Failure to Ensure Timely Monthly Drug Regimen Reviews by Pharmacist
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review for all residents, as required. Record review revealed that there was no documented evidence of a pharmacist's review of medication regimens for the months of January, February, and March 2025. This lapse affected all residents in the facility during that period. Additionally, the facility's policy titled 'Medication Regimen Review' did not specify time frames for the steps involved in the medication review process. During an interview, the current DON confirmed that the pharmacy did not provide medication regimen reviews for the specified months and was unaware that the policy lacked required time frames. The policy, last updated in July 2019, outlined the responsibilities of the consultant pharmacist but did not address the timing for each step in the review process. These deficiencies were identified during the recertification survey and were based on both record review and staff interview.