Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
A deficiency was identified when a consultant pharmacist failed to complete the required monthly medication regimen reviews for a resident diagnosed with Alzheimer's disease, cognitive impairment, and anxiety. The resident was admitted in early April, and documentation showed that a medication regimen review was completed by the pharmacist in April. However, there was no documentation of completed monthly medication regimen reviews for the months of May and June. The absence of these reviews was confirmed through clinical record review and interviews with the Director of Nursing, who acknowledged that no further documentation existed to indicate the reviews were performed for those months. The surveyor requested the missing documentation during meetings with facility leadership, but none could be provided, confirming the deficiency.
Plan Of Correction
No evidence of any actual ill effect exists on any of the residents in our community due to lack of adherence to the requirements of monthly medication regimen review. Resident #65's medications have been reviewed and will be reviewed going forward by the facility's new pharmacy consultant. The facility's current new pharmacy consultant has assured us that they will complete the residents' medication regimen reviews monthly. The first consultant report was provided on July 21st. An educational session was conducted by the Director of Nursing or designee with nursing staff on the importance of ensuring all residents have monthly medication regimen reviews by a pharmacy consultant. Audits of the drug regimen reviews will be completed monthly for 6 months, and any deficiencies will be addressed immediately and reported to the Director of Nursing for corrective action. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions, and to the Director of Nursing for corrective action.