Individual state approaches to assisted living/residential care (AL/RC) licensing and oversight in the United States result in different practice standards and requirements, including psychotropic medication use. We examined 170 psychotropic medication deficiency citations issued to 152 Oregon AL/RC settings from 2015 to 2019. Applied thematic analysis resulted in the following themes: (1) documentation issues are primarily responsible for noncompliance, (2) unclear parameters place direct care workers in a role paradox, and (3) there is a persistent disconnect about when to seek qualified expertise before requesting psychotropic medications. AL/RC-specific mechanisms for medication prescription and administration are necessary to improve the structure and processes of care. Policymakers might consider how regulations unintentionally incentivize task-oriented versus person-centered care practices.
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References
1.
BangashA.StubbsR.KhanF.SamnaniS.AzizH.MitraM. (2017). Association between antipsychotics and adverse outcomes in dementia. Progress in Neurology and Psychiatry, 21(4), 20–26. https://doi.org/10.1002/pnp.482
2.
BeeberA. S.ZimmermanS.MitchellC. M.ReedD. (2018). Staffing and service availability in assisted living: The importance of nurse delegation policies. Journal of the American Geriatrics Society, 66(11), 2158–2166. https://doi.org/10.1111/jgs.15580
3.
BeeberA. S.ZimmermanS.WretmanC. J.PalmertreeS.PatelK.SloaneP. D. (2021). Potential side effects and adverse events of antipsychotic use for residents with dementia in assisted living: Implications for prescribers, staff, and families. Journal of Applied Gerontology, 41(3), 798–805. https://doi.org/10.1177/07334648211023678
4.
BowblisJ. R.CrystalS.IntratorO.LucasJ. A. (2012). Response to regulatory stringency: The case of antipsychotic medication use in nursing homes. Health Economics, 21(8), 977–993. https://doi.org/10.1002/hec.1775
5.
BowblisJ. R.LucasJ. A.BruntC. (2015). The effects of antipsychotic quality reporting on antipsychotic and psychoactive medication use. Health Services Research, 50(4), 1069–1087. https://doi.org/10.1111/1475-6773.12281
6.
BowmanS. E.RogersW. A. (2016). Understanding decision making among direct care workers in assisted living. Journal of Cognitive Engineering and Decision Making, 10(4), 369–390. https://doi.org/10.1177/1555343416656952
7.
CarderP.ZimmermanS.WretmanC. J.PreisserJ. S.DysS.SloaneP. D. (2022). As-needed prescribing and administration of psychotropic medications in assisted living: A 7-state study. Journal of the American Medical Directors Association, 23(6), 1038–1044. https://doi.org/10.1016/j.jamda.2021.11.009
8.
CarderP. C. (2012). Learning about your residents”: How assisted living residence medication aides decide to administer pro re nata medications to persons with dementia. The Gerontologist, 52(1), 46–55. https://doi.org/10.1093/geront/gnr099
9.
CarderP. C.O’KeeffeJ. (2016). State regulation of medication administration by unlicensed assistive personnel in residential care and adult day services settings. Research in Gerontological Nursing, 9(5), 209–222. https://doi.org/10.3928/19404921-20160404-03
10.
CarderP. C.ZimmermanS.SchumacherJ. G. (2009). Understanding the intersection of individual needs and choices with organizational practices: The case of medication management in assisted living. The Gerontologist, 49(4), 463–473. https://doi.org/10.1093/geront/gnp063
11.
CastleN. G.EngbergJ. B. (2007). Nursing home deficiency citations for medication use. Journal of Applied Gerontology, 26(2), 208–232. https://doi.org/10.1177/0733464807300223
12.
CastleN. G.FergusonJ. C. (2010). What is nursing home quality and how is it measured?The Gerontologist, 50(4), 426–442. https://doi.org/10.1093/geront/gnq052
13.
CrossA. J.Etherton-BeerC. D.CliffordR. M.PotterK.PageA. T. (2021). Exploring stakeholder roles in medication management for people living with dementia. Research in Social and Administrative Pharmacy, 17(4), 707–714. https://doi.org/10.1016/j.sapharm.2020.06.006
14.
CrystalS.OlfsonM.HuangC.PincusH.GerhardT. (2009). Broadened use of atypical antipsychotics: Safety, effectiveness, and policy challenges. Health Affairs, 28(5), w770–781. https://doi.org/10.1377/hlthaff.28.5.w770
15.
DavilaH.JohnsonD. R. (2021). Maximizing well-being in the context of long-term services and supports: A Q methodological approach. Clinical Gerontologist, 45(5), 1155–1166. https://doi.org/10.1080/07317115.2021.1899092
FeredayJ.Muir-CochraneE. (2006). Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods, 5(1), 80–92. https://doi.org/10.1177/160940690600500107
18.
