Failure to Act on Pharmacist Medication Regimen Review Recommendation
Penalty
Summary
A deficiency occurred when the facility failed to act on a pharmacist's Medication Regimen Review (MRR) recommendation for one resident. The resident, who had diagnoses including paraplegia, depression, anxiety, hypertension, and pulmonary embolism, was receiving multiple medications such as Apixaban, Mirtazapine, Morphine Sulfate, Oxycodone, and Sertraline. The pharmacist's MRR recommended specific lab work (Primidone level, Phenobarbital level, Magnesium level), but there was no documentation that this recommendation was communicated to the physician. During staff interviews, the Interim Director of Nursing (IDON) acknowledged that the recommendation was not communicated due to a vacancy in the Director of Nursing position at the time. Review of facility policy confirmed that MRR recommendations are to be documented and acted upon, with follow-up to verify appropriate action. The failure to communicate and act on the pharmacist's recommendation resulted in the deficiency.