Failure to Timely Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act on consultant pharmacist recommendations from the monthly medication regimen review (MRR) in a timely manner for two residents. For one resident with diagnoses including hyperlipidemia, diabetes, and a history of heart attack, the pharmacist recommended uploading the results of a fasting lipid panel ordered in August. However, the test was not completed until five months later, despite the facility's policy requiring recommendations to be addressed by the next scheduled pharmacist visit. Interviews with facility staff confirmed that the expectation was for MRR actions to be completed within 30 days, but the delay was not explained. For another resident with a history of falls, depression, and anxiety, the pharmacist repeatedly recommended a Basic Metabolic Panel (BMP) to assess kidney function, noting that no such assessment had been done in the past year. This recommendation was documented in multiple monthly reviews and acknowledged by nursing staff and a nurse practitioner, with directions to complete the BMP and repeat it every six months. Despite these repeated recommendations, there was no evidence in the electronic health record that the BMP was ever completed.