Failure to Address Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to address pharmacy medication regimen review (MRR) recommendations for two residents reviewed for unnecessary medications. For one resident with multiple chronic conditions, including COPD, heart failure, and morbid obesity, the pharmacist repeatedly recommended reviewing the continued need for scheduled guaifenesin and the appropriateness of a long-standing as-needed lorazepam order. Despite these recommendations, there was no documentation that the physician or facility staff reviewed or acted upon them, and the resident continued to receive guaifenesin as scheduled, while lorazepam had not been administered for several months. For another resident with vascular dementia, schizoaffective disorder, and other neurological conditions, the pharmacist recommended assessing the need for a valproic acid level and considering vitamin D supplementation due to a low lab value. The MRR forms for this resident were not signed off by the attending physician, and there was no documentation that the recommendations were reviewed or addressed. Interviews confirmed that the staff member responsible for receiving pharmacy recommendations was unavailable, and the facility's policy required staff to act upon all MRR recommendations, which was not followed in these cases.