Failure to Document Medication Regimen Reviews
Penalty
Summary
The facility failed to provide documentation that medication regimen reviews (MRR) were completed for three residents. The facility's policy requires that the consultant pharmacist provide MRRs to designated personnel, who must ensure that the attending physician, medical director, director of nursing, and other necessary staff receive the recommendations. The attending physician is required to document in the resident's health record that any identified irregularity has been reviewed and what action, if any, has been taken. However, the facility did not maintain readily available copies of the consultant pharmacist's reports as part of the residents' permanent health records. Resident R4, admitted to the facility with diagnoses including high blood pressure, bipolar disorder, and dementia, was prescribed medications such as Trazodone and Ziprasidone. Despite pharmacist progress notes indicating irregularities and recommendations on two occasions, the facility failed to provide the consultant pharmacist reports for these dates. Similarly, Resident R26, with diagnoses of difficulty swallowing, dementia, and malnutrition, was prescribed Quetiapine. A pharmacist progress note indicated irregularities, but the corresponding report was not found in the resident's clinical record. Resident R78, diagnosed with Alzheimer's disease, dementia, and malnutrition, was prescribed several medications, including Escitalopram and Divalproex. A pharmacist progress note also indicated irregularities, yet the facility could not provide the consultant pharmacist report. During an interview, the Director of Nursing confirmed the inability to locate and provide the required documentation for the medication regimen reviews for these residents.
Plan Of Correction
Pharmacy recommendations were reviewed by physician and addressed for Residents #4, #26, and #78. Residents #4, #26 and #78 had no negative outcome. To identify other residents that have the potential to be affected, the DON/designee reviewed pharmacy recommendations from 9/2024 to current (date) to ensure they are reviewed by the physician and addressed timely. Corrections will be made as needed. To prevent this from recurring, the RDCS/designee educated DON/ADON/supervisors on ensuring pharmacy medication regimen reviews and recommendations are reviewed by the physician, addressed and documented timely. To monitor and maintain ongoing compliance, the DON/designee will audit pharmacy recommendations weekly x4 then monthly x2 to ensure pharmacy medication regimen reviews and recommendations are reviewed by the physician, addressed and documented timely. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.