Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia



      The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia.


      A mixed-methods study was performed.

      Setting and Participants

      During the first quarter of 2018 (January–March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica.


      Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ2 tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports.


      Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on Pro Re Nata (PRN) psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001).

      Conclusions and Implications

      This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Harris-Kojetin L.
        • Sengupta M.
        • Lendon J.P.
        • et al.
        Long-term care providers and services users in the United States, 2015–2016.
        Vital Health Stat. 2019; 3: 43
        • Kales H.C.
        • Gitlin L.N.
        • Lyketsos C.G.
        • et al.
        Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel.
        J Am Geriatr Soc. 2014; 62: 762-769
        • Chiu Y.
        • Bero L.
        • Hessol N.A.
        • et al.
        A literature review of clinical outcomes associated with antipsychotic medication use in North American nursing home residents.
        Health Policy. 2015; 119: 802-813
        • Dyer S.M.
        • Harrison S.L.
        • Laver K.
        • et al.
        An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia.
        Int Psychogeriatr. 2018; 30: 295-309
        • Bangash A.
        • Stubbs R.
        • Khan F.
        • et al.
        Association between antipsychotics and adverse outcomes in dementia.
        Prog Neurol Psychiatry. 2017; 21: 20-26
        • Harrison S.L.
        • Bradley C.
        • Milte R.
        • et al.
        Psychotropic medications in older people in residential care facilities and associations with quality of life: a cross-sectional study.
        BMC Geriatr. 2018; 18: 60
        • Center of Medicare and Medicaid Services
        Request to convey information: partnership to improve dementia care in nursing homes.
        • Center of Medicare and Medicaid Services
        Antipsychotic medication use data report (October 2020).
        • Maust D.T.
        • Kim H.M.
        • Chiang C.
        • Kales H.C.
        Association of the Centers for Medicare and Medicaid Services' National Partnership to Improve Dementia Care with the use of antipsychotics and other psychotropics in long-term care in the United States from 2009 to 2014.
        JAMA Intern Med. 2018; 178: 640-647
        • Bonner A.F.
        • Field T.S.
        • Lemay C.A.
        • et al.
        Rationales that providers and family members cited for the use of antipsychotic medications in nursing home residents with dementia.
        J Am Geriatr Soc. 2015; 63: 302-308
        • Centers for Medicare and Medicaid Services
        State operations manual chapter 7–survey and enforcement process for skilled nursing facilities and nursing f.
        • Center of Medicare & Medicaid Services
        State operations manual: appendix PP—guidance to surveyors for long term care facilities.
        • Kales H.C.
        • Gitlin L.N.
        • Lyketsos C.G.
        Assessment and management of behavioral and psychological symptoms of dementia. State of the art review.
        BMJ. 2015; 350: h369
        • American Geriatrics Society Beers Criteria Update Expert Panel
        American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults.
        J Am Geriatr Soc. 2019; 67: 674-694
        • Kolanowski A.
        • Boltz M.
        • Galik E.
        • et al.
        Determinants of behavioral and psychological symptoms of dementia: a scoping review of the evidence.
        Nurs Outlook. 2017; 65: 515-529
        • Castle N.G.
        • Fergusson J.C.
        What is nursing home quality and how is it measured?.
        The Gerontologist. 2010; 50: 426-442
        • Harrington C.
        • Carrillo H.
        • Garfield R.
        • et al.
        Nursing facilities, staffing, residents and facility deficiencies, 2009 through 2016.
        • Harrington C.
        • Olney B.
        • Carrillo H.
        • et al.
        Nurse staffing and deficiencies in the largest for-profit nursing home chains and chains owned by private equity companies.
        Health Serv Res. 2012; 47: 106-128
        • Lerner N.B.
        • Johantgen M.
        • Trinkoff A.M.
        • et al.
        Are nursing home survey deficiencies higher in facilities with greater staff turnover.
