possible contributing factor.

See our Nursing Home Falls in Rhode Island guide.

Medication overuse and staffing

CMS's current chemical-restraint guidance specifically recognizes the concern when medication is used to reduce the amount of staff effort required to meet a resident's needs. Staffing numbers alone do not prove this occurred, but staffing and care-delivery patterns can be relevant context.

See our Rhode Island Nursing Home Staffing Comparison guide.

What records may help families understand medication use?

• Current medication list.
• Physician or practitioner orders.
• Medication Administration Record (MAR).
• Behavior-monitoring documentation.
• Care plans.
• Psychiatric or behavioral-health assessments.
• Pharmacist medication-regimen reviews.
• Gradual-dose-reduction documentation.
• Documentation explaining why dose reduction is contraindicated, if applicable.
• Records of PRN administration and the reason each dose was given.
• Fall and functional assessments.

Rhode Island requires a pharmacist to review each nursing home resident's drug regimen at least monthly and report irregularities to the attending physician and director of nursing.

When does psychotropic medication use deserve closer investigation?

Closer review may be appropriate when:

• No clear diagnosis or clinical indication is documented.
• Medication appears to be used primarily for staff convenience.
• The resident or representative was not informed about major treatment changes.
• The resident becomes profoundly sedated without reassessment.
• Required monitoring does not occur.
• Frequent PRN use continues without practitioner evaluation.
• Behavioral causes and non-drug interventions are not addressed.
• Pharmacist concerns are repeatedly ignored.

These circumstances do not automatically establish misuse or neglect. They may justify discussing the medication with the prescriber, director of nursing or pharmacist and reviewing the underlying records.

If concerns remain unresolved

See our Medication Errors in Rhode Island Nursing Homes guide, Rhode Island Nursing Home Complaint guide, Long-Term Care Ombudsman guide, and Abuse & Neglect Resource Center.

Official sources and further reading

• Rhode Island — Licensing of Nursing Facilities
• CMS — Revised Long-Term Care Surveyor Guidance
• CMS State Operations Manual — Appendix PP
• Medicare Care Compare