Chemical Restraints in New Jersey Nursing Homes When Sedating Drugs Cross the Line

Chemical restraints in nursing homes and when sedating drugs cross the line

Many families first notice the change during a visit. Your loved one may seem unusually sleepy, confused or withdrawn. You may wonder whether a new medicine is the reason.

Chemical restraints in nursing homes are drugs used to control a resident’s behavior or movement for discipline or staff convenience. They are not used to treat a medical symptom. Federal and New Jersey rules give every nursing home resident the right to be free from chemical restraints used this way.

Antipsychotic and sedating drugs can be proper treatment, but only when a specific condition calls for them. If a drug problem involves the wrong dose or the wrong medicine, our page on medication errors in nursing homes covers that issue.

What families need to know

• a sedating drug should treat a diagnosed condition, not make a resident easier to manage
• federal rules limit how long as-needed psychotropic orders can last
• you can ask the care team why a drug was ordered and who agreed to it

What counts as a chemical restraint

The question is why a facility gives a drug, not just which drug it is. The same medicine can be proper treatment for one resident and a restraint for another. What matters is whether it treats a diagnosed medical symptom.

Under 42 CFR 483.10(e)(1), a resident has the right to be free from any chemical restraint used for discipline or convenience and not needed to treat medical symptoms. A drug used mainly to keep a resident quiet, still or easier to manage may fall into that category. So may a drug given because the unit is short-staffed.

Federal rules also place this right inside the protection against abuse and neglect. Under 42 CFR 483.12, the right to be free from abuse includes freedom from any physical or chemical restraint not needed to treat medical symptoms.

Drugs most often involved

Federal rules use the term psychotropic drug for any drug that affects the brain in ways linked to thinking, mood and behavior. Under 42 CFR 483.45(c)(3), that includes these four groups, among others. They are antipsychotics, antidepressants, antianxiety drugs and hypnotics, which are sleep medicines.

Antipsychotics draw the most attention in nursing homes. They are approved to treat certain mental health conditions. Some facilities also give them to residents with dementia to calm agitation or other behaviors.

Sleep medicines and calming drugs for anxiety raise similar questions. Each of these drugs can help the right patient. The concern is use without a documented reason, or use that continues long after the reason has passed.

The federal warning about antipsychotics and dementia

The U.S. Food and Drug Administration requires a boxed warning on antipsychotic drug labels. A boxed warning is the agency’s most prominent label warning. It says older adults who take these drugs for psychosis linked to dementia have a higher risk of death.

One drug’s FDA label lays out the data. Studies of 17 trials, mostly of newer antipsychotics, found a risk of death 1.6 to 1.7 times higher than with a placebo, an inactive pill. Most of the deaths appeared to be heart-related or caused by infections.

The labels also say these drugs are not approved to treat psychosis linked to dementia. This warning does not mean every antipsychotic order is wrong. It does mean a resident with dementia who receives one should have a clear documented reason and close monitoring.

Federal rules on chemical restraints in nursing homes

Nursing homes that take Medicare or Medicaid must follow 42 CFR 483.45(e). After a full review of the resident, the nursing home must follow several rules. The federal rule says:

• a resident who has not used psychotropic drugs does not get one unless it treats a specific condition diagnosed and documented in the record
• a resident who uses psychotropic drugs gets gradual dose reductions and behavioral approaches to try to stop the drugs, unless a doctor finds that unsafe
• a resident does not get a psychotropic drug on an as-needed order unless it treats a diagnosed condition documented in the record

Staff often call as-needed orders PRN orders. Under the same rule, PRN orders for psychotropic drugs generally last no more than 14 days. For drugs other than antipsychotics, the prescriber can extend the order by documenting the reason and how long it should last.

A PRN order for an antipsychotic is limited to 14 days. Before renewing it, the prescribing clinician must evaluate the resident to decide whether the drug is still appropriate.

Pharmacist review of the drug regimen

Federal rules add another check. Under 42 CFR 483.45(c), a licensed pharmacist must review each resident’s drugs and medical chart at least once a month. The pharmacist must report any problems to the resident’s doctor, the medical director and the director of nursing.

The facility must act on those reports. Problems include any drug the rule treats as unnecessary. So the monthly review is one place where staff should catch a sedating drug that isn’t needed.

You can ask whether a pharmacist flagged any concerns about your loved one’s medicines. You can also ask what the physician did in response.

Consent and the right to refuse

New Jersey also protects nursing home residents under state law. N.J.A.C. 8:39-4.1(a)(6) gives residents the right to be free from improper chemical and physical restraints. It bars restraints used for staff convenience or through excessive drug doses, and it applies whether or not a nursing home takes Medicare or Medicaid.

