Failure to Timely Document and Respond to Pharmacy Recommendations
Penalty
Summary
The facility failed to document and respond to recommendations made by consulting pharmacists in a timely manner for one resident reviewed for unnecessary medication use. The DON described the process for handling pharmacy recommendations, which involved printing and placing them in a binder in her office rather than in the resident's medical record or electronic chart. During the survey, the DON was unable to locate the relevant Monthly Medication Review (MRR) for the resident in question, and it was later revealed that the MRR had been held by a staff member until the day before the surveyor's inquiry. There was no documentation in the resident's record to show that the pharmacy's recommendation had been reviewed or acted upon prior to the surveyor's intervention. The deficiency was identified through medical record review and staff interviews, which showed that the facility did not follow its own procedures for timely documentation and response to pharmacy recommendations. The lack of documentation and delayed response to the pharmacist's recommendations regarding the resident's medication regimen, specifically concerning eligibility for Gradual Dose Reduction (GDR), was confirmed by the DON. This failure was evident for one out of five residents reviewed during the survey.