Missed Monthly Medication Regimen Review for a Resident
Penalty
Summary
The facility failed to conduct a required monthly Medication/Drug Regimen Review (MRR) for one of five sampled residents during the month of February 2025. Specifically, a resident with diagnoses including cerebral infarction, unspecified psychosis, and diabetes mellitus did not have their medication regimen reviewed by the consulting pharmacist as required by the facility's policy and procedure. The resident's admission record and Minimum Data Set (MDS) indicated various care needs and intact cognitive skills, but there was no documented evidence that their medications were reviewed during the specified month. Interviews with the Director of Nursing (DON) and the Pharmacy Consultant confirmed that the resident's name was not included in the MRR list for the month in question, and therefore, the review was not performed. The facility's policy requires that the consultant pharmacist review each resident's medication regimen at least monthly, including upon admission, to ensure appropriate medication management. The absence of the MRR was verified through record review and staff interviews, confirming non-compliance with established procedures.