Deficient Medication Regimen Review and Documentation
Penalty
Summary
The facility failed to ensure timely reporting and documentation of pharmacy recommendations during the monthly medication regimen review (MRR) process for two of five residents reviewed for unnecessary medications. For one resident, the pharmacist's MRR report for March was sent late, resulting in the attending physician signing the report after the subsequent month's review had already been conducted. Additionally, the MRR report for April was missing from the resident's medical record. The Director of Nursing (DON) confirmed that the pharmacist's recommendations were not communicated to the facility in a timely manner, and the facility's MRR policy did not specify a timeframe for the attending physician to respond to urgent needs identified by the pharmacist. For another resident, a review of pharmacy recommendations revealed that there was no documentation in the medical record indicating whether the attending provider had reviewed the pharmacist's recommendations or what actions, if any, were taken in response. The DON acknowledged that the required documentation of provider review and response to pharmacy recommendations was lacking. These deficiencies were identified through records review and staff interviews, highlighting lapses in the facility's medication management and documentation processes.