Failure to Provide Timely Monthly Drug Regimen Review and Communicate Medication Irregularities
Penalty
Summary
The facility's consultant pharmacist failed to provide a monthly Drug Regimen Review (MRR) for February 2025, as required by facility policy and federal guidelines. This omission resulted in the facility and physicians not receiving timely recommendations regarding residents' medication regimens. Specifically, the pharmacist did not communicate recommendations for gradual dose reduction (GDR) or request a physician's rationale and risk versus benefit analysis for certain psychotropic medications prescribed to residents. The absence of the February 2025 MRR meant that medication irregularities were not identified or addressed in a timely manner. For one resident with diagnoses including Alzheimer's disease, hypertension, anxiety, and depression, the medical record showed ongoing use of antipsychotic, antidepressant, and antianxiety medications. The pharmacist's review noted the lack of an allowable diagnosis for the antipsychotic medication and requested a risk versus benefit statement or discontinuation, but this recommendation was not sent to the facility or physician, resulting in no physician response. The resident's care plan required quarterly consultation with pharmacy and physician to consider dosage reduction, but this process was not followed due to the missing review. Another resident with diabetes and major depressive disorder was prescribed sertraline, an antidepressant. The pharmacist had previously recommended a GDR or rationale for continued use, but no physician response was documented. The February 2025 MRR, which reiterated this recommendation, was not sent to the facility until months later, and the physician did not receive it. Facility policy required the consultant pharmacist to review each resident's medication regimen monthly and communicate any irregularities to prescribers and facility leadership, but this was not done for the month in question.