Failure to Document Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRR) were completed by the facility after the consultant pharmacist made recommendations for two residents. The facility's policy requires a licensed pharmacist to perform a monthly drug regimen review, including the medical chart, to promote positive outcomes and minimize adverse consequences. However, for Resident R48 and Resident R53, there were no documented recommendations in their clinical records for several months throughout the year 2024, despite the consultant pharmacist's reviews. Resident R48 was admitted with diagnoses of high blood pressure, depression, and dementia, while Resident R53 had high blood pressure, diabetes, and dementia. During interviews, the Director of Nursing (DON) acknowledged that although the pharmacy conducts monthly reviews, the records were not found in the residents' files. This oversight indicates a failure to adhere to the facility's policy and ensure proper documentation and follow-up on the pharmacist's recommendations, as confirmed by the DON.
Plan Of Correction
R48 and R53 suffered no ill effects in regard to medication pharmacy review. MD reviewed and completed Medication Regimen Reviews for R48 and R53. House audit conducted to make sure no other MMR's were missing. Meeting held with pharmacy with Interim DON, NHA and Unit Manager to discuss process on clinical and medication pharmacy review. Re-training provided to NHA, ADON, and Unit Manager on 1/9/2025 by Pharmerica and additional pharmacy system access provided. Audits will be conducted on following medication regimen reviews weekly and ensuring MMRs are addressed and in record x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.