Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the pharmacy completed a Medication Regimen Review (MRR) at least once a month for two residents. According to the facility's policy, the drug regimen of each resident should be reviewed monthly by a licensed pharmacist to promote positive outcomes and minimize adverse consequences. However, the clinical records for two residents, one admitted with diagnoses including dementia, depression, and diabetes, and another with high blood pressure, diabetes, and dementia, showed that MRRs were not completed for several months in 2024. For the first resident, the clinical record lacked evidence of MRRs for February, April, May, June, July, September, October, and November 2024. Similarly, the second resident's record did not indicate MRRs for September, October, November, and December 2024. The Director of Nursing confirmed during an interview that the facility failed to complete the required monthly pharmacy MRRs, which is a violation of the facility's policy and federal regulations.
Plan Of Correction
Residents R 5 and R 56 medication regime review was completed by clinical pharmacist. Like residents have the potential to be affected. A house audit was completed by a clinical pharmacist to ensure current residents had a completed medication regime review. The Director of nursing and clinical pharmacist were educated on medication regime reviews by administrator of designee. The Director of nursing will audit the clinical pharmacist medication regime reviews monthly for compliance. Findings will be reported to quality assurance meetings.