SC attorney: Nursing home residents overprescribed antipsychotics, creating ‘horrific situations’

“Oh, would you look at that!” Janet Hart said.

It’s 2020, and Hart smiles while opening a present alongside her great-grandson, less than a year into her time at a nursing home in Canada.

But just four years later, much had changed for Hart, who had been diagnosed with dementia prior to moving into the senior citizens home.

A cell phone video from her daughter shows the 78-year-old Hart in a wheelchair, crying and clutching a baby doll. Her daughter, Tamara Hart, said her mother was over-medicated on antipsychotics at Santa Maria Senior Citizens Home and had become a “drooling zombie.”

Tamara Hart said her mother’s baby doll was her source of comfort after becoming “utterly defeated.”

The accusations are not an anomaly and not out of the realm of possibility. Nursing homes across North America are overprescribing and falsely administering antipsychotic medications to senior residents, according to experts, who say it’s easier and cheaper for homes to drug the elderly than to hire more caregivers.

And the problem is particularly prevalent in South Carolina, according to one attorney who said he gets frequent calls from loved ones ready to sue nursing homes.

Greenville attorney Matt Christian specializes in nursing home abuse cases. He said antipsychotics are often used to heavily sedate residents as a substitute for proper staffing. He attributed the staffing shortages to the greed of higher-level executives prioritizing profits over care.

“The problem is not that the nursing home chains don’t have the money,” Christian said. “They have the money. It’s a greed and lack of care issue.”

Christian said there’s another reason why nursing homes overprescribe antipsychotics.

Medicare reimburses facilities that use sedatives, including antipsychotics, when they are prescribed for medically necessary reasons. Christian said that means there’s a financial incentive for nursing homes to diagnose residents with psychological disorders.

So some nursing homes manipulate the system by diagnosing more residents, Christian said.

Making choices

Reports of antipsychotic usage can be found in the Minimum Data Set — a federally mandated quarterly report that U.S. nursing homes submit detailing medication use and other resident care data.

The data influences the facility’s quality rating under the Centers for Medicare and Medicaid Services (CMS), which evaluates nursing homes on metrics such as falls, antipsychotic use, depression, vaccinations, weight loss and community discharges.

Canada regulates nursing homes in much the same way, under the Canadian Standards Association.

For Tamara Hart and her mother, systematic failures caused her mother’s last years of life to “turn into hell” at Santa Maria Senior Citizens Home in Saskatchewan, Canada.

“When you go in there, you lose all of your rights, your dignity,” Tamara Hart said. “The loss of dignity turned into depression, which turned into agitation. And that was never who my mother was.”

Tamara Hart talked to and provided videos to the Carolina News & Reporter after seeing an inquiry posted by a reporter in a Facebook group focused on nursing home neglect and abuse.

Hart family members have not filed a lawsuit but said they’re not ruling that out.

Multiple voice messages left for Santa Maria Senior Citizens Home by the Carolina News & Reporter over a three-week period were not returned.

Video footage provided to the Carolina News & Reporter shows Janet Hart screaming and crying in distress as staff forcibly remove her bedcovers, undress her and place her in a sit-to-stand lift to transfer her to a wheelchair.

Santa Maria staff told Janet Hart’s family she was abusive toward them, accusing her of “combative behavior,” her daughter said. Tamara Hart told the Carolina News & Reporter that staff members were the ones being abusive, ultimately leading to her mother being prescribed eight antipsychotic drugs.

She said neither she, nor as far as she knows, her mother, were informed of the prescription changes.

Tamara Hart installed a camera in her mother’s room, which she informed her mother about, and described the footage viewed later as “shocking and devastating.”

Tamara Hart said staff would abruptly enter her mother’s room in the morning without speaking, ignoring her dementia and treating her like a “chore.”

Janet Hart was at the facility from 2020 to 2024, during which Tamara Hart said the abuse progressively worsened.

“The videos showed my mother was in so much fear and panic,” Tamara Hart said. “She would start kicking, yelling at them to stop. In her mind, she was fighting for her life.”

She said moving her mother back home was not an option at the time. But she said she lives with regret every day over that decision.

“I wish I just sucked it up and brought her home,” Tamara Hart said. “But in my heart, I believed (the home) would be the very best thing for her.”

Tamara Hart wanted to hire a lawyer but said a lack of responses from firms and the cost of upfront legal fees was a barrier.

Using antipsychotics

Charleston psychiatrist Dr. LalithKumar Solai said antipsychotics should only be used as a last resort to manage agitation in dementia patients.

He said non-medical approaches “always seem to work” once caregivers take the time to understand the patient.

