Failure to Conduct Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review (MRR) for one of the sampled residents, Resident 34. This oversight led to the resident receiving Lorazepam, a psychotropic medication, beyond the prescribed 14-day period without a physician's order for continuation. Resident 34, who was admitted with conditions including severe cognitive impairment and anxiety disorder, continued to receive Lorazepam from May 2024 through October 2024, despite the absence of a renewal order after the initial prescription expired on 6/14/24. The Director of Nursing confirmed the lapse in medication management and acknowledged that the irregularities in Lorazepam administration could have been identified if the MRR had been conducted as required. The Pharmacy Consultant also confirmed that the monthly MRR was not performed for Resident 34 during this period and stated that the medication should have automatically stopped after 14 days as per the order. The facility's policies and procedures, which mandate monthly MRRs and limit PRN orders for psychotropic drugs to 14 days, were not adhered to, resulting in this deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 34 was assessed and no concerns were noted. The Medical Director was immediately notified of the alleged deficient practice. Pharmacy Consultant and the Nurse Practitioner reviewed the current medications order of Resident 34 on 03/24/2025. The facility will continually strive to monitor residents' drug regimen reviews and Pharmacy reports regarding recommendations to physicians. The facility has Policies and Procedures designed to maintain these goals. Pharmacy review, consultant reviews, quality assurance monitoring, and staff training are examples of the many components utilized to achieve a complete drug regimen review process. On 03/24/2025, the Pharmacy Consultant reviewed the Psychotropic medication of Resident 34. Additionally, it was also reviewed and addressed by the Nurse Practitioner on the same day. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this alleged deficient practice as failure to follow up psychotropic medications with a stop date as indicated could lead to unnecessary, ineffective, and/or excessive dosage of psychotropic medication. The Pharmacy Consultant was immediately notified about the findings, who subsequently reviewed the psychotropic medication of Resident 34 and other residents. Follow-up meetings with the Nurse Practitioner and Pharmacy Consultant were held on 3/24/2025 in the DNS's office to ensure the monthly drug regimen review process will be implemented. Care was coordinated with hospice and the needs for continuing the psychotropic medication. The drug regimen of each resident must be reviewed at least once a month by a Consultant pharmacist. No other residents were found to be affected at this time. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure residents on psychotropic medications receive a thorough monthly pharmacy medication regimen review (MRR) to prevent the risk for residents receiving unnecessary, ineffective, and/or excessive dosage. The DNS provided an in-service on 03/12/2025 to LNs regarding the policy and procedure for carrying out medication orders, including Psychotropic Medications, with emphasis given on the importance of observing the stop date of PRN psychotropic medications when writing the orders. LNs are to ensure that the stop date of Psychotropic medications are observed. The DNS will review the accuracy of new PRN orders daily. The Pharmacy Consultant will review the medication regimen of each resident at least monthly or as needed and provide a written report to the DNS and the Attending Physicians. DNS/Designee will ensure and verify that monthly Drug regimen reviews will be conducted by the Pharmacy and are implemented. How the facility plans to monitor its performance to make sure that solutions are sustained: The DNS/Designee will monitor for compliance. Findings identified will be presented to the monthly QAPI meeting for 3 months for follow-up and recommendations. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/24/2025 F 756