Failure to Timely Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that providers reviewed and addressed irregularities identified by the pharmacist during the monthly Medication Regimen Review (MRR) in a timely manner for three out of five residents reviewed for unnecessary medications. For one resident, the pharmacist recommended reviewing the continued necessity of Gabapentin for post-herpetic neuralgia, but the physician did not address this recommendation until nearly two months later. Another resident was receiving Lipitor, and the pharmacist suggested a lipid panel be considered with the next lab draw and at least annually, but this recommendation was also not addressed by the physician until almost two months after it was made. For a third resident, the pharmacist recommended considering tapering or discontinuing Protonix, or documenting the medical necessity and risk versus benefit of continued therapy. There was no documentation that the provider reviewed or addressed this recommendation, and the resident continued to receive Protonix for acid reflux. The facility's policy requires that pharmacist recommendations be communicated and acted upon in a timely fashion, with a response prior to the next MRR, but this was not followed in these cases. Interviews with the Director of Nursing confirmed that the recommendations were not reviewed or addressed as required.