Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were completed and documented by the consultant pharmacist for one of four residents. According to facility policy, the consultant pharmacist is required to review each resident's medication regimen at least monthly and document the findings in the resident's medical record. For the resident in question, who had diagnoses including high blood pressure, coronary artery disease, and diabetes, there was no documentation of MRRs in the clinical record for multiple months spanning from April 2024 through April 2025. During the review, it was confirmed that the facility could not provide evidence of completed MRRs for the specified months. The Director of Nursing stated that the lack of documentation was due to the consultant pharmacist not having computer access and an inability to locate any MRRs for the relevant dates. This failure was verified through clinical record review, facility policy review, and staff interviews.