Failure to Act on Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that the Medical Director and Director of Nursing Services acted upon pharmacist recommendations for a resident reviewed for unnecessary medications. According to the facility's policy, a medication regimen review (MRR) must include a review of the resident's medical chart, and any identified irregularities are to be documented and sent to the attending physician, Medical Director, and Director of Nursing Services for action. For one resident with multiple diagnoses, including dementia and Parkinson's disease, a pharmacy consultation report recommended discontinuing two medications due to lack of use in the past 60 days. However, there was no documentation of the provider's response to these recommendations, and the DON confirmed that the pharmacy recommendation had not been acknowledged, leaving it unclear whether the medications were still necessary.