HrybykR. L.FrankowskiA. C.NemecM.PeeplesA. D. (2021). It’s a lot!” the universal worker model and dementia care in assisted living. Geriatric Nursing, 42(1), 233–239. https://doi.org/10.1016/j.gerinurse.2020.08.006
19.
JuneJ. W.MengH.DobbsD.HyerK. (2020). Using deficiency data to measure quality in assisted living communities: A Florida statewide study. Journal of Aging & Social Policy, 32(2), 125–140. https://doi.org/10.1080/08959420.2018.1563471
20.
KalesH. C.GitlinL. N.LyketsosC. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. BMJ, 350(8003), h369. https://doi.org/10.1136/bmj.h369
21.
KellyC.Craft MorganJ.KempC. L.DeichertJ. (2020). A profile of the assisted living direct care workforce in the United States. Journal of Applied Gerontology, 39(1), 16–27. https://doi.org/10.1177/0733464818757000
22.
KonetzkaR. T.YanK.WernerR. M. (2020). Two decades of nursing home compare: What have we learned?Medical Care Research and Review, 78(4), 295–310. https://doi.org/10.1177/1077558720931652
23.
LapaneK. L. (2018). Reducing off-label antipsychotic use in older adults: Time to look beyond the doors of nursing homes. Journal of the American Geriatrics Society, 66(6), 1055–1057. https://doi.org/10.1111/jgs.15262
24.
LeporeM. J.LimaJ. C.MillerS. C. (2020). Nursing home culture change practices and survey deficiencies: A national longitudinal panel study. The Gerontologist, 60(8), 1411–1423. https://doi.org/10.1093/geront/gnaa063
25.
LernerN. B.JohantgenM.TrinkoffA. M.StorrC. L.HanK. (2014). Are nursing home survey deficiencies higher in facilities with greater staff turnover. Journal of the American Medical Directors Association, 15(2), 102–107. https://doi.org/10.1016/j.jamda.2013.09.003
26.
ManginD.BahatG.GolombB. A.MalleryL. H.MoorhouseP.OnderG.PetrovicM.GarfinkelD. (2018). International group for reducing inappropriate medication use & polypharmacy (IGRIMUP): Position statement and 10 recommendations for action. Drugs & Aging, 35(7), 575–587. https://doi.org/10.1007/s40266-018-0554-2
27.
MaustD. T.KimH. M.ChiangC.KalesH. C. (2018). Association of the centers for medicare & 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 Internal Medicine, 178(5), 640–647. https://doi.org/10.1001/jamainternmed.2018.0379
28.
MaustD. T.LangaK. M.BlowF. C.KalesH. C. (2017). Psychotropic use and associated neuropsychiatric symptoms among patients with dementia in the USA. International Journal of Geriatric Psychiatry, 32(2), 164–174. https://doi.org/10.1002/gps.4452
29.
McKenzieG.TeriL.PikeK.LaFaziaD.van LeynseeleJ. (2012). Reactions of assisted living staff to behavioral and psychological symptoms of dementia. Geriatric Nursing, 33(2), 96–104. https://doi.org/10.1016/j.gerinurse.2011.12.004
30.
MuellerC.JohnC.PereraG.AarslandD.BallardC.StewartR. (2021). Antipsychotic use in dementia: The relationship between neuropsychiatric symptom profiles and adverse outcomes. European Journal of Epidemiology, 36(1), 89–101. https://doi.org/10.1007/s10654-020-00643-2
31.
NeuendorfK. A. (2019). Content analysis and thematic analysis. In BroughP. (Ed.), Advanced research methods for applied psychology: Design, analysis, and reporting (pp. 211–223). Routledge Taylor and Francis Groups.
ParsonsC. (2017). Polypharmacy and inappropriate medication use in patients with dementia: An underresearched problem. Therapeutic Advances in Drug Safety, 8(1), 31–46. https://doi.org/10.1177/2042098616670798
34.
PaudelA.GalikE.ResnickB.DoranK.BoltzM.ZhuS. (2020). A description of staff-resident interactions in assisted living. Clinical Nursing Research, 30(5), 690–698. https://doi.org/10.1177/1054773820974146
35.
ProcterR.WhertonJ.GreenhalghT. (2018). Hidden work and the challenges of scalability and sustainability in ambulatory assisted living. ACM Transactions on Computer-Human Interaction, 25(2), 1–26. https://doi.org/10.1145/3185591
36.
RamseyC. M.GnjidicD.AgogoG. O.AlloreH.MogaD. (2018). Longitudinal patterns of potentially inappropriate medication use following incident dementia diagnosis. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 4(1), 1–10. https://doi.org/10.1016/j.trci.2017.10.008
SenguptaM.LondonJ. P.CaffreyC.MelekinA.SinghP. (2022). Post-acute and long-term care providers and services users in the United States, 2017–2018. Vital Health Statistics, 3(47). https://www.cdc.gov/nchs/data/series/sr_03/sr03-047.pdf
39.
