Failure to Address and Document Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist were addressed in a timely manner and maintained as part of the permanent medical record for two residents. For one resident with chronic obstructive pulmonary disease (COPD), the consultant pharmacist recommended that instructions be added to the physician's order for Trelegy Ellipta inhaler to rinse the mouth after use to prevent oral thrush. This recommendation, made in February, was not addressed by the physician, and there was no documentation in the medical record indicating that the recommendation had been acted upon. For another resident with dementia and anxiety, who had been receiving Seroquel since admission, the consultant pharmacist made multiple recommendations over several months. These included requests for a psychiatric consult to review the appropriateness of Seroquel, consideration of a gradual dose reduction, and clarification or update of the diagnosis associated with the medication. The responses to these recommendations were either incomplete, lacking a rationale for continued use, or not documented at all. The diagnosis for Seroquel was eventually changed from sleep to depression, but there was no documentation in the medical record to indicate that the pharmacist's recommendations from August or January had been addressed. Interviews with facility staff confirmed that the process for addressing and documenting MRR recommendations was not consistently followed. The Unit Manager and DON acknowledged that recommendations were not always completed or uploaded into the electronic medical record as required, and the consultant pharmacist reported that his recommendations were not routinely addressed or documented by his next visit, as expected by facility policy.