Failure to Complete and Document Monthly Drug Regimen Reviews by Licensed Pharmacist
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review (MMR), including a review of the medical chart, for four out of five residents reviewed for unnecessary medications. Specifically, the facility did not have documentation of completed MMRs for certain months, lacked pharmacist signatures on the reviews, and did not have physician signatures indicating that recommendations had been addressed. The facility's policy required monthly reviews by a consultant pharmacist, with written reports provided to the attending physician and documentation of physician responses, but these steps were not consistently followed. For the residents involved, medical records showed complex conditions such as obstructive sleep apnea, major depressive disorder, dementia, Parkinson's disease, diabetes, hypertension, bipolar disorder, schizophrenia, COPD, and catatonic schizophrenia. These residents were prescribed multiple medications, including antidepressants, antipsychotics, anticonvulsants, hypoglycemics, antiplatelets, diuretics, opioids, antianxiety agents, anticoagulants, and antibiotics. The Minimum Data Set (MDS) assessments for these residents did not indicate that a drug regimen review had been completed, and in several cases, the documentation provided by the facility was either missing, incomplete, or contained inconsistencies in dates and signatures. Interviews with facility staff revealed that the facility had recently changed pharmacy providers and was still adjusting to new processes. The DON and pharmacy staff confirmed that MMRs were sometimes conducted remotely, and the forms sent to the facility did not always include the required pharmacist signature. Additionally, the DON's signature was sometimes dated prior to the actual review date, and recommendations from the pharmacist were not always signed off by the physician, as required by facility policy.