Failure to Complete Monthly Medication Review for Antibiotic Use
Penalty
Summary
The facility failed to complete a monthly medication regimen review (MRR) for a resident who was receiving Rifaximin, an antibiotic prescribed for encephalopathy. The resident was admitted with a history of metabolic encephalopathy and had been on Rifaximin since the previous year. A review of the resident’s records showed that no MRR was conducted for the months of January through March, despite the ongoing use of the antibiotic. The Infection Control Prevention Nurse (ICPN) confirmed that the resident’s Rifaximin use was not tracked or reviewed as part of the antibiotic stewardship log, as the focus was only on residents with infections. The ICPN also acknowledged that there was no documentation of side effect monitoring or routine assessment of the medication’s appropriateness in the resident’s clinical chart. Further interviews revealed that the DON expected all antibiotics, both short-term and long-term, to be tracked and reviewed monthly for indication of use and inclusion in the care plan. The facility’s policy required thorough MRRs to prevent, identify, and resolve medication-related problems, but this was not followed for the resident in question. The lack of monthly review and monitoring for the continued use of Rifaximin resulted in a failure to ensure the resident’s drug regimen was free from unnecessary drugs, as required by facility policy and federal regulations.