Failure to Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the consultant licensed pharmacist (CLP) during the monthly medication regimen review (MRR) were acted upon for a resident. Specifically, for a male resident with diagnoses including spinal stenosis, atrial fibrillation, and anxiety disorder, one MRR recommendation regarding a gradual dose reduction (GDR) or clinical contraindication (CC) for Trazadone was not followed up in a timely manner. Although a provider eventually declined the recommendation, documentation of timely review and follow-up was lacking. Additionally, another MRR recommendation noted the discontinuation of Trazadone and the initiation of Lexapro, with a plan to discuss the change at the next psychotropic meeting. However, there was no documentation available to confirm that this discussion took place, as the requested psychotropic meeting minutes were not provided. The DON confirmed that unit managers are responsible for reviewing MRRs within one week, but the absence of documentation indicates this process was not consistently followed.