        J Am Med Dir Assoc. 2014; 15: 102-107
        • McDonald S.M.
        • Wagner L.M.
        • Castle N.G.
        Staffing-related deficiency citations in nursing homes.
        J Aging Soc Policy. 2013; 25: 83-97
        • Towsley G.L.
        • Beck S.L.
        • Pepper G.A.
        Predictors of quality in rural nursing homes using standard and novel methods.
        Res Gerontol Nurs. 2013; 6: 116-126
        • Wagner L.M.
        • McDonald S.M.
        • Castle N.G.
        Impact of voluntary accreditation on deficiency citations in US nursing homes.
        The Gerontologist. 2012; 52: 561-570
        • Medicare
        Medicare basics.
        • Medicaid
        Date accessed: February 15, 2022
        • Cowles Research Group
        CASPER and OSCAR.
        • Medicare
        Providers & services.
        • ProPublica
        Nursing home inspect.
        • Center of Medicare and Medicaid Services
        Minimum Data Set (MDS) 3.0 for nursing homes and swing bed providers.
        • Saliba D.
        • Buchanan J.
        • Edelen M.O.
        • et al.
        MDS 3.0: brief interview for mental status.
        J Am Med Dir Assoc. 2012; 13: 611-617
        • Krippendorff K.
        Content Analysis: An Introduction to Its Methodology.
        2nd ed. Sage, 2003
      1. Marks D.F. Yardley L. Research Methods in Clinical and Health Psychology. Sage, 2003
        • Pain M.C.
        • Chadwick P.
        • Abba N.
        Clients' experience of case formulation in cognitive behaviour therapy for psychosis.
        Br J Clin Psychol. 2008; 47: 127-138
        • Manning J.
        In vivo coding.
        in: The International Encyclopedia of Communication Research Methods. John Wiley and Sons, 2017
        • QSR International Pty Ltd
        NVivo (Version 12).
        • Sandelowski M.
        The call to experts in qualitative research.
        Res Nurs Health. 1999; 21: 467-471
        • Center of Medicare and Medicaid Services
        Frequently asked questions related to long term care regulations, survey process, and training.
        • Guy W.
        ECDEU Assessment Manual for Psychopharmacology, Revised.
        National Institute of Mental Health, 1976
        • Jacobson S.A.
        • Pies R.W.
        • Katz I.R.
        Clinical Manual of Geriatric Psychopharmacology.
        American Psychiatric Publishing, 2007
        • Edelman T.S.
        • Lerner D.
        Examining inappropriate use of antipsychotic drugs, Part two: how surveyors describe how, when, and why they cite antipsychotic drug deficiencies.
        • Reus V.I.
        • Fochtmann L.J.
        • Eyler A.E.
        • et al.
        The American psychiatric association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia.
        Am J Psychiatry. 2016; 173: 543-546
        • Bessey L.J.
        • Walaszek A.
        Management of behavioral and psychological symptoms of dementia.
        Curr Psychiatry Rep. 2019; 21: 66
        • Lembke A.
        • Papac J.
        • Humphreys K.
        Our other prescription drug problem.
        N Engl J Med. 2018; 378: 693-695
        • Walsh K.A.
        • Sinnott C.
        • Fleming A.
        • et al.
        Exploring antipsychotic prescribing behaviors for nursing home residents with dementia: a qualitative study.
        J Am Med Dir Assoc. 2018; 19: 948-958.e12
        • Kales H.C.
        • Lyketsos C.G.
        • Miller E.M.
        • et al.
        Management of behavioral and psychological symptoms in people with Alzheimer’s disease: an international Delphi consensus.
        Int Psychogeriatr. 2019; 31: 83-90
        • Kales H.C.
        • Gitlin L.N.
        • Lyketsos C.G.
        When less is more, but still not enough: why Focusing on limiting antipsychotics in people with dementia is the wrong policy imperative.
        J Am Med Dir Assoc. 2019; 20: 1074-1079
        • Kerns J.W.
        • Winter J.D.
        • Winter K.M.
        • Kerns C.C.
        • Etz R.S.
        Caregiver perspectives about using antipsychotics and other medications for symptoms of dementia.
        Gerontologist. 2018; 58: e35-e45
        • Almutairi S.
        • Masters K.
        • Donyai P.
        The health professional experience of using antipsychotic medication for dementia in care homes: a study using grounded theory and focussing on inappropriate prescribing.
        J Psychiatr Ment Health Nurs. 2018; 25: 307-308
        • Resnick B.
        • Kolanowski A.
        • Van Haitsma K.
        • et al.
