Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a monthly Medication Regimen Review (MRR) was completed by the pharmacy for one resident. According to facility policy, the consultant pharmacist is required to perform an MRR for every resident upon admission and at least monthly thereafter, with copies of the reports and physician responses maintained as part of the permanent medical record. However, a review of the clinical record for a resident admitted with diagnoses including dementia, diabetes, and aphasia showed that there was no documentation of an MRR for the months of February, March, and May. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the required monthly pharmacy MRRs were not completed for the resident in question. The absence of these reviews was identified through examination of the resident's clinical record and facility policy documentation.
Plan Of Correction
R58 will have a pharmacy review completed and reviewed by MD. An audit of all other residents was conducted to identify those out of compliance with pharmacy reviews, and all identified residents will have a pharmacy review completed and reviewed by MD. Unit Managers will be educated on the need for monthly pharmacy review compliance and assisting with physician follow-up until completion is documented in resident charts. Unit Managers or designee will audit monthly pharmacy reviews weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at QAPI and revised as needed.