“I distinctly remember a patient who loves Diet Pepsi, and every time she was agitated, all we had to (do) was show her a picture of a can of Diet Pepsi, and she would calm down,” Solai said. “There was no need to give her medication.”

Christian, the attorney, said nursing homes have exploited a loophole to justify the use of antipsychotics by either falsifying government reports or misdiagnosing residents — often with schizophrenia.

“We’ve had an increasing number of cases where patients that have never been diagnosed with schizophrenia are suddenly diagnosed when they enter the facility, just to get away with the use of antipsychotics,” Christian said. “There have been many horrific situations.”

Christian said schizophrenia “almost always comes on much, much earlier in life.”

Christian recently represented David Blakeney, a 63-year-old dementia patient at Dundee Manor in Bennettsville, South Carolina, in a lawsuit.

After Blakeney was admitted in late 2016, Christian said Blakeney was diagnosed two weeks after admission with schizophrenia, a condition Christian said was never properly evaluated.

Blakeney was prescribed the antipsychotics Haldol and Zyprexa and suffered abuse and neglect, including extreme weight loss and bedsores, which led to the amputation of one of his feet, according to the lawsuit. Blakeney died after being at the facility for less than a year.

The lawsuit was settled in January 2022 for $295,000, according to South Carolina court records.

Centers for Medicare and Medicaid Services data shows schizophrenia diagnoses in nursing homes rose 70% from 2012 to 2021. Nearly one-third of reported cases during that period lacked corresponding Medicare claim histories, which is a record of all medical services a Medicare beneficiary has received and filed claims for.

Solai said schizophrenia is typically diagnosed in a person’s early 20s and is rarely identified after age 40.

Antipsychotics may be used to temporarily address severe dementia symptoms, he said. But prescribing more than one-fourth of the typical schizophrenic dosage is unsafe.

Members of Congress: Homes choose profit over quality care

Four long-time Democratic members of Congress recently sent a letter to three top nursing home executives saying they’re putting their greed above the welfare of residents.

Between 2019 and 2023, those nursing home entities paid more than $250 million to their senior executives, with a 30% rise in compensation from 2022 to 2023, according to S&P Capital IQ data the lawmakers provided in the letter.

Christian said the money is funneled from nursing homes to their parent companies. The parent companies then claim their facilities are losing money and operating at a deficit as billions of dollars across the industry flow to the top executives, he said.

While these financial maneuvers enable significant profits at the corporate level, they often leave individual facilities ill-equipped to provide adequate care, Christian said.

In South Carolina’s CMS rankings, nursing homes are falling short in key measures of quality and safety.

Of South Carolina’s 189 nursing homes, 21 held a one-star rating as of September.

The state ranked 49^th best on AARP’s 2023 Long-Term Services and Supports Scorecard, which evaluates homes’ affordability, safety, and access every three years. It also ranked 39^th best for inappropriate antipsychotic use.  

In August 2019, William Albert Cardwell died in Lexington County from an overdose of the antipsychotic Clozapine after staff at Brook Pine Community Residential Care Facility failed to conduct regular checks and properly monitor his medication, according to testimony in S.C. court records reviewed by Carolina News & Reporter.

The wrongful death lawsuit accused the facility of negligence for those failures. It was settled in November 2023 for $150,000.

In 2011, CMS implemented the National Quality Strategy to reduce health disparities and improve care under the Affordable Care Act. The strategy aims to reduce health disparities through improved care, healthier communities and more affordable healthcare.

Despite those efforts, Christian said staffing shortages and inadequate training undermine the success of reforms.

Alainna Lindsay said her mother, Kathleen Lindsay, was a victim of wrongful antipsychotic use at Elkton Nursing and Rehabilitation Center in Elkton, Maryland.

Kathleen Lindsay entered the facility for short-term rehab due to a broken elbow. According to her daughter, the staff mistakenly confused her with another resident who had serious mental health issues.

Alainna Lindsay said her mother was wrongfully given 2 mg of the antipsychotic Risperidone for six weeks. She said she went from “fully functional to bedridden.”

According to Alainna Lindsay, Elkton Nursing Home refused to admit its mistake after she continued to fight for her mother’s life, even drawing the nonprofit Delaware Hospice across state lines to intervene.

“I don’t think my mother would have lived but another couple of weeks if (Delaware Hospice) hadn’t gotten involved,” Alainna Lindsay said.

The daughter spent 97 days and $14,000 to get her mother moved into her home.

Like Tamara Hart, Alianna Lindsay reached out to the Carolina News & Reporter after seeing an inquiry posted in a Facebook group.

A representative for Elkton Nursing and Rehabilitation Center said an administrator would return a phone call from the Carolina News & Reporter. No one called back.