        Testing the evidence integration triangle for implementation of interventions to manage behavioral and psychological symptoms associated with dementia: protocol for a pragmatic trial.
        Res Nurs Health. 2018; 41: 228-242
        • Smeets C.H.
        • Smalbrugge M.
        • Zuidema S.U.
        • et al.
        Factors related to psychotropic drug prescription for neuropsychiatric symptoms in nursing home residents with dementia.
        J Am Med Dir Assoc. 2014; 15: 835-840
        • Kolanowski A.
        • Van Haitsma K.
        • Penrod J.
        • Hill N.
        • Yevchak A.
        “Wish we would have known that!” Communication breakdown impedes person-centered care.
        Gerontologist. 2015; 55: S50-S60
        • Marx K.A.
        • Stanley I.H.
        • Van Haitsma K.
        • et al.
        Knowing versus doing: education and training needs of staff in a chronic care hospital unit for individuals with dementia.
        J Gerontol Nurs. 2014; 40: 26-37
        • Jennings A.A.
        • Foley T.
        • Walsh K.A.
        • et al.
        General practitioners’ knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: a mixed-methods systematic review.
        Int J Geriatr Psychiatry. 2018; 33: 1163-1176
        • Harrison S.L.
        • Cations M.
        • Jessop T.
        • Hilmer S.N.
        • Sawan M.
        • Brodaty H.
        Approaches to deprescribing psychotropic medications for changed behaviours in long-term care residents living with dementia.
        Drugs Aging. 2019; 36: 125-136
        • Moth A.E.
        • Hølmkjær P.
        • Holm A.
        • et al.
        What makes deprescription of psychotropic drugs in nursing home residents with dementia so challenging? A qualitative systematic review of barriers and facilitators.
        Drugs Aging. 2021; 38: 671-685
        • Fazio S.
        • Pace D.
        • Flinner J.
        • Kallmyer B.
        The fundamentals of person-centered care for individuals with dementia.
        Gerontologist. 2018; 58: S10-S19
        • Gilster S.D.
        • Boltz M.
        • Dalessandro J.L.
        Long-term care workforce issues: practice principles for quality dementia care.
        Gerontologist. 2018; 58: S103-S113
        • Tjia J.
        • Hunnicutt J.N.
        • Herndon L.
        • et al.
        Association of a communication training program with use of antipsychotics in nursing homes.
        JAMA Intern Med. 2017; 177: 846-853
        • Sawan M.J.
        • Jeon Y.H.
        • Fois R.J.
        • et al.
        A qualitative study exploring visible components of organizational culture: what influences the use of psychotropic medicines in nursing homes?.
        Int Psychogeriatr. 2016; 28: 1725-1735
        • Sawan M.
        • Jeon Y.H.
        • Fois R.A.
        • Chen T.F.
        Exploring the link between organizational climate and the use of psychotropic medicines in nursing homes: a qualitative study.
        Res Social Adm Pharm. 2017; 13: 513-523
        • Ellis M.L.
        • Molinari V.
        • Dobbs D.
        • Smith K.
        • Hyer K.
        Assessing approaches and barriers to reduce antipsychotic drug use in Florida nursing homes.
        Aging Mental Health. 2015; 19: 507-516
        • Sheehan R.
        • Strydom A.
        • Brown E.
        • Marston L.
        • Hassiotis A.
        Association of focused medication review with optimization of psychotropic drug prescribing: a systematic review and meta-analysis.
        JAMA Netw Open. 2018; 1: e183750
        • Simmons S.F.
        • Bonnett K.R.
        • Hollingsworth E.
        • et al.
        Reducing antipsychotic medication use in nursing homes: a qualitative study of nursing staff perceptions.
        Gerontologist. 2018; 58: e239-e250
        • Plakiotis C.
        • Bell J.S.
        • Jeon Y.H.
        • et al.
        Deprescribing psychotropic medications in aged care facilities: the potential role of family members.
        Adv Exp Med Biol. 2015; 821: 29-43
        • Jansen J.
        • Naganathan V.
        • Carter S.M.
        • et al.
        Too much medicine in older people? Deprescribing through shared decision making.
        BMJ. 2016; 353: i2893
        • Devanand D.P.
        • Mintzer J.
        • Schultz S.
        • et al.
        The antipsychotic discontinuation in Alzheimer disease trial: clinical rationale and study design.
        Am J Geriatr Psychiatry. 2012; 20: 362-373
        • Sawan M.
        • Jeon Y.H.
        • Chen T.F.
        Shaping the use of psychotropic medicines in nursing homes: a qualitative study on organisational culture.
        Soc Sci Med. 2018; 202: 70-78