Failure to Timely Respond to and Implement Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely response and implementation of Medication Regimen Review (MRR) recommendations for a resident with dementia and chronic kidney disease. The Consultant Pharmacist made repeated recommendations to obtain a Vitamin D level on three separate occasions, but there was no documented evidence that the initial recommendation was reviewed or responded to by the provider. Although the provider eventually agreed to the recommendation, the Vitamin D level was not obtained until after multiple MRRs and provider consents. Additionally, the facility failed to maintain documentation of the MRRs in the resident's clinical record as required by policy. Repeated recommendations were also made by the Consultant Pharmacist to discontinue Loratadine, an antihistamine medication, over several months. While the provider agreed to discontinue the medication, there was no evidence that the order was implemented until several months later. The Director of Nursing was unable to provide documentation for several MRRs and could not explain the delay in discontinuing the medication after provider agreement. The process for handling MRRs involved emailing recommendations to the Unit Manager and placing them in the Provider's Communication Book, but this process did not ensure timely review or implementation of the pharmacist's recommendations.