Missing Medication Regimen Review Documentation
Penalty
Summary
The facility failed to maintain complete drug regimen review (MRR) documentation for one out of five sampled residents. For this resident, medication regimen reviews were conducted by the pharmacist in several months, and recommendations were made. However, copies of the MRRs for three specific months were missing from the resident's medical chart. According to the facility's own policy, all drug regimen review recommendations and prescriber's responses should be maintained in an easily retrievable location and filed with the permanent medical record. During interviews, the Director of Nursing, MDS Coordinator, and an RN confirmed that the MRRs for the specified months were not present in the resident's chart and were not available in the facility for review.