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Nursing Home
Investigation Finds Errors by Druggists
by Laurie Udesky, The
New York Times
January 27, 2012
Picture
Credit: Noah Berger for The Bay Citizen
A woman with a
medical history of seizures was prescribed the antipsychotic drug
Seroquel, despite research showing that elderly people who take
antipsychotic drugs are more likely to experience seizures. She was
also given the antidepressant Trazodone, which has been linked to an
increase in seizures among older patients. And then, according to a
recent investigation by the California Department of Public Health, the
woman was given a second antipsychotic drug, Risperdal. The combination
of the two antipsychotic medications, the investigators said, could
cause “life-threatening arrhythmias (irregular heartbeats).”
Despite
these potentially dangerous side effects, the pharmacist responsible
for reviewing the prescriptions of the woman, a resident of the
Greenhills Manor nursing home in Campbell, told state investigators
that he had not noted these irregularities or addressed them in the
patient’s chart.
Pharmacists
responsible for reviewing the medication of patients in California
nursing homes routinely allowed inappropriate and potentially lethal
prescriptions of antipsychotic medications, and failed to correct other
potentially dangerous drug irregularities, according to recent state
investigations.
In
reports obtained by The Bay Citizen, the department found that in 18 of
the 32 investigations conducted in California nursing homes between May
2010 and June 2011 — 17 of the 32 were in the Bay Area — pharmacists
failed to red-flag cases in which residents were inappropriately
prescribed powerful antipsychotic medications like Seroquel, a drug
used to treat schizophrenia. Pharmacists also overlooked or approved
cases in which medications were prescribed at questionable levels or in
unsafe combinations that could put patients at risk of seizures,
accidents or even death, according to the public health department.
“The
consultant pharmacists’ review, which is intended to identify
unnecessary or potentially inappropriate drugs among nursing home
residents, is defective in the state of California,” said Dr. Jonathan
Evans, a geriatrician and the vice president of the American Medical
Directors Association. He called the problem “widespread.”
The
state investigations also suggested a “probable correlation” between
the inadequate review of nursing home patients’ medications by
pharmacists and the failure of those nursing homes to pay a fair market
rate for the pharmacists’ services. A 1982 anti-kickback law requires
nursing homes to pay a fair rate for pharmacy services to discourage
consulting pharmacists from endorsing or extending the prescriptions of
expensive, and potentially dangerous, drugs. A majority of the nursing
homes where the state found patients who were inappropriately
prescribed antipsychotic medications were paying below-average fees for
pharmacy services.
The
California investigations come in the wake of a report last year by the
United States Department of Health and Human Services. The report
revealed that, in nursing homes nationwide, at least 40 percent of all
Medicare claims for so-called atypical antipsychotics, like Risperdal,
are inappropriate, given in excessive doses, given for too long, given
without the need for use, without adequate monitoring or “in the
presence of adverse consequences” and should be reduced or discontinued.
By
California state law, consulting pharmacists who work for nursing homes
are required to review residents’ charts monthly, and recommend to
prescribing doctors that medications be stopped, reduced or changed if
they pose potential dangers or are causing harmful side effects. The
state health department found in its investigations that pharmacists
failed to identify the misuse of antipsychotic medications in 90
percent of cases. In 59 percent of those cases, violations occurred in
nursing facilities that were cited for accepting pharmacy services
below cost.
The
average pay rate for California pharmacists is $56.29 an hour,
according to the Bureau of Labor Statistics. But a review of nursing
home records indicated that some were billed much less, in some cases
as low as $11 an hour. The state anti-kickback law bans nursing homes
from accepting below-market rates “from any pharmacist or pharmacy as
compensation or inducement for referral of business to any pharmacy.”
“When
pharmacy services are provided below cost, the pharmacist may be
recouping the losses by making drug recommendations according to
financial incentives instead of the best interests of the residents,”
said Anthony Chicotel, a lawyer with the California Advocates for
Nursing Home Reform, which plans to release a report on the state
investigations. “When their independence is compromised, the integrity
of their protective function is eviscerated.”
The
state investigations yielded a number of examples where the
pharmacists’ protective function appeared to be compromised.
At
Hillside Senior Care nursing home in Fremont, for example, a consulting
pharmacist was billed at a rate as low as $16.24 an hour, and no more
than $19.16 an hour, between January and May 2011. In the same period,
according to state investigators, a pharmacist at Hillside contradicted
a doctor’s request to cut back antipsychotic medication.
“We
have corrected this already with the department,” said Vilmar Agustin,
Hillside’s director of nursing.
At
the Herman Health Care Center in San Jose, investigators found that
between August 2010 and January 2011, pharmacist services were billed
for as little as $23.75 an hour and not more than $29.75. The state
also found prescription irregularities.
Mandy
Sollis, Herman Health’s business office director, wrote in an e-mail:
“We did increase our rate of pay to the pharmacy per regulations.” She
would not specify the amount, saying it was private.
In
the case of the elderly woman in Campbell who was prescribed drugs that
the state investigators said were potentially life-threatening, “With
regard to the investigation, I know there was a deficiency and a plan
of correction,” said Ed Basa, who had been the administrator at
Greenhills Manor at the time of the investigation last June.
At
the Empress Care Center in San Jose, investigators found that a
resident was kept on Risperdal and that the dosage was increased
“without evidence of effectiveness over an eight-month period.” Another
patient was on the antipsychotics Seroquel and Haldol, despite side
effects that included “continuous lip smacking and shaking of the arms
and legs.”
The
resident told investigators “he had been like that for a very long
time.” But the state found nothing in the resident’s chart to indicate
that he suffered from side effects.
In
another case at Empress, the state found that a resident with dementia
who “refused to shower, dress and be groomed” was prescribed Zyprexa,
one of a group of medications called “atypical” antipsychotics, which
the Food and Drug Administration warned in 2005 were not approved for
use in elderly people with dementia because they increase their risk of
dying. That warning was extended in 2008 to include older antipsychotic
drugs like Haldol.
Administrators
at the Empress Care Center did not return calls asking for comment.
Anita
Gore, a spokeswoman for the California Department of Public Health,
said the recent investigations prompted her agency to pass a regulation
limiting the prescription of antipsychotics for Medi-Cal recipients in
nursing homes to uses approved by the federal Food and Drug
Administration.
As
a matter of routine, Ms. Gore said, nursing homes found by the state to
be deficient have 10 days to submit plans of correction, but they can
request an extension. “There is no set deadline for submitting a plan
of correction,” she said.
Mr.
Chicotel of California Advocates for Nursing Home Reform said he was
disappointed with the state’s response to its own findings. Mr.
Chicotel said he was concerned that “not a single facility was issued a
citation or fined.”
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