Failure to Timely Act on Pharmacy Medication Recommendations
Penalty
Summary
A deficiency was identified when facility staff failed to act on pharmacy medication recommendations in a timely manner for one resident. The facility's policy requires that a licensed pharmacist perform a monthly drug regimen review (MRR) and that staff act upon all recommendations according to established procedures. For the resident in question, who had diagnoses including PTSD, chronic kidney disease, and a history of repeated falls, the pharmacist's MRR on 1/10/25 requested clarification regarding the frequency of administration for an as-needed Melatonin order, as the original order did not specify how often the medication should be given. Although the physician signed the MRR recommendation on 1/15/25, indicating that the frequency should be added, the Melatonin order remained unmodified and still lacked the required frequency of administration as of the review date. This failure to update the medication order as recommended by the pharmacist was confirmed during an interview with facility leadership, demonstrating noncompliance with the facility's own medication regimen review policy.