SiegelE. O.YoungH. M. (2020). Assuring quality in nursing homes: The black box of administrative and clinical leadership-A scoping review. The Gerontologist. 61(4), e147–e162. https://doi.org/10.1093/geront/gnaa175
40.
SikmaS. K.YoungH. M.ReinhardS. C.MunroeD. J.CartwrightJ.McKenzieG. (2014). Medication management roles in assisted living. Journal of Gerontological Nursing, 40(6), 42–53. https://doi.org/10.3928/00989134-20140211-02
41.
SmithL.CarderP.BucyT.WinfreeJ.BrazierJ. F.KaskieB.ThomasK. S. (2021). Connecting policy to licensed assisted living communities, introducing health services regulatory analysis. Health Services Research, 56(3), 540–549. https://doi.org/10.1111/1475-6773.13616
42.
SpellbringA. M.RyanJ. W. (2003). Medication administration by unlicensed caregivers: A model program. Journal of Gerontological Nursing, 29(6), 48–54. https://doi.org/10.3928/0098-9134-20030601-10
43.
SpetzJ.StoneR. I.ChapmanS. A.BryantN. (2019). Home and community-based workforce for patients with serious illness requires support to meet growing needs. Health Affairs, 38(6), 902–909. https://doi.org/10.1377/hlthaff.2019.00021
ThomasK. S.WretmanC. J.SloaneP. D.CarderP.SchwartzL.BeeberA. S.ZimmermanS. (2021). To what extent do local nursing home prescribing patterns relate to psychotropic prescribing in assisted living?Journal of the American Medical Directors Association, 22(9), 1813–1818. https://doi.org/10.1016/j.jamda.2020.11.037
46.
TrinkoffA. M.LernerN. M.StorrC. L.YoonJ. M.YangB. K.HanK. (2019). Nursing staff availability and other facility characteristics in relation to assisted living care deficiencies. Journal of Nursing Regulation, 10(1), 21–27. https://doi.org/10.1016/S2155-8256(19)30079-1
47.
TrinkoffA. M.YoonJ. M.StorrC. L.LernerN. B.YangB. K.HanK. (2020). Comparing residential long-term care regulations between nursing homes and assisted living facilities. Nursing Outlook, 68(1), 114–122. https://doi.org/10.1016/j.outlook.2019.06.015
48.
VaismoradiM.Vizcaya MorenoF.SletvoldH.JordanS. (2019). PRN medicines management for psychotropic medicines in long-term care settings: A systematic review. Pharmacy, 7(4), 157. https://doi.org/10.3390/pharmacy7040157
49.
WessonK. W.DonohoeK. L.PattersonJ. A. (2020). CMS mega-rule update and the status of pharmacy-related deficiencies in nursing homes. Journal of Applied Gerontology, 40(11), 1617–1627. https://doi.org/10.1177/0733464820967589
50.
WitryM. J.DoucetteW. R. (2014). Community pharmacists, medication monitoring, and the routine nature of refills: A qualitative study. Journal of the American Pharmacists Association, 54(6), 594–603. https://doi.org/10.1331/JAPhA.2014.14065
51.
YoonJ. M.TrinkoffA. M.GalikE.StorrC. L.LernerN. B.BrandtN.ZhuS. (2022). Deficiency citations on inappropriate psychotropics use related to care for behavioral symptoms of dementia. Journal of the American Medical Directors Association, 23(11), 1772–1779. https://doi.org/10.1016/j.jamda.2022.04.006
52.
YoungH. M.GrayS. L.McCormickW. C.SikmaS. K.ReinhardS.TrippettL. J.ChristliebC.AllenT. (2008). Types, prevalence, and potential clinical significance of medication administration errors in assisted living. Journal of the American Geriatrics Society, 56(7), 1199–1205. https://doi.org/10.1111/j.1532-5415.2008.01754.x
53.
YoungH. M.SikmaS. K.ReinhardS.McCormickW. C.CartwrightJ. C. (2013). Strategies to promote safe medication administration in assisted living settings. Research in Gerontological Nursing, 6(3), 161–170. https://doi.org/10.3928/19404921-20130122-01
54.
ZimmermanS.LoveK.SloaneP. D.CohenL. W.ReedD.CarderP. C. (2011). Medication administration errors in assisted living: Scope, characteristics, and the importance of staff training. Journal of the American Geriatrics Society, 59(6), 1060–1068. https://doi.org/10.1111/j.1532-5415.2011.03430.x
55.
ZimmermanS.ScalesK.WigginsB.CohenL. W.SloaneP. D. (2015). Addressing antipsychotic use in assisted living residents with dementia. Journal of the American Geriatrics Society, 63(9), 1970–1971. https://doi.org/10.1111/jgs.13625
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