Failure to Ensure Proper Drug Regimen Review and Documentation
Penalty
Summary
The facility failed to ensure appropriate drug regimen reviews for two residents. For one resident, the pharmacy recommended a specific tapering schedule for a nicotine patch, including a six-week period on a 14 mg dose before tapering to 7 mg, with clear stop dates. However, the resident was switched from 14 mg to 7 mg after only five days, rather than the recommended six weeks. The resident was not informed of this change, and the B-Unit Manager confirmed that nurse practitioners entered new orders after pharmacy recommendations, but she did not have access to the recommendations themselves. For another resident, the pharmacist recommended that the prescriber address the ongoing need for Seroquel, as there was no recent documentation of its necessity or the ability to taper the dose. The prescriber disagreed with the recommendation but did not provide a rationale on the Medication Regimen Review (MRR) form or in the medical record. The A-Unit Manager acknowledged that after discussing the case with the prescriber, she failed to document the reason for disagreement on the MRR form, despite signing it after the conversation.