Failure to Complete Monthly Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly drug regimen reviews, including review of the medical chart, for five residents. For several residents, including those with complex medical conditions such as COPD, diabetes, pressure ulcers, dementia, and major depressive disorder, there was no documented evidence that pharmacy medication regimen reviews were completed for multiple months, including March 2025 and several months in 2024. The absence of these reviews was confirmed through both record review and staff interviews, where the Director of Nursing (DON) was unable to provide the required documentation and acknowledged that if the reviews were not in the medical record, they had not been completed. Further interviews revealed confusion regarding the responsibility for conducting the monthly medication regimen reviews. The facility's contracted pharmacy reported that they only provided medications and reviewed them upon nursing staff request, while a third-party pharmacist was said to be responsible for the monthly reviews. However, there was no evidence in the residents' records that these reviews had occurred. This lack of documentation and follow-through resulted in the facility not meeting regulatory requirements for monthly pharmacist review of resident medication regimens.
Plan Of Correction
F756 – Drug Regimen Review, Report Irregular; Act On Element #1: The pharmacy consultant reviewed the resident medication regimen for R9, R33, R40, R41, and submitted recommendations to the attending physician. The physician acknowledged the recommendations and documented follow-up actions. Element #2: An audit of pharmacy consultant reports from the last 60 days was initiated to verify timely review, physician acknowledgment, and appropriate follow-up on identified concerns. Element #3: The Medication Regimen Review policy was reviewed by the Administrator and revised as necessary. Licensed Nurses and the Provider group were re-educated on the policy and procedure. Element #4: The Director of Nursing and/or designee will audit 5 resident records per week for 12 weeks to ensure all pharmacist recommendations are documented and acted upon. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025