Failure to Consistently Complete Monthly Pharmacy Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist consistently performed monthly drug regimen reviews, including review of the medical chart, for several residents as required by policy. For four of five residents reviewed for unnecessary medication use, documentation showed that monthly pharmacy reviews were missing for specific months. In some cases, such as with residents diagnosed with end stage renal failure, anxiety, major depression, dementia, schizophrenia, diabetes, and other serious conditions, the required monthly reviews were not completed or could not be located in the clinical records. Care plans for these residents indicated they were at risk for complications related to psychotropic and other high-risk medications, and interventions included monitoring for side effects and consulting with a pharmacist as needed. Interviews with the Director of Nursing Services (DNS) revealed that a change in pharmacy providers and a change in facility ownership led to lapses in pharmacy consultant services, resulting in missed monthly medication regimen reviews. The DNS was unable to provide documentation for the missing months and could not explain the absence of pharmacy consultations for other periods. Facility policy required monthly review and documentation of medication administration records, but these were not consistently completed or available for review for the affected residents.