Failure to Act on Pharmacy Recommendations in Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that irregularities identified in the medication regimen reviews (MRR) by the pharmacy were acted upon in a timely manner for two residents, Resident R2 and Resident R69. The facility's policy requires that the drug regimen of each resident be reviewed at least once a month by a licensed pharmacist, and any irregularities must be reported to the attending physician, medical director, and director of nursing. However, the clinical records for both residents did not include documentation of the recommendations made by the pharmacy during these reviews. Resident R2, who was admitted to the facility with diagnoses including Alzheimer's disease, heart failure, and diabetes mellitus, was on multiple medications such as Escitalopram, Quetiapine, and Lorazepam. Despite the pharmacy completing drug regimen reviews on several occasions, the clinical record lacked documentation of the recommendations made. Similarly, Resident R69, who had diagnoses of high blood pressure, anxiety, and depression, was also on medications like Escitalopram and Lorazepam. The clinical record for Resident R69 also failed to include the pharmacy's recommendations. Interviews with the Director of Nursing (DON) revealed that there was no established process for ensuring that the physician's responses to the MRRs were documented in the residents' clinical records. The DON admitted to not being fully aware of the procedure for handling MRRs and confirmed that the facility did not act on the pharmacy's recommendations in a timely manner for the two residents. This lack of action and documentation led to the deficiency noted in the report.
Plan Of Correction
1. Residents experienced no adverse effects. A whole house audit will be conducted on residents' pharmacy recommendations, and addressed as appropriate. 2. Facility pharmacy was educated on completion of resident drug regimen reviews. 3. NHA to educate DON/designee on drug regimen review process. 4. DON/designee to audit drug regimen reviews of 20% of residents weekly x4 weeks then monthly x 4 months. 5. Results to be submitted to QAPI for review and approval.