Failure to Conduct Timely Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a Drug Regimen Review (DRR) was completed for a resident, identified as Resident #13, within the required time frame. This resident was receiving a combination of medications, including a relaxer and other high-risk medications, which have the potential to cause serious interactions and side effects. Despite the requirement for a monthly review by a licensed pharmacist, the necessary review was not conducted, leading to a deficiency in compliance with federal regulations. Resident #13, who was admitted to the facility following an accident, was observed to be taking multiple medications, including high-risk ones, without a documented attempt at a Gradual Dose Reduction (GDR). The resident's Minimum Data Set (MDS) indicated that no GDR had been attempted, and there was a lack of assessment or follow-up information regarding the medication regimen. The psychiatrist involved in the resident's care acknowledged the effectiveness of the medications but also noted that recommendations for GDR were typically only followed when mandated by the pharmacy. Interviews with the Director of Nursing (DON) revealed that the resident had been observed with symptoms such as drooling and excessive sleepiness, which led to the discontinuation of one of the medications. However, the Medication Regimen Review Log showed no completed reviews for the resident, highlighting a failure in the facility's processes to ensure timely and appropriate medication management. This oversight in conducting the required DRR and addressing potential medication interactions contributed to the identified deficiency.
Plan Of Correction
F 756 Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #13 the psychiatrist reviewed the residents, medications listed below: decreased on from 45mg to 30mg. was decreased from 300mg to 200mg 1mg continue current dose; no changes. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the DON/designee of current residents receiving medication(s) to ensure Drug Regimen Reviews are acted upon to include: a medication review by the physician and/or psych provider indicating an attempt at a gradual dose reduction (GDR) and/or a failed GDR to support the rationale for continuing the current medication regimen medications to be completed by. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; DON and ADON reeducated by the Chief Nursing Officer on the components of this regulation and to ensure Drug Regimen Reviews are acted upon to include: a medication review by the physician and/or psych provider indicating an attempt at a gradual dose reduction (GDR) and/or a failed GDR to support the rationale for continuing the current medication regimen medications to be completed by. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure Drug Regimen Reviews are acted upon to include: a medication review by the physician and/or psych provider indicating an attempt at a gradual dose reduction (GDR) and/or a failed GDR to support the rationale for continuing the current medication regimen r/t medications 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing, Schedule to be modified PRN based on findings.