Failure to Communicate and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRR) were properly communicated to physicians and addressed in a timely manner for two residents. For one resident with dementia, malnutrition, and hypertension, there was no evidence in the medical record that a pharmacy recommendation made in April was provided to the physician or nurse practitioner for review and response. The resident's name was not listed on the pharmacy's report, and the Director of Nursing (DON) was unable to locate the relevant documentation or recommendation in the medical record. For another resident, the last documented MRR in the medical record was from March, with no indication that monthly reviews were completed or documented from April through July. Although a pharmacy recommendation was made in April regarding the use of a steroid inhaler, the recommendation was not addressed by the physician assistant until two months later, and the documentation was not included in the resident's medical record. The DON confirmed that the consultant pharmacist had not been documenting monthly MRRs in the electronic medical record, and was unsure why the April recommendation was not addressed in a timely manner.