Failure to Document Monthly Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews by a licensed pharmacist were properly conducted and documented for two of five sampled residents. For one resident with multiple complex diagnoses, including cerebral infarction, congestive heart failure, and severe cognitive impairment, the medical record showed no documentation of the pharmacist's monthly medication review or any resulting recommendations or medication adjustments, despite a progress note indicating a review had been completed. The Director of Nursing (DON) confirmed that no such documentation was available in the resident's medical record. Similarly, another resident with severe dementia, multiple comorbidities, and on hospice care had physician orders for numerous medications. Although the pharmacist's monthly progress notes stated that the medication regimen was reviewed and any irregularities were reported to the DON and prescriber, there was no evidence in the medical record of these reports or recommendations. The DON confirmed that the pharmacist's monthly review reports were not included in the resident's medical record or otherwise available. Facility policy required that consultant pharmacist recommendations be documented and made easily accessible to the care team, but this was not followed.