Failure to Complete Monthly Medication Regimen Reviews and Document Physician Rationale
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews (MRRs) for residents, as required by policy and regulation. Specifically, for one resident, there was no documentation of a pharmacist-conducted MRR for three separate months, despite the resident being continuously admitted during that period. Additionally, a pharmacy review identified a significant drug interaction and made a recommendation regarding the resident's medication regimen, but while the physician disagreed with the recommendation, no clinical rationale was documented for this disagreement. For another resident, the consultant pharmacist recommended a gradual dose reduction of an antidepressant medication, but the physician disagreed without providing a clinical rationale either on the form or in a progress note. The facility's policy requires that physicians and staff identify and address potentially significant medication-related problems, and that consultant pharmacists use monthly reviews to identify problematic medications. Interviews with the DON confirmed the lack of required documentation and rationale in both cases.