Failure to Complete and Implement Monthly Pharmacist Medication Reviews
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's medication regimen review recommendations were maintained and followed for one resident, and also failed to ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for another resident. For one resident with a history of encephalopathy, bipolar disorder, major depressive disorder, long-term use of anticoagulants and insulin, chronic pain, and heart failure, the consultant pharmacist made a recommendation on 3/31/2025 to either discontinue Apixaban or reduce the dose of Eliquis, which was agreed upon by the physician. However, this recommendation was not carried out by the facility, and there was no evidence in the medical record that the physician's response was acted upon in a timely manner. Additionally, for another resident with multiple diagnoses including atherosclerotic heart disease, polyneuropathies, diabetes mellitus, chronic pain, anxiety disorder, insomnia, and substance abuse, the facility was unable to provide evidence that monthly medication regimen reviews were completed by the consultant pharmacist for several months. Only three reviews were available for a period spanning from August 2024 through April 2025, indicating that the required monthly reviews were not consistently performed for this resident. The facility's policy requires that the Director of Nursing or designee ensure monthly drug regimen reviews are completed and that any outstanding recommendations are followed up with physicians or the Medical Director as needed. Despite this policy, the records reviewed showed lapses in both the completion of monthly reviews and the implementation of pharmacist recommendations, as evidenced by missing documentation and unaddressed recommendations in the residents' records.