Failure to Complete Monthly Medication Regimen Review for a Resident
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly Medication Regimen Review (MRR) for one of five residents for the months of February and March 2025. Specifically, the medication regimen for a resident with diagnoses including encephalopathy, schizophrenia, and major depressive disorder was not reviewed during these months, as evidenced by the absence of documentation in the MRR records. The resident was noted to have severely impaired cognitive skills and was dependent on staff for multiple activities of daily living. The resident was also prescribed high-risk medications, including antipsychotics, antianxiety agents, antidepressants, and an anticoagulant. During interviews and record reviews, the DON confirmed that all residents should be included in the monthly MRR and acknowledged that the resident's medications were not reviewed for the specified months. The DON stated that the consultant pharmacist typically sends the MRR via email, but she did not verify that all residents were included, resulting in the omission. The facility's policy required monthly pharmacist review of each resident's medication regimen to identify irregularities and clinically significant risks, but this process was not followed for the resident in question.