Under N.J.S.A. 30:13-5, residents have the right to information about their diagnosis, treatment and prognosis, or expected outcome. They may also participate in planning their care and refuse treatment. New Jersey nursing home regulations, under N.J.A.C. 8:39-4.1(a)(4), specifically protect the right to refuse medication and treatment after being informed of the possible consequences.

Federal rules also give residents the right to information about their care and a voice in treatment decisions. When a resident cannot make these decisions, a legal representative usually acts for them. So a new sedating drug should not come as a surprise to the family member who holds that authority.

If no one told you about a new psychotropic drug, you can ask why. Our article on nursing home residents’ rights in New Jersey explains these rights in more detail.

Signs a drug may be used as a restraint

No single sign proves a chemical restraint. A change in alertness may be a sign of neglect, but it can also come from illness, infection or a new diagnosis. Patterns over time often tell more than one visit.

• your loved one is much sleepier or harder to wake than before
• a sudden decline in speech, eating or walking
• new falls or unsteadiness after a new drug started
• staff describe your loved one mainly as difficult or disruptive
• a drug started after a behavior complaint with no new diagnosis
• staff give as-needed doses often, especially at night or on certain shifts

If your loved one becomes unusually difficult to wake, seek immediate medical attention. Do not stop or change prescribed medicine without medical guidance.

Our article on subtle signs of nursing home abuse covers other changes families may notice.

Questions to ask the care team

You have the right to calm, clear answers. These questions can help you understand why a doctor ordered a drug:

• What condition is this drug treating, and where does the record show that diagnosis?
• What behavioral approaches did staff try before the drug?
• When is the next gradual dose reduction planned?
• Is this an as-needed order, and when does it expire?
• Has the pharmacist reviewed this drug and raised any concerns?
• How were consent and authorization handled for this medication?

Write down the answers, the date and the name of the person you spoke with. Ask to discuss the drug and any planned changes at the next care plan meeting. Our article on nursing home care plans explains how those meetings work.

Records that show how a drug was used

Medication records can show whether a doctor ordered a drug for a documented reason. They can also show how often staff gave as-needed doses and who gave them. That helps families and attorneys see the full picture.

• physician orders and progress notes
• the medication administration record, which logs each dose
• behavior monitoring notes
• pharmacist monthly review reports
• care plans and any consent forms

Our article on nursing home injury records after neglect explains how to request the chart.

Common questions about chemical restraints in nursing homes

Is it legal for a nursing home to give my parent an antipsychotic?

It can be, when the drug treats a specific condition that is diagnosed and documented. Federal rules forbid using it for discipline or convenience when it is not needed to treat a medical symptom.

Can a nursing home sedate a resident because it is short-staffed?

Staff convenience is not a medical reason. Federal and New Jersey rules give residents the right to be free from chemical restraints used for convenience. Our page on nursing home neglect explains related care failures.

How long can an as-needed antipsychotic order last?

Under 42 CFR 483.45(e)(5), a PRN order for an antipsychotic is limited to 14 days. Before renewing it, the prescribing clinician must evaluate the resident to decide whether the drug is still appropriate.

Do assisted living facilities follow the same rules?

The federal rules in this article apply to nursing homes that take Medicare or Medicaid. Assisted living residents in New Jersey have their own bill of rights. An attorney can review which rules apply to a specific facility.

Can we file a complaint about overmedication?

Yes. You can contact the New Jersey Long-Term Care Ombudsman at 1-877-582-6995 or the Department of Health complaint hotline at 1-800-792-9770. Both accept concerns about nursing homes and assisted living facilities.

How Ballerini Law helps New Jersey families

The Law Office of Andrew A. Ballerini has over 40 years of experience. We help families with concerns about nursing home and assisted living neglect across New Jersey. We review the medication records, care plans and pharmacist reports to understand what happened.

Richard J. Talbot handles the firm’s nursing home cases. He is certified by the Supreme Court of New Jersey as a Civil Trial Attorney. He is also co-chair of the New Jersey Association for Justice Nursing Home Negligence Committee.

An attorney can visit you in the hospital or at home. If you have questions about your loved one’s care, we’re here to listen.

Call (856) 208-6810 to talk with our team. The consultation is free, and there’s no fee unless we recover compensation for you.

This article provides general information about chemical restraints in New Jersey nursing homes. It is not legal advice, and reading it does not create an attorney-client relationship. No aspect of this advertisement has been approved by the Supreme Court of New Jersey.