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F0756
E

Failure to Complete and Respond to Monthly Medication Regimen Reviews

Elizabethtown, Pennsylvania Survey Completed on 05-22-2025

Penalty

Fine: $21,519
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that monthly Medication Regimen Reviews (MRRs) were completed by a consultant pharmacist and that recommendations were responded to in a timely manner by the attending physician or prescriber for four out of five residents reviewed for unnecessary medications. Specifically, for one resident with hypertensive heart disease and chronic kidney disease, there were no pharmacy reviews documented for August and November 2024. Another resident with type 2 diabetes, end stage renal disease, and dependence on dialysis did not have pharmacy reviews documented for July, August, and April, and pharmacy recommendations from September and December 2024 were not responded to by facility staff or a prescriber. Additionally, a resident with major depressive disorder, hypertension, and anxiety disorder did not have pharmacy reviews completed for July and August 2024. Another resident with dementia and severe protein-calorie malnutrition also lacked pharmacy reviews for July and August 2024. Interviews with the DON confirmed the expectation that pharmacy reviews should be completed monthly and responded to appropriately, but these expectations were not met for the residents identified.

See complete original report
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