New staffing requirements. Industry pushback

Amid growing concerns over staffing shortages and care quality, CMS has introduced a landmark rule aimed at strengthening nursing home standards.

CMS issued a “final rule” in April that requires nursing homes to ensure each resident receives 3.48 hours of direct care from nursing staff every day — a first-time mandate, as no previous requirement specified care hours per resident.

The rule also mandates a registered nurse be on-site 24 hours a day and that states disclose how Medicaid payments are allocated to ensure transparency in staff compensation.

Despite these reforms, opposition has surfaced.

In their Sept. 13 letter, the four Congress members rebuked three major for-profit nursing home companies’ claims that they “cannot afford to meet new minimum staffing requirements.”

The letter states the rule’s implementation would save 13,000 lives annually, calling the companies’ dispute “insulting.”

“The basis of your opposition to minimum staffing standards appear to be quite simple: greed,” the lawmakers wrote.

Also, S.C. Attorney General Alan Wilson announced in October he is co-leading a lawsuit with 20 other state attorneys general to overturn the new nursing home staffing mandate.

The Carolina News & Reporter requested an interview with Wilson. A spokesperson said Wilson was out of town and no one was immediately available for an interview.

However, the spokesperson provided a press release in which Wilson said the mandate would mean financial ruin for nursing homes and families.

“This new staffing rule is impossible to implement based on the nursing shortage and will force the closure of nursing homes and raise costs at those that remain, devastating families financially and leaving people without the care they need,” Wilson said.

Sam Brooks, director of public policy for The National Consumer Voice, called the lawsuit “shameful.”

The National Consumer Voice is a non-profit advocacy organization based in Washington, D.C., that works to improve the quality of care in nursing homes and other long-term care facilities.

“The idea that 20 of the nation’s officers, who are charged with protecting the public, are taking the sides of a billion-dollar industry against nursing home residents is disgraceful,” Brooks said. “It goes to show how effective the nursing home industry is at convincing policymakers to make a big deal out of something that simply isn’t true. They are drowning out the voices of residents and putting them in further harm.”

South Carolina’s issues

The nursing home industry already faces a widespread workforce crisis.

The Health Resources and Services Administration predicts South Carolina will have the fourth-largest registered nurse shortage in the country by 2037, with a shortfall of 11,860 nurses. Registered nurses provide the most advanced direct care in nursing homes.

The AARP scorecard says wages for direct care workers in South Carolina are $2.84 per hour lower than other entry-level jobs in comparable occupations.

The scorecard also says the state’s nursing home staff turnover rate is 57.7% within any given year. That is higher than the already concerning national average of 53.9%.

Christian said staffing is 60-70% of nursing homes’ overhead. He suggests staffing shortages are an increased effort to line the pockets of executives.

Brooks said The National Consumer Voice advocates for federal and state laws to ensure transparency and accountability in the use of untracked funds.

“Billions of dollars each year go unaccounted for,” Brooks said. “This is taxpayer dollars. They’re getting rich off our pockets.”

Medicare, which is paid to older patients, and Medicaid, which goes to limited-income patients, are funded by federal and state taxes. In 2019, the federal government paid out $66.5 billion in nursing home care for Medicaid-covered residents, according to The Medicaid and CHIP Payment and Access Commission.

The National Consumer Voice’s Brooks thinks change will come only with community pressure.

“There’s going to come a day of accountability for lawmakers, but we can’t wait for that,” Brooks said. “People need to make their voices heard. One of the things we do constantly is try to get people to contact their senators and legislators and let them know. People don’t think it matters, but trust me, it does.”

Christian urges families to remain as involved as possible in their loved one’s care if a nursing home is the only option.

“You have to go visit,” Christian said. “You have to go at different times of the day. If you don’t, your loved one is going to get left in the wayside.”

CMS’s final rule regulations must be implemented by May 2027 by non-rural facilities and May 2029 by rural ones. Noncompliance could result in penalties, including facility closures, denial of Medicare payments for new admissions and mandatory resident transfers.

Tamara Hart described her mother as her rock — the type to invest herself in others and help those in need. A mother of three with a competitive spirit, she thrived in her real estate career.

“She accepted me exactly where I was at every point in my life,” Tamara Hart said. “It didn’t matter how or what I was going through. She was always there.”

Tamara Hart said she has been determined to bring about change ever since her mother died this year.

Part of that change involves becoming a source of support at the senior citizens home where her mother stayed, visiting every week to spend time with the residents.

“I’ve just come to love everyone in there,” Hart said. “But every time I go, I leave upset. … Whenever a new person comes in, all bright-eyed, I think to myself, ‘Oh, this isn’t going to last long.’”